Saturday, March 26, 2005

Happy Easter

Since it is Easter and I am Catholic, I thought I would post a well reasoned explanation of Catholic teaching on the Schiavo matter. The author is a Paulist Priest (and I attend a Paulist Church):

Terri Schaivo and Extraordinary means According to Catholic Teaching…

1. Since about the 1500s the ordinary/extraordinary means tradition has allowed patients (or, if incompetent, their delegates or next-of-kin) to weigh the benefits vs. the burdens of any given medical treatment in the context of their own personal life experiences, finances, pain tolerance, values, support network, etc. This was never an evaluation of means-alone, but means-in-context. On the whole, will I be more burdened or benefited by the treatment, given its side effects and my general condition or "totality"? So a surgery or piece of equipment or a medicine could not be declared "absolutely" or "categorically" ordinary (i.e. required).For example, a ventilator [which doesn't heal, but keeps one breathing artificially or assisted by machinery] may be "ordinary" in the case of a person with a lung infection who is on antibiotics and will soon regain his/her own breathing capacity. That same ventilator may be deemed "extraordinary" (i.e. optional) in the case of someone resuscitated after being dredged up from a frozen river. If his/her brain function was preserved because of hypothermia, we might leave them on the ventilator to see how much brain function will thaw and return. If, however, CAT scans, MRIs, etc. determine that only the brain stem is functioning, if that, then one can wean the person from the ventilator and if she/he doesn't breathe on their own, then they die -- and it is considered removal of "extraordinary," not "ordinary" means (i.e. Karen Ann Quinlan). So it is the SITUATION or CONTEXT, not the particular procedure alone. Also, we do not weigh a procedure vis-Ă -vis one body function, but in terms of whole bodily health or the patient's totality. e.g. dialysis, which may still work on one's kidneys, is no longer obligatory when someone has terminal cancer or after a massive, irreversible heart attack. We are the sum total of our health conditions, not isolated organ systems.

2. Now to Terri Schaivo in Fla. It has been the standard Catholic moral position across the 20th century, accepted tacitly by the Vatican and in some cases explicitly by Pius XII & a 1980s Decl. on Euthanasia, that when one is near death or terminally ill, one need not start (or continue) procedures that merely prolong dying. Hence, it is the accepted practice in all hospice programs that we do not hook terminally ill patients up to ventilators or artificially administered fluid and nutrition to prolong their dying. In ordinary/extraordinary language, the value of artificially moving their lungs or artificially bypassing their swallowing and digestive processes is not of enough benefit TO THE PATIENT, given their dying condition and, indeed, prolongation might prolong their suffering and the burden to others whom they love and would not want to burden unnecessarily.At the same time, in addition to clearly terminal conditions or imminently dying conditions (latter stage cancer, massive heart failure, etc.), the same moral consensus held about those in permanent comas. If one is so brain damaged that one will never wake up or be conscious again [to the best of our medical prognosis] then one can consider those treatments which merely prolong respiration or nutrition to be "extraordinary," not of enough benefit to this no-longer-conscious person, that they can be discontinued, allowing the person to finish their natural body shut-down or dying process. Just as we don't say that removal of a ventilator in such a case would be "suffocating" ot "smothering" them to death, we ought not indiscriminately label the cessation of artificial administration of fluids and nutrition with the harshly judgmental term "starvation."The case that is at hand, and on which one Vatican commission made a NEW statement a year or so ago, is that of patients in a PVS or Permanent Vegetative State. PVS -- if diagnosed accurately and allowed to go on long enough to determine no medical potential for reversal -- is EXACTLY like being comatose in terms of patient experience and consciousness. The difference is that in comatose or "unconscious" patients the patient's eyes remain closed -- no mid- or upper-brain activity is going on and their eyes never open. In PVS, the patient is similarly non-conscious, but sometimes his/her eyes are closed, sometimes open, giving the 'impression' of being "awake" vs. "asleep." Their autonomic nervous system may at times make their eyes flinch or their head turn with a jerk, but over time one can determine if this is a conscious response to stimuli (loud noises, a pointed finger, etc.) or merely a brain-stem based unconscious response (like knees responding to being tapped and eyes dilating when a light is shone into them).Part of the Schaivo controversy is that the parents disagree with the husband and all the major neurological data. They say she is NOT PVS and therefore is aware and responding, albeit at a very retarded level and that she can recover. All the reputable medical folks concur that she truly is PVS, not responding, and given the 14+ year time lapse, will not "awake" or regain "consciousness." Therefore, like the permanently unconscious patient, Catholic tradition (and Florida law and US law) allow one to consider the removal of artificially administered fluid and nutrition as "extraordinary" in this case, which means "optional" -- morally one could continue or not continue. In the state of Florida, as in most jurisdictions, if the patient's prior wishes are not clearly on record, then the state seeks either family consensus or, failing that, they prioritize who can speak for the patient. In almost all states, the wishes of one's spouse trumps that of parents or peer siblings in the case of adults. So, despite Gov. Bush's efforts to overturn Fla. law, which was declared unconstitutional, the state courts have rightly (in my judgment) said that the husband has the legal right to have the tube removed, based on the legal/moral interpretation I laid out above.The local bishop there, formerly Gen. Secr. of the USCCB, has been under tremendous pressure to neatly take a side. For the most part, while his rhetoric is strongly pro-life in terms of values, he has correctly echoed the complexity of the situation and noted that Catholics could weigh this individual case as "ordinary" or "extraordinary," and if the latter, could opt to forge ahead or stop the procedure.

3. A year or so ago a Vatican Commission on Bioethics (not a Congregation and not by a Papal decree) held a conference on the topic of fluid and nutrition, particularly vis-a-vis comatose and PVS patients. The bishop who heads that congregation and a small cadre of conservative Catholic ethicists championed that for PVS patients it is ALWAYS necessary to keep them hooked up, that artificially administered fluid and nutrition is ABSOLUTELY ordinary in all cases, definitively of sufficient benefit TO THE PATIENT to warrant its maintenance. When asked what constitutes "sufficient benefit to the patient" this school of thought suggests that maintaining biological life, even sans consciousness, is of sufficient benefit to the patient. Others, sympathetic to this position, will acknowledge that while it is of no real benefit to this particular patient, we ought to keep her/him alive to show our communal respect for life in general and in its weakest members. Critics suggest that this latter logic turns the patient into an object and does not base the decision on his/her best interest, but our societal self-image. Thus she/he is however unintentionally being "depersonalized" by the decision to keep them hooked up. At that same conference many (most?) theologians from around the world challenged these interpretations and the requirement to maintain artificially administered fluid and nutrition in PVS cases. One such paper was delivered by Ron Hamel of the Catholic Health Assoc. and John Collin Harvey, a venerable physician/ ethicist from Georgetown Medical Center. It was a lively conference with papers delivered on several sides and multiple facets of this complex issue. Near the end of the conference JP II appeared and attempted to read a short address to those assembled. But he was so ill/feeble as to be unable to finish his 2-3 page text. [It was then finished for him by the same bishop noted above.] Most believe that the same bp., chair of the Commission had crafted the pope's words -- since JP II is in such poor health and the language of the short address was almost verbatim that bishop's earlier address. Some said this afternoon papal elocution constituted a major papal decision and decree, a reversal of the long-standing mainstream Catholic moral position in behalf of "optionally" withholding such procedures from comatose and PVS patients -- being terminal patients, even if not imminently dying. Others -- most theologians present, around the world, and including me -- say that such a short afternoon address (not an encyclical, not officially promulgated) by an ailing pontiff is not tantamount to a FORMAL change in church teaching. Rather, it illustrates that JPII is "tilting toward" that group which wants to dissent from the tradition and make a change in the right-ward direction. He was weighing-in at an academic conference on a topic under new debate, but NOT closing off debate nor resolving the tension and disagreement at this point. In short, the matter is still under debate, but the official Vatican position is moving away from the tradition toward a new, more conservative conclusion. One difficulty, as I see it, is that the ordinary/extraordinary tradition has never declared any treatment in-itself to be ABSOLUTELY "ordinary." So to do so in this case is to put a big crack in the very logic of the ordinary/extraordinary tradition. It might also force us to reconsider ALL cases where fluid and nutrition are withheld or halted, since in 99% of those the procedure works on the "nutrition" problem, if divorced from the patient's totality or holistice best interest. Hospice practice might be drastically altered from accompanying folks through their natural dying, to long-term coma clinics and facilities. Tah Dah -- the Schaivo case becomes a test case. If the Vatican newspaper L'Osservatori Romano weighs in on it, as it just did, this still does not constitute a formal declaration by the Pope or official Vatican. I think the Church should be very wary of saying that all unconscious patients should be hooked up ad infinitum to artificially administered fluid and nutrition. If they do so, then it would be equally logical to say that ventilators can never be removed from such patients or that hospices must hook all terminal patients up to prolong their lives at whatever state of consciousness or personal benefit/burden. It seems to me that in a well-intentioned, but potentially misguided effort to buoy up our "defense of life" Catholic posture, we may be backing into to stepping into a VITALISTIC interpretation of the value of life (i.e. respiration and circulation sans consciousness) that has NEVER been our Catholic "pro-life" premise. 11th hour legal maneuvering and theological pronouncements related to such cases -- esp. when the language is loaded with terms like "killing," "starving," "murder," and "euthanasis" accusations -- makes for poor public policy, polarizing theology and philosophy, and lots of political posturing. Poor Terri Schaivo -- in her unconscious state she truly is in LIMBO. If she is allowed to finish dying, she will THEN be with the Lord. If she is maintained indefinitely, she will feel no pain, experience nothing here consciously, but will also -- in a soulful sense -- not be able to enter eternal life. She is neither dead nor fully, qualitatively participating in this life. I think the former, as-yet-still-intact Catholic tradition is wiser and more nuanced. I appreciate the renewed pro-life concern expressed by those conservatives wanting to change the Church's tradition, but I think PVS patients like Terri Schaivo may be the wrong place to start or to take this stand as if theirs is clearly or categorically a "pro life" conclusion. Akin to the Vatican's recent shift against capital punishment, the current Vatican "tilt" is a dissent from and change in church teaching, not an accurate representation of our past tradition. The Church can and does change its teaching. I'm just not sure in this end-of-life case those involved are carefuly weighing all that their ABSOLUTE mandate would imply or unleash. I hope this may be of some help to those of you pondering the present case. Be wary of "bandwagon" stances on either side, esp. from the Sunday pulpit. This is truly one of those "on the one hand" vs. "on the other hand" kind of cases.

Fr. Richard Sparks, CSP

2 Comments:

Blogger Susan Rose, CSJP said...

Ran across this humorous
peace from Commonweal
on another blog recently. It treats the Pope's statement
- the one that completely contradicts all of the tradition - as if it were a thesis
proposal submitted to an interdisciplinary committee for review at a Catholic
university. Raises a lot of the same questions.

Long story short - even the "Catholic position" is no where near as simple as the media would make it seem.

Life is messy.

10:25 AM  
Blogger Crapartist said...

The traditional view outlined in 1 seems most rational. I especially appreciate the appeal to best medical/scientific knowlege/practice. There are always reasonable and unreasonable folks in every population.

10:14 PM  

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