Prior to the revision, Directive 58 of the ERDs stated that there should be a "presumption in favor of providing nutrition and hydration" to patients with chronic conditions like PVS, and who are not imminently dying. The revision of ERD 58 now clarifies that such patients should receive food and water by "medically assisted" means if necessary:
In principle, there is an obligation to provide patients with food and water, including medically assisted nutrition and hydration for those who cannot take food orally. This obligation extends to patients in chronic and presumably irreversible conditions (e.g., the "persistent vegetative state") who can reasonably be expected to live indefinitely if given such care.
Pope John Paul II prompted the eventual revision when he addressed the 2004 international congress on "Life-Sustaining Treatments and Vegetative State:"
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, 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.
What specifically then does this revision mean and what conclusions can we draw from it?
(1) Clinical protocols that would indiscriminately withhold or remove ANH from patients, without due regard for the moral guidelines articulated in Directive 58, leave death by starvation or dehydration as the logical outcome. In the words of John Paul such an omission could constitute "true and proper euthanasia."
(2) Provision of food and water are to be considered a part of normal care giving (not an "extraordinary means"), even when provided artificially as with the assistance of a gastric feeding tube.
(3) This teaching extends beyond the specific case of persons in PVS to include any patient suffering a pathology that makes them unable to assimilate food and water without artificial assistance, such as advanced Alzheimer's disease or acute dementia.
(4) Directive 58 states that such provision is obligatory "in principle." We might ask then, under what circumstances can ANH be withheld or withdrawn from patients. ANH is not obligatory when it cannot reasonably be expected to prolong life, when it is judged to constitute an "excessive burden" for the patient (as in the rare instance that it might cause "significant physical discomfort") or when the patient can no longer assimilate food and water (as when death is imminent). Determining if and when ANH can be removed will often require responsible parties, especially those designated as healthcare proxies for their incapacitated loved ones, to consult with care-givers, other family members, the attending physicians and a priest or ethicist trained in the Church's moral teaching on these matters.
(5) Catholics considering end-of-life decisions should adhere to the moral truths affirmed in the revision of Directive 58; it would be immoral for them to indicate in their "living wills" or advance medical directives an across-the-board desire to forgo or have withdrawn -- without any further consideration -- the provision of food and water if they should suffer some severe cognitive impairment.
In sum, the revision of Directive 58 underscores the moral complexity of contemporary healthcare, as well as the competence of the Church in providing solid moral guidance on complex moral issues in healthcare. It reminds us, moreover that our brothers and sisters who find themselves in impaired states requiring the administration of ANH retain their full human dignity until their natural demise. "The loving gaze of God the Father" wrote John Paul II, "continues to fall upon them, acknowledging them as his sons and daughters, especially in need of help."
Father Thomas Berg is a priest in the Archdiocese of New York and Professor of Moral Theology at St. Joseph’s Seminary (Dunwoodie).