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October 19, 2004
Mysteries
....Why is Ohio Dominican University hosting (and presumably paying lotsa dough to) Ellen Goodman this coming Thursday?
At Thrownback, Fr. Rob Johansen wonders too, and has a look at a statement of Australian bishops on PVS.
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Because they are so pro-abort that they are willing to ignore really bad writing and really sloppy thinking?
Posted by: Donald R. McClarey at Oct 19, 2004 12:38:30 PM
Regarding the Australian Bishop's statement and the Holy Father's "Address To the International Congress on the Vegetative State" last March:
Isn't Michael Schiavo's argument essentially that Terri gave an oral, de facto advance directive specifying that she would find prolonged ANH feeding to be unduly burdensome?
And doesn't Church teaching, even after the Holy Father's March statement, recognize this as grounds to remove ANH?
The March statement directs caregivers to provide ANH as a default option, and forbids discontinuation on the grounds that treatment is "not of benefit" when it is successfully maintaining life.
But patients are still allowed to refuse ANH as an undue burden, and Catholic caregivers are generally to respect that choice.
Posted by: Rick at Oct 19, 2004 1:03:05 PM
"Unduly burdensome" is not code for "purely a matter of choice" (as "health of the mother" is often interpreted to mean by pro-abortionists).
The Aussie bishops themselves observed that "in Australia tube feeding is not normally too burdensome."
Posted by: penitens at Oct 19, 2004 1:37:27 PM
Actually what the Australian bishops observed was that "in Australia tube feeding is not normally too burdensome to others"
So tube feeding in the first world is not normally an overly burdensome expense. That doesn't mean it isn't repugnant to the patient, and hence perceived as overly burdensome.
It's my understanding that Catholic hospitals will typically respect the advance directive of a patient who declines ANH as overly burdensome. But some moralists seem to be arguing that such advance directives are not in accord with Church teaching, and Catholic hospitals should not be bound by them.
I don't think the Holy Father's March statement or the Australian Bishop's statement settles this matter. As far as I know, a Catholic may licitly refuse in advance ANH as overly burdensome and a Catholic hospital should still respect this directive.
Posted by: Rick at Oct 19, 2004 2:06:04 PM
"....Why is Ohio Dominican University hosting (and presumably paying lotsa dough to) Ellen Goodman this coming Thursday?"
Could it be that the price of admission to hear Ellen will more than cover Ellen's fee and leave the University with a profit? Could it be that fund raising is really at the bottom of inviting all dissident speakers to Catholic colleges? Do dissidents draw more audience than non dissidents therefore increasing profits? Just a research question.
Posted by: caroline at Oct 19, 2004 3:18:00 PM
Bottom-line, “unduly burdensome” cannot be equated with “an individual’s arbitrary choice.”
The U.S. bishops have been grappling with these issues too and while they did not achieve a comprehensive resolution of the issues involved, they made many important points.
Not all "repugnance" may be reasonable or morally appropriate. Nor should all “advance directives” be binding.
“A competent patient is the primary decisionmaker about his or her own health care, and is in the best situation to judge how the benefits and burdens of a particular procedure will be experienced. Ideally the patient will act with the advice of loved ones, of health care personnel who have expert knowledge of medical aspects of the case, and of pastoral counselors who can help explore the moral issues and spiritual values involved.
"A patient may wish to make known his or her general wishes about life support in advance; such expressions cannot have the weight of a fully informed decision made in the actual circumstances of an illness, but can help guide others in the event of a later state of incompetency. Morally even the patient making decisions for himself or herself is bound by norms that prohibit the directly intended causing of death through action or omission, and by the distinction between ordinary and extraordinary means.”
....
"Health care personnel should generally follow the reasonable wishes of patient or family, but must also consult their own consciences when participating in these decisions."
http://www.usccb.org/prolife/issues/euthanas/nutqa.htm
Posted by: penitens at Oct 19, 2004 4:49:15 PM
Caroline,
You mean to tell me that those students *pay* to hear whatever benighted speakers that U wishes to drag in? In that case, I would be surprised if Ms Goodman was not greeted with the sound of crickets at whatever venue she is to speak at.
Posted by: john hearn at Oct 19, 2004 5:15:02 PM
Are Catholic universities under the control of the local bishop?
Posted by: Steve Jackson at Oct 19, 2004 5:18:44 PM
>>>"Are Catholic universities under the control of the local bishop?"
Ultimately, yes, although I doubt any Bishops are involved in the day to day goings on at a Catholic college. That's why it has administrators.
Posted by: Jason at Oct 19, 2004 5:28:51 PM
I wouldn't mind so much if they invited "dissident" speakers if they also invited conservative, orthodox speakers on various issues...and also if they publicized the event with a kind of caveat attached.
There are people who believe things very different from what I believe and which seem to me to be not compatible with Catholicism (or Christianity) whom I would like to hear expound their arguments. College students should be able to analyze the words of such speakers and tease out their fundamental assumptions, and be able, politely, civily, to challenge these assumptions. My other condition for having such people speak at Catholic colleges would be that there be a question and answer period afterward, at least as long as the lecture, and that the speaker be advised to expect serious, probing questioning. Of course, the students would have to be trained to do this, and taught to do it with civility...but isn't that what college is for?
Susan F. Peterson
Posted by: Susan Peterson at Oct 19, 2004 5:36:47 PM
Penitens,
Thanks for your response. I understand that a patient can make an arbitrary or disordered choice to refuse food or ANH, and caregivers are not morally bound to respect this.
One example would be a young woman suffering from anorexia. Her refusal of food is clearly a disorder that should not be respected, even if food needs to be given to her artificially.
I do not put an advance directive against prolonged ANH in the case of pvs in the same category. The US bishops say,
Catholic theologians have traditionally viewed medical treatment as excessively burdensome if it is "too painful, too damaging to the patient's bodily self and functioning, too psychologically repugnant to the patient, too restrictive of the patient's liberty and preferred activities, too suppressive of the patient's mental life, or too expensive
I personally do not think it unreasonable for a patient to perceive prolonged ANH as repugnant. And I haven't seen any teachings from a bishops' conference or the Holy See that convince me otherwise.
Posted by: Rick at Oct 19, 2004 7:10:12 PM
Catholic theologians have traditionally viewed medical treatment as excessively burdensome if it is "too painful, too damaging to the patient's bodily self and functioning, too psychologically repugnant to the patient, too restrictive of the patient's liberty and preferred activities, too suppressive of the patient's mental life, or too expensive
The Holy Father's "Address To the International Congress on the Vegetative State" states the following:
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.
ANH can not fall under "excessively burdensome medical treatment" because it is not a medical treatment.
Posted by: bremlar at Oct 19, 2004 8:53:15 PM
It's not that simple, bremlar.
While providing food and water is not a medical act, insertion and care of a tube may be. As the Australian bishops say:
The Pope's statement does not explore the question whether artificial feeding involves a medical act or treatment with respect to insertion and monitoring of the feeding tube. While the act of feeding a person is not itself a medical act, the insertion of a tube, monitoring of the tube and patient, and prescription of the substances to be provided, do involve a degree of medical and/or nursing expertise. To insert a feeding tube is a medical decision subject to the normal criteria for medical intervention.
Again, as a matter of fact I believe Catholic hospitals will honor a patients' advance directive re: withdrawal of ANH if a patient should enter a pvs state.
Some moralists may argue that Catholic hospitals shouldn't honor such advance directives. But the Holy Father's March statement does not require this.
Posted by: Rick at Oct 19, 2004 10:41:09 PM
To insert a feeding tube is a medical decision subject to the normal criteria for medical intervention.
But we're not talking about the insertion of a tube, at least not in regards to Terri. We're talking about the removal of a tube. Once the tube is in, its purpose is to feed the person. Thus, according to the Holy Father, it is no longer a medical act.
I'm also not sure that the "prescription of the substances to be provided" is a medical act. I've been in the hospital, once for a period of over two months. During that time a nutritionist decided what things I could eat. I didn't have a wide selection, if any. This didn't make it morally acceptable for me to not eat, even though my meals were "prescribed" for me. I was being fed, and that was a natural, not medical, means of keeping me alive.
Posted by: bremlar at Oct 20, 2004 1:14:30 AM
Okay, I’ve given this a little more thought. I’m not sure I want to disagree with Rick re: the feeding tube. So let us assume for the moment that it can be considered burdensome treatment to insert or maintain a feeding tube, and thus it can be morally licit to refuse or remove one.
I think that the true meaning behind the Holy Father's statement is that food and water cannot be considered burdensome in the same way a medical treatment can be so considered. You can remove the tube, the medical treatment, for the reasons expounded upon by the bishops. What you cannot do is stop feeding the person altogether, because food is not a medical treatment. If this requires someone to spoon feed the patient small amounts of mush, so be it, but it is not morally licit to starve someone to death by not providing food. In other words, the right of the patient to refuse or remove the tube is not equivalent to the right of the caregivers to deny the patient food and water.
This is, if I remember correctly, also the crux of Terri's situation. Someone who has more intimate knowledge please correct me if I'm wrong, but I believe that there is some proof that Terri can swallow small amounts of food and water, and a good chance that she could be rehabilitated so as to be able to swallow more. The problem isn't necessarily that Michael wants to remove the tube. Rather, it is that Michael wishes to refrain from feeding Terri, and thus starve her to death. This is immoral.
To sum up what I believe is the proper application of the statements of both the bishops and the Holy Father: It may be morally licit to refuse ANH. It is never morally licit to completely deny someone food and water, and thus starve them to death.
Posted by: bremlar at Oct 20, 2004 1:49:12 AM
Bremlar,
Thanks for your comments.
I agree that if ANH were removed from a patient because the patient deemed the tubes too burdensome, the patient would have to be spoonfed, if possible. But I'm not sure that spoonfeeding is an option for patients in a pvs; I'd thought that damage to their cortex made them unable to swallow, as Father Kevin O'Rourke states here:
because of damage to the cerebral cortex, persons in p.v.s. are unable to eat, chew, and swallow
As far as I know, one may "stop feeding a patient altogther," if
(1) The patient reasonably finds tube feeding burdensome, and
(2) The patient cannot be fed in another manner
The Florida Bishops said in their statement on Terri Schiavo:
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
I don't think the Holy Father's March statement effects the validity of that passage at all. (Instead, it dismissed the proposition that ANH may be withdrawn from pvs patients on the grounds that is "of no benefit" to them).
The question I still have is whether the Church considers it "reasonable" for a patient to specify in advance that he or she would find long-term reliance on ANH overly burdensome. Current practice in Catholic hospitals suggests imo that such advance directives are reasonable. But I believe some moralists are trying to change this practice, by arguing that such advance directives are not reasonable.
Posted by: Rick at Oct 20, 2004 7:57:44 AM
Bremlar,
Thanks for your comments.
I agree that if ANH were removed from a patient because the patient deemed the tubes too burdensome, the patient would have to be spoonfed, if possible. But I'm not sure that spoonfeeding is an option for patients in a pvs; I'd thought that damage to their cortex made them unable to swallow, as Father Kevin O'Rourke states here:
because of damage to the cerebral cortex, persons in p.v.s. are unable to eat, chew, and swallow
As far as I know, one may "stop feeding a patient altogther," if
(1) The patient reasonably finds tube feeding burdensome, and
(2) The patient cannot be fed in another manner
The Florida Bishops said in their statement on Terri Schiavo:
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
I don't think the Holy Father's March statement effects the validity of that passage at all. (Instead, it dismissed the proposition that ANH may be withdrawn from pvs patients on the grounds that is "of no benefit" to them).
The question I still have is whether the Church considers it "reasonable" for a patient to specify in advance that he or she would find long-term reliance on ANH overly burdensome. Current practice in Catholic hospitals suggests imo that such advance directives are reasonable. But I believe some moralists are trying to change this practice, by arguing that such advance directives are not reasonable.
Posted by: Rick at Oct 20, 2004 7:58:34 AM
Bremlar,
Thanks for your comments.
I agree that if ANH were removed from a patient because the patient deemed the tubes too burdensome, the patient would have to be spoonfed, if possible. But I'm not sure that spoonfeeding is an option for patients in a pvs; I'd thought that damage to their cortex made them unable to swallow, as Father Kevin O'Rourke states here:
because of damage to the cerebral cortex, persons in p.v.s. are unable to eat, chew, and swallow
As far as I know, one may "stop feeding a patient altogther," if
(1) The patient reasonably finds tube feeding burdensome, and
(2) The patient cannot be fed in another manner
The Florida Bishops said in their statement on Terri Schiavo:
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
I don't think the Holy Father's March statement effects the validity of that passage at all. (Instead, it dismissed the proposition that ANH may be withdrawn from pvs patients on the grounds that is "of no benefit" to them).
The question I still have is whether the Church considers it "reasonable" for a patient to specify in advance that he or she would find long-term reliance on ANH overly burdensome. Current practice in Catholic hospitals suggests imo that such advance directives are reasonable. But I believe some moralists are trying to change this practice, by arguing that such advance directives are not reasonable.
Posted by: Rick at Oct 20, 2004 7:58:57 AM
Sorry about the triple post. I have no idea how that happened.
Posted by: Rick at Oct 20, 2004 8:06:03 AM
It is important to remember must have compassion for every person and every family that must deal with or contemplate these issues. At the same time, we must be careful not to be swept along with the culture that exalts convenience, comfort and aesthetics above the value of life itself.
As the U.S. bishops say, “First, in keeping with our moral teaching against the intentional causing of death by omission, one should distinguish between repugnance to a particular procedure and repugnance to life itself. The latter may occur when a patient views a life of helplessness and dependency on others as itself a heavy burden, leading him or her to wish or even to pray for death. Especially in our achievement-oriented society, the burden of living in such a condition may seem to outweigh any possible benefit of medical treatment and even lead a person to despair. But we should not assume that the burdens in such a case always outweigh the benefits; for the sufferer, given good counseling and spiritual support, may be brought again to appreciate the precious gift of life.”
They also say that, “we are gravely concerned about current attitudes and policy trends in our society that would too easily dismiss patients without apparent mental faculties as non-persons or as undeserving of human care and concern. In this climate, even legitimate moral arguments intended to have a careful and limited application can easily be misinterpreted, broadened and abused by others to erode respect for the lives of some of our society's most helpless members.”
To twist around George Tenet’s famous expression, at this time we may not have a “slam dunk” from the Magisterium that excludes a proper “undue burden” analysis in cases of ANH and PVS, but neither is every expression of a patient’s wishes a “slam dunk” for the moral choices regarding their care.
Peace.
Posted by: penitens at Oct 20, 2004 9:55:59 AM
"So let us assume for the moment that it can be considered burdensome treatment to insert or maintain a feeding tube, and thus it can be morally licit to refuse or remove one."
How does an advanced directive make inserting a tube "burdensome." It either is or it isn't.
The Holy Father said nutrition and hydration were "in principle" "proportionate" and "ordinary." Thus the actual means of food delivery itself must be seen as objectively burdensome (invasive, productive of complications) to even get to this point.
Posted by: al at Oct 20, 2004 10:30:55 AM
Penitens,
Good post. I agree with you.
I'm really just wondering if we'll ever get a "slamdunk" — ie, a magisterial teaching that perceiving prolonged ANH as unduly burdensome is not reasonable — and a routine refusal of Catholic hospitals to comply with advance directives mandating withdrawal of ANH in case of pvs.
Posted by: Rick at Oct 20, 2004 10:35:54 AM
Thus the actual means of food delivery itself must be seen as objectively burdensome
al, the USCBB document quoted earlier says specifically that a patient's repugnance to a procedure may make it unduly burdensome:
Catholic theologians have traditionally viewed medical treatment as excessively burdensome if it is "too painful, too damaging to the patient's bodily self and functioning, too psychologically repugnant to the patient, too restrictive of the patient's liberty and preferred activities, too suppressive of the patient's mental life, or too expensive
An advance directive would establish that a particular patient found the insertion and maintenance of tubes required for ANH to be "psychologically repugnant" and hence "unduly burdensome."
Recent teaching has clarified that ANH should not normally be seen, at least in the first world, as too expensive or too burdensome on others. ANH should also not be seen as "having no benefit" if it prolongs life.
But prolonged ANH may be perceived as overly burdensome by the patient — and recent teaching does not imply, to my mind, that such a perception is unreasonable.
Posted by: Rick at Oct 20, 2004 12:01:38 PM
Once a person cannot move on his or her own, it takes painstaking care to avoid pressure ulcers. Tube feeding tends to cause stool which is loose, even the improved fiber containing formulae used now. Incontinence tends to cause skin breakdown. A person, especially an elderly person (say, 70's or over, and sometimes younger if they were not in good general health) who cannot move himself, has an extremely high chance of having some form of skin breakdown. This can progress to localized infection, which can progress to generalized infection, requiring hospitalization. Do you know what Christopher Reeves died of? Infection in a decubitus ulcer-a bedsore-which got into his bloodstream. And one would think he could have paid for good care.
Furthermore, those who cannot swallow on their own or "protect their airway" frequently have reflux of tube feeding which they aspirate, leading to pneumonia and hospitalization for antibiotic treatment.
People who can't move also get contractures unless they are regularly routinely put through range of motion exercises. Their feet point down. Their knees bend more and more and can't be straightened;likewise their hips, elbows, fingers. Sometimes their fingers are so tight against their palms that their fingernails cause sores in their palms. This happens faster to older people, but it will eventually happen to anyone without muscular control.
Current hospitals and nursing homes are not staffed to provide the type of care that would reduce-I won't say entirely prevent- this kind of complication. Unless one has the financial resources to pay for better care by hiring private duty nurses, one is not going to receive this type of care consistently.
So when you say long term tube feeding, think skin breakdown, think pressure ulcers, think contractures, think aspiration pneumonia.
My advance directive says that if I am not conscious and cannot communicate and their is no reasonable hope of recovery, that I am not to be tube fed.
Susan F. Peterson
Posted by: Susan Peterson at Oct 20, 2004 1:31:43 PM
My advance directive says that if I am not conscious and cannot communicate and their is no reasonable hope of recovery, that I am not to be tube fed.
Thanks, Susan. If I remember correctly, you are a nurse. Do you wok in a Catholic health care system? Is it your understanding that such an advance directive would be honored by your hospital system?
Your advance directive seems very reasonable to me. I'd like to create a similar one for myself. But my sense is that some Catholic moralists consider advance directives such as yours illicit, and are urging Catholic hospitals not to honor them, because they believe one generally doesn't have the moral option of refusing ANH when it can be paid for and when it is effective in maintaining life.
Posted by: Rick at Oct 20, 2004 2:01:34 PM
