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Nutrition & Hydration/Persistent Vegetative State (PVS)

Nutrition & Hydration/Persistent Vegetative State (PVS)

For decades, our society has debated the moral and legal issues surrounding the use of – and withholding or withdrawal from – various forms of life-sustaining treatment or care, particularly for patients in what is known as a persistent vegetative state (PVS). For example, the Karen Ann Quinlan case was litigated in 1975-1976, but after being removed from mechanical ventilation in 1976, she lived for another nine years with the help of artificial nutrition and hydration (ANH). Beginning in the 1990s and continuing until her death on March 31, 2005—two days before the death of Pope (now Saint) John Paul II—ANH was the central issue in the Terri Schiavo case. During this time, Catholic theologians, and occasionally bishops, debated the underlying issue of providing ANH to those in a PVS. While the Schiavo case was gaining attention, Pope John Paul II delivered a speech on March 20, 2004, to “participants in the international congress on ‘Life-Sustaining Treatments and Vegetative State: Scientific Advances and Ethical Dilemmas,'” in which he taught that ANH for PVS patients is “in principle ordinary and proportionate, and thus obligatory.” Following that, on August 1, 2007, the Congregation for the Doctrine of the Faith (CDF) emphasized this teaching in a response (with accompanying commentary)1 to questions submitted by the United States Conference of Catholic Bishops (USCCB) (with some further clarification).
Several ecclesiastical documents (dating back to Pope Pius XII’s 1958 “The Prolongation of Life”) provide context for Pope John Paul II’s address, as well as a number of essays by theologians and others on the topic of PVS/ANH—some written before Pope John Paul’s address, others responding directly to him; some defending the position that ANH should normally be provided to PVS patients, others disagreeing. The anthology edited by Ronald Hamel and James Walter contains the following documents: Pope Pius XII’s teaching (Chapter 6), as well as the CDF’s “Declaration on Euthanasia” (Chapter 7); a statement by the Pontifical Academy of Sciences (Chapter 8); a statement by the Texas bishops (Chapter 9); a statement by the (then) National Conference of Catholic Bishops (now the USCCB) Committee for Pro- (Chapter 15). The Texas bishops’ statement (from 1990, a few years before Pope John Paul’s address) is the only one that holds that ANH for PVS patients is not morally required. Furthermore, Hamel and Walter include the American Academy of Neurology’s position paper on the topic (Chapter 1), which states that PVS patients are unconscious, and ANH should be used initially until a patient is clearly in a PVS, but ANH should be used initially until a patient is clearly in a PVS.

Several other essays in the Hamel and Walter volume defend, or come close to defending, what is now the Catholic Church’s clear teaching (that ANH for those in a PVS is obligatory). According to Myles Sheehan (Chapter 2), there are some contraindications for the use of ANH, and the mortality rate for ANH patients is high because many patients who are given ANH die in any case. However, Sheehan contends that there should be a presumption in favor of providing ANH, and that facility staffing plans and patient care plans should ensure that patients’ needs (including ANH) are met. Donald Henke (Chapter 4) provides a good history of the distinction in Catholic thought between “ordinary” and “extraordinary” means of sustaining life, dating back to Francisco de Vitoria and Dominic Soto in the 1500s and rooted even in St. Thomas Aquinas’ (1200s) thought, and continuing into the twentieth century and beyond. In the case of the PVS patient, Henke concludes that “the Catholic Church’s decision to promote the provision of AAHN [artificially assisted hydration and nutrition] to sustain the patient’s life is more in line with respect for the person than is a position that advocates the removal of AAHN.”
Nutrition & Hydration/Persistent Vegetative State (PVS)
Although Germain Grisez (Chapter 13) previously “thought that it is not reasonable to provide food to comatose patients,” he changed his mind for six reasons. Among these are the discoveries that tube feeding, as opposed to “the total cost of caring for” the patient, “costs very little” and “requires very little time,” and that caring for a family member serves not only the good of that person’s life but also “the good of human solidarity.” Grisez continues to acknowledge that the practical judgment in favor of feeding comatose patients may differ in a very poor society or in the case of a patient who, while still competent, clearly rejected ANH should she ever become comatose. He also notes—importantly, I believe—that withholding ANH in order to eliminate the burden inherent in the total care required by a patient necessarily means willing (rather than simply accepting) the patient’s death, because withholding ANH eliminates the burden of providing the other care also required by the patient only by causing her death. Grisez goes on to argue that bodily life “is an intrinsic part of one’s personal reality” and thus remains a good (and something one may not oppose) even when cognitive function has ceased (as when one is comatose, or—perhaps—when one is in a PVS). He claims that the alternative viewpoint is a form of dualism.

As we will see, Grisez is not the only contributor to these volumes who accuses his opponents of person-body dualism (the majority, but not all, are those arguing in favor of providing ANH to PVS patients and others with severe/permanent neurological deficits). I’ve long wondered if this is the most fruitful way to frame the debate. It appears to me that someone could (albeit mistakenly) deny that bodily life is intrinsically good by claiming that the unified person ceases to exist when cognitive function is no longer possible (and, at the other end of life, that the unified person does not yet exist until cognitive function becomes possible). This is distinct from the dualistic claim that the person is not a unified body-soul entity.

To put it another way, this position would imply a close analogy between PVS patients and those who are brain dead (and we might recall here that Pope John Paul II, who was undoubtedly aware that many organ systems continue to function together even after brain death, and who had over the years thought as much about philosophical anthropology as anyone has, nonetheless taught in a 2000 address that the use of neurological criteria for determining death “does not seem to c It appears to me that a more philosophically helpful response to those who believe that bodily life is no longer a good for those in a PVS would be one that seeks to demonstrate how some (even if minimal) “potential” (in the philosophical sense of the term) for cognitive function remains in PVS patients (unlike those who are brain dead); in other words, how the cases of PVS and brain death are not philosophically (or medically) analogous (more below on the question of what brain function may remain in PVS patients). (Of course, one could argue that brain death is not the death of a human being, in which case any similarity between brain death and PVS would not serve to establish that PVS patients do not require life-sustaining care. However, I am not among those who believe that the Church’s teaching on brain death is still permissible or that it is a philosophically sound view, even though respectful questioning of the teaching is certainly legitimate.)

Long of the USCCB’s Secretariat for Pro-Life Activities, Richard Doerflinger (Chapter 16), makes a brief argument that Pope John Paul II’s 2004 teaching “is not a radical shift but the culmination of a longstanding trend at the Vatican,” referring to Pope John Paul’s 1995 encyclical Evangelium Vitae, the 1995 Charter for Health Care Workers by the Pontifical Council for Pastoral Assistance to Health Care Workers, and a 1998 ad Mark Repenshek and John Paul Slosar (Chapter 17) rehearse some of the history of Catholic thought on the distinction between “ordinary” and “extraordinary” life-sustaining care (overlapping with Chapter 4), and show some sympathy for the criticism that Pope John Paul II’s address is at odds with how this distinction had previously been interpreted, but reject the criticism on the grounds that Pope John Paul (even while establishing a presumption in favor of “ordinary”) life-sustaining care) It is unclear what Repenshek and Slosar consider to be “appropriate surrogate decisions”; any elaboration of their claim would have to take into account Pope John Paul’s words in his address: “to admit that decisions regarding man’s life can be based on the external acknowledgment of its quality, is the same as admitting that increasing and decreasing levels of quality of life, and thus of human dignity, can be attributed from an external perspective to any sacrificial sacrifice.” (It appears that a surrogate decision would be “external,” though it could be based on criteria other than “quality of life.”)

Finally, in Chapter 20, John R. Connery, SJ discusses a court case involving ANH for a comatose patient. Connery’s essay concludes with an examination of testimony provided in that case (and apparently crucial in leading to the court’s decision that treatment could be withdrawn) by John Paris, SJ, that permanently unconscious patients have a low quality of life because they “have exhausted their potential for value and for living,” and that the CDF’s “Declaration on Euthanasia” supports this view. Connery objects to his brother Jesuit’s testimony, claiming that even unconscious life is beneficial and that the CDF does not suggest otherwise. This observation about the “Declaration on Euthanasia” is significant, in my opinion, because some authors (for example, some of those I will discuss next) argue that Pope John Paul II’s teaching contradicts that found in the “Declaration.”

Other essays collected by Hamel and Walter are more critical of the Church’s teaching and some theologians’ arguments that PVS patients should “in principle” receive ANH. Michael Panicola (Chapter 3) and Hamel and Panicola (Chapter 5) argue that prolongation of life in a PVS patient does not count as a “benefit,” and thus that the position that PVS patients should receive ANH is at odds with the traditional Catholic understanding that treatments that are more burdensome than beneficial are not obligatory. While, as previously stated, I am not convinced that this position necessarily/always implies “dualism,” I believe it is incorrect. For one thing, as Grisez and others have pointed out, the burdens imposed by ANH (as opposed to the other burdens associated with a PVS patient’s underlying condition) are typically quite minor. As a result, even if ANH is only marginally beneficial, the benefits would still outweigh the drawbacks. For another, it seems hasty and premature (at best) to judge that the patient’s body has lost all capacity for participating in rational life (as is, I believe, the case in brain death) and thus has lost the value otherwise attached to the body of a living human person for (at least) as long as some brain life/function (even if not “consciousness”) remains. (Although this isn’t the most important point, I’m not sure we can tell that a PVS patient isn’t “conscious.” The burden of proof appears to be on those who would deny this, that neurological arguments that such a patient is not conscious are not entirely convincing, and that arguments based on behavior or lack thereof are especially unconvincing (more on this later). Hamel and Panicola also claim that Pope John Paul II proposes a “limited physical understanding of benefit” along the way. The term “limited” appears to be misleading here; it is Hamel and Panicola, as well as others who share their viewpoint, who want to “limit” what “counts” as benefit (so that bodily life would not so count).

Thomas Shannon and Walter (Chapter 12) go into great detail about the responses of US bishops to a survey about diocesan policies on ANH. As Shannon and Walter conclude, diocesan policies on this subject vary greatly. Shannon and Walter then argue that ANH for PVS patients can be excessive and optional. They argue, among other things, that the life supported by ANH can be difficult. Furthermore, they claim that in order to differentiate between proportionate and disproportionate care,

The burden is to be assessed not only from the standpoint of the burdensome effects of the technology itself, but also from the standpoint of “the burdens that an individual experiences in pursuing the goals or ends of life” as a result of medical technology intervention.

I’m not sure how they reconcile this claim with their insistence that withdrawing ANH does not imply intent to die. Again, if ANH is withdrawn in order to relieve burdens other than those caused by ANH, the withdrawal of ANH only succeeds in relieving those other burdens by causing the patient’s death. In other words, the person who withdraws the ANH intends for the patient to die. Shannon and Walter would almost certainly disagree with my account of “intention,” because they are clearly using proportionalist terminology (e.g., “ontic value”) and methodology, which has its own way of defining “intention” and the like (and which is rejected by the Church, most notably in Pope John Paul II’s 1993 encyclical Veritatis Splendor). They also say things that could be considered dualism (“it is necessary to distinguish clearly and consistently between physical or biological life and personal life (personhood)”).

According to Daniel Sulmasy, OFM (Chapter 14), even when a treatment like ANH provides a benefit, it can still be significantly burdensome. He agrees that it is not (in and of itself) expensive, but adds that other forms of life-sustaining treatment, such as home continuous ambulatory peritoneal dialysis (CAPD), are becoming similarly affordable. He does not appear to address the question of whether CAPD may impose additional burdens that ANH does not. If it does, then teaching that ANH is in principle proportionate and obligatory does not imply the same conclusion about CAPD. If it does not (unlike outpatient hemodialysis), it is unclear why the conclusion that it is proportionate and obligatory would be problematic (Sulmasy seems to assume that this conclusion would be a problem and therefore that if the obligatory nature of ANH would also entail the obligatory nature of CAPD, then ANH cannot be obligatory). Sulmasy also claims that an unconscious patient on ANH may be “suffering” in some ways. Is the suffering he refers to caused by the ANH or by the patient’s underlying condition? If the latter, then removing ANH to relieve it would be intentional death.

Another essay (Chapter 18) by Shannon and Walter rehearses the history of the Catholic tradition and refers to Pope John Paul II’s teaching as “revisionist” in relation to this tradition. This argument is based on the claim that ANH is more burdensome than beneficial for PVS patients; if that is not the case (as other authors here argue), then the discontinuity is not real. It is not true that Pope John Paul resolves the issue simply “by definition or stipulation” that ANH is ordinary and proportionate, as Shannon and Walter claim (and obligatory). Rather, Pope John Paul II teaches that life is always a good, and that the burdens associated with ANH do not outweigh the benefit of sustaining life. Similarly, Kevin O’Rourke, OP (Chapter 19) makes a more respectful argument. O’Rourke’s essay is also included in the Tollefsen volume and will be discussed further below.

SJ Richard McCormick (Chapter 21) takes an unusual approach. On the one hand, he appears to suggest in the final pages of his essay that ANH may not be required. He claims that patients who require it “may be classified broadly as dying” (the word “broadly” appears to do a lot of “work”), that ANH “is a medical procedure,” that “its discontinuance need not involve aiming at… death,” and that quality of life is an important consideration. On the other hand, he sees “a huge potential for abuse” and that “the progression [regarding what types of care will be withheld from what types of patients, as he documents in the main part of his essay] is obvious, and obviously dangerous.” He concludes that “it is best to err on the side of preserving life, if at all.”

Christopher Tollefsen has compiled a collection of essays that, for the most part, back up the Church’s teaching that ANH is generally required for PVS patients. Many people agree with Tollefsen’s philosophical viewpoint, which is based on Germain Grisez and John Finnis’ “new natural law” theory. Bishop Anthony Fisher, OP (Chapter 1) draws on this and Alasdair MacIntyre’s perspectives to argue that those who are dependent, rather than autonomous, still have human dignity and inviolability and, as the Church has taught, should be provided with nutrition and hydration. Fisher also mentions the importance of food and drink in the Gospels and the Church. He connects the philosophical concept of human dignity to the Christian concept of sanctity of life, claiming that the latter “has the most bite at the margins, i.e., when it is most difficult to adhere to the principle of not killing the innocent.” Bishop Fisher concludes by responding to some of the criticisms leveled at the viewpoint he defends.

Drawing on the work of Alan Shewmon, MD, Michael Degnan (Chapter 2) contends, convincingly (to me), that neurological (as well as behavioral) evidence supports the view that “vegetative state” patients can feel pain. He also mentions that patients in this state are sometimes diagnosed with PVS prematurely, i.e., while they still have a good chance of recovery (statistically speaking) (during the first year). With these clarifications in mind, he argues (again, drawing on MacIntyre) that a community must provide ordinary/proportionate care to its members as part of its commitment to the common good, without which its authority over its members is illegitimate; and that ANH (even when not curative) offers a variety of benefits to both the patient and the community. Degnan, like Fisher, responds to some criticism.

William May (Chapter 3) summarizes some responses to Pope John Paul II’s 2004 address before briefly commenting on and responding to criticisms of that address, drawing on Shewmon and Grisez (May is Grisez’s frequent coauthor). Jacqueline Laing (Chapter 4) criticizes a 2005 English and Welsh law that requires ANH withdrawal in certain circumstances.

Alfonso Gómez-Lobo (Chapter 5) distinguishes between the view that life is a basic good and the claim that it is an absolute good that must be preserved at all costs, and he also acknowledges that withdrawing ANH does not always imply intending death. His argument on the latter point, however, is based on what he refers to as “traditional action theory,” which includes concepts such as the finis operis (“the objective of the action itself”) and the finis operantis (“the agent’s additional purpose”). True, the agent’s intention is the second of three determinants of the morality of the action (finis operantis). However, I believe that scholarship over the last four to five decades has convincingly demonstrated that the first determinant of an action’s morality is not the action’s objective, but rather the act itself (and that this is the authentically “traditional” position). When one speaks of an action’s “object, intention, and circumstances,” this is what the term “object” refers to. The incorporation of this development in action theory could help Gómez-argument. Lobo’s He also expresses concern that the development of ever more non-burdensome means of extending life will imply that all such means will always be proportionate, ordinary, and obligatory (compare Sulmasy’s point about CAPD, summarized above). I’m not convinced that this is as obviously “paradoxical and unpalatable” as he believes. I’m even less confident that we’ll be successful in developing such tools. As a result, I am not concerned about the potential long-term consequences of traditional (and current) approaches to life-sustaining treatments.

Joseph Boyle (another of Grisez’s frequent coauthors) offers some comments on Pope John Paul II’s address (Chapter 6), notes that “in principle” does not mean “always,” and contends that some cases in which ANH is required to sustain life are sufficiently different from PVS cases that ANH may not be required in those other cases (even though the same underlying principles continue to apply). He goes on to say that an advance directive opposing ANH is not necessarily suicidal (does not necessarily intend death). J.L.A. Garcia (Chapter 7) provides a possible interpretation and defense of Pope John Paul’s address, as well as some indications of when ANH is not morally obligatory.

Peter Cataldo (Chapter 8) responds to Garcia, mostly agreeing with him but making some helpful clarifications and additions. For one thing, Cataldo reconciles Pope John Paul II’s 2004 address, in which he stated that ANH is both a “artificial means” of providing water and food and a “natural means” of preserving life. Cataldo observes that providing food and water is an action that “naturally” (per se) tends to preserve life, even when the action employs “artificial” means such as a tube. This is an important point for Cataldo because the “natural” tendency of food and water to preserve life relates to the proper way of determining whether ANH is excessively burdensome in a particular case. If ANH does not accomplish this natural purpose in a specific case (per accidens) because the patient is unable to assimilate food and water, or (again, per accidens) causes complications and suffering, then it is not mandatory. Cataldo also denies that Pope John Paul II would always require that a patient’s refusal of ANH be respected. Rather, Cataldo contends, only the proper use of patient autonomy must be respected; a misuse of this autonomy may be legitimately corrected by a patient’s caregivers.

For another, he connects Pope Saint John Paul II’s March 2004 speech on ANH/PVS to a letter written by the late Pope in November of the same year, “on the Occasion of the 23rd National Congress of the Italian Catholic Physicians’ Association.” Pope John Paul II writes in this letter:

Personal dignity is a fundamental feature of every human being, and disparity is neither acceptable nor justifiable!

Cataldo is correct, it appears to me, that this is a development of Catholic teaching; additionally, it is an explicit rejection of person-body dualism and the like (perhaps even the sort of non-dualistic rejection of the PVS patient’s “personhood” that I sketched above). However, there is still a need to clarify who does (and does not) “count” as a living human being, because some critics may “bite the bullet” and argue that a PVS patient is no longer a living human being (based on a claim that the neurological insult that causes PVS is such a biological discontinuity that it renders one no longer the same organism, with the same nature, as one was before suffering this insult).

The following section of Tollefsen’s book is a “Symposium on the Views of Fr. Kevin O’Rourke, O.P.” Chapter 9 contains O’Rourke’s initial reflections on Pope John Paul II’s 2004 address (the same reflections published in the Hamel and Walter volume mentioned above). This is followed by a response from my Franciscan University of Steubenville colleague Patrick Lee (Chapter 10), a response to Lee by O’Rourke (Chapter 11), and another response to O’Rourke by Mark Latkovic (Chapter 12). (Chapter 12). O’Rourke attempts to express some of his disagreements with Pope John Paul in a way that adheres to the standards outlined in the CDF’s “Instruction on the Ecclesial Vocation of the Theologian.” O’Rourke, in particular, opposes what he refers to as Pope John Paul’s

assumption… that there is some benefit to prolonging life for a patient in a [PVS], even if the patient is unlikely to recover.

Second, O’Rourke disagrees with the “assumption” that various “medical facts and findings” regarding the improbability of recovery from PVS are invalid. Furthermore, he adds as “positive reasons for disagreement with the teaching” his long-held belief that PVS patients can no longer pursue the purpose of human life—friendship with God—and thus have no obligation to live.

Lee’s response correctly notes that it is not a “assumption” of Pope John Paul II’s teaching, but rather a component of that teaching, that sustaining life is beneficial in any case. He also points out that “relying on some scientists rather than others” is not the same as “ignoring” the others, and that “the Pope’s central teaching does not logically depend on these statements” about PVS patients’ prognosis. Lee argues that maintaining bodily life is always beneficial because friendship with God is something in which we participate, already in this life and as a body-soul composite. This is unquestionably correct. Lee asserts that the opposite position would be dualism; for the reasons stated above (and others, such as someone attempting to argue that bodily participation, here and now, in friendship with God is dependent on consciousness), I am not convinced that this is necessarily true. He also defends Pope John Paul’s claim that withholding ANH is “euthanasia,” arguing that withholding it can only be done to avoid the burdens of the patient’s continued life. This argument, I believe, requires some qualification. In some cases, ANH may be withheld due to a (misguided) belief that it is disproportionately burdensome (either because it is greatly burdensome or because the patient’s continued life is not greatly beneficial). In these cases, withholding ANH would be wrong (insofar as the benefits/burdens judgments are incorrect), but it would not involve intentional killing (as an end or means), and thus would not be euthanasia.

In turn, O’Rourke expresses confidence that the PVS diagnosis can be made with moral certainty, and that when such certainty exists, ANH can be withheld as more burdensome than beneficial. In making this response, he attempts to turn the charge of “dualism” back on those who make it:

If anyone is guilty of dualism, it is Grisez and his followers, because they elevate the “mere biological function of the body” (to use Lee’s terminology) to an absolute value.

If I’m not sure whether O’Rourke, Shannon, Walter, and others with similar views are dualists, I’m certain that Grisez and Lee are not (this despite some disagreements on my part with their philosophical anthropology). O’Rourke’s argument appears to be a non sequitur. Furthermore, it is difficult to sustain the claim that Grisez and Lee regard bodily life as a “absolute” value; not only do they deny doing so, but they argue in ways that contradict doing so when they defend the view that truly disproportionate treatments may be avoided. O’Rourke also attempts to refute the claim that ANH is not burdensome by stating that

PVS patients are usually treated in a hospital or a long-term care facility, which is very expensive. Even if a family attempts to care for a PVS patient at home on occasion, it necessitates constantly changing and turning the patient.

However, O’Rourke is referring to the burdens associated with PVS, not the burdens imposed directly by the use of ANH. If ANH is foregone in order to avoid the burdens mentioned by O’Rourke, we have euthanasia in the precise sense that Pope John Paul II suggests.

In his response to O’Rourke, Latkovic (a Grisez-Finnis supporter like Lee) makes several points (including also along the way the charge of dualism). For starters, PVS patients are not dying in the traditional sense (it cannot be maintained that denying them ANH simply allows them to die from their underlying condition). For another, maintaining unconscious bodily life (if PVS patients are indeed unconscious—Latkovic adds to Degnan’s evidence) is not without benefit, because even the unconscious retain their capacity for friendship with God (as indicated by the fact that the Church offers them several of the sacraments). For another, even if life is a secondary good in comparison to others (which Grisez, Latkovic, and others of their school deny, but which I affirm), this does not imply that the good of life can be licitly contradicted. Regarding the burdens associated with caring for a PVS patient, Latkovic agrees with John Finnis that someone making an advance directive should consider this (to apply in the event of PVS)

could [correctly] conclude that the duty to give and accept ordinary care entails no more than providing such food, water, and nursing care as is available from one’s own resources.

This appears to be correct. As Latkovic points out, Pope John Paul II calls for various types of “support” for families who must provide such care to a member. O’Rourke disregards this.

Tollefsen closes the book (Chapter 13) with an essay titled “Ten Errors Regarding End-of-Life Issues, Particularly Artificial Nutrition and Hydration.” The mistakes are as follows: (1) “It is permissible to act with the intention of allowing someone to die”; (2) “The relevant distinction is between acting and omitting”; (3) “ANH is futile care”; (4) “It is permissible to accept futile care”; (5) “All rejection of ‘ordinary care’ is suicidal”; (6) “No rejection of ‘extraordinary’ means is suicidal”; (7) “It is permissible to accept extraordinary treatment” Tollefsen’s classification of these as errors and explanation of why they are errors are, for the most part, correct. However, I have two possible disagreements with numbers 7 and 8.

If “extraordinary” treatment means treatment that will almost certainly be disproportionately burdensome, Tollefsen is correct in arguing that accepting it would be unreasonable and unconstitutional. However, the CDF’s Declaration on Euthanasia states that “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 expected result, taking into account the sick person’s state and his or her physical and moral resources.” Take note of the references to “risk” and “expected outcome.” A “disproportionate” treatment, it appears to me, is one that imposes a high “risk” of burdens and a low “expectation” of benefits. Indeed, in many cases, there is no certainty (or even close to certainty) that a treatment will be more burdensome than beneficial; all that is known is that it is possible or likely. Accepting an extraordinary means of treatment may be permissible if “disproportionate” and thus “extraordinary” are defined in terms of probabilities rather than certainties. The CDF continues, saying:

If no other adequate remedies are available, it is permissible, with the patient’s consent, to use the means provided by the most advanced medical techniques, even if these means are still in the experimental stage and are not without risk. Accepting them allows the patient to be generous in the service of humanity.

Such methods appear to be among the “extraordinary” ones. One could try to explain away the problem by referring to “generosity in the service of humanity” as the benefit that makes the burdens less than disproportionate and the treatment ordinary, but I’m not sure this would be convincing.

Tollefsen also contends that it is not only permissible to withdraw ANH (which I agree with), but also morally obligatory for doctors and family members to act in accordance with patients’ wishes to refuse ANH. While such wishes can be morally upright, they may not be in all cases, and in some cases it may be clear that they are not—for example, if a person making an advance directive states clearly and explicitly that she would not want to live in a PVS and, as a result, would not want ANH if in a PVS. In such cases, I believe Cataldo’s (discussed above) viewpoint on the limits of patient autonomy is more plausible. Tollefsen correctly observes that acting against a patient’s wishes in such a case would constitute civil disobedience, and adds:

If [Pope John Paul II] believed that following the requirements of the law in these matters was morally unacceptable, he would have said so.

Despite Tollefsen’s “certainly,” I am not convinced by this argument from silence. This is especially true given Pope John Paul’s three references in Evangelium Vitae (nn. 73, 74, and 89) to the need for conscientious objection to laws that unjustly permit euthanasia (as well as abortion). Why should the 2004 address (which mentions euthanasia) not be read in light of these Evangelium vitae statements?

Although Hamel and Walter’s volume is fairly balanced between opponents and supporters of the view that ANH should normally be provided to PVS patients, there may be more repetition among a number of its chapters (e.g., on the history of Catholic thought on life-sustaining care) than would have been ideal. I would also argue that the volume’s title, “the permanently unconscious patient,” is both ambiguous and presumptuous, because one of the most important questions to address in discussions of treatment for PVS patients is whether they are “conscious.” Although not all of the essays in Tollefsen’s volume are written from the perspective of the Grisez “new natural law” school (e.g., Garcia is not a member of this school), the volume is “tilted” fairly heavily toward this approach. It would have been beneficial for the collection to include a little more material that reflects alternative viewpoints while supporting and explaining the Church’s teaching.

However, both of these books have significant merits. A collection of material containing some of the most important ecclesiastical documents pertaining to ANH/PVS can be beneficial. Furthermore, especially those Catholics who want to participate in defending the Church’s teaching may benefit from hearing opponents’ arguments in their own words. The more one understands the specifics of the opposing viewpoint, the better one may be able to formulate convincing responses. As a result of these considerations, Hamel and Walter’s Artificial Nutrition and Hydration and the Permanently Unconscious Patient plays a role. Many people would benefit from reading a number of essays, all of which are sympathetic to what Pope John Paul II said about ANH/PVS in his 2004 address, and which seek to explain the Church’s teaching from that position of assent in various ways (reflecting varied interests and somewhat varied legitimate philosophical/theological perspectives). Tollefsen’s Artificial Nutrition and Hydration would be beneficial to these people.
After studying the course materials located on Module 7: Lecture Materials & Resources page, answer the following:

Cure / care: compare and contrast.
Basic care: Nutrition, hydration, shelter, human interaction.
Are we morally obliged to this? Why? Example
Swallow test, describe; when is it indicated?
When is medically assisted N/H indicated?
Briefly describe Enteral Nutrition (EN), including:
NJ tube
NG tube
Briefly describe Parenteral Nutrition (PN), including:
a. Total parenteral nutrition
b. Partial parenteral nutrition
Bioethical analysis of N/H; state the basic principle and briefly describe the two exceptions.
Case Study: Terry Schiavo (EXCEL FILE on Module 7: Lecture Materials & Resources page). Provide a bioethical analysis of her case; should we continue with the PEG or not? Why yes or why not?
Read and summarize ERD paragraphs #: 32, 33, 34, 56, 57, 58.
Submission Instructions:
The submission is to be clear and concise and students will lose points for improper grammar, punctuation, and misspelling.
If references are used, please cite properly according to the current APA style.

Ethical and Religious Directives (ERD) for Catholic Health Care Services (6th ed.). (2018).
Paragraphs: 32, 33, 34, 56, 57, 58
PHI 3633 WK 7.pdfDownload PHI 3633 WK 7.pdf
Cioffi, A. (2018, March 24). BIO 603 3 24 18 [Video file]. Retrieved fromBIO 603 3 24 18

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1. Professional & Expert Writers: Nursing Solved only hires the best. Our writers are specially selected and recruited, after which they undergo further training to perfect their skills for specialization purposes. Moreover, our writers are holders of masters and Ph.D. degrees. They have impressive academic records, besides being native English speakers.

2. Top Quality Papers: Our customers are always guaranteed of papers that exceed their expectations. All our writers have +5 years of experience. This implies that all papers are written by individuals who are experts in their fields. In addition, the quality team reviews all the papers before sending them to the customers.

3. Plagiarism-Free Papers: All papers provided by Nursing Solved are written from scratch. Appropriate referencing and citation of key information are followed. Plagiarism checkers are used by the Quality assurance team and our editors just to double-check that there are no instances of plagiarism.

4. Timely Delivery: Time wasted is equivalent to a failed dedication and commitment. Nursing Solved is known for timely delivery of any pending customer orders. Customers are well informed of the progress of their papers to ensure they keep track of what the writer is providing before the final draft is sent for grading.

5. Affordable Prices: Our prices are fairly structured to fit in all groups. Any customer willing to place their assignments with us can do so at very affordable prices. In addition, our customers enjoy regular discounts and bonuses.

6. 24/7 Customer Support: At Nursing Solved we have put in place a team of experts who answer to all customer inquiries promptly. The best part is the ever-availability of the team. Customers can make inquiries anytime.