Required for Survival: Food & Water as Moral Default

The May-June 2005 issue of Liguorian Magazine featured an article by Mark Miller, CSsR, entitled “The Controversy Surrounding Feeding Tubes.” I sent the following letter in response. It was not printed, and I never received a reply.
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Editor:

The May 2005 issue of Liguorian includes several beautiful tributes to Pope John Paul II, for which I commend you. His life of love and service, particularly in his role as Pope, was marked by holiness, fidelity to Truth, and tireless efforts on behalf of the world's most vulnerable.

The quality of your memorial section devoted to our beloved John Paul II makes the brief article by Fr. Mark Miller, CSsR, on feeding tubes all the more jarring. Fr. Miller rightly refers to the Pope's March 2004 allocution making it clear that the provision of food and water – even through a tube – must always be considered a part of ordinary care. But then Miller completely undermines the weight of the Holy Father's teaching by contrasting it with the work of “other moral theologians” who see food and water as optional – depending on “context and circumstances.”

This is pure relativism and is exactly the kind of muddled moralizing that John Paul was addressing. The last paragraph of Fr. Miller’s essay refers to “no swallowing ability, no awareness, and no sensation” – an apt description of a person in a persistent vegetative state, or any unconscious state for that matter. Where Fr. Miller makes a serious error is in following that description with the phrase, “the body slowly shuts itself down in a painless process.” This would occur only if there were an underlying and untreatable pathology that would inexorably lead to death, or if the individual were denied the ordinary elements required for survival – including, namely, food and water.

That is the crucial point: When food and water are withheld such that a person dies as a direct result, the only conclusion possible is that a willful homicide has occurred. How can it be otherwise? Obviously, when the provision of nutrition and hydration are no longer serving any purpose at all, and in fact become burdensome – even to the recipient – then it may be discontinued. But such a situation was not being addressed by the Pope’s allocution in the spring of 2004; he was addressing a narrowly prescribed set of circumstances, and it seems providential that, almost exactly a year later, the exact circumstance he had referred to burst into the public eye with the battle over Terri Schiavo.

Of course consideration must be made for the particular circumstances of individual cases, but what the Holy Father did (and admirably well, in my own opinion) is to help us know the limits of what can be debated, even in the hard cases. No one is claiming that food and water must be provided at all costs until the very last breath has passed one's lips; what the Pope declared is that no one should ever die from starvation and dehydration – and that is precisely what happens when feeding tubes are discontinued in the absence of underlying pathologies that naturally lead to death.
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A Person Must Never Be Allowed to Starve to Death

Theresa Marie Schiavo (1963-2005)

Thank you for the editorial "Every human life deserves dignity" (May 29, 2005), which comes significantly just about two months after Terri Schiavo's death. Since then, the issue of artificially supplied nutrition and hydration has virtually disappeared from the headlines, and it might seem that all the fuss about tube feeding has simply faded away. 

Nevertheless, the question of whether Schiavo was allowed to die or was killed is very much current for those who care for others in similar circumstances. While it is true that the courts allowed Terri's husband to remove his wife's feeding tube – thereby ensuring her death by starvation – they in no way legitimized what he did. Indeed, the drama surrounding Schiavo's demise only serves to illustrate how inhuman this practice is, and the revulsion most people of good will experienced during the ordeal makes it plain that it should never be allowed to happen again.

Unfortunately, as anyone who works in healthcare can attest, it is a situation that recurs with alarming frequency in our hospitals and nursing homes today – often with the prior consent of the victim. Many so-called "living wills" include clauses that allow signers to explicitly reject the artificial administration of food and water if they become incapacitated and unable to eat on their own. By signing these forms, people agree to accept a horrible death, whether wittingly or unwittingly, and too many doctors are all too willing to carry out those wishes once the circumstances present themselves. 

This is the kind of dangerous moral surrender that Pope John Paul II addressed in a speech he made back in March 2004. Speaking to a gathering of experts on persistent vegetative state (PVS), the pope made it very clear that the provision of nutrition and hydration must always be considered a part of ordinary care. Even when artificially administered, John Paul said, food and water "always represents a natural means of preserving life, not a medical act." The debate on this issue among moralists and theologians had gone on for many years, but the Holy Father's clear statement effectively put an end to the controversy. 

Even so, confusion on this issue is rampant, even among Catholics, and even those who were on the right side of the Schiavo issue are unaware of the full implications of her case. Much was made in the media of the question regarding Terri's wishes concerning what she'd want if she were in a PVS, but according to the Holy Father's instruction, a person's wishes are irrelevant to the provision of food and water. Simply put, a person must never be allowed to starve to death, no matter what that person desires or requests. 

A protestor outside the Florida courthouse where Terri's fate was decided.

Obviously, when the provision of nutrition and hydration is no longer serving any purpose at all – when nutrients can no longer be assimilated by the body or are not providing any comfort to someone whose death is imminent – then it may be discontinued. But such a situation was not being addressed by the pope in the spring of 2004; he was addressing a narrowly prescribed set of circumstances, and it seems providential that, almost exactly a year later, the specific circumstances he had referred to burst into the public eye with the battle over Terri Schiavo. We must never forget that Terri was not dying until her feeding tube was removed. This is the crucial point: When food and water are withheld such that a person dies as a direct result, the only possible conclusion is a willful homicide. 

Of course, consideration must be made for the particular circumstances of individual cases, but what the Holy Father has done is to help us know the limits of what can be debated, even in the hard cases. No one is claiming that food and water must be provided at all costs until the very last breath has passed ones lips; what the pope did declare is that no one should ever die from starvation and dehydration – and that is precisely what happens when feeding tubes are discontinued despite the absence of underlying pathologies that naturally lead to death. In fact, John Paul refers to such precipitate withdrawals of food and water as "euthanasia by omission."

No one would choose to be in a PVS for any length of time – whether 15 years or five years or even the required one year to attach that label to someone – but unforeseen and unfortunate things happen all the time, and it is in those very unforeseen and unfortunate situations that we are closest to the cross. Our brothers and sisters who are in a PVS (or "post-coma syndrome," as some Catholics writing on this topic are calling it to get away from the negative connotations associated with "vegetative") require our love an care. They are Christ, the Christ of Matthew 25 – "when I was hungry, you fed me; when I was thirsty, you gave me drink."

Can we do otherwise?
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A version of this essay originally appeared in Today's Catholic on June 19, 2005. Terri Schiavo died of marked dehydration on March 31, 2005.