A woman who finds out that her unborn baby has a severe brain abnormality has the pregnancy terminated in the second trimester. A hospital goes to court for permission to remove a feeding tube from a brain-injured, homeless man.
Cases like these are so commonplace today that they barely raise an eyebrow. But they have rarely involved Catholic institutions. However, in a trend that worries the pro-life movement, some Church-supported health care institutions and Catholic ethicists have begun to challenge Church practice and teaching.
In a 1993 article, "Anencephaly and the Management of Pregnancy", Sr. Jean deBlois, CSJ, senior associate for clinical ethics at The Catholic Health Association, cites anencephaly, a condition in which an unborn baby is missing major portions of the brain and skull, as a case where "the pregnancy may be terminated at any time". Although Sr. deBlois admits that "there is no life-threatening maternal pathology", she cites the possibility of difficulties during labor and delivery, the "emotional trauma" of the diagnosis on parents, and the lack of mental development in the baby as justification for "inducing labor to end the pregnancy". Emplying the principles of proportionality and double effect, she reasons that "the resulting fetal death is indirect" and thus not a directly intended abortion. Sr. deBlois further states that because "human life involves more than simply biologic life" and infants with anencephaly lack "psychologic, social, and creative capacities", such babies "can never acquire the quality of viability, properly understood" -- despite the traditional definition of viability as the ability to live outside the womb. Thus, she says, the termination of pregnancy is allowable at any point in pregnancy.
The article was later included in the 1994 book A Primer for Health Care Ethics -- Essays for a Pluralistic Society (deBlois, O'Rourke, and Norris) and there have been reports of such "terminations" being proposed and even occurring in Catholic hospitals, raising strong objections from both prolife and medical groups.
Dr. T. Murphy Goodwin, assistant professor of maternal-fetal medicine at the University of Southern California, writing in the March 1996 issue of Ethics and Medics, notes that "Even in Catholic institutions, early induction has been proposed as a humane option with the reasoning that the proportionate benefit to the fetus of living a few more weeks is outweighed by almost any burden on the mother and the family." But, he counters, "there is rarely any physical risk to the mother of carrying through an anencephalic gestation compared to early induction (of labor)" "Early induction before viability ," Dr. Goodwin wrote, "hastens the death of the child for the purpose of ending the parents' grief."
Dr. William Burke, a neurologist and associate professor of neurology at St. Louis University, concurs with Dr. Goodwin's opinion and told the Register that "the diagnosis of anencephaly cannot be made with absolute certainty prior to birth and, even after birth, errors in diagnosis have been described in (medical) literature". He also strongly objected to Sr. deBlois' new definition of viability and says that "anencephalic infants have the same intrinsic value as any other human being, normal or disabled". Dr. Burke said he was "outraged" when other doctors told him that such abortions had already occurred at a Catholic hospital.
Mary Kay Culp, president of Missouri Right to Life, says "I worry that arguments like Sr. deBlois' will be used to undermine our efforts to protect the lives of all unborn babies with disabilities. This article gives tacit support to many pro-abortion arguments and I am deeply disturbed that this is coming from a Catholic source."
Archbishop Justin Rigali of St. Louis, writing in the June 2, 1995 edition of the St. Louis Review, underlined the "extreme importance (of) is the witness of the Catholic health care community of the Archdiocese in not cooperating in any abortion of anencephalic fetuses or in the donation of the infants' organs before they're dead."
Prolifers were also stunned when the Jan. 21, 1996 edition of the St. Louis Post-Dispatch reported that St. Anthony's Medical Center was going to court to ask permission to remove the feeding tube from Lucio Bretana, a 44-year-old homeless man, who sustained severe head injuries following a beating and had been a patient at the Catholic institution for six months. Because Mr. Bretana could not speak for himself and no relatives were found, a court-appointed guardian and lawyer, Robert Weis, was appointed. Mr. Weis opposed the removal of Mr. Bretana's feeding tube based on Missouri law requiring "clear and convincing" evidence of a prior decision by a person that he or she would want food and water withdrawn in such a situation. The court ultimately agreed and Mr. Bretana was transferred to a non-Catholic long-term health facility where he is today.
After the court hearing, Thomas Hooyman, Ph.d., the Catholic ethicist for St. Anthony's, said that the hospital "was comfortable" with the court's decision despite his support of the petition for removal of food and water. Dr. Hooyman further stated that such a case showed the importance of having an advance directive which would allow removal of tube feedings.
Dr. Karen Pentella, chairperson of the Medical Ethics Committee of Christian Hospital Northeast/Northwest, criticized the court decision to continue feedings. In her letter to the editor of the St. Louis Post-Dispatch, she maintained that "Each human being has a right, and perhaps even a obligation, to die when life no longer has any quality or meaning."
For pro-lifers, this calls to mind the similar Nancy Cruan case, which figured prominently in both recent federal circuit court decisions that favored a right to physician-assisted suicide. As the Ninth Circuit Court stated last month, "When Nancy Cruzan's nutrition and hydration tube was removed, she did not die of an underlying disease. Rather, she was allowed to starve to death. In fact, Ms. Cruzan was not even terminally ill at the time, but had a life expectancy of 30 years... (t)he removal of her gastrostomy tube, which was clearly the precipitating cause of her death, is not considered to be the legal cause only because a judicial judgment has been made that removing the feeding tube is permissible."
Fr. Kevin O'Rourke, director of the Center for Health Care Ethics in St. Louis, who supported the Cruzan parents' efforts to remove their daughter's feeding tube, has argued that removing feeding tubes in such a case is not intended to cause death but that death "may be anticipated". He stated that the ethical standard of withdrawing care or treatment that is futile or burdensome is met in the Cruzan case because food and water would not restore Nancy Cruzan to "some degree of cognitive-affective function" and that "the Cruzan family is burdened by the condition of Nancy". He further cited "persistent vegetative state (as) a psychic burden for a person".
In a 1991 interview with Our Sunday Visitor magazine, Fr. O'Rourke said that the moral imperative to spoon-feed or provide food and water by tube would arise "if there is medical evidence that the injury is reversible -- that she would be able to know, love, relate to people" and that the treatment would have a clear benefit for the patient. Fr. O'Rourke was referring to Christine Busalacchi, another young woman said to be in a "vegetative state", but who was being retrained to eat by mouth. Fr. O'Rourke later testified in her court case that removal of her feeding tube was consistent with Catholic teaching. She died in March, 1993 after her feeding tube was removed.
More recently, in a March 1996 essay in the Center for Health Care Ethics' newsletter, Father Patrick Norris, OP discussed the case of Michael Martin, a Michigan man who was severely brain-injured after a car-train accident, but who is conscious and able to "nod, smile and grip with his right hand". The Michigan Supreme Court recently refused to allow Mr. Martin's wife to order his feeding tube removed. Fr. Norris criticized the court's decision because, he maintained, the court ignored "the best interests of the patient". He theorizes that "the reluctance to discontinue treatment often originates from the emotional reluctance to remove artificial nutrition and hydration from a conscious patient, even though the removal of nutrition and hydration need not cause pain nor suffering during the dying process if proper care is given (e.g., proper mouth care)". He also worries that "sentencing patients to medical limbo has already helped to generate calls for euthanasia."
Thomas Marzen, J.D. and Dan Avila, J.D., of the National Legal Center for the Medically Dependent and Disabled, wrote in the University of Detroit Mercy Law Review, "the wordless language of Mr. Martin -- conveyed by gesture and affect rather than by noun and verb -- attests just as eloquently to the indomitable will to live."
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1. "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." Declaration on Euthanasia. Prepared by the Sacred Congregation for the Doctrine of the Faith. May 5, 1980.
2. "Negative judgments about the 'quality of life' of unconscious or otherwise disabled patients have led some in our society to propose withholding nourishment precisely in order to end these patients' lives. Society must take special care to protect against such discrimination. Laws dealing with medical treatment may have to take account of exceptional circumstances, when even means for providing nourishment may become too ineffective or burdensome to be obligatory. But such laws must establish clear safeguards against intentionally hastening the deaths of vulnerable patients by starvation or dehydration." Statement on Uniform Right of the Terminally Ill Act. NCCB Committee for Pro-Life Activities. June, 1986.
3. "(I)t is our considered judgment that while legitimate Catholic moral debate continues, decisions about these (persistent vegetative state) patients should be guided by a presumption in favor of medically assisted nutrition and hydration... Such measures must not be withdrawn in order to cause death, but they may be withdrawn if they offer no reasonable hope of sustaining life or pose excessive risks or burdens". "Nutrition and Hydration: Moral and Pastoral Reflections" U.S. bishops' Pro-Life Committee. 1992.
4. "Some state Catholic conferences, individual bishops and the NCCB Committee on Pro-Life Activities have addressed the moral issues concerning medically assisted hydration and nutrition... These statements agree that hydration and nutrition are not morally obligatory either when they bring no comfort to a person who is imminently dying or when they cannot be assimilated by a person's body. The NCCB Committee on Pro-life Activities report, in addition, points out the necessary distinctions between questions already resolved by the magisterium and those requiring further reflection, as, for example, the morality of withdrawing medically assisted hydration and nutrition from a person who is in the condition which is recognized by physicians as the 'persistent vegetative state'... There should be a presumption in favor of providing nutrition and hydration to all patients, including patients who require medically assisted nutrition and hydration, as long as this is of sufficient benefit to outweigh the burdens involved to the patient." Ethical and Religious Directives for Catholic Health Care Services, U.S.Bishops meeting. 1994.
5. "The administration of food and liquids, even artificially, is part of the normal treatment always due to the patient when this is not burdensome for him: their undue suspension could be real and properly so-called euthanasia." Charter for Health Care Workers by the Pontifical Council for Assistance to Health Care Workers. Approved by the Congregation for the Doctrine of the Faith. Published 1995.