Advances in technology and changes in the practice of medicine raise new questions about the teachings of the Catholic Church concerning death, the treatment of dying patients, the provision of nourishment and fluids to dying or comatose patients, and living wills. The principles governing these matters are clear, but their proper application to specific cases is often more difficult to discern. We wish therefore to speak to the Catholic people of Florida and to all people of good will about these subjects.
GENERAL PRINCIPLES
Our Judeo-Christian heritage holds that life is the gift of a loving God, and that each human being is made in the image and likeness of God. As Christians we also celebrate the fact that we have been redeemed by Jesus Christ and are called to share eternal life. We see life as a sacred trust over which we can claim stewardship, but not absolute dominion.
Therefore the Church condemns all direct attacks on life at any of its stages, including murder, euthanasia and willful suicide. It matters not whether death results from an affirmative act or a deliberate omission intended to cause death. The Vatican Declaration on Euthanasia states:
By euthanasia is understood an action or an omission which of itself or by intention causes death, in order that all suffering may in this way be eliminated. Euthanasia's terms of reference, therefore, are to be found in the intention of the will and in the methods used.
These prohibitions against murder, euthanasia, suicide and assisted suicide are based on the inherent dignity and fundamental value of each human being, and thus cannot be rejected on grounds of political pluralism or religious freedom.
Prolonged illness and the agony it sometimes brings cry out for the compassion and support of the entire community. The story of Jesus tells us that suffering need not be useless, but can become meaningful and redemptive through our response as we care for the sick and especially for those who are terminally ill. Illness and intense suffering do not justify the deliberate taking of human life, but rather call for a profound recognition of and respect for the dignity of the patient. Such dignity is not lost through illness because it resides in our relationship to God. Consequently the deliberate taking of life, even with the intention of ending suffering, is not permissible, nor is it a response worthy of a faithful steward. Medicine that is administered to suppress pain is permissible, even though it may have the side effect of hastening death, so long as the intention is to ease the pain.
Faithful stewardship over life requires us to preserve and promote it, to take care of our own health and to seek necessary medical care from others. This does not require that every possible remedy be used in every circumstance. Pope Pius XII explained this as follows:
But normally one is held to use only ordinary means--according to the circumstances of persons, places, times and culture--that is to say, means that do not involve any grave burden for oneself or another. A more strict obligation would be too burdensome for most 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 as long as he does not fail in some more serious duty. (Pius XII: "The Prolongation of Life" in The Pope Speaks 4:4:393 1957)
Subsequently, in 1980, the Vatican Declaration on Euthanasia elaborated on these principles:
In the past, moralists replied that one is never obliged to use "extraordinary" means. This reply, which as a principle still holds good, is perhaps less clear today, by reason of the imprecision of the term and the rapid progress made in the treatment of sickness. Thus some people prefer to speak of "proportionate" and "disproportionate" means. In any case, it will be possible to make a correct judgment as to the means by studying the type of treatment to be used, its degree of complexity or risk, its cost and the possibilities of using it, and comparing these elements with the result that can be expected, taking into account the state of the sick person and his or her physical and moral resources.
The application of this principle becomes difficult in many cases and should be made by the patient in consultation with his or her family, physician, and priest or minister, whenever that is possible.
With technological development and changes in medicine, the Church has been called on more and more to protect the dignity of the human person and to assert its ethic of life against an ethic that threatens the dignity of the unproductive and the weak.
The first principle, which is one that must be stated clearly and firmly, is that the disabled person (whether the disability be the result of a congenital handicap, chronic illness or accident, or from mental or physical deficiency, and whatever the severity of the disability) is a fully human subject with the corresponding innate, sacred and inviolable rights. This statement is based upon the firm recognition of the fact that a human being possesses a unique dignity and an independent value from the moment of conception and in every stage of development, whatever his or her physical condition. This principle, which stems from the upright conscience of humanity, must be made the inviolable basis of legislation and society. (Vatican Statement on the International Year of Disabled Persons, Origins, Vol. 10, Page 747, May 7, 1981.)
PROVISION OF SUSTENANCE
Regarding the artificial provision of sustenance, i.e. nourishment and hydration, the question arises whether it is always required or is a course of treatment that can be withdrawn like other life prolonging procedures. This issue raises important questions under the general principles that we have previously discussed. Clearly it is wrong to intentionally cause the death of anyone; we have an obligation to take all ordinary means to protect and preserve our own life and the lives of others; we are not obligated to use extraordinary means, or means that are either useless or unduly burdensome.
In most cases there is not an excessive burden in the artificial administration of nutrition and hydration. The total care of such patients may be a burden, but it is the burden of this particular treatment that must be judged, not the burden of the person's life itself. We can never justify the withdrawal of sustenance on the basis of the quality of life of the patient.
...Because human life has inherent value and dignity regardless of its condition, every patient should be provided with measures which can effectively preserve life without involving too grave a burden. Since food and water are necessities of life for all human beings and can generally be provided without the risks and burdens of more aggressive means for sustaining life, the law should establish a strong presumption in favor of their use. (Statement on Uniform Rights of the Terminally Ill Act, NCCB Committee for Pro-Life Activities, June, 1986, Origins, Vol. 16, Page 222.)
Clearly, nourishment or hydration may be withheld or withdrawn where that treatment itself is causing harm to the patient or is useless because the patient's death is imminent, as long as the patient is made comfortable. In general the terms "death is imminent" and "terminally ill" imply that a physician can predict that the patient will die of the fatal pathology within a few days or weeks, regardless of what life prolonging methods are utilized.
A treatment is judged excessively burdensome if it is too painful, too damaging to the patient's bodily self and functioning, too psychologically repugnant to the patient, too suppressive of the patient's mental life, or prohibitive in cost. Moral certainty of excessive burdensomeness is required to justify withdrawal of artificial hydration and nutrition.
The application of these principles to a patient who has been diagnosed with medical certainty to be permanently comatose, but whose death is not imminent, has aroused controversy. As stated, the strongest presumption must be given to continuing artificial sustenance. While the benefit is greatly reduced due to the lack of consciousness, human life itself is a good, and the life of comatose persons must be accorded respect. By the same token, the burdens of this treatment are limited, there being no, or very little, pain, discomfort or psychological repugnance. The cost of artificial nutrition and hydration is usually minimal, not much more than the cost of ordinary feeding. Thus we can say as a general rule that artificial sustenance should not be withheld or withdrawn from these patients.
It has been argued that to keep such persons alive through artificial sustenance involves serious financial burdens. On the other hand, we would point out that it is a financial burden to keep alive other classes of persons, such as those with severe mental illnesses or retardation or those with long-term disabilities. As the Church stated in its 1981 document for the International Year of Disabled Persons, "The respect, the dedication, the time and means required for the care of handicapped persons, even of those whose mental faculties are greatly affected, is the price that a society should generously pay in order to remain truly human."
The conclusions we have made in this paper are based on responsible stewardship of human life. We must take normal means to protect and preserve our own life and the lives of others. We are not obliged to use means that are useless or unduly burdensome. The question of whether we are obliged to provide artificial sustenance depends on whether particular circumstances would render such provision useless or excessively burdensome. It is necessary to note that the judgment made here is not that the person's life is useless or excessively burdensome. If the judgment made is that the particular means used to preserve life are useless because death is imminent or the means are excessively burdensome, there is no moral duty to provide them.
However, there is a grave danger that laws permitting the withdrawal of artificial sustenance will be construed in the context of euthanasia. If statutes or court decisions look upon the withdrawal as an act causing death and then permit such an act, then the door is opened for legal justification of other acts which more directly and immediately cause death. If the law is to permit the withdrawal of sustenance in limited circumstances, it should allow this, not as an act justifiably causing death because of the diminished quality of life of the patient, but rather as an act withholding useless or excessively burdensome means of prolonging life.
Hence one must not advocate the withdrawal of sustenance in a context or with reasoning which leads to euthanasia, a moral evil that is to be condemned.
LIVING WILLS
The term "living will" is a generic term given to documents by adults instructing family and physician to provide, withhold or withdraw life prolonging procedures at such time as the patient becomes incompetent and suffers from a terminal condition. There are many different versions or variations of living wills, some of which are morally acceptable while others are clearly wrong. Chapter 765, Florida Statutes, sets up a form of a "declaration" which is in effect a "living will." The Catholic Health Association and the Diocese of Venice have distributed similar forms, as have others.
Living wills have a limited role, but a well recognized one in the treatment of dying patients. A living will is most helpful for a person who has learned of a terminal diagnosis, and wishes to make some plans for his or her future treatment.
There are certain particular cautions that should be taken in executing a living will. First, the document should clearly distinguish between a terminal condition in which death is imminent, and other conditions in which one could live a long time with easily provided medical care. Second, one should never ask for or demand euthanasia, mercy killing or the withholding of "ordinary means" of sustaining life. This is not only wrong for the signer of the document, but it also does a serious injustice to physicians, family and medical personnel to whom such immoral demands are made. Third, if there is any possibility that the signer may become pregnant, then certainly every measure should be called for to preserve the life of the unborn child.
Whenever a person executes such a document, he or she has to confront the realities of life and of death. It is a time when the family, especially a spouse, should be consulted and decisions are best made together. A person's physician and sometimes an attorney should be consulted. One need not shy away from executing a living will.
CATHOLIC HEALTH PERSONNEL
We would like to take this opportunity to thank the people working in health care. This includes administrators, physicians, nurses, and all health and pastoral care persons. We thank them on behalf of all the people whose lives they touch through their healing ministry and we remind them of the tremendous influence they have on the people who come to them.
The testimony of the Gospel makes it clear that they are following in the footsteps of Jesus and are helping the Church to fulfill its great ministry to those who are ill. To them we say: Jesus is speaking to you as he did to his apostles when he said "cure the sick." You have various special talents and spiritual gifts. Let the power of the Lord heal your patients, bodily and spiritually, through your loving and caring ministry.
CONCLUSION
All of us face these questions either personally or as members of our society. As Christians we are assured by the words of St. Paul: "None of us lives to himself, and none of us dies to himself. If we live, we live to the Lord and if we die, we die to the Lord; so then, whether we live or whether we die, we are the Lord's." (Rom. 14:7-8).
As people of Florida and of this nation, our charge is well expressed by the Holy See:
The quality of a society and a civilization is measured by the respect shown to the weakest of its members. A perfect technological society which only allowed fully functional members and which neglected, institutionalized or, what is worse, eliminated those who did not measure up to this standard or who were unable to carry out a useful role, would have to be considered as radically unworthy of man however economically successful it might be. Such a society would in fact be tainted by a sort of discrimination no less worthy of condemnation than racial discrimination; it would be discrimination by the strong and "healthy" against the weak and the sick. It must be clearly affirmed that a disabled person is one of us, a sharer in the same humanity. By recognizing and promoting that person's dignity and rights we are recognizing and promoting our own dignity and our rights. (Statement of the Holy See on the International Year of the Disabled, Origins, Vol. 10, Page 748.)
Edward A. McCarthy
Archbishop of Miami
Thomas J. Grady
Bishop of Orlando
W. Thomas Larkin
Bishop of St. Petersburg
John J. Snyder
Bishop of St. Augustine
J. Keith Symons
Bishop of Pensacola-Tallahassee
Thomas V. Daily
Bishop of Palm Beach
John J. Nevins
Bishop of Venice
Agustin A. Roman
Auxiliary Bishop of Miami
Norbert M. Dorsey
Auxiliary Bishop of Miami