There was little media attention last November when the U.S. bishops revised, by a vote of 219-4, their moral guidelines for Catholic hospitals, known as the “Ethical and Religious Directives for Catholic Health Care Services.” It was a long-expected move to update, in line with recent Vatican and papal clarifications, a guideline on providing patients with adequate nutrition and hydration.
Now, however, blogs on the Internet are buzzing over a late-February article in Kaiser Health News, a publication of the Kaiser Family Foundation. Headlined “Catholic directive may thwart end-of-life wishes,” the article calls the update “new policy” and suggests that Catholic hospitals will ignore a person’s living will or end-of-life directive.
“The directive raises fresh questions about the ability of patients to have their end-of-life treatment wishes honored,” the Kaiser article states. It concludes with a quote from Barbara Coombs Lee, president of pro-assisted-suicide Compassion & Choices (formerly known as the Hemlock Society), saying that the bishops are trying to “guilt and shame” people.
‘Not so fast’
Several blogs have picked up the Kaiser article, including the health blog at The New York Times, which declared: “Voluntary end-of-life measures banned at Catholic hospitals.”
Not so, says Capuchin Father Thomas Weinandy, executive director of the U.S. bishops’ Committee on Doctrine: “I think some people in the media, for whatever reasons, want to scare people, and because of that they say that the Catholic health care institutions will not honor their end-of-life requests. But the only end-of-life requests that the Catholic Church won’t honor are those that are immoral and contrary to teaching of the Catholic Church.”
So, what actually changed with the revision of the ERD? Nothing substantial. The ERD were last revised in 2001, so they did not reflect a 2004 address Pope John Paul II made to participants in a Vatican-organized international congress on the vegetative state medical condition. Nor did the ERD reflect a 2007 reply from the Vatican’s Congregation for the Doctrine of the Faith to questions from the U.S. bishops’ conference. Those questions had been raised by the Terri Schiavo case, when her husband successfully fought to remove the assisted nutrition and hydration that had kept Terri alive for years. Some Catholic ethicists approved his action.
The 2001 ERD stated in Directive 58, “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.” The new Directive 58 (see box) changes “presumption in favor” to “obligation” and further clarifies the directive.
Bishop William E. Lori of Bridgeport, Conn., chairman of the bishops’ Committee on Doctrine, told Catholic News Service that the revision was necessary “particularly since the recent clarifications by the Holy See have rendered untenable certain positions that have been defended by some Catholic theologians and ethicists.”
Father Weinandy said the revision was based on long-standing principles regarding end-of-life care.
“What caused the change in the ERDs is the advance in medical technology,” he said. “Providing nutrition and hydration is much more readily available and acceptable and easier to do than in the past; and so what changed was the medical technology, not the teaching of the Church.”
Legal questions also have been raised about a Catholic hospital’s right to refuse directions in living will. Catholic hospitals are on firm legal ground on this matter, according to Leonard Nelson III, a professor and specialist in health care law at Cumberland School of Law of Samford University in Birmingham, Ala., and author of “Diagnosis Critical: The Urgent Threats Confronting Catholic Health Care” (OSV, $29.95).
A hospital has the right to say it won’t honor someone’s wish for treatment, he said, but state laws usually require that the hospital arranges for the patient’s transfer.
Likewise, a doctor may decline to go along with a re-quested treatment, explained John Haas, president of the National Catholic Bioethics Center. “Physicians will not abide by an advance directive if they are convinced it is bad medicine or not in the best interest of the patient,” Haas said.
Indeed, advance directives are often not helpful because they cannot anticipate particular situations, so they can be set aside easily, said Fred Everett, co-director of the Office of Family Life of the Diocese of Fort Wayne-South Bend, Ind.
Everett, who also is a lawyer, gave the example of a person who might write in a directive that he does not wish to be placed on a respirator. However, he said, that person might develop a health emergency that requires temporary use of a respirator to help him recover.
That is why Everett and many other experts recommend that instead of writing an advance directive, people should name a health care representative who knows their values and can make realistic and timely decisions about treatment if the person is unable to do so himself.
Everett said that he believes the update of the ERD is causing a stir now because some people have “pushed the envelope” on what is acceptable in a Catholic hospital. If it has become accepted practice to misinterpret the ERD, “this is a jarring wake-up call, and so some people are going to be upset,” he said. Catholic hospitals are not trying to impose difficult conditions on patients, Everett continued, but rather are trying to give the very best care.
“This is a very pastoral document,” Father Weinandy said. It is not meant “to frighten or scare people not to go to Catholic health care institutions, but rather to show them Catholic health care institutions are being run under and guided under Catholic auspices; and therefore they are going to get the care that should be afforded them as human beings created in the image and likeness of God.”
Ann Carey writes from Indiana.
What it says (sidebar)
In principle, there is an obligation to provide patients with food and water, including medically assisted nutrition and hydration for those who cannot take food orally. This obligation extends to patients in chronic and presumably irreversible conditions (e.g., the “persistent vegetative state”) who can reasonably be expected to live indefinitely if given such care. Medically assisted nutrition and hydration become morally optional when they cannot reasonably be expected to prolong life or when they would be “excessively burdensome for the patient or [would] cause significant physical discomfort, for example resulting from complications in the use of the means employed.” For instance, as a patient draws close to inevitable death from an underlying progressive and fatal condition, certain measures to provide nutrition and hydration may become excessively burdensome and therefore not obligatory in light of their very limited ability to prolong life or provide comfort.
— Directive 58 (revised November 2009)