Sunday, December 20, 2009
News, In this Issue...

Do no harm

Catholic clergy, hospitals torn over new church directives

Brother Hilary McGee of the Franciscan Brotherhood of Peace wears a button in support of Terri Schiavo in 2006 on the one-year anniversary of her death.
 Tim Boyles/Getty Images

By Charles Stanley
 
Advocates for choice in end-of-life care are worried that Catholic hospitals, nursing homes and other health care facilities may refuse to honor patients’ wishes that they not be kept alive by artificial means.

Their worries stem from recent changes to the “Religious and Ethical Directives for Catholic Health Care” made in November by the United States Conference of Catholic Bishops (USCCB). The Directives cover Catholic doctrine regarding health care from conception to death, and apply to treatment of patients in Catholic hospitals regardless of the patient’s religious beliefs.

There are 17 Catholic health care facilities in Georgia. Two of the largest are St. Joseph’s Hospital in Atlanta and St. Mary’s Hospital in Athens. According to the Catholic Health Assocation of the United States (CHA), citing data from a 2007 American Hospital Association annual survey, Catholic health care comprises the nation’s largest group of not-for-profit health care sponsors, systems, and facilities. The most recent data available shows that Catholic hospitals saw 5.5 million admissions and nearly 30 million inpatient days in a single year.

The Directives, which all Catholic health care facilities in the U.S. must abide by, now describe medically assisted nutrition and hydration as a “moral obligation,” rather than the USCCB’s previous position, which one representative to the conference described as a “presumption in favor of maintaining medically assisted nutrition and hydration.”
 
Groups who support patients’ rights not to be kept on life support cite a clause in the Directives stating, “The free and informed judgment made by a competent adult patient concerning the use or withdrawal of life-sustaining procedures should always be respected and normally complied with, unless it is contrary to Catholic moral teaching.”

Steve Hopcraft, media director for Compassion and Choices, a group that advocates for expanded choice in end-of-life care, fears that patients of Catholic hospitals across the country could be unwittingly putting decisions about their end-of-life care in the hands of Catholic bishops. For some patients, he says, Catholic health care may be the only available option. 

“Catholic health care providers are put in a very difficult, I think untenable position,” says Hopcraft. “They may want to respect patients’ wishes, but this makes it impossible.”
Catholic health care representatives, however, say patients’ wishes are always considered in all aspects of treatment and claim that groups like Compassion and Choices are deliberately misleading the public about Catholic health practices.

The CHA, a voluntary membership organization representing Catholic hospitals, long-term care and other health care providers, released a statement in November which reads:
“In the vast majority of cases, patients’ advance directives will be honored. … There may be the occasional situation, such as some patients in a persistent vegetative state, when what the patient is requesting through his or her advance directive is not consistent with the moral teaching of the Church. In these few cases, the Catholic health care facility would not be able to comply.”

“MORALLY OBLIGATORY”

According to the USCCB, the changes to the Directives were meant to clarify the Church’s position on end-of-life care and incorporate statements made by Pope John Paul II in March 2004. The papal statements were made in the midst of the public legal battle over the fate of Terri Schiavo, who had been kept alive by a feeding tube in a persistent vegetative state for nearly 15 years. November’s changes would seem, to some, to indicate that Catholic health care facilities may ignore advance directives by patients expressing a desire not to be kept alive in a permanent vegetative state (PVS) or similar irreversible condition through medically assisted nutrition and hydration—as delivered by a feeding tube, for example.

Speaking before participants in the International Congress on “Life-Sustaining Treatments and Vegetative State: Scientific Advances and Ethical Dilemmas,” John Paul II, predecessor of the current Pope, Benedict XVI, told listeners, “I should like particularly to underline how the administration of water and food, even when provided by artificial means … should be considered … morally obligatory.”

The moment the Pope spoke those words, they became Catholic doctrine. Previously, Catholic health care facilities, which are subordinate to their local bishops, operated on the presumption that patients in a persistent vegetative state should be given nourishment for so long as it would keep them alive. However, some fear that with the presumption now spelled out as an “obligation” and the apparent subjugation of “free and informed judgment” to “Catholic moral teaching,” Catholic health care providers might ignore advance directives made by patients who do not wish to be kept alive indefinitely on a feeding tube.

Compassion and Choices’ Hopcraft cites an incident in 2000 as indicative of the sort of situation that might result from the recent changes to the Directives. Years before the Pope’s statements on assisted nutrition and hydration, Philadelphia Cardinal Justin Rigali, then Archbishop of St. Louis, personally intervened in the treatment of Steven G. Becker, a 29-year-old patient at St. John’s Mercy Medical Center, who was in a persistent vegetative state.
 
An account in the National Catholic Reporter states “Rigali required that artificially administered food and water be given Steven G. Becker as long as he remained in a Catholic hospital.”

Becker was eventually removed from the hospital and died at home. Now, with the Church more actively asserting its moral stance that removal of a feeding tube from a patient who needs it to live is tantamount to euthanasia, Hopcraft says the stage is set for Church leadership to intervene when patients’ wishes conflict with Catholic doctrine.

THE DIGNITY AND VALUE OF HUMAN LIFE

Father Thomas G. Weinandy, executive director for the Secretariat of Doctrine at the USCCB, says the position of the Catholic Church, and therefore the imperative for Catholic hospitals, is clearly outlined in the recently updated directive.

“If a patient or person comes to a Catholic hospital and has an advance directive [stating] that if they are diagnosed with being in a permanent vegetative state, that even if they could live indefinitely with nutrition and hydration that they would want the nutrition and hydration to cease, then that advance directive could not be honored in a Catholic hospital because that would be seen as participating in passive euthanasia,” says Father Weinandy. “A person could live if this were done, and the very fact that they don’t want it done is because they want to die.”

Weinandy goes on to describe the way a Catholic health care provider might address a situation where an advance directive runs contrary to Catholic beliefs:

“Whoever was speaking on behalf of the hospital would tell [the patient’s representative] what the Catholic Church’s teaching is and why it holds to that,” he says. “If they want that [patient’s] directive followed, they’d need to move them to another health care facility where that directive would be followed. … The context of this is the Catholic Church trying to maintain the dignity and value of human life, whether the person is ill or healthy,” he says.

Alan Sanders, director for the Center for Ethics at St. Joseph’s Hospital, metro Atlanta’s only Catholic hospital, emphasizes that patients’ wishes are considered an important part of the moral discernment process in medical treatment decisions. He does, however, stop short of providing assurance that all advance directives would be honored by Catholic health care providers, noting that no health care provider can guarantee that a patient’s wishes will be followed 100 percent of the time.

He points to language in the Directives pertaining to a person’s right to “forgo extraordinary or disproportionate means of preserving life,” as protection of a patient’s right to have his or her wishes considered in the event they are faced with a chronic and irreversible condition such as being in a long-term coma.

According to the Directives, proportionate means are “those that in the judgment of the patient offer a reasonable hope of benefit and do not entail an excessive burden or impose excessive expense on the family or community.”

As an acute care facility, Sanders says, St. Joseph’s is unlikely to encounter a decision to remove a feeding tube from a patient in a persistent vegetative state. However, he is confident that the wording, which leaves the judgment of what would be considered an undue burden up to the patient, ensures that patients’ wishes will be considered in all cases.

“The patients’ wishes, however, will still be weighed against Catholic moral teaching,” says Sanders.
He feels that the Directives obligate health care providers to respect patients’ choices while articulating Catholic beliefs about when medically assisted nutrition and hydration should be used.
He characterizes the changes in the Directives as an order against allowing patients to die because of a perceived lack of quality of life. “The Directives,” he says, “[signal] that a persistent vegetative state is not in and of itself a valid reason to justify removal of a feeding tube.”

However, Sanders believes that patients’ or their surrogates’ concerns about matters arising from being maintained in a PVS could constitute the sort of undue burden recognized by the Directives, making it acceptable to remove a feeding tube. 

Father Weinandy admits an excessive burden could result from a prolonged period in which a patient is being kept alive via medically assisted nutrition and hydration. 

“If the person was constantly getting infections from the feeding tube, or bedsores are getting infected,” he says, “then it could reach a situation where it would be better [to terminate care].”
Sanders allows that the intention of the Directives may appear cryptic. He believes this is because they are meant to outline principles rather than prescribe solutions to specific circumstances. Because the cases addressed by the Directives’ end-of-life tenets are rare and generally surrounded by unique variables, he says, they must be evaluated on a case-by-case basis.

“We like to have things in black and white,” he says. “But Catholic moral tradition doesn’t work that way.”

Like Sanders, Weinandy believes the Directives may be applied differently depending on a particular situation. “On the ground,” he says, “doctors, family and the patient himself have to make practical judgments of how and in what way the principles are applicable. You can’t write the rule for every scenario.”

Also, Sanders questions the motivation for the outrage voiced by Compassion and Choices, adding the choices the group advocates regarding end-of-life care go far beyond cases involving PVS. 

“This is a group that advocates euthanasia,” Sanders says of Compassion and Choices. “I think that’s important to note.”

The advocacy group’s portrayal of this topic has similarly raised the ire of the CHA, which, in a statement on Dec. 9, retorted “Recent statements by Compassion and Choices … are not merely unfortunate, they seem to be deliberately misleading and unnecessarily anxiety-producing.”

The statement is signed by Tom Nairn and Ron Hamel, directors for ethics at the CHA. They continue: “In those rare instances when the Catholic health care organization is not able to comply with an advance directive, it is not permitted [emphasis theirs] to impose medically administered nutrition and hydration contrary to the patient’s wishes. Instead, other options would be explored.”

Fred Caesar, special assistant to the president of the CHA, tells The Sunday Paper that such instances would be rare, but one of those explored options “might include the transfer of the patient to another facility.”

LEGAL QUESTIONS

Alan Meisel, founder and director of the University of Pittsburgh’s Center for Bioethics and Health Law, wonders if Catholic hospitals could be compelled by law to respect patients’ advance directives, regardless of the Church’s moral stance. He says it is not clear whether the legally binding power of an advance directive would outweigh the Church’s right to administer medicine in accordance with its beliefs. 

Meisel cites a 1986 New Jersey case, in which a court ruled that Beverly Requena, a 55-year-old patient dying of ALS, could not be forced by her hospital, Respiratory Rehabilitation Center of Riverside Hospital in Boonton, N.J., to either accept medically assisted nutrition and water or leave the hospital, despite the hospital’s policy of not withholding food from a patient.

The Requena case, however, does not influence the law outside of New Jersey, and may not even serve as precedent within the state, because it only went as high as the Appellate Division of the New Jersey Superior Court. Furthermore, the court’s decision in that case suggested that, had the hospital made its policy known beforehand, the justices might not have sided with Beverly Requena.

“[If] the hospital seeks to impose a treatment on a patient which that person does not want, to impose that treatment is battery,” he says,but adds a caveat: “One could say since you’ve admitted yourself to a Catholic hospital, that’s a form of consent.

“If I were a patient with a directive," he continues, "I would probably add to it that I didn’t want to be taken to a Catholic hospital."

Father Weinandy believes the directives handed down by the Church are not only legal, but protected by the United States Constitution.

“I would like to think that for the government to require Catholic hospitals to abide by these [patient] advance directives would be against the First Amendment freedom to practice one’s religion without being intimidated or coerced into doing something that is opposed to one’s religion,” he says. “Would it be unconstitutional for the government to say a Jewish hospital has to serve pork? I think so.”

The one thing all parties agree on is that it is important for people to make their wishes known in advance. Sanders, whose work with St. Joseph’s involves increasing public knowledge and understanding of advance directives, says designating a trusted person to make decisions is the most effective way to ensure that a person’s wishes will be honored. He notes that while the overwhelming majority of people will never find themselves in such a situation, unexpected medical problems that leave patients unable to make their own decisions are so nuanced that a friend or family member equipped to make a good judgment call is more effective than knowledge of a patient’s preference in a hypothetical situation that may not directly translate to reality.

“We’re talking about the unique and the rare,” says Sanders, “not the normal and routine.” SP