Truncating Catholic tradition

Florida bishops avoid full consideration of ethical issues in Schiavo case

By EDWARD R. SUNSHINE

For most of Christian history, Roman Catholics wrote the book on medical ethics. As David Kelly explains in Contemporary Catholic Health Care Ethics, the best discussions and writings on moral issues in medicine took place in the church from the 12th century until about 1970, when the secular discussion of bioethics began to develop rapidly. The reasons were simple: pastoral concern for the physical and not just the spiritual health of those under clerical care, well-developed medical and moral traditions from ancient Greece and Rome that were preserved and expanded by clerics and laity in the church, and awareness that matters of health and life involved moral issues of great importance. So it is not surprising that church leaders were active in the controversial discussions about the case of Terri Schiavo, who died March 31.

The Catholic bishops in Florida have taken the lead in this discussion, and rightfully so. Terri Schiavo was Catholic and a Florida resident, as are her parents, Bob and Mary Schindler. At the practical level, her situation is of acute interest because many people find themselves faced with similar issues. At the theoretical level, the questions raised are important for how they relate to traditional Catholic teachings. The bishops’ teachings have been sometimes less than helpful, however, because they have not represented adequately their own medical ethical traditions. By selecting and using limited aspects of the received tradition, the bishops have avoided full consideration of the issues.

Pope John Paul II’s 1980 “Declaration on Euthanasia” is the standard Catholic reference on end-of-life issues. In section IV, it presents this set of principles: 1) It is for the consciences of sick persons or those qualified to speak in their name to make these decisions. 2) There is a duty to care for one’s own health or to seek care from others. 3) Those who care for the sick should use remedies that seem necessary or useful. 4) The principle that one is never obliged to use “extraordinary” or “disproportionate” means to preserve life still holds good. 5) “In any case, it will be possible to make a correct judgment as to the means by studying the type of treatment to be used, its degree of complexity or risk, its cost and the possibilities of using it, and comparing these elements with the result that can be expected, taking into account the state of the sick person and his or her physical and moral resources.” 6) It is wrong to “impose on anyone the obligation to have recourse to a technique which is already in use but which carries a risk or is burdensome.”

Clarification is necessary here to avoid needless confusion. First of all, to say that it is for the conscience of sick persons (or their proxies) to decide means that conscience is the ultimate subjective norm of morality in those particular cases. That is standard Catholic moral teaching. When the bishops and the pope teach, however, they discuss objective norms of morality that apply in general. They do not (indeed, cannot) tell people how to act in conscience because conscience is the domain of the person before God. Second, the distinction between “extraordinary” and “ordinary” means is a moral, not a medical, distinction. This means that ill persons, not doctors, determine what constitutes “extraordinary” and “ordinary” means, and that they do this according to an assessment of the burdens and benefits involved, not in line with the criteria of normal medical practice. It is here that differences in moral judgment often arise.

In a March 2004 address on “Life-Sustaining Treatments and Vegetative State,” Pope John Paul II said, “The administration of water and food, even when provided by artificial means … 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 [sic] suffering.” (Emphasis in original.) It is not clear how to reconcile this statement with the principles of the 1980 document on euthanasia, nor is it evident what authority an address might have in comparison with an official Vatican document, such as the “Declaration on Euthanasia.” Whatever the case, this application needs justification and discussion within the context of the received tradition as represented by the “Declaration on Euthanasia”; otherwise, it becomes merely an assertion of ecclesiastical authority, with little grounding in reason.

So not everyone understands and applies the principles of the “Declaration on Euthanasia” in the same way, nor even does the same pope do so at all times. One approach starts by presuming in favor of artificially provided nutrition and hydration and urging much caution in terminating the same. In the tradition, this method of discernment goes by the name “tutiorism,” a word coined from the Latin tutus (safe), in the comparative form tutior (more safe), commonly referred to as “taking the safer course.” It restricts the freedom to decide to accept death by limiting the category of “extraordinary” means that may be rejected, by expanding the category of “ordinary” means that must be employed, and by considering only the burdens of a particular treatment.

Benefits and burdens

The other approach is best expressed in the “Declaration on Euthanasia” (No. 5 of the principles quoted above). It extends the freedom to decide by restricting what counts as “ordinary” means that must be employed, by expanding the “extraordinary” means that may be rejected, and by considering both the benefits and burdens of the whole situation. Each approach has its strengths and weaknesses. The value of the discussion comes precisely in the mutual probing and challenging of both and the ensuing give-and-take that occurs, because that is the way our awareness and clarity about these kinds of moral issues develop.

In the Schiavo case, the Florida bishops chose the more restrictive approach. This goes back at least to their 1989 “Statement on the Life, Death and the Treatment of Dying Patients.” In that document, they say, “In most cases there is not an excessive burden in the artificial administration of nutrition and hydration. The total care of such patients may be a burden, but it is the burden of this particular treatment that must be judged.” They go on to relate the benefit received from artificially provided nutrition and hydration to how imminent death is, whether “a physician can predict death within a few days or weeks, regardless of what life prolonging methods are utilized.” They conclude by drawing a comparison between “persistent vegetative state” and a disability. Thus they minimize the burden of providing nutrition and hydration by feeding tube, restrict denial of the same to the time when death is looming in the very near future, and implicitly challenge the medical diagnosis of “persistent vegetative state.”

Statements specific to the Schiavo case by Florida bishops have followed the same pattern. In October 2002, Bishop Robert Lynch of St. Petersburg, where Schiavo resided, wrote that the church would “refrain from passing judgment on the actions of anyone in this tragic moment.” But in early August 2003, he said, “We are obliged to preserve our own lives, and help others preserve theirs, by use of means that have a reasonable hope of sustaining life without imposing unreasonable burdens on those we seek to help, that is, on the patient and his or her family and community,” adding that “it is not clear whether the medically assisted nutrition and hydration is delaying her dying process to no avail, is unreasonably burdensome for her, and contrary to what she would wish if she could tell us.” He recommended that “Terri’s family be allowed to attempt a medical protocol which they feel would improve her condition.”

The Catholic bishops of Florida issued a statement about the Schiavo case in late August 2003. This came two days after they were the targets of strong criticism from Pamela Hennessy, media coordinator for Schiavo’s parents, because the Florida Catholic Conference had requested a commutation of the death sentence of Paul Hill for two murders he had committed outside an abortion clinic. Hennessy wrote to the conference: “I respectfully request that you convey to the Florida bishops that, if all life is truly sacred, their defense of a convicted killer coupled with their disinterest in the life of a disabled and innocent woman is beyond offensive.”

In their subsequent statement, the bishops said, “Church teaching is clear that there should be a presumption in favor of providing medically assisted nutrition and hydration to all patients as long as it is of sufficient benefit to outweigh the burdens involved to the patient. ... If Mrs. Schiavo’s feeding tube were to be removed because the nutrition she receives is of no use to her, or because she is near death, or because it is unreasonably burdensome for her, her family or caregivers, it could be seen as permissible”; however, the bishops asked for “additional time to allow greater certainty as to her true condition.”

In November 2003, Archbishop John Favalora of Miami wrote, “In the case of a patient whose death is imminent -- that is, no matter what is done medically, the person will die within a few hours or a few days -- the church teaches that nourishment or hydration may be withheld ‘as long as the patient is made comfortable.’ ” So now the 1989 definition of imminent death (“a few days or weeks”) is compressed into “a few hours or a few days.” In March 2005 statement, Favalora refers to Schiavo’s “eventual death by starvation” and says: “Whenever there is serious scientific ambiguity, morally one must follow the safer course. Food and water can be denied only if death is imminent or if it proves to worsen the individual’s condition.” So the medical diagnosis is ambiguous, artificially provided nutrition and hydration become food and water, and the summary description is starvation.

The bishops’ increasingly strident rejection of arguments contrary to theirs is not helpful in this case. They bring up valid considerations but leave the impression that Catholic tradition has nothing else to say. But what if persons who are seriously ill, though not faced with imminent death according to the bishops’ definition, decide not to eat or drink? The Schiavo case was different, because she was not competent, so others had to decide for her. Why have proxies, however, if they cannot make decisions as they think persons in their care would wish? The bishops run the risk of claiming themselves to be proxies of last resort for medical choices and decisions of conscience, something never envisioned by Catholic moral tradition.

Courts uphold diagnosis

In the Catholic discussions that refer specifically to the Schiavo case, the issues are: 1) what her medically diagnosed condition meant; 2) how to designate artificially provided nutrition and hydration, whether as “ordinary” or as “extraordinary” means of preserving life; and 3) whether to consider only the burdens or both the benefits and burdens at stake.

First of all, the diagnosis: The medical consensus in this case was not ambiguous. Through eight years of litigation, the diagnosis had been “persistent vegetative state,” and the courts repeatedly upheld that diagnosis. What may be ambiguous, however, is the moral understanding of that diagnosis. For the bishops, even a diagnosis of “persistent vegetative state” meant simply that Schiavo was living differently from what is considered normal. But another moral perspective would see Schiavo’s condition as lethal, because her brain damage was preventing her from eating and drinking.

Secondly, the bishops think it evident that artificially provided nutrition and hydration are “ordinary” means of preserving life, which they are for someone who wishes them and accepts them. But Schiavo could not express a wish, and she could not accept on her own what was offered since she could not swallow. She was fed through a feeding tube that was forced on her and itself may have constituted a burden. Here the question is whether the bishops are looking at the “extraordinary/ordinary” distinction in a medical or moral way. Only their reasons for the designation can determine this. But the bishops give none; they only declare nutrition and hydration are “ordinary” means.

Thirdly, the bishops claim that the tubal feeding is not burdensome without giving good reasons, and they do not evaluate other burdens or benefits. After 15 years of continual deterioration in Schiavo’s condition, with no medical prognosis that she would improve, it was unclear how she would benefit from the machines that were keeping her alive.

Why should forced tubal feeding to persons in “persistent vegetative state,” as opposed to the normal intake of food and drink, be considered “ordinary”? Why do foreseen benefits to the ill persons not come into consideration, but only a cursory review of the burdens? The bishops provide inadequate reasons, though the church traditions in medical ethics are based on rational argument, not just hierarchical authority.

In extreme examples, rational discussion has disappeared completely. A Florida bishop recently wrote a newspaper article that stated that the denial of nutrition and hydration was comparable with abortion, ethnic cleansing and the Nazi program of euthanasia as examples of the mystery of iniquity. Besides having nothing to do with the Schiavo case, these examples are appeals to emotion, not reason. Next he compared Schiavo to Christopher Reeve, saying, “Terri, however, is not being kept alive by any machine as was Reeve for most of his last decade of life. She only needs assistance to be fed.” Apparently, the pump that runs the feeding tube does not count as a machine. Finally, he said: “And so, Holy Week, the annual remembrance of Jesus’ passion and death, begins with the Passion [sic] of Terri Schiavo.” Terri gets compared to Jesus and merits the upper case “P,” while Jesus only gets a lower case letter. No wonder non-Catholics find such statements unworthy of serious consideration and Catholics are at a loss to explain and defend what they mean.

What Catholics need in this tragic situation is a vigorous, rational discussion of various courses of action and a fair evaluation of the strengths and weaknesses of each. What they are getting from the bishops of Florida is a limited and one-sided picture of a difficult issue, at times tinged with embarrassing rhetoric. Catholics deserve better. We should all try to make that the lasting legacy of Terri Schiavo.

Edward R. Sunshine is associate professor of theology at Barry University in Miami Shores, Fla.

National Catholic Reporter, April 8, 2005