Catholic Medical Quarterly Volume 70(1) February 2020
Withdrawal of Nutrition and Hydration, and Withdrawal Of Ventilation:
What Does Tradition Say?
Michal Pruski, PHD, MA, AFHEA, MRSB
With recent guidance from the BMA and RCP on the withdrawal of nutrition from patients, and how the cause of death is being recorded (1), and the case of Vincent Lambert (2), the debate surrounding withdrawal of care and treatment has been rekindled in Catholic circles. In this article, I wish to highlight some of traditional principles that form the basis of such decision-making. I discuss these within the context of the withdrawal of nutrition and hydration (NaH), as well as ventilation, to elucidate the key points.
Ordinary and Extraordinary Means
Probably the most in-depth study of the meaning of ordinary and extraordinary means has been undertaken by Cronin.(3) Ordinary means are those that are obligatory for one to use (i.e. it is illicit for one to refuse them), while extraordinary means are optional (i.e. it is licit for one to refuse them). This distinction stems from the inherent value and dignity of human life, the unconditionally binding negative precepts of the Natural Law, but only generally binding positive precepts of Natural Law, and the primacy of spiritual ends. Cronin analysed the opinions of theologians across time and concluded with several points, the most crucial being (3):
15) Ordinary means of conserving life may be defined as those means commonly used in given circumstances, which this individual in his present physical, psychological, and economic condition can reasonably employ with definite hope of proportionate benefit.
16) Extraordinary means of conserving life may be defined as those means not commonly used in given circumstances, or those means in common use which this individual in his present state physical, psychological and economic condition cannot reasonably employ, or if he can, will not give him definite hope of proportionate benefit.
Cronin also stated that (3):
11) A relative norm suffices in determining a means as an ordinary or extraordinary means of conserving life.
12) There is no absolute norm according to which certain means of conserving life are clearly ordinary for all men. A relative norm must be applied.
13) It does seem that an absolute norm can be established according to which certain means of conserving life are clearly extraordinary means of conserving life.
14) It would be allowable to establish a general norm in regard to ordinary means, by which certain means of conserving life are characterized as ordinary means of conserving life for most men.
According to this account no means can be deemed to be ordinary in all situations, but there are some means which can be always considered extraordinary. Therefore, one cannot state that NaH is always an ordinary means, or that because one is very rich one must use a very expensive treatment because one can afford it. Yet, one can say that NaH is generally an ordinary means (for it is nowadays a common, inexpensive, effective and largely painless), and that a person cannot refuse a means because they want to die or because the proxy decision makers deems the life of the patient not worth living (4). These points seem to agree with St John Paul II that NaH ‘should be considered, in principle, ordinary and proportionate, and as such morally obligatory, 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’ (5), as well as with what (now) Archbishop Fisher wrote (6):
‘Traditional medical ethics has never required that doctors strive relentlessly to maintain the last vestiges of physical life. Some treatments will be withheld or withdrawn for good therapeutic reasons. Their continued use may be of no therapeutic value (futile). Or they may impose a burden (such as pain, indignity, risk, cost etc.) which those concerned feel is greater than the benefit gained. But here doctors do not indulge in arbitrary ‘quality of life’ decision-making; they do not give or remove treatments with intent to kill. Instead they make a therapeutic judgment about the helpfulness or not of the proposed medical treatment in dealing with the patient’s illness. Thus some treatments will be medically indicated and morally required (‘ordinary’); others will be optional (‘extraordinary’); and still others will be contra-indicated (and immoral).’
Care versus Treatment
One distinction often employed is between ordinary nursing care and medical treatment. NaH is placed in the first category, while ventilation in the latter (7). This distinction is absent in the traditional accounts. Both ventilatory and NaH support are essential parts of patient care, and, as will be seen, from the traditional perspective it does not matter whether care is medical care or not. The traditional accounts are full of references to foods which one is not obliged to eat even if one knew that they would extend one’s life, as well as with explicit statements that certain situations excuse one from even consuming food in general. For example, Vitoria states that if one can only take food ‘with the greatest of effort and as though by a means of a certain torture’ he is excused ‘at least from mortal sin’ (3).
Griese (basing his work on Cronin’s) claims that such a distinction can be made (7), and tries to justify the difference on physiological grounds between NaH and ventilation. His claim, briefly, is that artificial means of supplementing NaH enterally merely overcome a pathological obstruction in the digestive system, but do not replace the digestive system, while total parenteral (TPN) means to replace the work of digestive system, and as such should be considered a medical intervention. He then likens the use of ventilation to TPN. This argument is problematic for several reasons. Firstly, it needs to be stated that oxygen is as vital to human life as is food and water (this point is made by Moraczewski in a text aslo published in the same volume) (8). Secondly, no means of providing NaH, nor ventilation (or even Extra Corporeal Memberane Oxygenation – ECMO) is a form of treatment. They all supply a vital component for life rather than treat a disease state. Moreover, Griese’s analogy fails in its detail, for the ventilation is analogous to artificial enteral means of NaH support, while the equivalent of TPN is ECMO. One could argue that we are culturally used to feeding people (e.g. guests and babies) and so the social obligation to provide NaH is greater than for ventilation. Yet, it is the case that we could refuse to serve a guest a food when they drop in for a quick visit (however impolite that would not be), we could not refuse to give them air. As such, perhaps our standard for not withholding oxygen from others should be even more stringent than for NaH.
Griese (7) and Moraczewski (8) both disagree on the weight and interpretation of various recent Catholic documents. Interestingly, Griese cites a friend-of-the-court brief of the Catholic Bishops of New Jersey, where they compare withdrawal of nutrition to murder by asphyxiation, further countering any significant moral difference between the withdrawal of ventilation and NaH (7). Even when Griese cites a statement by the US Catholic Bishops’ Committee for Pro-Life Activities (7) to try to justify the special status of the provision of NaH, the document states the same traditional criteria for its use, highlighting that while there should be a presumption for providing NaH, under certain circumstances it can be withdrawn, including when they become burdensome and ineffective.
Noteworthy, the traditional account distinguishing between ordinary and extraordinary means places the same obligation on the use of ordinary means, regardless of anyone declaring them care or therapy. Ordinary care should not be interrupted (9), but when authors have given examples of what they generally considered ordinary care it included ‘compassion and spiritual and affective support due to every human being in danger’ (10) and ‘alimentation, blood transfusion, injections, etc.’ (11) – a mix of care and therapy. As such, there are no lighter criteria for refusing therapeutic measures, but perhaps therapeutic interventions might reach the threshold of becoming extraordinary at an earlier stage than most care measures. Yet, it is possible that - for a specific patient - artificial nutritional supplementation becomes an extraordinary means, but an ostensibly more involved intervention, such as antibiotics, remains an ordinary means.
The Conscious Patient
Let us consider how these principles apply to the provision of NaH and ventilation to the conscious patient. The conscious patient can still pursue the spiritual goals of life, and as such the benefits of clinically sound interventions are always proportionate, unless death is imminent (ie. hours, rather than 6 months) or there are medical contraindications to the intervention, e.g. ‘tube feeding’ would not be indicated if the patient cannot assimilate food or if there is a high risk of infection due to the technique (7). If death is imminent, and the withdrawal of such measures would allow the person to, for example, attend one last Mass, then the benefit of the treatment would not be proportionate. It is unlikely that the withdrawal of nutritional support for a couple of hours would have any significant impact on the patient’s length of life, and, as De Lugo notes, ‘to conserve his life for such a brief time because the obligation of conserving life by ordinary mean is not an obligation of using means for such a brief conservation – which is morally considered nothing at all’ (3). If this mode of support would become too economically taxing for the patient, it could also be licitly refused - though this is not a very likely scenario at the moment in the NHS. Yet, the possibility of discomfort, pain and psychological taxation can be significant enough to render such a measure extraordinary for a given individual. If it is the burden of the applied measure that is the reason for the withdrawal (and not a perceived burden of life), then the withdrawal is licit even if the measure is clinically beneficial. While the patient cannot licitly argue that they want to die, they can say that they prefer to die than to live with such a taxing form of life support (12). This is, of course, on the assumption that efforts have been made to alleviate the burden e.g. through pain management and psychological support. Before withdrawing these interventions, the patient should also be encouraged to complete any necessary preparations, both spiritual and financial. There is also nothing stopping the patient to request the resumption of such interventions. Until then both NaH and ventilation remain obligatory, whether in a natural or artificial/assisted form, and for the conscious patient both support modalities become extraordinary under the exact same relative criteria.
The Permanently Unconscious Patient
For the permanently unconscious patient, the criteria of physical and psychological discomfort are not applicable by virtue of their condition (7). The evaluation of the economic burden shift to the next of kin taking care of the patient, but, as mentioned earlier, in the UK it should not generally have an impact on the analysis. Importantly, the care for the patient is never itself a justifying burden, but excessive financial cost for an elderly relative that would unable one to take due care of other relatives could be considered a justifying virtual impossibility (7,9). As such, the main criterion for evaluation becomes the effectiveness of the procedure. If clinically it is improbable that the patient will regain consciousness, then NaH and ventilation, could be deemed extraordinary interventions. Of course, this is a grave matter - the judgment about the state of the patient should not be made rashly and, if in doubt, a presumption should be made for the prolongation of care (13). For example, while recognising that NaH is not obligatory under all circumstances, the United States Conference of Catholic Bishops deems it generally obligatory for patients in a persistent vegetative state (PVS) (14), a view supported by Griese (7) and a study group from the Pontifical Academy of Sciences (10). If NaH support is ordinary care in PVS cases, then so is ventilation. When such care has been deemed extraordinary, the Congregation for the Doctrine of Faith highlights that a hospital can licitly take into account the issue of resource allocation (9). Therefore, a hospital could refuse to continue ventilation, as well as NaH, to a permanently unconscious patient with no realistic chance of recovery, if these (in their case extraordinary resources) could be given to someone for whom they would be considered ordinary care. Of course, the relatives have no duty to request the removal of extraordinary means.
There is just one standard for determining extraordinary interventions, which applies both to treatment and care, and is equally applicable to the withdrawal of NaH and ventilation. As it is a relative standard, it might qualify as an intervention differently at different time points. Withdrawal of extraordinary care is optional for the patient, but if an ineffective extraordinary treatment incurs significant costs to the community, the medical team could refuse to provide it. Indeed, an obstinacy to try to prolong one’s life by the finest resources could be considered ‘reprehensible’ (see quote from Sanchez on pp. 42-43 in Cronin’s work). Artificial NaH and ventilation, clearly are not such an obstinate means – they supply the basic necessities of life. Yet, when the burden of their provision increases (or their effectiveness decreases), they can be licitly withdrawn - but this must never be done as a judgment of the worthiness of the patient’s life. While suffering can be voluntarily accepted, we should not demand it, nor should we fall into the trap of vitalism. If one wishes to make arguments supported by tradition, one has to defend both modalities to the same extent, by placing ventilation into a different category then NaH, one risks inconsistency (though each modality might reach the extraordinary threshold at a different time).
If means of ventilatory or NaH support are withdrawn this should be documented. While both BMA and RCP (1), and Moraczewski (8) note that the original pathological condition should be regarded as the cause of death, contrary to BMA and RCP’s guidance (1) withdrawal of NaH or ventilation should be noted on the certificate. The coroner’s investigation should be there to investigate whether it was an appropriate withdrawal, or if foul play was involved: whether the withdrawal was just the physical or also the moral cause of death (8), for withdrawal of a procedure simply to eliminate the burden that it imposes (which can never be life itself) is different from withdrawal to achieve the likely consequence (i.e. death) that will follow from it (12,15).
NaH and ventilator support can be withdrawn under the rare circumstances where these support modalities are associated with futility and burden, but never because the patient’s life is ‘not worth living’ or because death itself is desired. The traditional view defends the sanctity of life, while preventing us from falling into vitalism. If one is to claim that NaH can never be withdrawn one must be willing to administer it when the patient cannot absorb the nutrients and the procedure’s side effects are greater than the benefits. This would be to worship the means of medicine and forgo its goals. If one is to disconnect long-term mechanical ventilation, then one needs to provide a coherent answer to why it is different from NaH withdrawal, and the grounds for such a distinction are often poor. Coherent justifications of our actions are particularly important now that Catholic teaching is under considerable attack.
The author wants to thank Michael Wee and Nathan Gamble for their constructive comments on drafts of this manuscript.
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Conflict of Interest and Funding: None
Michal Pruski, PhD, MA, AFHEA; Trainee
Critical Care Scientist with Manchester Metropolitan University NHS Foundation Trust
& Manchester Metropolitan University ,