1. 1 Artificial Nutrition and Hydration Jan C. Heller, Ph.D. Ethics and Theology Providence Health & Services

2. 2 Presentation Objectives Review current relevant ERDs regarding the initiation and withdrawal of artificial nutrition and hydration (ANH) Trace recent development of moral tradition for use of ANH in Catholic health care Questions concerning possible future developments Discussion

3. 3 Etiquette Press * 6 to mute Press # 6 to unmute Keep your phone on mute unless you are dialoging with the presenter Never place phone on hold

4. 4 Relevant ERDs 58: A presumption in favor… There should be a presumption in favor of providing nutrition and hydration to all patients, including patients who require medically assisted nutrition and hydration, as long as this is of sufficient benefit to outweigh the burdens involved to the patient (emphasis added).

5. 5 Relevant ERDs 56: Determining what counts as benefits and burdens… A person has a moral obligation to use ordinary or proportionate means of preserving his or her life. Proportionate means are those that in the judgment of the patient offer a reasonable hope of benefit and do not entail an excessive burden or impose excessive expense on the family or the community (emphasis added).

6. 6 Relevant ERDs 57: Determining what counts as benefits and burdens… A person may forgo extraordinary or disproportionate means of preserving life. Disproportionate means are those that in the patient’s judgment do not offer a reasonable hope of benefit or entail an excessive burden, or impose excessive expense on the family or the community (emphasis added).

7. 7 Relevant ERDs 59: Withdrawal of life-sustaining procedures… The free and informed judgment made by a competent adult patient concerning the use or withdrawal of life-sustaining procedures should always be respected and normally complied with, unless it is contrary to Catholic moral teaching (emphasis added).

8. 8 2001 ERDs…A Transition …The USCCB Committee on Pro-Life Activities’ report…points out the necessary distinction between questions already resolved by the magisterium and those requiring further reflection, as, for example, the morality of withdrawing medically assisted hydration and nutrition from a person who is in the condition that is recognized by physicians as the “persistent vegetative state” (PVS) (ERD, 2001, p. 30). –PVS is not considered a “terminal condition” medically

9. 9 John Paul II’s 2004 Allocution “…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 [i.e., generally] ordinary and proportionate, and as such morally obligatory insofar and until it is seen to have attained its proper finality, which in the present case consists in providing nourishment to the patient and the alleviation of his suffering” (emphasis added).

10. 10 2007 Responsum to USCCB First question: Is the administration of food and water (whether by natural or artificial means) to a patient in a “vegetative state” morally obligatory except when they cannot be assimilated by the patient’s body or cannot be administered to the patient without causing significant physical discomfort?

11. 11 2007 Responsum to USCCB Response: Yes. The administration of food and water even by artificial means is, in principle, an ordinary and proportionate means of preserving life. It is therefore obligatory to the extent to which, and for as long as, it is shown to accomplish its proper finality, which is the hydration and nourishment of the patient. In this way suffering and death by starvation and dehydration are prevented.

12. 12 2007 Responsum to USCCB Second question: When nutrition and hydration are being supplied by artificial means to a patient in a “permanent vegetative state,” may they be discontinued when competent physicians judge with moral certainty that the patient will never recover consciousness?

13. 13 2007 Responsum to USCCB Response: No. 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.

14. 14 Current Developments In May/June issue of Health Progress, Cardinal Rigali (Chair, Pro-Life Activities) and Bishop Lori (Chair, Doctrine) called for revision of the 2001 ERDs to make sure there’s no confusion re: the interpretation and application of the Responsum Reportedly, this revision has been drafted, but it has not (yet) been circulated to Catholic health care –Rather than speculate about the revision, let me raise a number of questions that have been raised that it hopefully will help to clarify

15. 15 Questions re: Future Developments Whose values will get to determine what counts as proportionate and disproportionate care (ERD 56 and 57)? Will ANH be considered a “life-sustaining technology” (ERD 59) that, by law (PSDA), can be refused or withdrawn like any other medical treatment?

16. 16 Questions re: Future Developments Is it permissible to withdraw ANH (at the request of a valid surrogate) from a PVS patient who is otherwise not in a terminal condition due to other co-morbidities? Should patients or surrogates be informed of relevant ERD changes re: ANH and PVS if they could affect future treatments, or is a general statement (like ERD 59) sufficient?

17. 17 Discussion