Dr Peter Au-Yeung Chairman Diocesan Bioethics Committee Catholic Diocese of Hong Kong

+ Recovery from severe brain damage + Apparent wakefulness without detectable awareness + Persistent after 6-12 months + No further recovery expected + Usually breathes unaided + Usually needs tube feeding

+ Spectrum of states, including minimally aware state, etc + Concerns about misdiagnosis + May have hidden residual cognitive function + Effects of zolpidem and levodopa etc

+ Collapsed in 1975 (aet 21) + Recovered to “PVS” + Parents went to Court to remove her from ventilator + Courts approved stopping ventilation + Could breathe unaided + Died from pneumonia 9 years later

+ Drowned after being thrown out of car in accident + Recovery to PVS, kept alive by tube feeding + Family wanted to remove tube feeding + Courts needed “clear and convincing evidence” + Evidence later found and tube removed + Cruzan died 11 days later + Legacy of Advanced Directives and Living Wills

+ Crushed at the Hillsborough football disaster (aet 18) + Injuries left him in PVS + Doctors and parents want to withdraw feeding + Tube feeding (artificial nutrition and hydration – ANH) ruled medical treatment + Can be withdrawn if not in patient’s best interests

+ Cardiac arrest PVS since then + Long legal battle by husband to stop tube feeding + Legal battle fought by parents to prevent this + Tube removed Died 13 days later

+ Life sustaining therapy + Extra-ordinary or disproportionate therapy + No moral obligation to start (Allocution on Reanimation, Pius XII, 1957) + Carries significant medical risks (eg VAP)

+ Large range from TPN to tube feeding + Often used to denote tube feeding + Can be Nasogastric (NG) or Gastrostomy tube + Latter can be done via endoscopy (PEG) + Often use special milk-based feed + Actually most can be fed using pureed food

+ Often needed due to impaired swallowing + Placement of tube can involve significant risks + Tube placement rightly viewed as medical treatment (say if involve GA) + Feeding through a functioning tube is not treatment

+ Mainstream medicine can view tube feeding in PVS as futile medical therapy + Catholic Church teaches that such tube feeding as usually ordinary and proportionate + Beware geriatrics study showing tube feeding as not affecting mortality + Their alternative is careful spoon feeding!!

I …. reaffirm strongly that the intrinsic value and personal dignity of every human being do not change, no matter what the concrete circumstances of his or her life. (Speech Of John Paul II To The International Congress on Life Sustaining Treatments And Vegetative State Saturday 20 March 2004, no.3) the value of a man’s life cannot be made subordinate to any judgement of its quality expressed by other men (ibid, no.6)

A man, even if seriously ill or disabled in the exercise of his highest functions, is and always will be a man, and he will never become a “vegetable” or an “animal”. (ibid, no.3)

The obligation to provide the “normal care due to the sick in such cases” includes, in fact, the use of nutrition and hydration … waning hopes for recovery … cannot ethically justify the cessation or interruption of … nutrition and hydration. Death by starvation or dehydration … as a result of their withdrawal … true and proper euthanasia by omission. (ibid, no.4)

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. Its use, furthermore, should be considered, in principle, ordinary and proportionate, and as such morally obligatory (ibid, no.4)

We acknowledge that every human being has the dignity of a human person, ….based on human nature itself, … a permanent and intangible value that cannot depend on specific circumstances of life and cannot be subordinated to anyone's judgment. (no.9)

withdrawing nutrition and hydration, necessarily administered to VS patients in an assisted way, … followed inevitably by the patients' death as a direct consequence…has to be considered a genuine act of euthanasia by omission, which is morally unacceptable. (no.10)

+ The administration of food and water even by artificial means is, in principle, an ordinary and proportionate means of preserving life. + A patient in a “permanent vegetative state” is a person with fundamental human dignity and must, therefore, receive ordinary and proportionate care which includes, in principle, the administration of water and food even by artificial means. Responses To Certain Questions Of The United States Conference Of Catholic Bishops Concerning Artificial Nutrition And Hydration (Aug 2007)

the general ethical criterion … the provision of water and food, even by artificial means, always represents a natural means for preserving life, and is not a therapeutic treatment. Its use should therefore be considered ordinary and proportionate, even when the “vegetative state” is prolonged. (last paragraph)

+ Shortage of organs for transplants + Various strategies to try and increase supply + One suggestion to re-define “death” + “Higher brain definition” to allow organ harvesting in PVS patients

+ Human dignity is unaffected by the vegetative state + Assaults on their dignity by secular “morality” is serious + Euthanasia through starvation and dehydration becoming accepted + Proposal even to use such persons as organ donors

+ Tube feeding is ordinary and proportionate care + No need to employ disproportionate means + Such persons not “burdens” on society + “Challenges” to our model of healthcare delivery + Beware therapeutic obstinacy (esp in resuscitation)