Dr. May presents and explains various positions taken on the question of caring for patients in a ‘persistant vegitatave state’. Dr. May then presents and defends the position taken by JohnPaul II in his address of March 20, 2004.
I will (1) comment on the so-called “‘Persistent’ Vegetative State”; (2) summarize responses by US Catholic bishops and theologians to the issue prior to Pope John Paul II’s important address of March 20, 2005; (3) present John Paul II’s address and its significance; (3) consider the negative responses given to it by a large number of American theologians; and (4) defend the Holy Father’s position, showing how unfounded are the objections leveled against it.
1. Comments on the “‘Persistent’ Vegetative State”
At the end of International Congress “Life-Sustaining Treatments and Vegetative State: Scientific Advances and Ethical Dilemmas” (Rome 17-20 March 2004), the World Federation of Catholic Medical Associations (FIAMC) issued a statement in which the scientists who participated in the Congress offered several considerations regarding the nature of this alleged “state”, among them the following:
1. Vegetative State (VS) is a state of unresponsiveness, currently defined as a condition marked by: a state of vigilance, some alternation of sleep/wake cycles, absence of signs of awareness of self and of surroundings, lack of behavioural responses to stimuli from the environment, maintenance of autonomic and other brain functions.
2. VS must be clearly distinguished from: encephalic death, coma,”locked-in” syndrome, minimally conscious state. VS cannot be simply equalled to cortical death either, considering that in VS patients islands of cortical tissue which may even be quite large can keep functioning.
3. general, VS patients do not require any technological support in order to maintain their vital functions.
4. VS patients cannot in any way be considered terminal patients, since their condition can be stable and enduring.
5. VS diagnosis is still clinical in nature and requires careful and prolonged observation, carried out by specialized and experienced personnel, using specific assessment standardized for VS patients in an optimum controlled environment. Medical literature, in fact, shows diagnostic errors in a substantially high proportion of cases. For this reason, when needed, all available modern technologies should be used to substantiate the diagnosis.
6. Modern neuroimaging techniques demonstrated the persistence of cortical activity and response to certain kinds of stimuli, including painful stimuli, in VS patients. Although it is not possible to determine the subjective quality of such perceptions, some elementary discriminatory processes between meaningful and neutral stimuli seem to be nevertheless possible.
7. No single investigation method available today allows us to predict, in individual cases, who will recover and who will not among VS patients.
8. Until today, statistical prognostic indexes regarding VS have been obtained from studies quite limited as to number of cases considered and duration of observation. Therefore, the use of adjectives like “permanent” referred to VS should be discouraged, by indicating only the cause and duration of VS.
Note that in no. 8) the scientists who participated in this important congress explicitly declare that the adjective “permanent” not be used to describe the condition because such use is not warranted by the facts. Note also that in no. 6) the scientists indicate that persons in the “vegetative” state may be able to experience pain.
2. Responses Prior to Pope John Paul II’s Address
Responses by U.S. Bishops
The bishops of the U.S. gave contradictory answers. Although directive no. 58 of the Ethical and Religious Directives for Catholic Health Care Services (Nov. 1994) clearly affirms that one ought to presume that nourishment so provided be given such persons “as long as this is of sufficient benefit to outweigh the burdens involved to the patient,” some individual bishops and the Texas Conference of Catholic Bishops had earlier concluded that doing so is futile and useless. The Texas Bishops, who did not provide extensive argument, claimed that someone in PVS was “stricken with a lethal pathology which, without artificial nutrition and hydration will lead to death.” They held that withholding or withdrawing artificially provided food from such persons “is simply acknowledging the fact that the person has come to the end of his or her pilgrimage and should not be impeded [by artificially provided food] from taking the final step.  Some individual bishops issued statements of a similar nature. 
On the other hand, in 1992 the Committee for Pro-Life Activities of the NCCB prepared a document that surveyed relevant medical literature dealing with the issue and different positions taken by moral theologians. The Pro-Life Committee explicitly stated that it did not find persuasive the rationale of some theologians that since persons in the PVS condition can no longer pursue the spiritual goal of life feeding them artificially is futile and/or unduly burdensome. The Committee concluded: “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.”<!–[if !supportFootnotes]–>[i]<!–[endif]–>
John Paul II singled out this paper for praise in a talk to a group of U.S. bishops on their ad limina visit to the Vatican in 1998. 
Even before this, in 1992, The Pennsylvania bishops had issued a somewhat similar document, replete with references to pertinent medical literature, declaring: “As a general conclusion, in almost every instance there is an obligation to continue supplying nutrition and hydration to the unconscious patient. There are situations in which this is not the case [e.g., when the patient can no longer assimilate the food and its provision is hence useless], but these are exceptions and should not be made into the rule.” In their judgment artificially providing food to PVS patients is “clearly beneficial in terms of preservation of life,” nor does it add a “serious burden” in the vast majority of cases. Consequently, it is in principle morally obligatory. 
Several individual bishops and other conferences of bishops issued statements reaching similar conclusions as the Pro-Life Committee and the Pennsylvania bishops. 
B. The Theological Position Claiming that Tubal Feeding of PVS Patients Is Not Morally Required
The leading proponent of this position was Kevin O’Rourke, O.P.  O’Rourke claimed that his view was rooted in the teaching of Pope Pius XII. In an important address to a congress of anesthesiologists, Pius had said:
…normally one is held to use only ordinary means [to prolong life]–according to the circumstances of persons, places, times, and culture–that is to say, means that do not involve any grave burdens for oneself or another. A more strict obligation would be too burdensome for most men and would render the attainment of the higher, more important good too difficult. Life, health, all temporal activities are in fact subordinated to spiritual ends. On the other hand, one is not forbidden to take more than the strictly necessary steps to preserve life and health so long as he does not fail in some more important duty. 
O’Rourke claimed that the Pope’s emphasis on the spiritual goal of life
specifies more clearly the terms “ordinary” and “extraordinary.” A more adequate and complete explanation of “ordinary” means to prolong life would be: those means which are obligatory because they enable a person to strive for the spiritual purpose of life. “Extraordinary” means would seem to be those means which are optional because they are ineffective or a grave burden in helping a person strive for the spiritual purpose of life. 
While O’Rourke correctly interpreted the teaching of Pius XII by saying that a means is extraordinary if it imposes a grave burden on a person and prevents him from pursuing the spiritual goal of life, he errs greatly when he claims that a means is extraordinary when it is “ineffective…in helping a person strive for the spiritual purpose of life” and that a means is ordinary precisely and only insofar as it enables a person to strive for the spiritual purpose of life. Many people, including some seriously handicapped children and mentally impaired adults, are incapable of pursuing the spiritual goal of life. People with very severe mental disabilities cannot do so because in order to do so a person must be able to make judgments and free choices. But these unfortunate human beings are still persons; their lives are still good, and it is good for them to be alive. If they should fall sick or be otherwise in danger of death, they surely have a right to “ordinary” care, and others have a serious moral responsibility to protect and preserve their lives unless the efforts to do so are themselves futile or excessively burdensome. Thus, for example, if an elderly person suffering from a malady that renders him incompetent and incapable of engaging in specifically human acts should suffer a cut artery and be in danger of dying because of loss of blood, it would surely be morally obligatory to stop the bleeding by appropriate means. Such means are surely “ordinary” or “proportionate.” Yet, on O’Rourke’s analysis, they would be “extraordinary” inasmuch as they would in no way be effective in helping this person to pursue the spiritual purpose of life.
Applying his understanding of Pius XII’s teaching to persons said to be in the PVS condition, O’Rourke maintained that since these individuals are not capable of pursuing the spiritual goal of life and since feeding them tubally is ineffective in helping them do so, then such feeding is not required. He also claimed that such individuals are suffering from a “fatal pathology” and that all one does by “feeding” such persons tubally is to preserve “mere physiological functioning.” His associate Benedict Ashley, O.P., shared this position. 
C. The Position Holding That Artificially Providing Food to PVS Persons Is Obligatory
This view, like that of Ethical and Religious Directives, of the Pennsylvania Bishops and the Pro-Life Committee of the National Conference of Catholic Bishops, holds that artificially providing food to permanently unconscious persons (those in the PVS state) is to be regarded ordinarily as morally obligatory insofar as it is neither useless nor unduly burdensome. With several others I developed this view in “Feeding and Hydrating the Permanently Unconscious and Other Vulnerable Persons.” 
We began by articulating major presuppositions and principles, among them that human bodily life is a great good, that it is personal, not subpersonal, that it is inherently good not merely instrumentally so, that no matter how heavily burdened such life remains a good.
We held that withholding/withdrawing various forms of preserving life, including the provision of food and water by tubal means, is morally permissible if the means employed is either useless or excessively burdensome. We affirmed that it is useless or relatively so if the benefits provided are nil or insignificant in comparison to the burdens imposed, and that it is excessively burdensome if benefits offered are not worth pursuing for one or more objective reasons: too painful, too damaging to the person’s bodily life and functioning, too restrictive of the patient’s liberty and preferred activities, too suppressive of the person’s mental life, too expensive, etc.
We acknowledged explicitly that “if it is really useless or excessively burdensome to provide someone with nutrition and hydration, then these means may rightly be withheld or withdrawn, provided that this omission does not carry out a proposal to end the person’s life but rather is chosen to avoid the useless effort or the excessive burden of continuing to provide the food and fluids.”  However, after examining the issue, we judged that tubally providing food and hydration to the permanently unconscious and other vulnerable persons was neither useless nor excessively burdensome and that consequently it ought to be given. We thus concluded:
in the ordinary circumstances of life in our society today, it is not morally right, nor ought it to be legally permissible, to withhold or withdraw nutrition and hydration provided by artificial means to the permanently unconscious or other categories of seriously debilitated but nonterminal persons. Rather, food and fluids are universally needed for the preservation of life, and can generally be provided without the burdens and expense of more aggressive means of supporting life. Therefore, both morality and law should recognize a strong presumption in favor of their use.<!–[if !supportFootnotes]–>[ii]<!–[endif]–>
We also argued that by caring for such persons in this way another good, that of human solidarity, was served.
Since some, for example O’Rourke, argued that the expense entailed in feeding PVS patients must realistically be regarded as terribly burdensome in our society, we acknowledged that no one would want his family bankrupted in order to provide him with tubally assisted feeding. But does this mean that O’Rourke is correct? At present, the cost for taking care of PVS patients is usually covered in great part by insurance or other programs. But one cannot legitimately avoid excessive expense (if this does become an issue) by abandoning care for the person and by intentionally bringing his death about by starvation. There are morally legitimate ways to reduce the cost of care. Persons put into the situation of caring for a loved one in the PVS state or other conditions are not obliged to have them cared for in highly expensive hospitals or nursing homes (if insurance and governmental help are inadequate). They can remove them from these costly institutions, take them home and do the best they can with the help of such services as hospice care, volunteers from the parish or neighborhood, etc. The high standards of care possible in expensive institutions might not be possible, but one can still maintain solidarity with the person doing what one can, including providing food and nourishment by tubal means (not too difficult to do once begun, even at home). One does not have to endure undue financial burdens.
3. Pope John Paul II’s Address of March 20, 2004
A. Context and Key Themes
This Address, given at the conclusion of the International Congress “Life-Sustaining Treatments and Vegetative State: Scientific Advances and Ethical Dilemmas,” co-sponsored by the Pontifical Academy for Life and the International Federation of Catholic Medical Associations, was based on the latest medical and scientific findings relevant to the “vegetative” state. 
Among the principal ideas Pope John Paul articulated are the following:
1.”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.” (no. 3; emphasis in the original).
2. The right of the sick person, even one in the vegetative state, to basic health care. Such care includes “nutrition, hydration, cleanliness, warmth, etc.” and “appropriate rehabilitative care” and monitoring “for clinical signs of eventual recovery” (no. 4).
3. The moral obligation, in principle, to provide food and water to persons in the “vegetative” state by tubal means: “I should like to underline how the administration of food and water, 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, insofar as and until it seen to have attained its proper finality, which in the present case consists in providing nourishment to the patient and alleviation of his suffering” (no. 4, emphasis in the original).
4. The need to resist making a person’s life contingent on its quality: “it is not enough to reaffirm the general principle according to which the value of a man’s life cannot be made subordinate to any judgment of its quality…it is necessary to promote the taking of positive actions as a stand against pressures to withdraw hydration and nutrition as a way to put an end to the lives of these patients” (no. 6; emphasis in original).
5. The principle of solidarity: “It is necessary, above all, to support those families who have had one of their loved ones struck down by this terrible clinical condition” (no. 6; emphasis added).
John Paul II emphasized that the providing of food and water even by artificial means is to be regarded “in principle”(emphasis added) “‘ordinary’ and ‘proportionate’ and as such morally obligatory.” Thus although such provision is obligatory in principle, the Pope allowed for those cases in which the provision of nutrition and hydration would not be appropriate, either because they would not be metabolized adequately, or because their mode of delivery would be gravely burdensome.
As the Australian bishops have noted, the Pope’s statement does not explore the question whether artificial feeding involves a medical act or treatment with respect to insertion and monitoring of the feeding tube. While the act of feeding a person is not itself a medical act, the insertion of a tube, monitoring of the tube and patient, and prescription of the substances to be provided, do involve a degree of medical and/or nursing expertise. To insert a feeding tube is a medical decision subject to the normal criteria for medical intervention.<!–[if !supportFootnotes]–><!–[endif]–> I bring this up because some may claim that, since providing food/water by tubal means requires a medical act to insert the tube, such feeding is itself a medical treatment and not an act of caring. This is not true. But the insertion of a feeding tube, particularly through enteral and not perienteral means, is neither futile nor burdensome in almost all cases.
4. Negative Responses
The principal negative responses to John Paul II’s Address were the following: it marked “a significant departure from the Roman Catholic bioethical tradition,” it was not in conformity with the 1980 Vatican Declaration on Euthanasia, and was not so primarily because it imposes excessively severe burdens on the families of such persons Thus John Paris, S.J., claimed that the pope’s talk ran counter to over 400 years of Church teaching, mandated use of excessively burdensome means, was probably written not by the pope but by Bishop Elio Sgreccia, who “represents the radical right-to-life segment of thinking.”<!–[if !supportFootnotes]–>[x]<!–[endif]–> Edward Sunshine found the Pope’s address so utterly incompatible with the 1980 Declaration on Euthanasia that it is “merely an assertion of ecclesiastical authority, with little grounding in reason,”<!–[if !supportFootnotes]–>[xi]<!–[endif]–> and John Tuohey likened it to a faulty thesis proposal by a graduate student ignorant of traditional Catholic teaching.<!–[if !supportFootnotes]–>[xii]<!–[endif]–> Boston College moral theologian Lisa Sowle Cahill asserted apodictically that John Paul II was not the author of the document and like others contended that it is simply incompatible with traditional Catholic teaching.<!–[if !supportFootnotes]–>[xiii]<!–[endif]–>
O’Rourke has not published any essay dealing explicitly with this issue since John Paul II’s March 20, 2004 address, although he seems to hold that tubally feeding persons in the “vegetative” state can be withheld or withdrawn because of the burdens such care imposes on the families of these persons. in an article in National Catholic Bioethics Quarterly.<!–[if !supportFootnotes]–>[xiv]<!–[endif]–> And this was the position he took in a debate with me over the issue on April 26, 2005 for the priests of the Archdiocese of Detroit. During the debate O’Rourke at times indicated that he had abandoned his earlier rationale for not providing food/hydration by tubal means to persons in the so-called persistent vegetative state based on the futility of doing so insofar as it would not enable such persons to pursue the spiritual goal of life. Nonetheless, one of the major points noted in a print-out of his power-point presentation and in his remarks was his colleague Benedict Ashley’s assertion that “the human body is human precisely because it is made for intelligence” and is thus “subordinate to the good of the immaterial and contemplative intelligence,” with the implied conclusion that all interventions prolonging bodily life are not obligatory if one can no longer use intelligence to pursue the spiritual goal of life.
Moreover, during the debate, he sought to rebut my claim that, if his interpretation of Pius XII’s statement were correct, then there would be no obligation to stop the bleeding of a trisomy 13 baby and others severely disabled mentally because doing so would not “enable” them to pursue the spiritual goal of life. He claimed that such individuals are still capable of “affection.” This may well be true; but dogs and cats are capable of “affection.” But this is far cry from the ability to engage in human acts, an ability O’Rourke and Ashley require, i.e., acts requiring not merely “cognitive/affective” abilities [which, like babies, chimpanzees and dogs have] but intelligence and free choice.
During the debate he explicitly argued that feeding/hydrating pvs patients by tubal means was disproportionate/extraordinary because of the burdens doing so imposed on their care-givers. He also made it clear that he thought the March 20 2004 address was incompatible both with the Declaration on Euthanasia and John Paul II’s later address of November 12, 2004.
5. Defense of John Paul II’s Address
A. Compatibility of the March 20 Address with “Traditional Catholic Teaching”
In Evangelium vitae, John Paul II explicitly appealed to the Declaration on Euthanasia to distinguish euthanasia “from the decision to forgo… medical procedures which no longer correspond to the real situation of the patient, either because they are by now disproportionate to any expected results or because they impose an excessive burden on the patient and his family…. To forgo extraordinary or disproportionate means is not the equivalent of suicide or euthanasia; it rather expresses acceptance of the human condition in the face of death” (65). Thus John Paul II obviously agreed that it appropriate to withhold or withdraw the provision of nutrition and hydration is withheld or withdrawn for legitimate reasons (futility, burdensomeness). Moreover, his teaching in no way requires that tubally assisted feeding and hydration be maintained at all costs, but only when the benefits such assistance provides are present and no excessive burdens are imposed. If in particular instances such feeding/hydration would not effectively preserve life or alleviate suffering it would lack its beneficial effect and would be futile.
Some months after his March 20, 2004 address, as noted above, John Paul delivered another address on November 12, 2004 in which he once again reaffirmed the Catholic tradition according to which aggressive treatment, i.e., treatment that “is ineffective or obviously disproportionate to the aims of sustaining life or recovering health.” He then went on to speak of the need to continue “palliative care” especially for patients with terminal diseases.  This address is in perfect conformity with, and in no way contrary to, his teaching on March 20 of the same year on the obligation, in principle, to provide food and hydration to the permanently unconscious “insofar as and until it is seen to have attained its proper finality, which in the present case consists in providing nourishment to the patient and alleviation of his suffering” (March 20 address, no. 3; emphasis added).
His statement is fully compatible with the Ethical and Religious Directives for Catholic Health Care Facilities, no. 58: “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) and with the documents on this issue prepared by the Pennsylvania Conference of Bishops and the Committee for Pro-Life Activities of the NCCB. How then is it opposed to the Catholic tradition?
B. Does John Paul II Impose Excessively Grave Burdens on Families?
Does the Pope’s teaching, as American theologians assert, impose grave burdens on the families of those whose lives are sustained by providing them tubally with food and water even when they are not consciously aware of themselves or others? Simply feeding/hydrating the persons in the “vegetative” condition does not impose burdens on families or other care-givers, just as feeding those paralyzed from the neck down or suffering loss of all limbs does not impose excessive burdens on care-givers. The heavy burden they carry is not caused by the feeding but rather by the seriously debilitating condition of those for whom they care. But this is a burden that must in justice be accepted by others. Would those opposing John Paul II claim that we should stop feeding the demented, the paralyzed, quadruple amputees, and individuals who are simply “not with it”?
Moreover, withholding or withdrawing tubally provided food and water would not eliminate the burden of care-givers; only the death of those cared for would end the burden. Germain Grisez, after noting that as these severely impaired persons’ loved ones witness what is done to provide food and other care they experience a great and undeniable burden, correctly said:
Of course, this burden will be eliminated if food is withheld, but only because the comatose person will be eliminated. Thus, to decide not to feed a comatose person in order to end the burden and his or her loved ones experience is to choose to kill that person in order to end the miserable state in which he or she now lives. 
John Paul II himself was keenly aware of the great hardship that families of PVS patients endure in caring for them. He thus outlined some important positive steps to help these patients and their families, and “…to stand against pressures to withdraw hydration and nutrition as a way to put an end to the lives of these patients” (no. 6). John Paul II suggested the following concrete practical ways to help:
…the creation of a network of awakening centers with special treatment and rehabilitation programs; financial support and home assistance for families when patients are moved back home at the end of intensive rehabilitation programs; the establishment of facilities which can accommodate those cases in which there is no family able to deal with the problem or to provide “breaks” for those families who are at risk of psychological and moral burnout (no. 6).
Such steps would demonstrate society’s concern and love for these seriously impaired individuals. From a specifically Christian perspective, they would give powerful testimony to the faithfulness and selflessness of Christian love, which continues to be expressed even when those who receive it can show no appreciation – even when they are apparently totally unaware of this loving presence. For in providing care only to those who can thank us and return the favor do we not already have our reward?
Committee for Pro-Life Activities, National Conference of Catholic Bishops, Nutrition and Hydration: Moral and Pastoral Reflections (Washington, D.C.: United States Catholic Conference, 1992), Publication No. 516-X, p. 7. The document was also printed in Origins: NC News Service 21 (1992) 705-711; the citation is found at 711.
 This point has been further developed by one of the co-authors, Germain Grisez who in a later work has said: “life-sustaining care for [persons] severely handicapped does have a human and Christian significance in addition to the one it would derive precisely from the inherent goodness of their lives. This additional significance is…profoundly real, just as is the significance of [a husband’s faithfulness to a permanently unconscious] wife, which continues to benefit not only the person being cared for but the one giving care” (Grisez, Difficult Moral Questions [Quincy, IL: Franciscan Press, 1997], p. 223).
O’Rourke, “Open Letter to Bishop McHugh: Father Kevin O’Rourke on Hydration and Nutrition,” 351-352.
 On this see the brief review of the Congress’s work given by Richard Doerflinger, “John Paul II on the ‘Vegetative’ State: An Important Papal Speech,” Ethics&Medics 29.6 (June, 2004), 3. Doerflinger himself was a participant at the Congress.
 On this see Thomas A. Shannon and James J. Walter, “Implications of the Papal Allocution on Feeding Tubes,” Hastings Center Report 34.4 (July-August 2004), 18-20, at 18; see also Ronald Hamel and Michael Panicola, “Must We Preserve Life?”
 See, for example, Sister Jean DeBlois, “Prolonging Life or Interrupting Dying? Opinions Differ on Artificial Nutrition and Hydration,” Aquinas Institute, Spring 2004 Newsletter, available at http://www.ai.edu, and John Paris, S.J. , “No Moral Sense,” in an interview with Brian Braiker of Newsweek and available on http://www.msnc.mnsn.com/id/7276850/site/newsweek/print/1/displaymode/1098/.