Catholic Medical Quarterly Vol 76 (3) August 2026

Commentary On “A Catholic Guide to End-of-Life Decision-Making”.
Released by the Catholic Bishops Conference of New York State. April 20th, 2026.

P.Pullicino, MD, PhD. Professor of Neurology.
W.J.Burke, MD, PhD. Emeritus Professor of Neurology.

The Catholic Bishops of New York produced a document on “End of Life Decision making”. Professors Burke and Pullicino reviewed it and, sadly, found many problems. Here are their conclusions

This document is unfortunately very problematic.
Firstly, the Introduction states that the document is guided by the Catholic Magisterium, and it falls down on this point in terms of Pope John Paul II’s insistence that a sick patient’s dignity is never diminished, as discussed below.
Secondly it commits cardinal errors in terms of protecting the life of patients that were brought to light with the banning of the Liverpool Care Pathway in the United Kingdom in 2012 such as predicting which patients are dying.
Either of these fundamental concerns should immediately lead to rejection of these guidelines for medical care of the seriously ill.

Catholic Magisterium

In his 1995 encyclical Evangelium Vitae (“The Gospel of Life”), he affirmed that the first and most fundamental right of the human person is life itself. He wrote that “the first right of the human person is his life. He has other goods and some are more precious, but this one is fundamental — it is the condition of all the others” [1]

Pope John Paul II teaching states that if the burden of care is on the family, care can be withdrawn only if it is extraordinary or disproportionate, not if it is ordinary and proportionate. There are real extraordinary means whose use or not is a medical judgement and not morally obligatory. These may include: putting the patient on a respirator, dialysis or organ transplantation. These extraordinary means are always extraordinary; they do not become ordinary means of preserving life such as food and water. As such, the use or not of these extraordinary means of preserving life are a medical judgment made by the patient with their physician. [2]

However, in the New York States Bishops Commentary it states “Ordinary care means are those that offer a reasonable hope of benefit and would not entail excessive burden on us, our family or the community.” This statement is not only wrong, but it is dangerous because by using the preposition “or” it implies that the burden of care could be judged by how the family, or community (e.g. taxpayer) are affected, independent of the patient. This would allow euthanasia. The Church teaches that the burden on the family, by itself does not justify withdrawing care that is proportionate and necessary for the well-being of the patient.

Dignity of Patient

Pope John Paul II said that patient dignity is inherent and remain intact regardless of health or disability.[3] The Commentary does not define relative inaccurate terms such as “hope of well-being” to quantify the effect of treatment on the patient. The only valid goal of medicine is the reduction of morbidity and mortality of disease,[4] or the provision of life-prolonging treatments. “Reasonable hope of benefit” is a very subjective criterion and incorporates a quality-of-life determination by the physician. It is in fact a “best interest” determination by carers on behalf of the patient. “Best interest” determinations have been shown to be “legal fiction” [5] as they project the quality-of-life biases of the carers onto the patient rather than really determine what is in the patient’s benefit. We should not lose sight of the fact that life itself is the most important benefit, as clearly stated by John Paul II (see above).

Errors of “End-of-Life Care” pathways

On page 5, the document speaks of the patient "entering the dying process" as a reason for withdrawal fluids and nutrition. There is no scientifically defined entity known as the dying process let alone being able to determine when someone has entered it. In the Liverpool Care Pathway the patient was deemed to be dying and having entered "the dying process." This was used as an excuse for withdrawal of nutrition and hydration. Likewise, “prolonging the dying process” on page 4 is a medically meaningless phrase used to justifying removing active treatment.

Hydration and Nutrition

The section on nutrition and hydration rightly states that it is an obligation to give nutrition and hydration. While food and water are ordinary means even by gastric tube feeding even for those in the persistent vegetative state, if there is a bowel obstruction that would result in aspiration, provision of food by this means is no longer medically indicated or morally obligatory. However, some reasons given for not giving food and fluids do not stand up to scrutiny:

a. “when the patient has entered the dying process the body can no longer properly assimilate food and water”. There is no published scientific physiological evidence for either the “dying process” or that near death fluids or nutrition are harmful. The fact is dehydration and lack of nutrition make the body vulnerable and severe dehydration or malnutrition can be a cause of death. It is therefore highly dangerous to give an unverifiable diagnosis that someone is in the “dying process” and then discontinue fluid and nutrition on the basis of this. It is effectively hastening death by dehydration/malnutrition and a form of euthanasia.

b. “when death is imminent. (within days)” There is no scientific way to determine when someone is going to die within days.[6] This determination is an exercise in prognostication. It has been repeatedly shown that these are frequently wrong and gives to those clinicians who use them, a “self-fulfilling prophecy” tendency that causes a deterioration of medical care. [7]

c. side effects of an NG tube are said to be severe agitation (how can you tell this unless the patient is awake?); a tube may cause discomfort, but this can easily be managed by replacing or padding the tube not removing it. Aspiration; this is always a risk that is minimised by careful positioning of patient, placement of tube and aspirating before feeding, it is not a reason for not feeding unless it is repeated or intractable. Similarly the risk of infection. A patient who cannot be tube fed for medical reasons is rare, but includes for example recent gastric surgery.

Pope John Paul II has said that food and fluids are normal care due to patients. It is a natural means of preserving life and cannot be considered as a medical act.[8]

P.Pullicino, MD, PhD. Professor of Neurology.
W.J.Burke, MD, PhD. Emeritus Professor of Neurology.

References

  1. Pope John Paul II, Christifideles Laici (1988), no. 38
  2. Ordinary means of preserving life by definition are means that are always required to maintain life such as food and water. The procedures mentioned such as organ transplantation or the ventilator are almost never used to maintain life i.e. they are not ordinary means to preserve life. They are extra-ordinary by definition.
    We do not say that these extraordinary means to preserve life should never be used. We just point out who should be the decision maker on their use, the patient and the doctor.
    Pope John Paul II mentions only that ordinary means i.e food and water are required. He does not mention any extraordinary means that are morally required. Because he states that life itself is a benefit adding these extraordinary means as morally required would cause a serious problem by making the decision makers chose between acting rationally or doing something immoral.
  3. Evangelium Vitae (The Gospel of Life) no. 71.
  4. Stanford Encyclopedia of Philosophy
  5. Holm, S. and Edgar, A. (2008) Best Interest: A Philosophical Critique. Health Care Anal 16:197–207.
  6. Thirty-one years ago when Pope John Paul II wrote Evangelium Vitae (section 65), it was assumed that imminent death could be clearly recognised. He would require its determination was certain in order to allow refusal of life supporting treatment. Recent research has shown that imminent death is often wrongly diagnosed. The best Early Warning Score for predicting this is only 74% specific. Covino, M et al. (2023) Predicting ICU admission and death in the Emergency Department. Resuscitation 190:23,109876. Palliative care research shows similar figures: White N, et al., BMJ Supportive & Palliative Care 2022;12:e785-e791.
  7. Becker et al, (2001) Withdrawal of support in intracerebral hemorrhage may lead to self-fulfilling prophecies. Neurology; 56:766.
  8. Pope John Paul II March 20 2004. Address to International Congress on “Life sustaining treatment and the Vegetative State”.