Schiavo case highlights divisions in Catholic views on treatment

By JOE FEUERHERD
Washington

Catholic teaching and secular medical ethicists agree that those charged with deciding the fate of deeply debilitated family members should ultimately weigh two factors. First, the medical situation -- what precisely is the person suffering from and what are the benefits and burdens that would likely flow from a particular course of action? Next, the patient’s wishes: What would the family member want?

It’s a thoughtful two-tiered analysis that, in the extraordinarily tangled case of 41-year-old Terri Schiavo, provides precious little guidance.

Medically, Florida courts have accepted the determination that Schiavo is in a “persistent vegetative state” -- unaware of the world, unable to interact with those around her, and unlikely to improve. Others, including Schiavo’s parents, contend that she may be in a “minimally conscious state” -- aware to some degree of her environment, capable of limited interaction, and a candidate for therapeutic treatment that could yield tangible benefits.

“You’ve got competent medical experts lined up on both sides,” said Dr. John Kilner, president of The Center for Bioethics and Human Dignity, Bannockburn, Ill.

And Schiavo’s wishes? Florida courts have sided with Schiavo’s husband, Michael, who says that prior to Terri’s February 1990 incapacitation, she told him that she would not wish to continue to live if she found herself in such circumstances. But Michael Schiavo, say others, is hopelessly compromised -- with both financial conflicts (he benefited from a malpractice award related to Terri’s care) and personal interests (he is involved in a relationship with another woman who is the mother of his two children).

“You can’t help but wonder about his motives,” said Russell B. Connors, assistant professor of theology at Minnesota’s College of St. Catherine.

“In the absence of an advance directive, there’s commonly an ordering of who is in the best position to act in [the patient’s] best interests and it’s normal and natural that the spouse would be at the top of the list because the spouse has a unique relational commitment to that person,” said Kilner. But in the Schiavo case, “virtually anyone would be in a better position [to carry out that role] than her husband.”

Despite disputes over the nature of Terri Schiavo’s condition and her intentions, the law has spoken and the gastric tube that provided her nourishment has been removed.

Does Catholic teaching allow for such a course of action? It depends, once again, on both the individual circumstances and the individual answering the question.

Though the terms are often misunderstood, traditional Catholic teaching distinguishes between “extraordinary” and “ordinary” means of medical treatment. “Extraordinary” doesn’t necessarily mean cutting edge. Instead it relates to the burdens (physical, financial, familial) and benefits (such as extended life) that a particular treatment or procedure might entail. Depending on the circumstances, treatment with an antibiotic could be considered “extraordinary,” while use of a ventilator to allow breathing may be “ordinary.” Generally speaking, Catholics are free to forgo “extraordinary” treatment and obligated to accept “ordinary” treatment.

As the U.S. bishops said in June 2001, “A person may forgo extraordinary or disproportionate means of preserving life. Disproportionate means are those that in the patient’s judgment do not offer a reasonable hope of benefit or entail an excessive burden, or impose excessive expense on the family or the community.” The bishops’ “Ethical and Religious Directives for Catholic Health Care Services” also say, “There should be a presumption in favor of providing nutrition and hydration to all patients, including patients who require medically assisted nutrition and hydration, as long as this is of sufficient benefit to outweigh the burdens involved to the patient.”

Such nuances -- “sufficient benefit to outweigh the burdens involved” -- were largely cast aside a year ago by Pope John Paul II when he declared that nutrition and hydration is not treatment, but instead a routine form of care that should be available to everyone, including those in a persistent vegetative state.

“The sick person in a vegetative state, awaiting recovery or a natural end, still has the right to basic health care (nutrition, hydration, cleanliness, warmth, etc.), and to the prevention of complications related to his confinement to bed,” John Paul II told a March 2004 conference on Life Sustaining Treatment and Vegetative State: Scientific Advances and Ethical Dilemmas.

“I should like particularly, to underline how the administration of water and food, even when provided by artificial means, always represents a natural means of preserving life, not a medical act,” the pope continued. “Its use, furthermore, should be considered, in principle, ordinary and proportionate, and as such morally obligatory, insofar as and until it is seen to have attained its proper finality, which in the present case consists in providing nourishment to the patient and alleviation of his suffering.”

The pope continued, “Death by starvation or dehydration is, in fact, the only possible outcome as a result of their withdrawal. In this sense, it ends up becoming, if done knowingly and willingly, true and proper euthanasia by omission.”

In the year since he uttered those words, John Paul II’s language has been parsed (“in principle,” “insofar as and until”) and his intent questioned. Was he speaking authoritatively? But in an area where bishops, theologians and Catholic medical ethicists choose their words with considerable care, the pope’s relatively blunt declaration took many, not least administrators at church-run hospitals, by surprise.

The pope’s comments have had an effect. Catholic health care agencies worldwide have reviewed their procedures and some ethicists have rethought and rearticulated their positions. But the pontiff’s remarks do not amount to a definitive last word on the question of artificially administered food and water.

The question of whether artificially provided nutrition and hydration amounts to medical treatment “has remained disputed” with different bishops offering varying views, notes M. Therese Lysaught, associate professor in the Department of Religious Studies at the University of Dayton, Ohio. “Originally these kinds of interventions were meant to assist other forms of medical treatment, as methods to carry a person through a crisis situation” and were “seen as part of an entire medical treatment program,” said Lysaught.

In the case of those in a persistent vegetative state, such care, which includes the surgery necessary to place the feeding tube, is “clearly medically administered and is probably rightly categorized as medical treatment,” said Lysaught. Which means, she said, “that it then falls under the calculus of ‘ordinary’ and ‘extraordinary’ treatment.”

Said Connors, “There are intelligent Catholics of goodwill who are on both sides of the fence here. Quite a number of bishops and many, many medical ethicists have taken a different line of thought -- that [provision of nutrition and hydration through artificial means] is indeed a medical treatment and subject to the same kind of analysis as any other medical treatment,” such as a consideration of the “hoped-for benefits and the burdens that are involved.”

What does that mean for Terri Schiavo?

“I think Terri Schiavo has the fatal pathology of not being able to eat food or drink water which is being bypassed by medically supplied nutrition and hydration,” said Connors. “If the nutrition and hydration is ceased, she will die of the underlying pathology, just as when you remove a ventilator the cause of death is the condition that keeps the patient from breathing.”

Not so, argues Fr. Michael Orsi, professor of law at Ave Maria University, Naples, Fla.

“Terri Schiavo is not dying of anything -- she is just unable to eat … and we have a moral obligation to hydrate and to give nutrition to someone who is unable to do that for themselves.” Said Orsi: “To remove that feeding tube is to kill Terri Schiavo, there is no other intention here.”

Orsi draws a distinction between someone suffering a terminal illness and those in a persistent vegetative or minimally conscious state. “If the person is dying and all the nutrition and hydration is doing is prolonging death and interfering with the dying process you might, in fact, have an obligation to stop that. Life is a very sacred thing, but it is not the ultimate.” But that is not the case with Schiavo, says Orsi, whose situation is more comparable to that of a baby dependent on adults to provide food and nutrition than to a terminally ill person.

Underlying the political, social, ethical, legal and religious disputes that surround Schiavo’s case is a question: Fifteen years after suffering an incapacitating illness that has left her bedridden and largely unresponsive to the world around her, is Terri Schiavo’s life worth living?

It’s a question, suggested Orsi, best left unanswered. “How much consciousness is there of someone who has Alzheimer’s disease?” he asked. Orsi said he is fearful of the consequences to society if “quality of life” becomes the measure by which such decisions are made.

While allowing that in the case of someone like Schiavo a conscientious Catholic could elect to remove a feeding tube, Lysaught sees considerable merit in doubts raised about the practice. “The church holds that our actions affect not only other people but ourselves and our character, that once I engage in an action where I intend to do something morally evil it becomes easier to do it again,” said Lysaught.

Noting that two-dozen national disability rights groups have supported efforts to restore Schiavo’s feeding tube, Kilner cautions that “quality of life scales” are a “very dangerous way of approaching the care of people when we don’t know what their wishes are.”

Connors, meanwhile, argues that society’s euthanistic impulse might actually be furthered “if we start mandating certain types of treatment that always must be given in a certain set of circumstances.” Part of what is “fueling the movement toward euthanasia and assisted suicide is the very dramatic fear people have that they will end up … like Terri Schiavo.”

Joe Feuerherd is NCR Washington correspondent. His e-mail address is jfeuerherd@natcath.org.

National Catholic Reporter, April 1, 2005