Nutritional Support and Human Dignity within the End-of-Life Context

The Problem

“Quality of life” and “death with dignity” have more than a few folks erroneously asserting that the range of legally-acceptable end-of-life options should include “voluntary euthanasia,” and/or “physician-assisted suicide” also known as “physician aid in dying.” [1]  In a recent commentary entitled Human Dignity and the End of Life, Cardinal Rigali and Bishop Lori explain the Church’s position that artificially-delivered nutrition and hydration in support of patients who are chronically ill but not “actively” or “imminently” dying amounts to ordinary care while also demonstrating that the Church recognizes that such interventions are sometimes uncalled for within the end-of-life context. [2]

Within this essay, I unpack the meaning of “human dignity” and apply it to a real-world case while bearing in mind causality, proportionality, and respect for life to help folks better apply the Church’s teaching regarding tube feeding to their own situations.

Relevant Question

Is it possible for a human being to exist stripped of his/her last shred of dignity such that hastening his/her death by withholding food and/or fluids becomes necessary for “this” or “that” human being to “die with dignity” within an acceptable overarching “quality of life?”  In other words, by feeding “this” patient, might “I” be violating his/her “dignity” by forcing him/her to continue living a life of unacceptably-lesser “quality” than “A” or “B” or “C” . . .

Attributed and Intrinsic Human Dignity

Franciscan friar and physician Daniel P. Sulmasy distinguishes between two real types of human dignity, one which can be fully lost and another which can never be lost. [3]  For example, the chief executive officer (CEO) of a given corporation has “attributed dignity” in accord with his/her attained position.  This is both a dignity that he/she lacked prior to becoming CEO and a dignity that he/she will eventually lose.  If “I” understand “attributed dignity” to be the whole of human dignity, “I” will think that a person can exist with little or no “dignity.”  Thus, “I” might validly but erroneously assert that if our CEO suffers an apparently-permanent loss of rational capacity necessary for “dignified” daily activities such as eating, using the restroom, speaking, etc., his/her “dignity” will necessarily be reduced or even completely lost.

“I” might then validly but erroneously claim that folks should be allowed to plan ahead for such a “loss of dignity” by signing an advanced directive enabling specific persons to help them end their “undignified” lives at some future point, especially when a “timely” and “dignified” death seems nowhere to be found given the demands of “quality of life.”

This “attributed dignity” is real, and the suffering that goes with losing all or part of it is not to be taken lightly.  That being said, if “I” recognize that this former CEO is much more than a mere CEO-with-other-desirable-attributes, then “I” can grasp the possibility that this human being, even in his/her greatly-reduced state remains fully dignified in the depths of his/her being.

Notwithstanding the fact that this particular “he or she” really does suffer a significant loss of his/her former level of “attributed dignity” following a tragic event such as a catastrophic stroke, he/she does not lose even the smallest amount of his/her “intrinsic dignity.”  This is the case because even in the face of such tragic loss, our loved one who was a highly-revered CEO fully remains a son/daughter of God unconditionally loved and sustained by God, “my” brother and fellow dignitary to whom “I” remain devoted through thick and thin.

Cardinal Rigali and Bishop Lori specifically distinguish between non-complicated and complicated PVS.  In cases in which patients suffering the effects of non-complicated PVS are best helped with attaining proper nutrition and/or hydration via a device such as a G-tube or a Peg-tube, we are to provide them with such support.  Why?  In and of itself, PVS does not actively kill people.  Thus, if we stop helping these patients receive proper levels of nutrition and hydration, they dehydrate and/or starve to death.  Bearing in mind our distinction between “intrinsic” and “attributed” dignity, we see that anything less than provision of food and fluids in such cases amounts to an objective violation of “this” patient’s “intrinsic dignity” and “right to life.”

That being said, PVS is sometimes complicated by other factors which combine in ways irreversible and proximately-lethal in spite of our best efforts.  Sometimes, this nexus called “actively” or “imminently” dying actually renders food and fluids via tube ineffective and disproportionately risky.  Cardinal Rigali and Bishop Lori recognize this in their mention of Pope John Paul II’s refusal of such measures at the end of his life.  I am not intimately aware of the fine details of Pope John Paul II’s case; thus, I share another such case.

PVS and End-Stage Multi-Systems Organ Failure

While serving as a health care chaplain and ethicist a couple of years ago, I was intimately involved with a case in which the patient was completely non-responsive and “actively” dying of end-stage multi-systems organ failure secondary to graft vs. host disease.  Within his dying process, his gut could no longer absorb food and fluids.  Even if it could have done so, his internal organs could not have handled it.  The medical team knew that the feeding should be stopped.  Thus, they met with the patient’s health care proxy decision maker (proxy) to seek consent for doing so.

The proxy was in a very tough spot.  The patient had made it known to him that he wanted “everything possible” to be done for him.  The proxy had heard that the Church had said that “food and fluids must be given in all circumstances” because not doing so amounted to “killing the patient.”  He wanted to ensure that his loved-one’s life and dignity was fully respected. Thus, he chose to fight against the medical team discontinuing the tube feedings.

The proxy’s baseline instinct was excellent regarding human life and dignity.  However, in the heat of this gut-wrenching situation, he did not understand that the Church’s position on tube feeding also takes into account causality and proportionality.

As we helped him fully grasp the multi-causative nexus of his friend’s non-reversible impending death and the fact that the patient could not even absorb yet alone benefit in any way from continuing the tube feeding, the proxy was able to allow the medical team to discontinue the feedings while remaining highly attentive and responsive to the complex needs of the patient.  We gave the patient last rights and commended him to the intercession of the Blessed Mother along with all other supportive measures.  In the end, the patient’s intrinsic right to life and dignity were respected in accord with the fact that he was imminently dying, not from lack of food and/or fluids, but from irreversible and factually-lethal end-stage multi-systems organ failure.

Final Analysis

In the above case, had discontinuation of food and fluids been the cause of death, withholding them would have been objectively wrong.  Cardinal Rigali and Bishop Lori rightly point out that any “act or omission which by itself or by intention causes death in order that all suffering may in this way be eliminated” is never justifiable (C.D.F. Declaration on Euthanasia).  This is so because “human life is the basis of all goods” including intrinsic and attributed dignity.

In the end, any attempt to cut human life short necessarily violates full human dignity in the name of a dignity-reduced-to-mere-attribution-hence the application of the contemporary formulation “death with dignity.”  This is why clearly understanding the causality of death in “this” case and the proportionality of tube feeding while fully respecting human life and dignity must be clearly thought through in each case prior to deciding for or against this usually-ordinary care modality which is sometimes disproportionate.

LITERATURE CITED

[1]  Schoen, Elenor. “The Movement That Won’t Die,” The Catholic World Report.  18.5.  May 2008. 48.

[2] Rigali, Justin and William Lori.  “Human Dignity and the End of Life,” America, August 4, 2008.

[3] Sulmasy, Daniel.  “A Keynote Presentation: Dignity and Vulnerability,” The Catholic Health Association of the United States 2003 Physician Leader Forum.  To obtain a copy of this 39 minute oral presentation and other educational resources log on to CHA’s website at www.chausa.org or contact CHA’s order processing office at (314)253-3458.

(© Fr. Christopher M. Saliga, O.P. R.N.)