Nutrition and Hydration: Moral and Pastoral Reflections
A Statement of the NCCB Committee for Pro-Life Activities
Modern medical technology seems to confront us with many questions not
faced even a decade ago. Corresponding changes in medical practice have
benefited many but have also prompted fears by some that they will be
aggressively treated against their will or denied the kind of care that is their
due as human persons with inherent dignity. Current debates about
life-sustaining treatment suggest that our society’s moral reflection is having
difficulty keeping pace with its technological progress.
A religious view of life has an important contribution to make to these
modern debates. Our Catholic tradition has developed a rich body of thought on
these questions, which affirms a duty to preserve human life but recognizes
limits to that duty.
Our first goal in making this statement is to reaffirm some basic principles
of our moral tradition, to assist Catholics and others in making treatment
decisions in accord with respect for God’s gift of life.
These principles do not provide clear and final answers to all moral
questions that arise as individuals make difficult decisions. Catholic
theologians may differ on how best to apply moral principles to some questions
not explicitly resolved by the Church’s teaching authority. Likewise, we
understand that those who must make serious health care decisions for themselves
or for others face a complexity of issues, circumstances, thoughts, and emotions
in each unique case.
This is the case with some questions involving the medically assisted
provision of nutrition and hydration to helpless patients—those who are
seriously ill, disabled, or persistently unconscious. These questions have been
made more urgent by widely publicized court cases and the public debate to which
they have given rise.
Our second purpose in issuing this statement, then, is to provide some
clarification of the moral issues involved in decisions about medically assisted
nutrition and hydration. We are fully aware that such guidance is not
necessarily final, because there are many unresolved medical and ethical
questions related to these issues, and the continuing development of medical
technology will necessitate ongoing reflection. But these decisions already
confront patients, families, and health care personnel every day. They arise
whenever competent patients make decisions about medically assisted nutrition
and hydration for their own present situation, when they consider signing an
advance directive such as a "living will" or health care proxy document, and
when families or other proxy decision makers make decisions about those
entrusted to their care. We offer guidance to those who, facing these issues,
might be confused by opinions that at times threaten to deny the inherent
dignity of human life. We therefore address our reflections first to those who
share our Judeo-Christian traditions, and second to others concerned about the
dignity and value of human life who seek guidance in making their own moral
The Judeo-Christian moral tradition celebrates life as the gift of a
loving God, and respects the life of each human being because each is made in
the image and likeness of God. As Christians we also believe we are redeemed by
Christ and called to share eternal life with him. From these roots the Catholic
tradition has developed a distinctive approach to fostering and sustaining human
life. Our Church views life as a sacred trust, a gift over which we are given
stewardship and not absolute dominion. The Church thus opposes all direct
attacks on innocent life. As conscientious stewards we have a duty to preserve
life, while recognizing certain limits to that duty:
1. Because human life is the foundation for all other human goods, it has a
special value and significance. Life is "the first right of the human person"
and "the condition of all the others."(1)
2. All crimes against life, including "euthanasia or willful suicide," must
be opposed.(2) Euthanasia is "an action or an omission which of itself or by
intention causes death, in order that all suffering may in this way be
eliminated." Its terms of reference are to be found "in the intention of the
will and in the methods used."(3) Thus defined, euthanasia is an attack on life
which no one has a right to make or request, and which no government or other
human authority can legitimately recommend or permit. Although individual guilt
may be reduced or absent because of suffering or emotional factors that cloud
the conscience, this does not change the objective wrongfulness of the act. It
should also be recognized that an apparent plea for death may really be a plea
for help and love.
3. Suffering is a fact of human life, and has special significance for the
Christian as an opportunity to share in Christ’s redemptive suffering.
Nevertheless there is nothing wrong in trying to relieve someone’s suffering; in
fact, it is a positive good to do so, as long as one does not intentionally
cause death or interfere with other moral and religious duties.(4)
4. Everyone has the duty to care for his or her own life and health and to
seek necessary medical care from others, but this does not mean that all
possible remedies must be used in all circumstances. One is not obliged to use
either "extraordinary" means or "disproportionate" means of preserving life—that
is, means which are understood as offering no reasonable hope of benefit or as
involving excessive burdens. Decisions regarding such means are complex and
should ordinarily be made by the patient in consultation with his or her family,
chaplain or pastor, and physician when that is possible.(5)
5. In the final stage of dying one is not obliged to prolong the life of a
patient by every possible means: "When inevitable death is imminent in spite of
the means used, it is permitted in conscience to take the decision to refuse
forms of treatment that would only secure a precarious and burdensome
prolongation of life, so long as the normal care due to the sick person in
similar cases is not interrupted."(6)
6. While affirming life as a gift of God, the Church recognizes that death is
unavoidable and that it can open the door to eternal life. Thus, "without in any
way hastening the hour of death," the dying person should accept its reality and
prepare for it emotionally and spiritually.(7)
7. Decisions regarding human life must respect the demands of justice,
viewing each human being as our neighbor and avoiding all discrimination based
on age or dependency.(8) A human being has "a unique dignity and an independent
value, from the moment of conception and in every stage of development, whatever
his or her physical condition." In particular, "the disabled person (whether the
disability be the result of a congenital handicap, chronic illness or accident,
or from mental or physical deficiency, and whatever the severity of the
disability) is a fully human subject, with the corresponding innate, sacred and
inviolable rights." First among these is "the fundamental and inalienable right
8. The dignity and value of the human person, which lie at the foundation of
the Church’s teaching on the right to life, also provide a basis for any just
social order. Not only to become more Christian, but to become more truly human,
society should protect the right to life through its laws and other
While these principles grow out of a specific religious tradition, they
appeal to a common respect for the dignity of the human person. We commend them
to all people of goodwill.
Questions About Medically Assisted Nutrition and Hydration
In what follows we apply these well-established moral principles to the
difficult issue of providing medically assisted nutrition and hydration to
persons who are seriously ill, disabled, or persistently unconscious. We
recognize the complexity involved in applying these principles to individual
cases and acknowledge that, at this time and on this particular issue, our
applications do not have the same authority as the principles themselves.
1. Is the withholding or withdrawing of medically assisted nutrition and
hydration always a direct killing?
In answering this question one should avoid two extremes.
First, it is wrong to say that this could not be a matter of killing simply
because it involves an omission rather than a positive action. In fact a
deliberate omission may be an effective and certain way to kill, especially to
kill someone weakened by illness. Catholic teaching condemns as euthanasia "an
action or an omission which of itself or by intention causes death, in
order that all suffering may in this way be eliminated." Thus "euthanasia
includes not only active mercy killing but also the omission of treatment when
the purpose of the omission is to kill the patient."(11)
Second, we should not assume that all or most decisions to
withhold or withdraw medically assisted nutrition and hydration are attempts to
cause death. To be sure, any patient will die if all nutrition and hydration are
withheld.(12) But sometimes other causes are at work—for example, the patient
may be imminently dying, whether feeding takes place or not, from an already
existing terminal condition. At other times, although the shortening of the
patient’s life is one foreseeable result of an omission, the real purpose
of the omission was to relieve the patient of a particular procedure that was of
limited usefulness to the patient or unreasonably burdensome for the patient and
the patient’s family or caregivers. This kind of decision should not be equated
with a decision to kill or with suicide.
The harsh reality is that some who propose withdrawal of nutrition and
hydration from certain patients do directly intend to bring about a
patient’s death, and would even prefer a change in the law to allow for what
they see as more "quick and painless" means to cause death.(13) In other words,
nutrition and hydration (whether orally administered or medically assisted) are
sometimes withdrawn not because a patient is dying, but precisely because a
patient is not dying (or not dying quickly) and someone believes it would be
better if he or she did, generally because the patient is perceived as having an
unacceptably low "quality of life" or as imposing burdens on others.(14)
When deciding whether to withhold or withdraw medically assisted nutrition
and hydration, or other forms of life support, we are called by our moral
tradition to ask ourselves: What will my decision do for this patient? And what
am I trying to achieve by doing it? We must be sure that it is not our intent to
cause the patient’s death—either for its own sake or as a means to achieving
some other goal such as the relief of suffering.
2. Is medically assisted nutrition and hydration a form of "treatment" or
Catholic teaching provides that a person in the final stages of dying
need not accept "forms of treatment that would only secure a precarious and
burdensome prolongation of life," but should still receive "the normal care due
to the sick person in similar cases."(15) All patients deserve to receive normal
care out of respect for their inherent dignity as persons. As Pope John Paul II
has said, a decision to forgo "purely experimental or ineffective interventions"
does not "dispense from the valid therapeutic task of sustaining life or from
assistance with the normal means of sustaining life. Science, even when it is
unable to heal, can and should care for and assist the sick."(16) But the
teaching of the Church has not resolved the question whether medically assisted
nutrition and hydration should always be seen as a form of normal care.(17)
Almost everyone agrees that oral feeding, when it can be accepted and
assimilated by a patient, is a form of care owed to all helpless people.
Christians should be especially sensitive to this obligation, because giving
food and drink to those in need is an important expression of Christian love and
concern (Mt. 10:42 and 25:35; Mk. 9:41). But our obligations become less clear
when adequate nutrition and hydration require the skills of trained medical
personnel and the use of technologies that may be perceived as very
burdensome—that is, as intrusive, painful, or repugnant. Such factors vary from
one type of feeding procedure to another, and from one patient to another,
making it difficult to classify all feeding procedures as either "care" or
Perhaps this dilemma should be viewed in a broader context. Even medical
"treatments" are morally obligatory when they are "ordinary" means—that is, if
they provide a reasonable hope of benefit and do not involve excessive burdens.
Therefore, we believe people should make decisions in light of a simple and
fundamental insight: Out of respect for the dignity of the human person, we
are obliged to preserve our own lives, and help others preserve theirs, by the
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.
We must therefore address the question of benefits and burdens next,
recognizing that a full moral analysis is only possible when one knows the
effects of a given procedure on a particular patient.
3. What are the benefits of medically assisted nutrition and hydration?
According to international codes of medical ethics, a physician will see
a medical procedure as appropriate "if in his or her judgment it offers hope of
saving life, reestablishing health or alleviating suffering."(18)
Nutrition and hydration, whether provided in the usual way or with medical
assistance, do not by themselves remedy pathological conditions, except those
caused by dietary deficiencies. But patients benefit from them in several ways.
First, for all patients who can assimilate them, suitable food and fluids
sustain life, and providing them normally expresses loving concern and
solidarity with the helpless. Second, for patients being treated with the hope
of a cure, appropriate food and fluids are an important element of sound health
care. Third, even for patients who are imminently dying and incurable, food and
fluids can prevent the suffering that may arise from dehydration, hunger, and
The benefit of sustaining and fostering life is fundamental, because life is
our first gift from a loving God and the condition for receiving his other
gifts. But sometimes even food and fluids are no longer effective in providing
this benefit, because a patient has entered the final stage of a terminal
condition. At such times we should make the dying person as comfortable as
possible and provide nursing care and proper hygiene as well as companionship
and appropriate spiritual aid. Such a person may lose all desire for food and
drink and even be unable to ingest them. Initiating medically assisted feeding
or intravenous fluids in this case may increase the patient’s discomfort while
providing no real benefit; ice chips or sips of water may instead be appropriate
to provide comfort and counteract the adverse effects of dehydration.(19) Even
in the case of the imminently dying patient, of course, any action or omission
that of itself or by intention causes death is to be absolutely rejected.
As Christians who trust in the promise of eternal life, we recognize that
death does not have the final word. Accordingly, we need not always prevent
death until the last possible moment; but we should never intentionally cause
death or abandon the dying person as though he or she were unworthy of care and
4. What are the burdens of medically assisted nutrition and hydration?
Our tradition does not demand heroic measures in fulfilling the
obligation to sustain life. A person may legitimately refuse even procedures
that effectively prolong life, if he or she believes they would impose
excessively grave burdens on himself or herself, or on his or her family and
community. 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 to the patient’s liberty and preferred activities, too suppressive
of the patient’s mental life, or too expensive."(20)
Because assessment of these burdens necessarily involves some subjective
judgments, a conscious and competent patient is generally the best judge of
whether a particular burden or risk is too grave to be tolerated in his or her
own case. But because of the serious consequences of withdrawing all nutrition
and hydration, patients and those helping them make decisions should assess such
burdens or risks with special care.
Here we offer some brief reflections and cautions regarding the kinds of
burdens sometimes associated with medically assisted nutrition and hydration.
Physical risks and burdens. The risks and objective complications of
medically assisted nutrition and hydration will depend on the procedure used and
the condition of the patient. In a given case a feeding procedure may become
harmful or even life-threatening. (These medical data are discussed at length in
an appendix to this paper.)
If the risks and burdens of a particular feeding procedure are deemed serious
enough to warrant withdrawing it, we should not automatically deprive the
patient of all nutrition and hydration but should ask whether another procedure
is feasible that would be less burdensome. We say this because some helpless
patients, including some in a "persistent vegetative state," receive tube
feedings not because they cannot swallow food at all but because the tube
feeding is less costly and difficult for health care personnel.(21)
Moreover, because burdens are assessed in relation to benefits, we should ask
whether the risks and discomfort of a feeding procedure are really excessive as
compared with the adverse effects of dehydration or malnutrition.
Psychological burdens on the patient. Many people see feeding tubes as
frightening or even as bodily violations. Assessments of such burdens are
necessarily subjective; they should not be dismissed on that account, but we
offer some practical cautions to help prevent abuse.
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.
Second, our tradition recognizes that when treatment decisions are made,
"account will have to be taken of the reasonable wishes of the patient
and the patient’s family, as also of the advice of the doctors who are specially
competent in the matter."(22) The word "reasonable" is important here. Good
health care providers will try to help patients assess psychological burdens
with full information and without undue fear of unfamiliar procedures.(23) A
well-trained and compassionate hospital chaplain can provide valuable personal
and spiritual support to patients and families facing these difficult
Third, we should not assume that a feeding procedure is inherently repugnant
to all patients without specific evidence. In contrast to Americans’ general
distaste for the idea of being supported by "tubes and machines," some studies
indicate surprisingly favorable views of medically assisted nutrition and
hydration among patients and families with actual experience of such
Economic and other burdens on caregivers. While some balk at the idea,
in principle cost can be a valid factor in decisions about life support. For
example, money spent on expensive treatment for one family member may be money
otherwise needed for food, housing, and other necessities for the rest of the
family. Here, also, we offer some cautions.
First, particularly when a form of treatment "carries a risk or is
burdensome" on other grounds, a critically ill person may have a legitimate and
altruistic desire "not to impose excessive expense on the family or the
community."(25) Even for altruistic reasons a patient should not directly intend
his or her own death by malnutrition or dehydration, but may accept an earlier
death as a consequence of his or her refusal of an unreasonably expensive
treatment. Decisions by others to deny an incompetent patient medically
assisted nutrition and hydration for reasons of cost raise additional concerns
about justice to the individual patient, who could wrongly be deprived of life
itself to serve the less fundamental needs of others.
Second, we do not think individual decisions about medically assisted
nutrition and hydration should be determined by macro-economic concerns such as
national budget priorities and the high cost of health care. These social
problems are serious, but it is by no means established that they require
depriving chronically ill and helpless patients of effective and easily
tolerated measures that they need to survive.(26)
Third, tube feeding alone is generally not very expensive and may cost no
more than oral feeding.(27) What is seen by many as a grave financial and
emotional burden on caregivers is the total long-term care of severely
debilitated patients, who may survive for many years with no life support except
medically assisted nutrition and hydration and nursing care.
The difficulties families may face in this regard, and their need for
improved financial and other assistance from the rest of society, should not be
underestimated. While caring for a helpless loved one can provide many
intangible benefits to family members and bring them closer together, the
responsibilities of care can also strain even close and loving family
relationships; complex medical decisions must be made under emotionally
difficult circumstances not easily appreciated by those who have never faced
Even here, however, we must try to think through carefully what we intend by
withdrawing medically assisted nutrition and hydration. Are we deliberately
trying to make sure that the patient dies, in order to relieve caregivers of the
financial and emotional burdens that will fall upon them if the patient
survives? Are we really implementing a decision to withdraw all other forms of
care, precisely because the patient offers so little response to the efforts of
caregivers? Decisions like these seem to reach beyond the weighing of burdens
and benefits of medically assisted nutrition and hydration as such.
In the context of official church teaching, it is not yet clear to what
extent we may assess the burden of a patient’s total care rather than the burden
of a particular treatment when we seek to refuse "burdensome" life support. On a
practical level, those seeking to make good decisions might assure themselves of
their own intentions by asking: Does my decision aim at relieving the patient of
a particularly grave burden imposed by medically assisted nutrition and
hydration? Or does it aim to avoid the total burden of caring for the patient?
If so, does it achieve this aim by deliberately bringing about his or her death?
Rather than leaving families to confront such dilemmas alone, society and
government should improve their assistance to families whose financial and
emotional resources are strained by long-term care of loved ones.(28)
5. What role should "quality of life" play in our decisions?
Financial and emotional burdens are willingly endured by most families to
raise their children or to care for mentally aware but weak and elderly family
members. It is sometimes argued that we need not endure comparable burdens to
feed and care for persons with severe mental and physical disabilities, because
their low "quality of life" makes it unnecessary or pointless to preserve their
But this argument—even when it seems motivated by a humanitarian concern to
reduce suffering and hardship—ignores the equal dignity and sanctity of all
human life. Its key assumption—that people with disabilities necessarily enjoy
life less than others or lack the potential to lead meaningful lives—is also
mistaken.(30) Where suffering does exist, society’s response should not be to
neglect or eliminate the lives of people with disabilities, but to help correct
their inadequate living conditions.(31) Very often the worst threat to a good
"quality of life" for these people is not the disability itself, but the
prejudicial attitudes of others—attitudes based on the idea that a life with
serious disabilities is not worth living.(32)
This being said, our moral tradition allows for three ways in which the
"quality of life" of a seriously ill patient is relevant to treatment decisions.
1. Consistent with respect for the inherent sanctity of life, we should
relieve needless suffering and support morally acceptable ways of improving each
patient’s quality of life.(33)
2. One may legitimately refuse a treatment because it would itself create an
impairment imposing new serious burdens or risks on the patient. This
decision to avoid the new burdens or risks created by a treatment is not the
same as directly intending to end life in order to avoid the burden of living in
a disabled state.(34)
3. Sometimes a disabling condition may directly influence the benefits and
burdens of a specific treatment for a particular patient. For example, a
confused or demented patient may find medically assisted nutrition and hydration
more frightening and burdensome than other patients do because he or she cannot
understand what it is. The patient may even repeatedly pull out feeding tubes,
requiring burdensome physical restraints if this form of feeding is to be
continued. In such cases, ways of alleviating such special burdens should be
explored before concluding that they justify withholding all food and fluids
needed to sustain life.
These humane considerations are quite different from a "quality of life"
ethic that would judge individuals with disabilities or limited potential as not
worthy of care or respect. It is one thing to withhold a procedure because it
would impose new disabilities on a patient, and quite another thing to say that
patients who already have such disabilities should not have their lives
preserved. A means considered ordinary or proportionate for other patients
should not be considered extraordinary or disproportionate for severely impaired
patients solely because of a judgment that their lives are not worth living.
In short, while considerations regarding a person’s quality of life have some
validity in weighing the burdens and benefits of medical treatment, at the
present time in our society judgments about the quality of life are sometimes
used to promote euthanasia. The Church must emphasize the sanctity of life of
each person as a fundamental principle in all moral decision making.
6. Do persistently unconscious patients represent a special case?
Even Catholics who accept the same basic moral principles may strongly
disagree on how to apply them to patients who appear to be persistently
unconscious—that is, those who are in a permanent coma or a "persistent
vegetative state" (PVS).(35) Some moral questions in this area have not been
explicitly resolved by the Church’s teaching authority.
On some points there is wide agreement among Catholic theologians.
1. An unconscious patient must be treated as a living human person with
inherent dignity and value. Direct killing of such a patient is as morally
reprehensible as the direct killing of anyone else. Even the medical terminology
used to describe these patients as "vegetative" unfortunately tends to obscure
this vitally important point, inviting speculation that a patient in this state
is a "vegetable" or a subhuman animal.(36)
2. The area of legitimate controversy does not concern patients with
conditions like mental retardation, senility, dementia, or even temporary
unconsciousness. Where serious disagreement begins is with the patient who has
been diagnosed as completely and permanently unconscious after careful testing
over a period of weeks or months.
Some moral theologians argue that a particular form of care or treatment is
morally obligatory only when its benefits outweigh its burdens to a patient or
the care providers. In weighing burdens, they say, the total burden of a
procedure and the consequent requirements of care must be taken into account. If
no benefit can be demonstrated, the procedure, whatever its burdens, cannot be
obligatory. These moralists also hold that the chief criterion to determine the
benefit of a procedure cannot be merely that it prolongs physical life, since
physical life is not an absolute good but is relative to the spiritual good of
the person. They assert that the spiritual good of the person is union with God,
which can be advanced only by human acts, i.e., conscious, free acts. Since the
best current medical opinion holds that persons in the persistent vegetative
state (PVS) are incapable now or in the future of conscious, free human acts,
these moralists conclude that, when careful diagnosis verifies this condition,
it is not obligatory to prolong life by such interventions as a respirator,
antibiotics, or medically assisted hydration and nutrition. To decide to omit
non-obligatory care, therefore, is not to intend the patient’s death, but only
to avoid the burden of the procedure. Hence, though foreseen, the patient’s
death is to be attributed to the patient’s pathological condition and not to the
omission of care. Therefore, these theologians conclude, while it is always
wrong directly to intend or cause the death of such patients, the natural dying
process which would have occurred without these interventions may be permitted
While this rationale is convincing to some, it is not theologically
conclusive and we are not persuaded by it. In fact, other theologians argue
cogently that theological inquiry could lead one to a more carefully limited
These moral theologians argue that while particular treatments can be judged
useless or burdensome, it is morally questionable and would create a dangerous
precedent to imply that any human life is not a positive good or "benefit." They
emphasize that while life is not the highest good, it is always and everywhere a
basic good of the human person and not merely a means to other goods. They
further assert that if the "burden" one is trying to relieve by discontinuing
medically assisted nutrition and hydration is the burden of remaining alive in
the allegedly undignified condition of PVS, such a decision is unacceptable,
because one’s intent is only achieved by deliberately ensuring the patient’s
death from malnutrition or dehydration. Finally, these moralists suggest that
PVS is best seen as an extreme form of mental and physical disability—one whose
causes, nature, and prognosis are as yet imperfectly understood—and not as a
terminal illness or fatal pathology from which patients should generally be
allowed to die. Because the patient’s life can often be sustained indefinitely
by medically assisted nutrition and hydration that is not unreasonably risky or
burdensome for that patient, they say, we are not dealing here with a case where
"inevitable death is imminent in spite of the means used."(37) Rather, because
the patient will die in a few days if medically assisted nutrition and hydration
are discontinued,(38) but can often live a long time if they are provided, the
inherent dignity and worth of the human person obligates us to provide this
patient with care and support.
Further complicating this debate is a disagreement over what responsible
Catholics should do in the absence of a final resolution of this question. Some
point to our moral tradition of probabilism, which would allow individuals to
follow the appropriate moral analysis that they find persuasive. Others point to
the principle that in cases where one might risk unjustly depriving someone of
life, we should take the safer course.
In the face of the uncertainties and unresolved medical and theological
issues, it is important to defend and preserve important values. On the one
hand, there is a concern that patients and families should not be subjected to
unnecessary burdens, ineffective treatments, and indignities when death is
approaching. On the other hand, it is important to ensure that the inherent
dignity of human persons, even those who are persistently unconscious, is
respected, and that no one is deprived of nutrition and hydration with the
intent of bringing on his or her death.
It is not easy to arrive at a single answer to some of the real and personal
dilemmas involved in this issue. In study, prayer, and compassion, we continue
to reflect on this issue and hope to discover additional information that will
lead to its ultimate resolution.
In the meantime, at a practical level, we are concerned that withdrawal of
all life support, including nutrition and hydration, not be viewed as
appropriate or automatically indicated for the entire class of PVS patients
simply because of a judgment that they are beyond the reach of medical treatment
that would restore consciousness. We note the current absence of conclusive
scientific data on the causes and implications of different degrees of brain
damage, on the PVS patient’s ability to experience pain, and on the reliability
of prognoses for many such patients.(39) We do know that many of these patients
have a good prognosis for long-term survival when given medically assisted
nutrition and hydration, and a certain prognosis for death otherwise—and we know
that many in our society view such an early death as a positive good for a
patient in this condition. Therefore 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.
In light of these concerns, it is our considered judgment that while
legitimate Catholic moral debate continues, decisions about these patients
should be guided by a presumption in favor of medically assisted nutrition and
hydration. A decision to discontinue such measures should be made in light of a
careful assessment of the burdens and benefits of nutrition and hydration for
the individual patient and his or her family and community. Such measures must
not be withdrawn in order to cause death, but they may be withdrawn if they
offer no reasonable hope of sustaining life or pose excessive risks or burdens.
We also believe that social and health care policies should be carefully framed
so that these patients are not routinely classified as "terminal" or as prime
candidates for the discontinuance of even minimal means of life support.
7. Who should make decisions about medically assisted nutrition and
"Who decides?" In our society many believe this is the most important or
even the only important question regarding this issue, and many understand it in
terms of who has legal status to decide. Our Catholic tradition is more
concerned with the principles for good moral decision making, which apply
to everyone involved in a decision. Some general observations are appropriate
A competent patient is the primary decision maker 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.(40) 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
When a patient is not competent to make his or her own decisions, a proxy
decision maker who shares the patient’s moral convictions, such as a family
member or guardian, may be designated to represent the patient’s interests and
interpret his or her wishes. Here, too, moral limits remain relevant—that is,
morally the proxy may not deliberately cause a patient’s death or refuse what is
clearly ordinary means, even if he or she believes the patient would have made
such a decision.
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. A physician or nurse told to participate in a
course of action that he or she views as clearly immoral has a right and
responsibility either to refuse to participate in this course of action or to
withdraw from the case, and he or she should be given the opportunity to express
the reasons for such refusal in the appropriate forum. Social and legal policies
must protect such rights of conscience.
Finally, because these are matters of life and death for human persons,
society as a whole has a legitimate interest in responsible decision making.(41)
In this document we reaffirm moral principles that provide a basis for
responsible discussion of the morality of life support. We also offer tentative
guidance on how to apply these principles to the difficult issue of medically
assisted nutrition and hydration.
We reject any omission of nutrition and hydration intended to cause a
patient’s death. We hold for a presumption in favor of providing medically
assisted nutrition and hydration to patients who need it, which presumption
would yield in cases where such procedures have no medically reasonable hope of
sustaining life or pose excessive risks or burdens. Recognizing that judgments
about the benefits and burdens of medically assisted nutrition and hydration in
individual cases have a subjective element and are generally best made by the
patient directly involved, we also affirm a legitimate role for families’ love
and guidance, health care professionals’ ethical concerns, and society’s
interest in preserving life and protecting the helpless. In rejecting broadly
permissive policies on withdrawal of nutrition and hydration from vulnerable
patients, we must also help ensure that the burdens of caring for the helpless
are more equitably shared throughout our society.
We recognize that this document is our first word, not our last word, on some
of the complex questions involved in this subject. We urge Catholics and others
concerned about the dignity of the human person to study these reflections and
participate in the continuing public discussion of how best to address the needs
of the helpless in our society.
Appendix: Technical Aspects of Medically Assisted Nutrition and Hydration
Procedures for providing nourishment and fluids to patients who cannot
swallow food orally are either "parenteral" (bypassing the digestive tract) or
"enteral" (using the digestive tract).
Parenteral or intravenous feeding is generally considered "more hazardous and
more expensive" than enteral feeding.(42) It can be subdivided into peripheral
intravenous feeding (using a needle inserted into a peripheral vein) and central
intravenous feeding, also known as total parenteral feeding or hyperalimentation
(using a larger needle inserted into a central vein near the heart). Peripheral
intravenous lines can provide fluids and electrolytes as well as some nutrients;
they can maintain fluid balance and prevent dehydration, but cannot provide
adequate nutrition in the long-term.(43) Total parenteral feeding can provide a
more adequate nutritional balance, but poses significant risks to the patient
and may involve costs an order of magnitude higher than other methods of tube
feeding. It is no longer considered experimental and has become "a mainstay for
helping critically ill patients to survive acute illnesses where the prognosis
had previously been nearly hopeless," but its feasibility for lifelong
maintenance of patients without a functioning gastrointestinal tract has been
Because of the limited usefulness of peripheral intravenous feeding and the
special burdens of total parenteral feeding—and because few patients so
completely lack a digestive system that they must depend on these measures for
their sole source of nutrition—enteral tube feeding is the focus of the current
debate over medically assisted nutrition and hydration. Such methods are used
when a patient has a functioning digestive system but is unable or unwilling to
ingest food orally and/or to swallow. The most common routes for enteral tube
feeding are nasogastric (introducing a thin plastic tube through the nasal
cavity to reach into the stomach), gastrostomy (surgical insertion of a tube
through the abdominal wall into the stomach), and jejunostomy (surgical
insertion of a tube through the abdominal wall into the small intestine).(45)
These methods are the primary focus of this document.
Each method of enteral tube feeding has potential side effects. For example,
nasogastric tubes must be inserted and monitored carefully so that they will not
introduce food or fluids into the lungs. They may also irritate sensitive
tissues and create discomfort; confused or angry patients may sometimes try to
remove them; and efforts to restrain a patient to prevent this can impose
additional discomfort and other burdens. On the positive side, insertion of
these tubes requires no surgery and only a modicum of training.(46)
Gastrostomy and jejunostomy tubes are better tolerated by many patients in
need of long-term feeding. Their most serious physical burdens arise from the
fact that their insertion requires surgery using local or general anesthesia,
which involves some risk of infection and other complications. Once the surgical
procedure is completed, these tubes can often be maintained without serious pain
or medical complications, and confused patients do not often attempt to remove
1. Congregation for the Doctrine of the Faith, Declaration on Procured
Abortion (Washington, D.C.: United States Catholic Conference, 1974), no.
2. Second Vatican Council, Pastoral Constitution on the Church in the
Modern World (Gaudium et Spes), no. 27. Suicide must be distinguished from
"that sacrifice of one’s life whereby for a higher cause, such as God’s glory,
the salvation of souls or the service of one’s brethren, a person offers his or
her own life or puts it in danger," Congregation for the Doctrine of the Faith,
Declaration on Euthanasia (Washington, D.C.: United States Catholic
Conference, 1980), part 1.
3. Declaration on Euthanasia, part 2.
4. See Declaration on Euthanasia, part 3; United States Catholic
Conference, Ethical and Religious Directives for Catholic Health Facilities
(Washington, D.C.: United States Catholic Conference, 1971), directive 29.
5. Declaration on Euthanasia, part 4.
7. Ibid., Conclusion.
8 Gaudium et Spes, no. 27; Declaration on Procured Abortion,
9. Vatican Statement on the International Year of Disabled Persons (March 4,
1981), section 1, no. 1, and section 2, no. 1 in Origins 10:47 (May 7, 1981):
10. Declaration on Euthanasia, Introduction; Declaration on Procured
Abortion, nos. 10-11, 21; Congregation for the Doctrine of the Faith,
Instruction on Respect for Human Life in Its Origin (Boston: St. Paul
Editions, 1987), part 3.
11. Archbishop John Roach, "Life-Support Removal: No Easy Answers,"
Catholic Bulletin (March 7, 1991): 1 (citing Biomedical Ethics Commission of
the Archdiocese of St. Paul-Minneapolis).
12. "If all fluids and nutrition are withdrawn from any patient, regardless
of the condition, he or she will die—inevitably and invariably. Death may come
in a few days or take up to two weeks. Rarely in medicine is an earlier death
for the patient so certain," Ronald E. Cranford, M.D., "Patients with Permanent
Loss of Consciousness," in By No Extraordinary Means, ed. Joanne Lynn
(Bloomington, Ind.: Indiana University Press, 1986), 191.
13. See the arguments made by a judge in the Elizabeth Bouvia case and by the
attorneys in the Hector Rodas case, among others. See Bouvia v. Superior
Court, 225 Cal. Rptr. 297, 307-308 (1986) (Compton, J., concurring);
Complaint for the Declaratory Relief in Rodas Case, Issues in Law and
Medicine 2 (1987): 499-501, quoted verbatim from Rodas v. Erkenbrack,
no. 87 ev. 142 (Mesa County, Colo., filed Jan. 30, 1987).
14. As one medical ethicist observes, interest in a broadly permissive policy
for removing nutrition and hydration has grown "because a denial of nutrition
may in a long run become the only effective way to make certain that a large
number of biologically tenacious patients actually die." Daniel Callahan, "On
Feeding the Dying," Hastings Center Report 13 (October 1983): 22.
15. Alfred O’Rahilly, Moral Principles (Cork, Ireland: Cork University
Press, 1948), no. 5.
16. Address to a Human Pre-Leukemia Conference, November 15, 1985: Acta
Apostolicae Sedis 78 (1986): 361. Also see his October 21, 1985 address to a
study group of the Pontifical Academy of Sciences: "Even when the sick are
incurable, they are never untreatable; whatever their condition, appropriate
care should be provided for them," Acta Apostolicae Sedis 78 (1986): 314;
Origins 15:25 (December 5, 1985): 416.
17. Some groups advising the Holy See have ventured opinions on this point,
but these do not have the force of official church teaching. For example, in
1985 a study group of the Pontifical Academy of Sciences concluded: "If a
patient is in a permanent, irreversible coma, as far as can be foreseen,
treatment is not required, but all care should be lavished on him, including
feeding," Pontifical Academy of Sciences, "The Artificial Prolongation of Life,"
Origins 15:25 (December 5, 1985): 415. Since comatose patients cannot
generally take food orally, the statement evidently refers to medically assisted
feeding. Similar statements are found in Pontifical Council Cor Unum,
Question of Ethics Regarding the Fatally Ill and the Dying (Vatican City:
Vatican Press, 1981), 9; "Ne Eutanasia Ne Accanimento Terapeutico," La
Civiltà Cattolica 3280 (February 21, 1987): 324.
18. World Medical Association, Declaration of Helsinki (1975), II.1.
19. See Joyce V. Zerwekh, "The Dehydration Question," Nursing (January
20. See William E. May et al., "Feeding and Hydrating the Permanently
Unconscious and Other Vulnerable Persons," Issues in Law and Medicine 3
(Winter 1987): 208.
21. Ronald E. Cranford, "The Persistent Vegetative State: The Medical Reality
(Getting the Facts Straight)," Hastings Center Report 18 (February/March
22. Declaration on Euthanasia, part 4 (emphasis added).
23. Current ethical guidelines for nurses, while generally defending patient
autonomy, reflect this concern: "Obligations to prevent harm and bring benefit .
. . require that nurses seek to understand the patient’s reasons for refusal. .
. . Nurses should make every effort to correct inaccurate views, to modify
superficially held beliefs and overly dramatic gestures, and to restore hope
where there is reason to hope," American Nurses’ Association Committee on
Ethics, "Guidelines on Withdrawing or Withholding Food and Fluids," BioLaw
2 (October 1988): U1124-1125.
24. In one such study, "70 percent of patients and families were 100 percent
willing to undergo intensive care again to achieve even one month of survival";
"age, severity of critical illness, length of stay, and charges for intensive
care did not influence willingness to undergo intensive care," Danis et al.,
"Patients’ and Families’ Preferences for Medical Intensive Care," Journal of
the American Medical Association 260 (August 12, 1988): 797. In another
study, out of thirty-three people who had close relatives in a "persistent
vegetative state," twenty-nine agreed with the initial decision to initiate tube
feeding and twenty-five strongly agreed that such feeding should be continued,
although none of those surveyed had made the decision to initiate it. See Tresch
et al., "Patients in a Persistent Vegetative State: Attitudes and Reactions of
Family Members," Journal of the American Geriatrics Society 39
(January 1991): 17-21.
25. Declaration on Euthanasia, part 4.
26. "In striving to contain medical care costs, it is important to avoid
discriminating against the critically ill and dying, to shun invidious
comparisons of the economic value of various individuals to society, and to
refuse to abandon patients and hasten death to save money," Hastings Center,
Guidelines on the Termination of Life-Sustaining Treatment and Care of the Dying
(Briar Cliff Manor, N.Y.: Hastings Center, 1987), 120.
27. A possible exception is total parenteral feeding, which requires
carefully prepared sterile formulas and more intensive daily monitoring.
Ironically, some current health care policies may exert economic pressure in
favor of TPN because it is easier to obtain third-party reimbursement. Families
may pay more for other forms of feeding because some insurance companies do not
see them as "medical treatment." See U.S. Congress, Office of Technology
Assessment, Life-Sustaining Technologies and the Elderly, OTA-BA-306
(Washington, D.C.: Government Printing Office, July 1987), 286.
28. "One can never claim that one wishes to bring comfort to a family by
suppressing one of its members. The respect, the dedication, the time and the
means required for the care of handicapped persons, even of those whose mental
faculties are gravely affected, is the price that a society should generously
pay in order to remain truly human," Vatican Statement, section II, no. 1
in Origins, p. 748 (see no. 9 above). The Holy See acknowledges that
society as a whole should willingly assume these burdens, not leave them on the
shoulders of individuals and families.
29. For example, see P. Singer, "Sanctity of Life or Quality of Life?"
Pediatrics 72 (July 1983): 128-129. On the use and misuse of the term "quality
of life," see Cardinal John O’Connor, "Who Will Care for the AIDS Victims?"
Origins 19:33 (January 18, 1990): 544-548. Some Catholic theologians agree
that a low "quality of life" justifies withdrawal of medically assisted feeding
only from patients diagnosed as permanently unconscious. This argument is
discussed separately in section 6 below.
30. See David Milne, "Urges MDs to Get Birth Defects Patient’s Own Story,"
Medical Tribune (December 12, 1979): 6.
31. United States Catholic Conference, Pastoral Statement of the U.S.
Catholic Bishops on Persons with Disabilities (Washington, D.C.: United
States Catholic Conference, 1978).
32. Some patients with disabilities ask for death because all their efforts
to build a life of self-respect are thwarted; a "right to die" is the first
right for which they receive enthusiastic support from the able-bodied. See Paul
K. Longmore, "Elizabeth Bouvia, Assisted Suicide and Social Prejudice,"
Issues in Law and Medicine 3 (Fall 1987): 141-168.
33. "Quality of life must be sought, in so far as it is possible, by
proportionate and appropriate treatment, but it presupposes life and the right
to life for everyone, without discrimination and abandonment," John Paul II,
Address of April 14, 1988 to the Eleventh European Congress of Perinatal
Medicine, Acta Apostolicae Sedis 80 (1988): 1426; The Pope Speaks
33 (1988): 264-265.
34. See Archbishop Roger Mahony, "Two Statements on the Bouvia Case,"
Linacre Quarterly 55 (February 1988): 85-87.
35. Coma and persistent vegetative state are not the same. Coma, strictly
speaking, is generally not a long-term condition, for within a few weeks a
comatose patient usually dies, recovers, or reaches the plateau of a persistent
vegetative state. "Coma implies the absence of both arousal and content. In
terms of observable behavior, the comatose patient appears to be asleep, but
unlike the sleeping patient, he cannot be aroused from this state. . . . The
patient in the vegetative state appears awake but shows no evidence of content,
either confused or appropriate. He often has sleep-wake cycles but cannot
demonstrate an awareness either of himself or his environment," Levy, "The
Comatose Patient,"in The Clinical Neurosciences, ed. R. Rosenberg (New
York: Churchill Livingstone, 1983), 1:956.
36. While his pejorative connotation was surely not intended by those coining
the phrase, we invite the medical profession to consider a less discriminatory
term for this diagnostic state.
37. O’Rahilly, no. 5.
38. Because patients need nutritional support to live during the weeks or
months of observation required for responsible assessment of PVS, the cases
discussed here involve decisions about discontinuing such support rather than
39. One recent scientific study of recovery rates followed up 84 patients
with a firm diagnosis of PVS. Of these patients, "41 percent became conscious by
six months, 52 percent regained consciousness by one year, and 58 percent
recovered consciousness within the three-year follow-up interval." The study was
unable to identify "predictors of recovery from the vegetative state," that is,
there is no established test by which physicians can tell in advance which PVS
patients will ultimately wake up. The data "do not exclude the possibility of
vegetative patients regaining consciousness after the second year," though this
"must be regarded as a rare event," H. S. Levin, C. Saydjari, et al.,
"Vegetative State After Closed-Head Injury: A Traumatic Coma Data Bank Report,"
Archives of Neurology 48 (June 1991): 580-585.
40. Some Catholic moralists, using the concept of a "virtual intention," note
that a person may give spiritual significance to his or her later suffering
during incompetency by deciding in advance to join these sufferings with those
of Christ for the redemption of others.
41. See NCCB Committee for Pro-Life Activities, "Guidelines for Legislation
on Life-Sustaining Treatment" (November 10, 1984), Origins 14:32 (January
24, 1985): 526-528; "Statement on the Uniform Rights of the Terminally Ill Act"
(June 1986), Origins 16:12 (September 4, 1986): 222-224; United States Catholic
Conference, Brief as Amicus Curiae in Support of Petitioners, "Cruzan
v. Director of Missouri Department of Health v. McCanse," U.S. Supreme
Court, No. 88-1503, Origins 19:21 (October 26, 1989): 345-351.
42. David Major, M.D., "The Medical Procedures for Providing Food and Water:
Indications and Effects," in By No Extraordinary Means, ed. Joanne Lynn
(Bloomington, Ind.: Indiana University Press, 1986), 27.
43. Peripheral veins (e.g., those found in an arm or leg) will eventually
collapse after a period of intravenous feeding and will collapse much faster if
complex nutrients such as proteins are included in the formula. See U.S.
Congress, Office of Technology Assessment, Life-Sustaining Technologies and
the Elderly, OTA-BA-306 (Washington, D.C.: U.S. Government Printing Office,
July 1987), 283-284.
44. Major, 22, 24-25. Also see OTA, 284-286.
45. See Major, 22, 25-26.
46. Major, 22; OTA, 282-283; Ross Laboratories, Tube Feedings: Clinical
Applications (1982), 28-30.
47. Major, 22; OTA, 282. Many ethicists observe that there is no morally
significant difference in principle between withdrawing a life-sustaining
procedure and failing to initiate it. However, surgically implanting a feeding
tube and maintaining it once implanted may involve a different proportion of
benefit to burden, because the transient risks of the initial surgical procedure
will not continue or recur during routine maintenance of the tube.