Abstract
There is no doubt that medical nutrition and hydration to persons in a state of post-coma unresponsiveness [PCU], also called a “persistent vegetative state” should be provided. In agreement with Pope John Paul II, human persons with PCU remain persons and full members of the human community. Although the extent of their unresponsiveness needs to be taken into account in determining appropriate medical treatment, this does not alter their nature as human persons. Hence, they are always to be regarded as subjects of our care and solicitude. The view that they are incapable of acting towards spiritual ends and so it is not morally obligatory to continue nutrition and hydration is rejected, since this implies a loss of personhood. In addition, it is accepted that the burdens of caring for them should not be left solely to their families, but quite properly is also a responsibility of the community and the State. Irrespective of whether provision of medical nutrition and hydration is regarded as medical treatment or normal care, no person with PCU should be left uncared for. This could mean, however, that in some instances, appropriate care could include withdrawal of medical nutrition and hydration.
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Notes
- 1.
I shall use the term ‘post-coma unresponsiveness’ rather than ‘persistent vegetative state’ to underline the point that individuals in such circumstances have not been reduced to vegetables. Moreover, such a designation fails to cover the significant variations amongst patients suffering from post-coma unresponsiveness.
- 2.
Aruna Shanbaug, who was 25 years old at the time of her assault and died on May 18, 2015, was the centre of a debate about euthanasia in India. In 2010, a journalist, Pinki Virani, applied to the Indian Supreme Court to have her medical nutrition and hydration withdrawn. While the Court determined that it might be withdrawn, they left it to her primary carer, the King Edward Hospital to decide on her further treatment. The Hospital resolved to continue palliative care (Barnagarwala 2015). For a longer account, which provides more detail of the palliative care provided by generations of nurses, see Aravumada (2015). There are, as can be expected, varying views about Shanbaug’s treatment and whether medical nutrition and hydration should have been withdrawn. From some points of view, such as Pinki Virani’s, Shanbaug’s life was a life of hell.
- 3.
Well-being and welfare are, of course, connected. Well-being is connected to a person’s psychological state and so can be distinguished from welfare. That is, someone might have diligently sought to look after another’s welfare, but failed to have addressed deeper issues affecting their well-being. For example, a deep sorrow over a lost loved one may not be readily recognisable, despite the outward needs of a person being addressed.
- 4.
It will be presumed throughout that references to the provision of food (nutrition) include the provision of water (hydration).
- 5.
As Goméz-Lobo (2008, p. 106) points out, the provision of a PEG tube would not be available to villagers in a remote part of the world, whereas provision of food and water would be. Moreover, the tube’s insertion requires a medical procedure, so it seems to be a matter of logic that it be considered medical treatment.
- 6.
Some commentators use the term “proportionate” interchangeably with the term “ordinary.” It seems to me that a distinction between the two can be drawn. John Paul II uses both terms, referring to the provision of MNH as ordinary and proportionate. This seems right, since we can take a treatment to be ordinary, but in certain circumstances may not be proportionate because of the patient’s condition.
- 7.
Pius XII says, “La vie, la santé, toute l’activité temporelle, sont en effet subordonnées à des fins spirituelles.” [“Life, health, all temporal activity are subordinated, in fact, to spiritual ends”; my translation].
- 8.
Erik Meidl (2006) provides a number of case studies in which he examines the appropriateness of medical nutrition and hydration. Although none of the cases involve persons with PCU, there is good discussion of the complications that can arise and, in most of the cases, he considers provision of MNH appropriate.
- 9.
Both “care” and “treatment” can be ordinary or extraordinary. There is no sharp line to be drawn between care and treatment. For example, a nurse may be extraordinarily devoted to the care of a patient by being attuned to his needs, ensuring he has extra blankets or pillows, answering calls, being patient, helping him with eating and so on. This could clearly be classed as care. Because the nurse is so devoted to the care of her patient, we might call it extraordinary. In the case of MNH, it can be care if it is routine and ordinary, as described above for the person living with Wolff-Hirschorn. Treatments will normally involve a drug regimen, surgical interventions and the like, so will generally differ from care. Preventive measures, such as taking aspirin daily to thin the blood in order to prevent heart attack, could be classed as a treatment, but could also be care.
- 10.
There are a number of cases where patients would have a reasonable hope of benefit from a treatment, but it is too expensive or the treatment is experimental. Some cancer treatments, for example, may provide benefits, but are very expensive. Patients are not obliged to seek such treatment. See Brock (2010).
- 11.
The Canadian Catholic Bioethics Institute (2004, p. 775) observes that treatments cannot be classified ahead of time as ordinary or extraordinary, that is, before a careful assessment of the benefits and burdens to patients has been made. It is nevertheless, desirable to have some sense of what might be considered as ordinary and what might not, since such considerations are part in the assessment of benefits and burdens.
- 12.
Anthony Fisher (2012, pp. 218–20) provides some discussion of the appeal to human dignity as a reason for providing or continuing the provision of MNH. He observes that it is vulnerable to attack unless supported by a robust anthropology that holds that human beings are the kind of beings that are to be respected because of their very nature as beings that have reason and free will, irrespective of whether or not they are able to exercise these capacities .
- 13.
Clearly it will not be nutrition and hydration alone, but basic care as well.
- 14.
Jason Eberl’s (2005) defense of O’Rourke’s Thomistic argument is persuasive insofar as it interprets Aquinas’s distinction between human deliberative—or voluntary—acts and involuntary acts, pointing out that persons with PCU cannot perform deliberative or voluntary acts. We cannot be considered to have attained virtue , for example, unless we have consciously consented to act virtuously. We cannot be accidently just, prudent, or courageous. This is the heart of the argument. Someone who is no longer able to act deliberately cannot decide to act virtuously and so cannot act for an ultimate end; conversely, they are not able to act viciously either.
- 15.
To be fair, O’Rourke does not exclude the intellectually disabled from having consciousness and from medical treatment (Latkovic 2005, p. 509).
- 16.
It is accepted that agents will always choose to act according to what they perceive as good, but this does not mean that they always act in order to attain an ultimate end. They might act simply for immediate kinds of ends.
- 17.
Here the thought is that, if persons had not led exemplary lives before they fell into a state of PCU, then they do not any longer have an opportunity to remedy this and direct their lives toward the ultimate end, which is God. It would be cruel beyond belief if God’s goodness and mercy did not allow in some way for them to achieve the ultimate end. Purgatory was postulated as a place where the dead could atone for their sins and enable individuals to reach their ultimate end. Suffering in purgatory was considered by Aquinas to be far greater than any physical suffering here on earth (ST IIIa, Supp., App. 1, q. 2). If Aquinas is right, God’s mercy may be such that it allows for some atonement to occur here before death. This is not to say we prolong suffering, since we are not privy to God’s plans, but on the contrary do what we can to alleviate it. It should make us cautious, however, about how we treat those in a state of PCU.
- 18.
This is the thought expressed in Scripture when Jesus says, “I am the vine and you are the branches. If you remain in me and I in you, you will bear much fruit. Without me you can do nothing” (John 15:5). Paul elaborates, “We being many, are one body in Christ, and every one members of one another” (Romans 12:5).
- 19.
This argument is much more fully developed in Fisher (2012, pp. 213–47), who beautifully expresses the theological idea that providing food and drink is sign and symbol of solidarity with our suffering brothers and sisters.
- 20.
It is not just a matter of an incorrect diagnosis of PCU, but the complexity of the condition about which medical science still has much to learn. Claus and Nel (2006) describe the action of Zolipidem on three permanent vegetative state patients, all in a state of PVS for over 3 years. The drug was able to arouse the patients and they showed improvement in their conditions, including, in at least one case, being able to respond meaningfully to family, friends, staff and strangers. More recently, Puggina et al. (2012, p. 261) have suggested that the rate of misdiagnosis of PCU has not improved over the last 15 years. Importantly, Puggina et al. (2012, p. 262) report that fMRI neuroimaging shows that some partial cortical functioning is retained in severely injured brains. This is not to suggest that there may not be some patients in which injury is so severe that it is morally certain that they cannot recover any functioning, but this may be a much smaller cohort than at first appears and may only be ascertainable with certainty post-mortem.
- 21.
Even in the conduct of the spiritual acts of mercy, such as providing good counsel, the recipient of the counsel may not recognise that he or she is being counseled. This does not mean no counseling was given. Hence even a physical action may not be recognised as such, though it might be conceded that the person would presumably recognise that he or she was spoken to. What we want to establish is that mental acts, that is, the intended act, not including the physical activity, might not be observed and hence, still less, would it be recognized as a spiritual act. Now in the case of a mental act by someone with PCU, there is no apparent accompanying physical act that is observed, but it does not mean that there is no mental act, and hence does not mean there is no spiritual act. Such physical activity that occurs—e.g., a twitch—may not be recognised as anything other than a reflex, and may or may not intended.
- 22.
It is also possible to expand the action to include some of the consequences, since a single, reduced intention—such as moving a finger to flip a switch—is not particularly explanatory. Hence, the intended action could have been to illuminate the room, as the simple intentional moving of a finger does not explain why the finger was moved in the first place.
- 23.
It can be conceded that some animals might exhibit consciousness and reasoning, which suggests some kind of inner life, but they are not human beings made in the image and likeness of God. This confers a dignity on human beings that is unique. Human beings in a PCU state do not lose this dignity because of a loss of functions.
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Ozoliņš, J.(.T. (2017). On the Provision of Medical Nutrition and Hydration. In: Eberl, J. (eds) Contemporary Controversies in Catholic Bioethics. Philosophy and Medicine(), vol 127. Springer, Cham. https://doi.org/10.1007/978-3-319-55766-3_27
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