Food Tube Ethics

A reader writes:

The question most troubling me is whether the Pope’s statement also applies to terminally ill patient’s whose death is certain and imminent.

For example, someone who does not have a feeding tube and who has a terminal illness slips into a coma. My understanding of Church teaching is that use of a feeding tube is not mandated in this case.

The ability to significantly extend life through feeding tubes for a large number of people is something that is relatively new. Prior to the invention of plastic, antibiotics, and effective antiseptics, it would have been very difficult for technology like this to be used to extend the lives of large numbers of people. As a result, there are still aspects of this question that are being thought through by moral theologians. Eventually (within the next 20 years, in all likelihood, and definitely within the next 50 given the aging of the European population) these questions will be much more thoroughly explored and certain of the solutions proposed by moral theologians will be signed off on–or rejected–by the Magisterium.

Even though there are questions left to be definitively answered, the outlines of the correct answers are already becoming clear. Before getting into the substance of the matter, though, I’d like to put out a couple of warnings:

First, there are some ostensible experts in clerical collars making the rounds of the talk shows and editorial pages right now who are saying very dismissive things about recent Vatican interventions on this subject, accusing the Holy See, among other things, of upending centuries of Catholic moral theology.

This is simply not true.

The deliverances of these individuals are grossly defective and not to be trusted. Among other problems with what they have been saying, it simply is not possible to take statements made four or five hundred years ago regarding the moral obligations that pertain to feeding patients and plop them down in a twenty-first century context taking no account of the change in technology. Five hundred years ago it was much harder to deliver nutrition and hydration to an individual in a wide variety of medical situations than it is now. It is now much easier to do so, and that changes things.

Further, there is such a thing as doctrinal development, and hundreds of years ago we were less doctrinally developed in this area than we present are. The last fifty years have seen a dramatic stimulus to doctrinal development in this area due to the development of new medical technologies and the rise of the culture of death. One cannot appeal to things five hundred years ago to trump recent development, though that is a frequent tactic of dissenters on every part of the ecclesiastical spectrum.

The second warning is that not all prestigious or seemingly official statements on matters in this area are to be taken without nuance. Some seemingly official statements (e.g., documents ostensibly issued by national conferences) have been found problematic in light of later Vatican interventions, which have served as correctives to some of the things being said on lower levels.

The warnings being given, let’s look at the core of the matter.

As Evangelium Vitae made reaffirmed, euthanasia properly-so-called is an intrinsically evil act that can never be performed. EV provided the following definition of euthanasia:

Euthanasia in the strict sense is understood to be an action or
omission which of itself and by intention causes death, with the
purpose of eliminating all suffering [EV 65].

For euthanasia to occur, four conditions must thus be fulfilled:

1. There must be an action or omission of action.
2. This must cause death "of itself" (i.e., it is a sufficient condition to cause death).
3. This must "by intention" cause death.
4. The purpose must be to eliminate suffering.

In the case of failing to administer food and water through a feeding tube (either by not installing one or by removing or discontinuing the use of one), condition (1) is fulfilled as this is an act of omission.

Since food and water are necessary for life, condition (2) is also fulfilled if the person can only or will only eat through a food tube.

The question of whether failing to administer food and water through a feeding tube constitutes euthanasia is thus determined by whether conditions (3) and (4) are fulfilled.

It may be the case that one is fulfilled without the other. For example, if one withholds food and water from a spouse because one wants the spouse to die for reasons unrelated to ending suffering (e.g., because one is afraid of what the spouse might one day tell the police or because one wishes to inherit money or property) then condition (3) is fulfilled but condition (4) is not fulfilled. In these cases what occurs is not euthanasia but simply murder.

Similarly, one could intend condition (4) to be fulfilled without condition (3). This would happen, for example, if the insertion of the food tube would itself cause damage to the patient that would only exacerbate his suffering.

In an earlier post I mentioned what happens to many folks when their bodies stop manufacturing albumin. In those cases, continuing to administer food and water will actually harm the person. With a terminally ill person in that condition, one could omit the food tube in order to minimize pain (getting us at least in the direction of fulfilling condition 4) without thereby intending to cause the person’s death, so condition (3) is not satisfied. In that case there is no euthanasia.

In the case of a terminially ill person who has lost the ability to manufacture albumin (and everyone I’ve heard of who has lost the ability to manufacture albumin is terminally ill) continuing to administer food and water would not only not help the person live longer but could actually hasten the person’s death due to the damage it does to the body, meaning that the act would be morally licit.

This is what the 2004 PVS address is getting at when it states:

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. 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.

While the administration of food and water is considetered "in principle ordinary and proportionate," this may not apply in particular cases, as with a person unable to process the food and water. In that case it is no longer ordinary and proportionate, in that it fails to attain its proper finality–nourishment and alleviation of the patient’s suffering. In such cases it ceases to be morally obligatory.

To focus this on the situation the reader asks about, let’s look again at the conditions he mentioned:

The question most troubling me is whether the Pope’s
statement also applies to terminally ill patient’s whose death is
certain and imminent.

For example, someone who does not have a feeding tube and who has a
terminal illness slips into a coma. My understanding of Church teaching
is that use of a feeding tube is not mandated in this case.

This situation seems to involve two conditions:

• The patient’s death is certain to be imminent (all of our deaths are morally certain; the point is that imminent death is certain).
• The patient has slipped into a coma.

The key factor here is the first. Whether the person has slipped into a coma is not really relevant. If someone has slipped into a coma and will remain in one for twenty years (i.e., death is not imminent) then you can’t starve them. The real issue is the imminence of the person’s death.

It seems to me that the first condition is significant for but not of itself sufficient for making the non-administration of food and water licit. Here’s why:

If a person’s death is extremely imminent (say, an hour from now) then there seems little point in putting in a food tube that will not buy the person any more life. In such a case it would not be morally obligatory.

On the other hand, if the person’s death is not that imminent (say, a month from now) then there would be a point in putting in a food tube since it would buy the person the extra life they would not otherwise have and so would be morally obligatory unless there is some other factor affecting the situation (e.g., the patient’s body no longer manufactures albumin, the food tube needs to be inserted through the stomach and would hurt a great deal or have a significant risk of infection due to a compromised immune system).

The nearness of death thus seems to be an important factor in determining whether it is morally required to administer food and water in these cases, but not the only factor to be taken into consideration:

• If the administration of food and water would not buy the person any more life then it would not be necessary.
• If it would buy the person more life but at a cost proportionate to the gain (e.g., the person will be in screaming agony in that additional time) then it may be forgone as it no longer achieves its principal finality, per the 2004 PVS address.
• If it would buy the person more life and the cost is not proportionate to the gain (e.g., it involves only mild discomfort) then it is obligatory.

Unfortunately, the Church has not yet developed a system for weighing the relative proportions of costs and gains in this area, which to different individuals may seem incommensurate to each other. This part is where the individual’s conscience (the patient’s or the person who speaks for the patient) comes into play at present. Hopefully (and probably) we will have more guidance from the Magisterium on this point in the future.

Hope this helps!