Fr. Richard McBrien and Others Mislead Catholic Public: Allege Schiavo Feeding Tube Removal OK

March 8, 2006

J.P. Hubert Jr. MD FACS
Catholic Biomedical Ethicist

©CCWVA

Recently, multiple revisionist Catholic writers including some "Catholic" Theologians have opined on the significance of the Terry Schiavo case asserting that it was morally licit to remove her feeding tube, thus insuring that she would die of dehydration. This author has rebutted them in the past.[1] Unfortunately, various writers continue to promulgate opinions which contradict constant Catholic magisterial teaching as if it were compatible with orthodox Catholic belief and practice. The latest article adds to the perfidy by incredibly; alleging that the late Holiness Pope John Paul II's 2004 allocution on the Persistent Vegetative State was itself "revisionist."[2]

In the past several days, Paul Lauritzen PhD, in an article for Commonweal Magazine 3/7/2006 entitled: "Revisiting Schiavo case - Feeding-tube removal raised question about Catholic end-of-life teachings" joined a number of other Catholic writers all of whom question the clear teaching of the Magisterium and that of our late Holy Father His Holiness John Paul II on the issue of the obligatory nature of providing nutrition to patients in whom a diagnosis of persistent vegetative state (PVS) has been made or those otherwise severely disabled patients who are unable to provide for their own sustenance. In so doing, Mr Lauritzen has quoted incorrectly, incompletely and out of context from Vatican statements in an apparent attempt to establish the antithesis of actual magisterial teaching. For example, he writes:

"To see what assumptions are embedded in the claim that Schiavo was euthanized, it is useful to consider the definition of euthanasia set out in the Vatican's 1980 Declaration on Euthanasia. According to the declaration, euthanasia is '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.'

Framed in this way, the Schiavo case throws into sharp relief a central moral question raised by the prospect of withdrawing a feeding tube from any patient in a persistent vegetative state (PVS). Do we inevitably intend death when we remove a feeding tube from a PVS patient?"

First the Declaration on Euthanasia was promulgated in 1981 a reference for which is included in the bibliography. Second, the short quotation selected is so diminutive and out of context as to be unintelligible. Third, Professor Lauritzen commits the same error that so many revisionist (dissenting) Catholic moral theologians do by incorrectly asserting that the only morally relevant issue is that of "intent" carefully avoiding the other two important components of every moral decision that of the "object rationally chosen" and the "circumstances." According to orthodox Catholic teaching, if the object rationally chosen is morally illicit, the moral act can never be made licit by appealing to a purportedly admirable "intent" which is what Mr. Lauritzen attempts to do in the short snippet included above.

With regard to the issue of providing sustenance to a person in whom a diagnosis of PVS has been made, the Magisterium has spoken definitively that food and water are ordinary supportive care not medical treatment and to withhold them irrespective of the "intent" is gravely immoral.[3] Removing a feeding tube from such a person, (a PVS patient) who is totally dependent upon it for food and water is to choose to kill them by omission (object rationally chosen). In other words, the object rationally chosen is morally illicit and thus the moral act is illicit irrespective of the intent or circumstances. This was pointed out explicitly by Pope John Paul II in 2004.[4] He wrote:

"The obligation to provide the 'normal care due to the sick in such cases' (Congregation for the Doctrine of the Faith, 'Iura et Bona,' p. IV) includes, in fact, the use of nutrition and hydration... Death by starvation or dehydration is, in fact, the only possible outcome as a result of their withdrawal. In this sense it ends up becoming, if done knowingly and willingly, true and proper euthanasia by omission (emphasis mine).

In this regard, I recall what I wrote in the Encyclical Evangelium Vitae, making it clear that "by euthanasia in the true and proper sense must be understood an action or omission which by its very nature and intention brings about death, with the purpose of eliminating all pain"; such an act is always "a serious violation of the law of God, since it is the deliberate and morally unacceptable killing of a human person" (n. 65)."

Professor Lauritzen attempts to play the "word game" by emphasizing the significance of the word "direct"[5] with respect to euthanasia essentially positing that it was only "indirect" euthanasia in the Schiavo case, a distinction without a difference that! Pope John Paul II removed all doubt about how this is to be understood in his 2004 allocution above. Professor Lauritzen is demonstrably wrong. The Schiavo case represents exactly the kind of "euthanasia by omission" which the Pope addressed with respect to patients in whom a diagnosis of PVS has been made. Terry Schiavo either had PVS or MCS. If the former, Pope John Paul II's teaching means that removing her feeding tube was morally wrong, if the latter (MCS) was the proper diagnosis, it would have been morally wrong as well. No one who understands the physiology of tube feeding believes that the process of removing a percutaneously placed enteric feeding tube causes the death of a patient simply from its being removed. The death ensues as a direct consequence of desiccation dehydration, pre-renal azotemia, complete renal shut-down, hyper-kalemia, profound metabolic acidosis and ultimately cardiac arrest.

An unfortunate example of complete medical/metaphysical confusion on the part of Professor Lauritzen is the following:

"No one has diagnosed the confusion here more perceptively that Daniel Callahan in his important book, The Troubled Dream of Life. According to Callahan, modern medicine has come to see death as an enemy that must be fought by any and all means. And because medicine has been so enormously successful in combating the causes of early death and thereby lengthening the average life span, we have come increasingly to act as if death is not a natural fact of life, but a failure of human will."

Whether this is true or not is clearly debatable and even if true, it is completely irrelevant to the point at issue which is whether or not it is morally licit according to Catholic magisterial teaching to stop tube feeding a person in whom a diagnosis of PVS has been made. Clearly it is not. If Professor Lauritzen personally wishes to recommend it however, he is free to do so as a personal suggestion understanding that it clearly does not enjoy Catholic magisterial support. He writes further:

"From a traditional fatalism in the face of the biological realities of human embodiment, we have moved to a moralism that condemns every concession to human finitude as a moral failing. Indeed, says Callahan, we have lost any sense of nature as acting independently of human choice, as if no death that could have been prevented could be anything other than the result of an intentional act."

Sad to say, the above has absolutely nothing to do with the question at hand. Continuing:

"Thus, to say that removing a feeding tube from a PVS patient is necessarily to aim at death is to conflate human action and natural events. It is to fail to recognize that dying is commonly associated biologically with a natural inability to eat or drink. If we do not conflate human and natural causality, it is perfectly sensible to say that a person suffering from a severe brain injury who cannot eat or drink is in fact dying, even if we can intervene and postpone that dying for years. Not starting or stopping artificial nutrition and hydration in such a case is not necessarily to aim at death, though one could intend death in such circumstances."[6]

Dying is associated with all kinds of physiological manifestations including cessation of brain function, heart and lung function, digestive tract function etc. All sorts of patients are unable to eat or drink for a variety of reasons and for various periods of time. Would Professor Lauritzen contend that they are all dying as well?

Contrary to Professor Lauritzen's assertion above, it is not perfectly sensible to claim that a severely brain injured person who cannot eat is in fact dying. Many severely brain injured persons have completely recovered. Particularly likely to recover are those who sustain a severe global hypoxic encephalopathic insult as a complication of Cardiac Surgery or sudden Cardiac death. The paragraph above is virtually unintelligible from a medical perspective and must be rejected in total.

There is no intellectually honest way to portray what occurred in the Schiavo case as anything but "Euthanasia by omission" as Pope John Paul II described it in his 2004 allocution. His teaching then, (contrary to Professor Lauritzen and apparently Thomas Shannon and Jim Walter to whom he refers for support in labeling Pope John Paul II's teaching revisionist), was completely consistent with prior Magisterial documents when examined in detail, in context and in totality.[7] The 2004 Papal teaching specifically addressed the issue of PVS and the moral necessity of providing sustenance as a part of basic supportive and humane care, not extraordinary medical intervention. In so doing Pope John Paul II was removing all doubt about the way in which to properly interpret prior magisterial documents/teaching.

While it is completely understandable and appropriate that people wish to be compassionate to those who suffer with PVS, MCS and other severe disabilities, ending their lives by dehydrating them to death is not a morally licit way to do so. The Magisterium, multiple Popes and the CCC have all emphasized the proper way in which to provide sensitive and compassionate care as well as gospel love.[8] Pope John Paul II's remarks in that regard are particularly illuminating:

"In particular, the term permanent vegetative state has been coined to indicate the condition of those patients whose 'vegetative state' continues for over a year. Actually, there is no different diagnosis that corresponds to such a definition, but only a conventional prognostic judgment, relative to the fact that the recovery of patients, statistically speaking, is ever more difficult as the condition of vegetative state is prolonged in time.

However, we must neither forget nor underestimate that there are well-documented cases of at least partial recovery even after many years; we can thus state that medical science, up until now, is still unable to predict with certainty who among patients in this condition will recover and who will not.

Faced with patients in similar clinical conditions, there are some who cast doubt on the persistence of the 'human quality' itself, almost as if the adjective 'vegetative' (whose use is now solidly established), which symbolically describes a clinical state, could or should be instead applied to the sick as such, actually demeaning their value and personal dignity. In this sense, it must be noted that this term, even when confined to the clinical context, is certainly not the most felicitous when applied to human beings.

In opposition to such trends of thought, I feel the duty to reaffirm strongly that the intrinsic value and personal dignity of every human being do not change, no matter what the concrete circumstances of his or her life (emphasis mine). A man, even if seriously ill or disabled in the exercise of his highest functions, is and always will be a man, and he will never become a 'vegetable' or an 'animal.'

Even our brothers and sisters who find themselves in the clinical condition of a 'vegetative state' retain their human dignity in all its fullness. The loving gaze of God the Father continues to fall upon them, acknowledging them as His sons and daughters, especially in need of help.

Medical doctors and health-care personnel, society and the Church have moral duties toward these persons from which they cannot exempt themselves without lessening the demands both of professional ethics and human and Christian solidarity."

However, it is not enough to reaffirm the general principle according to which the value of a man's life cannot be made subordinate to any judgment of its quality expressed by other men; it is necessary to promote the taking of positive actions as a stand against pressures to withdraw hydration and nutrition as a way to put an end to the lives of these patients. (Emphasis mine).

It is necessary, above all, to support those families who have had one of their loved ones struck down by this terrible clinical condition. They cannot be left alone with their heavy human, psychological and financial burden. Although the care for these patients is not, in general, particularly costly, society must allot sufficient resources for the care of this sort of frailty, by way of bringing about appropriate, concrete initiatives such as, for example, the creation of a network of awakening centers with specialized treatment and rehabilitation programs; financial support and home assistance for families when patients are moved back home at the end of intensive rehabilitation programs; the establishment of facilities which can accommodate those cases in which there is no family able to deal with the problem or to provide "breaks" for those families who are at risk of psychological and moral burn-out.

Proper care for these patients and their families should, moreover, include the presence and the witness of a medical doctor and an entire team, who are asked to help the family understand that they are there as allies who are in this struggle with them. The participation of volunteers represents a basic support to enable the family to break out of its isolation and to help it to realize that it is a precious and not a forsaken part of the social fabric."

It would be remiss of the author not to include a critique of the relevant assertions of another "Catholic" Theologian who has commented extensively about the Terry Schiavo case and who supports the removal of feedings tubes from patients in whom a diagnosis of PVS has been made.

Specifically, Fr. Richard P. Mc Brien, the Crowley-O'Brien Professor of Theology at the University of Notre Dame in an article posted at Tidings online did a great disservice to the Schiavo family and to faithful Catholics everywhere in August, 2005.[9] In only paraphrasing the medical findings of Terry Schiavo's detailed 39 page official autopsy report, Professor Mc Brien without properly quoting the original document or providing accurate reference citations has engaged in obfuscation, misrepresentation and sophistry.[10] One can only assume that this represents an attempt to further his well-known opposition to the tube-feeding of patients reputed to be in a "persistent vegetative state" (PVS).[11] There are so many errors in his article that one hardly knows where to begin. In the interest of civility and charity, the author will provide a detailed point by point analysis of his faulty reasoning and spurious conclusion.

The first assertion made by Fr. Mc Brien is as follows:

"An autopsy report released in mid-June, three months after the death of Terri Schiavo, disclosed that Mrs. Schiavo's brain had withered to half the normal size, that the damage to it was irreversible, that she was unaware of her surroundings, and that the deterioration of her brain had left her blind. Medical examiners concluded that no treatment could have even remotely improved her condition."[12]

In addition to his use of non-medical terminology such as "Mrs. Schiavo's brain had 'withered' to half normal size" without any attempt being made to place that finding in context, one immediately notices that Fr. Mc Brien has juxtaposed descriptions of the post-mortem anatomy of Terry's brain with conclusions which might or might not legitimately be drawn from those anatomical findings. For example: "she was unaware of her surroundings" (which is never mentioned in the autopsy report by the way); rather than a more reasonable statement that on review of all the medical data it remains unclear whether she was aware of her surroundings. Or this statement that does not appear in the autopsy report at all; "Medical examiners concluded that no treatment could have even remotely improved her condition" [13] as if "not being able to improve her condition" was a legitimate excuse for removing basic sustenance in the form of food and water albeit by feeding tube. It is vital to recall that Terry Schiavo was medically stable prior to the removal of her feeding tube and not suffering from a terminal illness which is the relevant piece of medical and ethical information in the absence of a clear and concise express wish not to be given basic sustenance.[14]

Note also that Fr. Mc Brien has made prognostic assertions which are not only outside his academic purview but are factually incorrect. The differentiation of "persistent vegetative state" (PVS) from "minimally conscious state" (MCS) is clinical not anatomico-pathological. Without a credible attempt to treat/improve Terry's condition, (which was not done since the early 1990's) it is impossible to know whether any progress could have been made. If she was suffering from a MCS rather than PVS, some significant progress might well have been made and even in the case of suspected PVS, some patients have improved according to the accumulated medical literature. It remains unclear clinically (despite the performing of a complete autopsy [which cannot confirm or refute the presence of PVS]) whether she had PVS or not, a conclusion which the medical examiner specifically makes on page 8 of his June 30, 2005 autopsy report:

"Was Mrs. Schiavo in a Persistent Vegetative State (PVS)?

PVS is a clinical diagnosis arrived at through the examination of living patients. Postmortem correlations to PVS with reported pathological findings have been reported in the literature, but the findings vary with the etiology of the adverse neurological event".....Jon R. Thogmartin MD, Medical Examiner.

And from the Neuropathologist's special report on page 9 of his letter to Dr. Thogmartin dated June 8, 2005 included as part of the official autopsy report:

"Neuropathologic examination alone of the decedent's brain-or any brain for that matter-cannot prove or disprove a diagnosis of persistent vegetative state or minimally conscious state"...Stephen J. Nelson MD, Neuropathologist.

The clinical presence and or differentiation of these two entities (PVS and MCS) are not possible in this case beyond reasonable doubt for several reasons. First, while the medical literature has reported the neuropathological findings in PVS they are not uniform in all patients. They have not been reported at all in MCS. Dr. Nelson stated this in his June 8, 2005 letter:

"The anatomical basis for a persistent vegetative state differs somewhat from case to case for several reasons..."[15]

"There are numerous publications in the neurologic and neuropathologic literature of the correlates that exist between the clinical examination and clinical diagnosis of a patient in persistent vegetative state and the subsequent neuropathological findings at autopsy. The persistent vegetative state and minimally conscious state are clinical not pathological ones, (emphasis mine). The neuropathological findings of the persistent vegetative state have been well described in the medical literature, including long survival after cardiac arrest, yet there are no similarly published neuropathologic descriptions specific to the minimally conscious state."[16]

In other words, the diagnosis of PVS cannot be made only on anatomic grounds (autopsy or radiographic examination).

Second, public records including court documents disclose that no recent complete clinical neurological examinations were allowed by the court (after 2002) or Michael Schiavo which might have provided greater clinical certainty with respect to the diagnosis. This was truly unfortunate. Thus, as of March 2005 when the court was asked by Congress to reconsider the ruling which ordered that Terry's feeding tube be removed, we have as part of the record George Felos' arranged (Michael Schiavo's attorney) neurological examinations conducted by Dr. Gambone and Dr. Cranford (a neurologist with a well known record of testifying in "right to die" [euthanasia] cases) and a Board member of the "Choice in Dying Society" who concluded that Terry had PVS as did Dr. Gambone and a court appointed neurologist selected by Judge Greer (Dr. James Barnhill), all from three years earlier.[17] Cranford's opinion is obviously suspect since he had a known "conflict of interest." Also from 2002 is the contrary neurological opinion of Dr. Hammesfahr selected by the Schindler's who stated that Terry did not have PVS.

"Dr. William Hammesfahr, a neurologist petitioned by the Schindlers, testified that Terri shows cognitive function and would benefit from a treatment called vasodilatation... 'I spent about 10 hours across about three months [examining Terri] and the woman is very aware of her surroundings. She's very aware. She's alert. She's not in a coma. She's not in PVS,' Hammesfahr told CNN Tuesday night. 'With proper therapy, she will have a tremendous improvement. I think, personally, that she'll be able to walk, eventually, and she will be able to use at least one of her arms.'

Terri responds to her mother.

Portions of a four-hour videotaped examination of Terri by Hammesfahr were shown to the court during the evidentiary hearing. In the video, Terri appears to interact with her mother with a reaction of happiness, follow commands to open and shut her eyes and lift limbs, and tracks a Mickey Mouse balloon across the room with her eyes.

Anderson later described her behavior in a statement to an appellate court.

'Terri smiles appropriately, she laughs appropriately, she tracks a balloon with her eyes, she tracks a set of flashing lights with her eyes, she opens her eyes wide on command, she squeezes her eyes shut on command, she turns her head and looks in the direction of the speaker, she follows Dr. Hammesfahr's movements around the room with her eyes, and, perhaps most poignantly, Terri tries as hard as she can to do that which is asked of her,' Anderson said."[18]

At the very least, in and around March 2005 prior to the final removal of Terry's feeding tube and subsequent death, a court ordered second opinion should have been obtained from a neutral neurologist or if none could be found, one with a known bias against euthanasia in order to balance the testimony of Dr. Cranford the euthanasia advocate who testified for Michael Schiavo. This would have insured that an up to date medical review was performed and would also have complied with the reconsideration of the case that Congress and the President requested. Note that the affidavit of Dr. William Cheshire (Mayo Clinic Neurologist who examined Terry 5 days after her feeding tube was removed in March 2005, the most recent) contains his statement and belief that she suffered from MCS not PVS.[19] Unfortunately, his findings were never formally considered due to the federal appeals court's refusal to grant a de-novo review. The autopsy findings while "consistent" with PVS are also consistent with MCS. Neither entity can be confirmed by autopsy alone. Both can be associated with a high incidence of "error in diagnosis"[20] and thus the definitive clinical diagnosis in Terry's case remains unclear.

Fr. Mc Brien's statement "Medical examiners concluded that no treatment could have even remotely improved her condition" is very misleading first because it cannot be made with medical certainty and because it attempts to falsely justify removing the feeding tube from a medically stable and severely disabled person simply for not being able to "clinically improve" (something which was never demonstrated empirically and cannot be determined by anatomic pathological examination in any event). Thus it represents a total fabrication based presumably on what he would like to conclude in order to buttress his argument. Moreover, the issue of "improvement" or lack of same has no bearing on whether it is ever morally licit to purposely withhold food and water from a severely disabled person according to Pope John Paul II who definitively and recently addressed the issue specifically before he died:

"The sick person in a vegetative state, awaiting recovery or a natural end, still has the right to basic health care (nutrition, hydration, cleanliness, warmth, etc.), and to the prevention of complications related to his confinement to bed, (emphasis mine). He also has the right to appropriate rehabilitative care and to be monitored for clinical signs of eventual recovery,

I should like particularly to underline how the administration of water and food, even when provided by artificial means, always represents a natural means of preserving life, not a medical act, (emphasis mine). 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.

The obligation to provide the 'normal care due to the sick in such cases' (Congregation for the Doctrine of the Faith, 'Iura et Bona,' p. IV) includes, in fact, the use of nutrition and hydration (emphasis mine) (cf. Pontifical Council 'Cor Unum,' 'Dans le Cadre,' 2, 4, 4; Pontifical Council for Pastoral Assistance to Health Care Workers, Charter of Health Care Workers, No. 120). The evaluation of probabilities, founded on waning hopes for recovery when the vegetative state is prolonged beyond a year, cannot ethically justify the cessation or interruption of minimal care for the patient, including nutrition and hydration. Death by starvation or dehydration is, in fact, the only possible outcome as a result of their withdrawal. In this sense it ends up becoming, if done knowingly and willingly, true and proper euthanasia by omission, (emphasis mine).

In this regard, I recall what I wrote in the encyclical 'Evangelium Vitae,' making it clear that "by euthanasia in the true and proper sense must be understood an action or omission which by its very nature and intention brings about death, with the purpose of eliminating all pain"; such an act is always "a serious violation of the law of God, since it is the deliberate and morally unacceptable killing of a human person" (No. 65) (Emphasis mine). Besides, the moral principle is well known, according to which even the simple doubt of being in the presence of a living person already imposes the obligation of full respect and of abstaining from any act that aims at anticipating the person's death...

As a pledge and support of this, your authentic humanitarian mission to give comfort and support to your suffering brothers and sisters, I remind you of the words of Jesus: "Amen, I say to you, whatever you did for one of these least brothers of mine, you did for me" (Matthew 25:40)."[21]

The Pope made it absolutely clear that feeding a person with PVS is obligatory recognizing that it will be done by feeding tube which under the circumstances is not disproportionate or extraordinary.[22] This is a clear repudiation of Fr. Mc Brien's position and one which he had an obligation as a Catholic Priest and Theologian to present and yet didn't. Pope John Paul II further said:

"In particular, the term permanent vegetative state has been coined to indicate the condition of those patients whose "vegetative state" continues for over a year. Actually, there is no different diagnosis that corresponds to such a definition, but only a conventional prognostic judgment, relative to the fact that the recovery of patients, statistically speaking, is ever more difficult as the condition of vegetative state is prolonged in time. However, we must neither forget nor underestimate that there are well-documented cases of at least partial recovery even after many years; we can thus state that medical science, up until now, is still unable to predict with certainty who among patients in this condition will recover and who will not", (emphasis mine).[23]

Thus the Pope was teaching that even in the case of PVS one can never be certain that the diagnosis is correct or that eventual improvement will not occur; a reality which is in agreement with the accumulated medical literature on the subject.

Other orthodox Catholic moral theologians have come to a similar conclusion; that it is morally obligatory to provide food and water for patients in a Persistent Vegetative State.[24] William May has written extensively on this issue both in his seminal work: Catholic Bioethics and the Gift of Human Life, Huntington Indiana, 2000, and in numerous other articles with multiple colleagues. His position which is medically correct is that PVS patients are "not in fact dying of any fatal pathology. They are simply persons [who are] seriously impaired."[25] Thus, they require food and water and other kinds of daily comfort care which they are no longer able to provide for themselves. Others provide it in-keeping with the parable of the "good Samaritan." In this Professor May is relating the exact sentiments expressed by Pope John Paul II quoted above and Pope Pius XII in his 1957 address to the International Congress of Anesthesiologists.[26] Pope Pius XII's remarks in entirety support those of Pope John Paul II, William May and others including Germaine Grisez and Bishop James T. McHugh rather than refuting them as Fr. Mc Brien has suggested. He has taken only one very specific clause from Pope Pius XII's remarks out of context and distorted it as he has the short passage from the CCC that he included.

Relevant to this topic and which Fr. Mc Brien totally omitted from his article is the data found in the Catechism of the Catholic Church as promulgated in 1997:

CCC# 2273: "The inalienable right to life of every innocent human individual is a constitutive element of a civil society and its legislation."

CCC# 2276: "Those whose lives are diminished or weakened deserve special respect. Sick or handicapped persons should be helped to lead lives as normal as possible."

CCC# 2277: "Whatever its motives and means, direct euthanasia consists in putting an end to the lives of handicapped, sick, or dying persons. It is morally unacceptable.

Thus an act or omission which, of itself or by intention, causes death in order to eliminate suffering constitutes a murder gravely contrary to the dignity of the human person and to the respect due to the living God, his Creator. The error of judgment into which one can fall in good faith does not change the nature of this murderous act, which must always be forbidden and excluded."

Had Fr. Mc Brien presented the foregoing, it would have been impossible for him to have taken the position he did. Instead he vaguely cited "pre-Vatican II Popes" and specifically Pope Pius XII inaccurately demonstrating an unparalleled lack of scholarship. While it is true that constant magisterial teaching does hold that one is not obligated to employ "extraordinary means" in order to maintain one's life, he failed to discuss what the term "extraordinary" actually means from the perspective of the teaching magisterium or the relevant medical realities. Pope John Paul II recently clarified the issue specifically in the setting of PVS (which Fr. Mc Brien completely ignored), indicating that tube feeding and comfort care is not extraordinary or disproportionate care for someone who is suffering from PVS. The following quote is Fr. Mc Brien's description of the relevant magisterial teaching:

"For many Catholics --- including priests and theologians educated in the years prior to, during, and immediately after the Second Vatican Council (1962-65) --- the Terri Schiavo case was always morally clear-cut. The traditional teaching of the Catholic Church for at least four centuries --- a teaching reaffirmed and extended by the most prominent of the pre-Vatican II popes, Pius XII (1939-58) --- distinguished between ordinary and extraordinary means of preserving life. No one, the church consistently taught, is obliged to use extraordinary means to sustain their life on this earth.

"Over the course of centuries, the meaning of "extraordinary" has fluctuated. As medical technology took great leaps forward, beginning especially with the pontificate of Pius XII, the church recognized the need to revise its definition of the term."

"Almost every reputable Catholic moral theologian who commented on the Schiavo case concluded that continuing the use of a feeding tube to keep Mrs. Schiavo alive was a clear instance of an extraordinary means, and as such could be dispensed with, (emphasis mine). The autopsy report removed all doubt that the withdrawal of the feeding tube, far from being an act of euthanasia or even outright murder, was entirely consistent with traditional Catholic moral principles" (emphasis mine).

The first two quotes above are actually quite reasonable but they support the position the author takes not that of Fr. Mc Brien as will be demonstrated. The quote immediately above is incompatible with the 2 preceding it however that is; it contradicts the traditional teaching about the nature of what is ordinary and extraordinary by alleging that the tube feeding of Terry Schiavo represented extraordinary means (discussed below) which it decidedly does not. It also states that the withdrawal of Terry's feeding tube was not an act of euthanasia which it clearly was. It was euthanasia by omission in the words of Pope John Paul II and the many Vatican commentators who spoke out about it.

Note that Fr. Mc Brien simply asserts without providing any documentation that his position is the one which follows Church Tradition (which it does not), and is shared by almost all "reputable Catholic moral theologians" (which it is not) at least those who publicly commented on the case (who if they share his opinion are also wrong and in clear disagreement with the magisterium). His statement assumes that the correct moral interpretation is simply a matter of "majority rules" not whether it is compatible with actual Catholic teaching as consistently promulgated by the magisterium. He simply surmises that he and other revisionist Catholic moral theologians represent the entire "universe" of relevant Catholic moralists who have opinions on this issue. It also suggests (incorrectly) that only the opinions of those who publicly commented at the time were worthy of belief which is ridiculous on its face. Many orthodox Catholic moral theologians as well as the United States Conference of Catholic Bishops, Pope John Paul II, Bishop James McHugh, the CDF and others have written and spoken extensively about the morally obligatory nature of tube-feeding PVS patients which Fr. Mc Brien totally ignored.[27] Directive no. 58 of the Ethical and Religious Directives for Catholic Health Care Services, November 1994, reads as follows:

"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."[28]

The important point here is that all patients in principle are presumed to be "worthy" of nutrition and hydration including those who require a feeding tube. This is the case as long as the benefit outweighs the burden "to the patient" that is, the burden to the patient of the nutrition and hydration itself, not the burden the "patient" may represent from the perspective of certain health care providers or other interested parties. To be completely clear, it is never morally licit to argue that a PVS patient should be denied tube feedings on the basis that the patient is a burden or that their life is unworthy of living. As Professor May has rightly taught, to do so requires promulgating a false dualism (subject/object dualism) in which the patient's personhood includes only their spiritual existence and in which their body is only instrumentally utilized by their soul rather than being an integral part of the person that is; composite part along with the soul during life. The former position is incompatible with Catholic teaching on human anthropology as consistently held by the magisterium. The substance view of personhood is the correct one in which the human person is composed of a body/soul composite in unity.[29] Thus the human person is a "body and a soul person" rather than being a "spirit person" only who possesses or uses a body. The latter position is neo-Platonic (part of an epistemology of Spiritualism) and the true Catholic position is characterized by the Aristotelian/Thomistic synthesis. Pope John Paul II reiterated this teaching on multiple occasions.[30] In his address to the working group of the Pontifical Academy of Sciences he referred to the Vatican II document Gaudium et spes in that regard:

"Though made of body and soul, man is one. Through his bodily composition he gathers to himself the elements of the material world; thus they reach their crown through him, and through him raise their voice in free praise of the Creator.(6) For this reason man is not allowed to despise his bodily life, rather he is obliged to regard his body as good and honorable since God has created it and will raise it up on the last day."[31]

Note also that Fr. Mc Brien cited the following section from the CCC but in an incomplete manner and totally out of context. He quoted only the portion which seemingly supports his position which was extremely brief and redacted:

"In the words of The Catechism of the Catholic Church, such means would be "disproportionate to the expected outcome" (n. 2278)."

Professor Mc Brien also failed to provide a definition or discussion of what "disproportionate" means.[32] Nor did he explain how he arrived at the conclusion that "tube feeding" is "extraordinary" or disproportionate; a position which is indefensible irrespective of whether there are other moral theologians who also spuriously believe it. As anyone even remotely familiar with gastrostomy tube feeding can attest, such feedings can be carried out in the home very easily by a family care-giver who employs a blender and regular food prepared for easy insertion into the tube. The author has cared for patients who employed this technique. It does not require special food sources, a hospital or a nursing home setting although such special feedings can be obtained and the costs defrayed by insurance or Medicare. Daily maintenance of the feeding tube requires minimal training and care. The initial placement of the feeding tube can be done without general anesthesia percutaneously in a few minutes at very low risk and without discomfort. From the medical perspective, it is a complete fabrication to claim that "tube-feeding" represents extraordinary or disproportionate treatment/care.

The actual relevant passages from the CCC are reproduced in entirety below so as to elucidate the actual teaching of the Church which is diametrically opposed to Fr. Mc Brien's characterization.

CCC# 2278: "Discontinuing medical procedures that are burdensome, dangerous, extraordinary, or disproportionate to the expected outcome can be legitimate: it is the refusal of "over-zealous" treatment. Here one does not will to cause death; one's inability to impede it is merely accepted. The decisions should be made by the patient if he is competent and able or, if not, by those legally entitled to act for the patient, whose reasonable will and legitimate interests must always be respected."

As indicated above, tube feeding is not dangerous, "over-zealous" or burdensome by any reasonable estimation.

CCC# 2279: "Even if death is thought imminent, the ordinary care owed to a sick person cannot be legitimately interrupted,(emphasis mine). The use of painkillers to alleviate the sufferings of the dying, even at the risk of shortening their days, can be morally in conformity with human dignity if death is not inevitable. Palliative care is a special form of disinterested charity. As such it should be encouraged."

Even here, the CCC makes it clear that so-called palliative "comfort care" is part of ensuring the dignity of the patient and is not only part of justice but charity as well.

What did Terry Schiavo Actually Have?

It remains unclear whether Terry Schiavo suffered from PVS or MCS despite a complete autopsy. The differentiation is clinical not anatomic. The diagnosis remains in doubt primarily due to the fact that she was not subjected to a court ordered and considered thorough and timely neurological examination by a disinterested neutral neurologist in the period immediately prior to the removal of her feeding tube and subsequent death. We will never know with reasonable certainty whether intensive rehabilitative therapy could have allowed her to experience clinical improvement. Under these unfortunate circumstances, one must strongly suspect that she suffered from PVS (rather than MCS)[33] based on the protracted clinical course she experienced subsequent to the documented severe brain injury resultant from diffuse hypoxic encephalopathy (oxygen deprivation and secondary brain injury) at the time of her collapse, the etiology of which remains in question according to the medical examiner.

Even if Terry did have PVS, it was totally immoral to remove her feeding tube since it clearly represented euthanasia by omission. This is true on the basis of classical moral philosophical principles (Aristotelian/Thomistic philosophy) as well as constant Catholic Church teaching. In that regard the magisterium has strongly suggested in the past and very emphatically recently (Pope John Paul II) that it is morally obligatory to provide basic sustenance (food and water) to persons who are severely disabled but not dying including those suspected of being in a persistent vegetative state. This includes tube-feeding which is not extraordinary or disproportionate!

Fr. Richard Mc Brien has seriously misrepresented the medical facts in the Terry Schiavo case and has failed to present authentic Catholic magisterial teaching on the subject of providing nutrition to PVS patients and others who are severely disabled but not dying. He persists obstinately and irresponsibly despite magisterial clarity in promoting revisionist moral theology incompatible with Catholic orthodoxy.

Professor Lauritzen has falsely accused the late Pope John Paul II of engaging in revisionist Catholic moral theology with respect to his teaching in the area of Euthanasia and the tube feeding of patients in whom a diagnosis of PVS has been made. [34] Nothing could be further from the truth. The late Pope followed classical Catholic moral philosophical principles in his allocution on PVS and the morally obligatory nature of continuing tube feeding for these tragically affected patients. He appropriately outlined the relevant medical/ethical issues and stressed the need to be positive and supportive of these patients and their families as has his successor Pope Benedict XVI.

Professor Lauritzen and Fr. Mc Brien have disseminated revisionist moral theology by dissenting from clear and constant magisterial teaching in the area of Euthanasia and from the Catholic commitment which ensures the dignity of every human life particularly those who are severely disabled. In so doing their activities promote confusion among the Catholic faithful and must be rejected lest authentic Catholic teaching be adulterated.

_________________

Doctor Hubert is a Biomedical Ethicist and Health Care Policy Advisor to Common Good and its Catholic Way project.He is a retired Cardio-Thoracic surgeon with a long interest in ethics particularly bio-medical ethics. As a "high-tech" heart surgeon he was frequently confronted with complex and difficult medical problems and resultant ethical decisions. Dr. Hubert has written extensively in the area of embryonic stem cell research and human cloning for biomedical research including an extensive philosophical treatment entitled; "Justice and Freedom for the Human Embryo: The Philosophy of the Human Person, the Body/Soul issue and Ethics." He has also written on other ethical topics including Euthanasia and issues involving War/Peace and Suicide Terrorism. His other academic interests include the "Creation/Evolution" debate. Recently, he completed a work entitled; The Contemporary Origin's Debate in which he proposed a testable "Origin's model. Dr. Hubert has a special interest in Catholic apologetics particularly as it concerns the evangelization of non-believers with a background in the natural and biological sciences. He is a "revert" to orthodox Catholicism from scientific naturalism with an avid interest in the fusion of faith and reason. Dr. Hubert has become a regular contributor to Catholic Way.

_________________

END NOTES

[1] John P. Hubert Jr. MD FACS, "The Brain is not the Soul: The Tragic Error of the Terry Schiavo case" The Catholic Way at: http://sites.silaspartners.com/partner/Article_Display_Page/0,,PTID5339|CHID14|CIID2171570,00.html.

[2] Paul Lauritzen PhD, "Revisiting Schiavo case - Feeding-tube removal raised question about Catholic end-of-life teachings" Commonweal Magazine 3/7/2006. "Although some commentators have wanted to suggest that John Paul's remarks did not break significantly with traditional Catholic teaching, Thomas Shannon and Jim Walter have persuasively argued that the allocution (and the Vatican statements that led up to it and have flowed from it) represents a shift in Catholic teaching. According to Shannon and Walter (see Theological Studies 66, 2005), among the changes that characterize the revisionist position is the view that providing artificial nutrition and hydration is obligatory"

[3] Pope John Paul II, "Papal Address on the 'Vegetative State' and Euthanasia: Intrinsic Value and Personal Dignity of Every Human Being Do Not Change", March 20, 2004, address to participants of the International Congress on "Life-Sustaining Treatments and Vegetative State: Scientific Advances and Ethical Dilemmas"; See also the March 7, 2006 statement of Pope Benedict XVI "Even when the problems of disabled people touch their minds or their sensorial and intellective capacities, they remain fully human, with the sacred and inalienable rights that belong to humans.... "human beings, irrespective of the conditions in which they live and of the capacities they are capable of expressing, possess unique and extraordinary worth from the very beginning of their existence to the moment of natural death."

[4]Ibid, "The sick person in a vegetative state, awaiting recovery or a natural end, still has the right to basic health care (nutrition, hydration, cleanliness, warmth, etc.), and to the prevention of complications related to his confinement to bed. He also has the right to appropriate rehabilitative care and to be monitored for clinical signs of eventual recovery,

I should like particularly to underline how the administration of water and food, even when provided by artificial means, always represents a natural means of preserving life, not a medical act, emphasis mine). 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.

The obligation to provide the 'normal care due to the sick in such cases' (Congregation for the Doctrine of the Faith, 'Iura et Bona,' p. IV) includes, in fact, the use of nutrition and hydration (emphasis mine) (cf. Pontifical Council 'Cor Unum,' 'Dans le Cadre,' 2, 4, 4; Pontifical Council for Pastoral Assistance to Health Care Workers, Charter of Health Care Workers, No. 120). The evaluation of probabilities, founded on waning hopes for recovery when the vegetative state is prolonged beyond a year, cannot ethically justify the cessation or interruption of minimal care for the patient, including nutrition and hydration. Death by starvation or dehydration is, in fact, the only possible outcome as a result of their withdrawal. In this sense it ends up becoming, if done knowingly and willingly, true and proper euthanasia by omission.

In this regard, I recall what I wrote in the encyclical 'Evangelium Vitae,' making it clear that 'by euthanasia in the true and proper sense must be understood an action or omission which by its very nature and intention brings about death, with the purpose of eliminating all pain'; such an act is always 'a serious violation of the law of God, since it is the deliberate and morally unacceptable killing of a human person' (No. 65) (Emphasis mine).

Besides, the moral principle is well known, according to which even the simple doubt of being in the presence of a living person already imposes the obligation of full respect and of abstaining from any act that aims at anticipating the person's death..."

[5]Paul Lauritzen PhD, "Revisiting Schiavo case - Feeding-tube removal raised question about Catholic end-of-life teachings" Commonweal Magazine 3/7/2006. "In the key passage, John Paul makes two claims. First, providing nutrition and hydration is a form of care, not a form of treatment. Second, withdrawing a feeding tube is essentially to aim at death. With regard to the second point, he said: "Death by starvation or dehydration is, in fact, the only possible outcome as a result of this withdrawal. In this sense it ends up becoming, if done knowingly and willingly, true and proper euthanasia by omission."

What should we make of this claim? The first thing to note is what is not being said. John Paul does not assert that removing a feeding tube is directly to kill the patient (emphasis mine). In terms of the definition of euthanasia set out in the Declaration on Euthanasia, removing a feeding tube is not an action "which of itself" causes death. This is important because if removing the feeding tube is not wrong per se, then, if it is wrong, it must be so because of the intention of the will in removing the tube. (Recall that the declaration defines euthanasia in reference to "the intention of the will and in the methods used.")"

[6] Lauritzen, Commonweal Magazine, March, 7, 2006.

[7] Professor Lauritzen referenced an article by Shannon and Walter, Theological Studies 66, 2005. The author has not read the article or been able so far to obtain it. Please see the extensive bibliography appended for details of relevant magisterial teaching.

[8] CCC# 2276: "Those whose lives are diminished or weakened deserve special respect. Sick or handicapped persons should be helped to lead lives as normal as possible"; See also Pope Benedict XVI's March 7, 2006 statement regarding the disabled and this year's Lenten Brazilian Fraternity theme "Fraternity and Disabled People" which he wrote "promotes reflection and is an encouragement to renew the commandment to charity with greater force, especially towards people suffering some form of disability... an attitude of tenderness and consolation..." toward "our brothers and sisters in Christ."

[9] Rev. Richard P. McBrien, "The Schiavo case re-visited" Tidings, August 5, 2005 at: http://www.the-tidings.com/2005/0805/essays.htm as of 8/09/05.

[10] He provided no detailed references from Magisterial teaching which address the issue of caring for the disabled or handicapped person who is not dieing of a fatal illness, only one short snippet from the CCC taken out of context.

[11] Numerous examples exist including an interview on the O'Reilly Factor in which he expressed this view.

[12] Mc Brien, "The Schiavo case re-visited".

[13] Which could not be ascertained by autopsy examination in any case, particularly if the diagnosis was either "Persistent Vegetative State or "Minimally Conscious State" (according to the accumulated medical literature which is even cited in the autopsy report both by the medical examiner and as detailed references).

[14] No such oral or written desire was ever documented beyond reasonable doubt. The lower court judge Greer simply believed the oral testimony of 3 individuals (Michael Schiavo, his brother and sister-in-law) all of whom had a conflict of interest with respect to ending Terry's life. Terry had not signed an AMD (Advanced Medical Directive) and had not appointed a medical surrogate for health care decision making.

[15] Stephen J. Nelson MD, (Neuropathologist) report found on page 9 of his letter to Dr. Thogmartin dated June 8, 2005 included as part of the final official autopsy report.

[16] Ibid.

[17] "LIFE AND DEATH TUG OF WAR The whole Terri Schiavo story,15-year saga of brain-injured woman no clear-cut, right-to-die case" World Net Daily, posted March 24, 2005 at http://www.worldnetdaily.com/news/article.asp?ARTICLE_ID=43463.

[18] Ibid.

[19] William Cheshire, MD. Affidavit, March 23, 2005 describing neurologic exam of Terry Schiavo and diagnostic conclusions; G.T. Giacino et al. The Minimally Conscious State: Definition and Diagnostic Criteria. Neurology, 2002; 58: 349-353; S. Laureys et al. Brain function in coma, vegetative state, and related disorders. Lancet Neurology 2004; 3: 537-546.

[20] K. Andrews et al. Misdiagnosis of the Vegetative State: retrospective study in a rehabilitation unit. British Medical Journal 1996; 313; 13-16; N.L. Childs et al. Accuracy of Diagnosis of Persistent Vegetative State. Neurology 1993; 43: 1465-1467.

[21] Pope John Paul II, "Papal Address on the 'Vegetative State' and Euthanasia: Intrinsic Value and Personal Dignity of Every Human Being Do Not Change", March 20, 2004, address to participants of the international congress on "Life-Sustaining Treatments and Vegetative State: Scientific Advances and Ethical Dilemmas."

[22] The author is aware that some Catholic moralists insist that tube feeding of a PVS patient can be disproportionate, burdensome or ineffective. In the case of Terry Schiavo, there was no indication that the feedings were ineffective. Quite the contrary, they kept her alive for almost 15 years. As in other PVS cases the feeding tube was easily maintained without infection or complication indicating that it was not burdensome for her. There is no rational case which can be made in this case that the tube feeding was disproportionate. The only reason to discontinue them was in order to accomplish "mercy killing" on the assumption that Terry had a life that she would consider unworthy of living. This is euthanasia by omission as Pope John Paul II described it above.

[23] Ibid.

[24] William E. May. Catholic Bioethics and the Gift of Human Life. (Huntington Indiana: Our Sunday Visitor Publishing Division Our Sunday Visitor, Inc., 2000), p. 268; William E. May et al. "Feeding and Hydrating the Permanently Unconscious and Other Vulnerable Persons," Issues in Law and Medicine 3 (1987) 203-217; William E. May et al. "Caring for Persons in the 'Persistent Vegetative State'" Anthropotes: Rivista di Studi sulla persona e la famiglia 13.2 (1997) 317-331; William E. May et al. "Tube Feeding and the 'Vegetative' State," Part One, Ethics & Medics 23.12 (December 1998) 1-2; William E. May et al. "Tube Feeding and the 'Vegetative' State," Part Two, Ethics &Medics 24.1 (January 1999) 3-4.

[25] May. Catholic Bioethics and the Gift of Human Life p. 268.

[26] Pope Pius XII, "The Prolongation of Life: An Address to an International Congress of Anesthesiologists," in 1957, as reprinted in Death, Dying, and Euthanasia, p. 284.

[27] William E. May et al. "Feeding and Hydrating the Permanently Unconscious and Other Vulnerable Persons," Issues in Law and Medicine 3 (1987) 203-217; William E. May et al. "Caring for Persons in the 'Persistent Vegetative State'" Anthropotes: Rivista di Studi sulla persona e la famiglia 13.2 (1997) 317-331; William E. May et al. "Tube Feeding and the 'Vegetative' State," Part One, Ethics & Medics 23.12 (December 1998) 1-2; William E. May et al. "Tube Feeding and the 'Vegetative' State," Part Two, Ethics &Medics 24.1 (January 1999) 3-4; Committee for Pro-Life Activities, National Conference of Catholic Bishops, Nutrition and Hydration: Moral and Pastoral Reflections (Washington, D.C.: United States Catholic Conference, 1992), Publication No. 516-X, p. 7; The Declaration on Euthanasia, promulgated by the Congregation for the Doctrine of the Faith, Rome, May 5, 1981; Reverend James Mc Hugh, Bishop of Camden, N.J., "Artificially Assisted Nutrition and Hydration" (September 21, 1989), in Origins: NC News Service 19 (1989) 314-316; Ethical and Religious Directives for Catholic Health Care Services (November 1994), No. 58; Pope John Paul II, "Papal Address on the 'Vegetative State' and Euthanasia: Intrinsic Value and Personal Dignity of Every Human Being Do Not Change", March 20, 2004, address to participants of the international congress on "Life-Sustaining Treatments and Vegetative State: Scientific Advances and Ethical Dilemmas"; New Jersey State Catholic Conference, "'Friend-of-the-Court Brief to the New Jersey Supreme Court': Providing Food and Fluids to Severely Brain Damaged Patients" (November 3, 1987), Origins: NC News Service 16 (1987) 542-553;Pennsylvania Conference of Catholic Bishops, "Nutrition and Hydration: Moral Considerations," in Origins: NC News Service 21 (1992) 542-553;Father Thomas Williams, Legionary of Christ, dean of theology at the Regina Apostolorum Pontifical University in Rome, "'95 Encyclical Foresaw Cases Like Terri Schiavo's' Theologian Points Up a Key Problem in Florida Battle" Rome, March 22, 2005. (Zenit.org). "The case of Terri Schiavo has nothing to do with disproportionate means to keep a person alive at all costs, regardless of the suffering such measures provoke. Here we are talking about the most basic care consisting of hydration and nutrition. Terri is not terminally ill, but the removal of her feeding tube will effectively kill her by starvation... In fact, the Holy Father wrote in No. 64 of the encyclical [Evangelium vitae]: 'Here we are faced with one of the more alarming symptoms of the [culture of death,] which is advancing above all in prosperous societies, marked by an attitude of excessive preoccupation with efficiency and which sees the growing number of elderly and disabled people as intolerable and too burdensome'... It's not a question of Terri's parents being right and Terri's husband wrong. The problem lies in giving anyone the power over another's life. Society must not permit that a person's life or death hangs in the balance because of the way others feel about them. All human life must be defended and protected in law, not for what it means to others, but for what it is in itself."

[28] See May, p. 263 for further discussion.

[29] See my: "Justice and Freedom for the Human Embryo in light of: The Philosophy of the Human Person, the Body/Soul Issue and Ethics,(Personhood cannot be acquired or lost), Social Justice Review, 95: November-December, 2004, and an expanded version at TCR.com.

[30] See William E. May, Catholic Bioethics and the Gift of Human Life, pp 287, 289, 290, 291; May on p. 287 refers to the writing of Pope John Paul II to the Working Group of the Pontifical Academy of Sciences, Dec. 10, 1989 on the definition and meaning of death for a Christian as well as the nature of the human person. 14 "...When we consider that every individual is a living expression of unity and that the human body is not just an instrument or item of property, but shares in the individual's value as a human being, then it follows that the body cannot under any circumstances be treated as something to be disposed of at will." For details see Pope John Paul II, "Discourse of John Paul II to the Participants of the Working Group," in Working Group on the Determination of Brain Death and Its Relationship to Human Death (December 10-14, 1989) (Pontificiae Academiae Scientiarum Scripta Varia, 83), eds. R. J. White, H. Angstwurm, and I. Carrasco de Paula (Vatican City: Pontifical Academy of Sciences, 1992), no. 2, p. xxiv.

[31] See also Gaudium et spes, no.14.

[32] See John Finnis. Fundamentals of Ethics. (Washington, D.C.: Georgetown University Press, 1983) pp.106-107 for a discussion of proportionality; See also William E. May. Catholic Bioethics and the Gift of Human Life. (Huntington Indiana: Our Sunday Visitor Publishing Division Our Sunday Visitor, Inc., 2000) Chapter 7, particularly pp. 254-262.

[33] Although Dr. William Cheshire (Mayo Clinic Neurologist and bioethicist who opposes euthanasia examined Terry 5 days after the feeding tube had been removed), stated in an affidavit dated March 23, 2005 that in his medical opinion it was more likely that she suffered from a minimally conscious state (MCS) and that the diagnosis of PVS was in error. This data was never presented in court nor was the affidavit prepared by Speech Pathologist Sarah Green Mele which suggested that Terry could form words on some occasions and might have been able to develop some language ability had she been given proper speech and swallowing therapy. Dr. Cheshire stressed that on the basis of prior C.T. scans of the brain Terry still had some cerebral cortex remaining. He indicated that based on new facts which have come to light in the understanding of PVS from the realm of Neurology research; PET scan and or fMRI would have been useful in further delineating her diagnosis and prognosis with respect to her potential response to therapy. See N.D. Schiff et al. fMRI reveals large-scale network activation in minimally conscious patients. Neurology 2004; 64: 514-523 and on the difficulty in determining "awareness" see S. Laureys et al. Cortical processing of noxious somatosensory stimuli in the persistent vegetative state. Neuroimag 2002; 17: 732-741 and Multi-Society Task Force on PVS. Medical aspects of the persistent vegetative state- second of two parts. The New England Journal of Medicine 1994; 330: 1572-1579.

[34] Paul Lauritzen, PhD. "Both the view that providing nutrition and hydration for PVS patients is morally obligatory and the position that providing a feeding tube is a form of care and not treatment represent a shift in Catholic teaching.

Understandably, commentators who have noted this shift have sought to downplay its significance, perhaps hoping that the change will be confined to cases involving persistent vegetative states. My own view, though, is that the changes are much more profound than anyone has acknowledged. They threaten to dismantle not simply Catholic teaching on end-of-life issues but much of Catholic moral theology generally. When natural constraints on human actions are treated so cavalierly, when what we can technically do appears to determine what we ought to do, the wisdom of the tradition that recognizes the goodness of our embodied existence and the fact that mere existence is not an ultimate good, seems to have been lost. If the ordeal of the Terri Schiavo case helps us to recognize the possibility of such a loss, it will not have been in vain."

_____________________

Bibliography:

Andrews K., Murphy L., Munday R. et al. Misdiagnosis of the Vegetative State: retrospective study in a rehabilitation unit. British Medical Journal 1996; 313; 13-16.

Catechism of the Catholic Church, 2nd Edition, Washington: United States Catholic Conference, 1997.

Cheshire, William MD. Affidavit, March 23, 2005 describing neurologic exam of Terry Schiavo and diagnostic conclusions.

Childs N.L., Mercer W.N., Childs H.W. Accuracy of Diagnosis of Persistent Vegetative State. Neurology 1993; 43: 1465-1467.

Committee for Pro-Life Activities, National Conference of Catholic Bishops, Nutrition and Hydration: Moral and Pastoral Reflections (Washington, D.C.: United States Catholic Conference, 1992), Publication No. 516-X, p. 7.

Declaration on Euthanasia, promulgated by the Congregation for the Doctrine of the Faith, Rome, May 5, 1981.

Ethical and Religious Directives for Catholic Health Care Services, November 1994.

Finnis, John. Fundamentals of Ethics. Washington, D.C.: Georgetown University Press,1983.

Finnis, John. Moral Absolutes: Tradition, Revision, and Truth. Washington, D.C.: The Catholic University of America Press, 1991.

Giacino G.T. et al. The Minimally Conscious State: Definition and Diagnostic Criteria.Neurology, 2002; 58: 349-353.

Grisez, Germaine, "Should Nutrition and Hydration Be Provided to Permanently Comatose and Other Mentally Disabled Persons?" Linacre Quarterly 57 (1990) 30-43. Grisez, Germaine. Difficult Moral Questions. Quincy, IL: Franciscan Press, 1997.

Hubert, John MD. "Justice and Freedom for the Human Embryo in light of the Philosophy of the Human Person, the Body/Soul Issue and Ethics" Social Justice Review, vol. 95, November-December, 2004, no.11-12.

"FIAMC'S FINAL STATEMENT ON VEGETATIVE STATE." Life-Sustaining Treatments and Vegetative State, Scientific advances and ethical dilemmas, Symposium, Rome, 17-20 March 2004.

Lauritzen, Paul PhD, "Revisiting Schiavo case - Feeding-tube removal raised question about Catholic end-of-life things" Commonweal Magazine 3/7/2006.

Laureys S. et al. Brain function in coma, vegetative state, and related disorders. Lancet Neurology 2004; 3: 537-546.

Laureys S. et al. Cortical processing of noxious somatosensory stimuli in the persistent vegetative state. Neuroimag 2002; 17: 732-741.

May, William E. An Introduction to Moral Theology. Second Edition, Huntington Indiana: Our Sunday Visitor Publishing Division, 2003.

May, William E. Catholic Bioethics and the Gift of Human Life. Huntington Indiana: Our Sunday Visitor Publishing Division Our Sunday Visitor, Inc., 2000.

May, William E. et al. "Feeding and Hydrating the Permanently Unconscious and Other Vulnerable Persons," Issues in Law and Medicine 3 (1987) 203-217.

May, William E. et al. "Caring for Persons in the 'Persistent Vegetative State'" Anthropotes: Rivista di Studi sulla persona e la famiglia 13.2 (1997) 317-331.

May, William E. et al. "Tube Feeding and the 'Vegetative' State," Part One, Ethics & Medics 23.12 (December 1998) 1-2.

May, William E. et al. "Tube Feeding and the 'Vegetative' State," Part Two, Ethics & Medics 24.1 (January 1999) 3-4.

Multi-Society Task Force on PVS. Medical aspects of the persistent vegetative state- second of two parts. The New England Journal of Medicine 1994; 330: 1572-1579.

New Jersey State Catholic Conference, "'Friend-of-the-Court Brief to the New Jersey Supreme Court': Providing Food and Fluids to Severely Brain Damaged Patients" (November 3, 1987), Origins: NC News Service 16 (1987) 542-553.

Pennsylvania Conference of Catholic Bishops, "Nutrition and Hydration: Moral Considerations," in Origins: NC News Service 21 (1992) 542-553.

Pope John Paul II, encyclical letter, Evangelium Vitae, 1995.

Pope John Paul II, Vatican II document, Gaudium et spes, 1965.

Pope John Paul II, encyclical letter, Veritatis Splendor, 1993.

Pope John Paul II, "Discourse of John Paul II to the Participants of the Working Group," in Working Group on the Determination of Brain Death and Its Relationship to Human Death (December 10-14, 1989) (Pontificiae Academiae Scientiarum Scripta Varia, 83), eds. R. J. White, H. Angstwurm, and I. Carrasco de Paula (Vatican City: Pontifical Academy of Sciences, 1992).

Pope John Paul II, "Papal Address on the 'Vegetative State' and Euthanasia: Intrinsic Value and Personal Dignity of Every Human Being Do Not Change", March 20, 2004, address to participants of the International Congress on "Life-Sustaining Treatments and Vegetative State: Scientific Advances and Ethical Dilemmas."

Pope Pius XII, "The Prolongation of Life: An Address to an International Congress of Anesthesiologists," as reprinted in Death, Dying, and Euthanasia.

Reverend James Mc Hugh, Bishop of Camden, N.J., "Artificially Assisted Nutrition and Hydration" (September 21, 1989), in Origins: NC News Service 19 (1989) 314- 316.

Schiavo, Terry, Official Autopsy Report in PDF format, Case # 5050439 performed April 1, 2005, Dr. Jon R. Thogmartin Medical Examiner, Pinellas County, Florida. Schiff, N.D. et al. fMRI reveals large-scale network activation in minimally conscious patients. Neurology 2004; 64: 514-523.

Williams, Legionary of Christ Father Thomas, dean of theology at the Regina Apostolorum Pontifical University in Rome, "'95 Encyclical Foresaw Cases Like Terri Schiavo's' Theologian Points Up a Key Problem in Florida Battle" Rome, March 22, 2005. (Zenit.org)

Contact

Common Good
https://www.catholic.org VA, US
Dr. John P Hubert, MD, FACS - Advisor to Common Good, 757 546-9580

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