‘Living Wills’ Should Foster a Patient’s Will to Live

Italy’s approval of Advance Directives, commonly called “living wills,” enables forward-looking medical planning, but needlessly compromises physician conscience rights and facilitates denial of food and water, long-understood to be a form of basic and ordinary care.

(photo: Pixabay/CC0)

In late 2017 Italy’s Senate approved, in a 180-71 vote, legislation permitting patient-created Advance Directives. The law endorses a form of Advance Directives so permissive that Italians won’t simply be able to outline their health care wishes prior to possible incapacity, but in fact will be able to hasten their own deaths. Tragically, this appears to be intentional on the part of legislators — some actively endorsing such a lamentable vision for Italian health care, and others presumably “going along” for reasons of expediency.

Marco Cappato, a prominent member of Italy’s Radical Party and so-called “right to die” activist, was among those cheering Italy’s Advance Directives law explicitly for the logic that it has introduced into his country, which is that vulnerable patients may now actively bring about their own death by denial of basic care. Specifically, the law makes it possible for Italians who are not actively dying to refuse food and water. Further, such patients may impose their will to do so on potentially unwilling physicians who will enjoy no conscientious objection rights. In remarks to the Associated Press, Cappato plainly shared his next legislative priority: “[W]e are still missing the legalization of euthanasia that we’ll propose to the next parliament.”

Yet Italy remains predominantly Catholic in terms of its cultural identity. It’s worth underscoring that Cappato’s assertion that Italy is “still missing” legalized euthanasia would be disputed by Catholics, who are called to recognize that the withdrawal of food and water for patients who are not actively dying represents a form of euthanasia that doesn’t simply facilitate, but in fact causes, a person’s death by starvation and dehydration.

In March 2004 remarks, Pope John Paul II addressed this issue directly, in part apparently to respond to the then-ongoing public debate over whether U.S. courts would allow Terri Schiavo, a cognitively disabled 40-year-old woman who did not rely on any life-support machines, to be fatally deprived of food and water. “The sick person … awaiting recovery or a natural end, still has the right to basic health care,” observed John Paul II, specifying a right to “nutrition, hydration, cleanliness, warmth, etc.” as well as “the right to appropriate rehabilitative care.”

“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…” the Holy Father took care to underscore. “Death by starvation and dehydration is, in fact, the only possible outcome as a result of their [food and water’s] withdrawal.”

In these few sentences John Paul II summarized the simple, expert, and mainstream medical opinion on the issue of providing food and water as a basic right to patients who are not actively dying and who, for whatever reason, cannot feed themselves, while at the same time providing a coherent moral basis for life-affirming health care for patients in some of the most difficult circumstances.

Yet such a traditional view — that medicine should never be a means by which death is intentionally brought about — has been under attack for more than half a century by advocates who are more concerned with advancing an absolutist vision of individual autonomy. On  the peripheral fringes of this vision are medically vulnerable patients who often find themselves excluded from life-affirming care.

While Terri Schiavo is perhaps the most internationally prominent victim of the euthanasia mentality of denying basic care, countless other “Terri Schiavos” suffer at the hands of indifferent nations and governments. Indeed, Eluana Englaro, described in 2009 as Italy’s Terri Schiavo,” was another prominent victim of government-facilitated euthanasia. Italian legislators seem, unfortunately, to have taken the wrong lessons from Eluana’s case, if they remember her. Eluana was not reliant on life support, but simply required food and water due to cognitive disability. At the time, Italian medical professionals refused to participate in her family-sought death by dehydration, and prior to her death the Catholic religious sisters who oversaw caring for her simply refused to comply with a court order to starve and dehydrate her to death. Even Italy’s Minister of Labour, Health, and Social Policies came to Eluana’s defense, warning death advocates that it was “illegal” for health care facilities funded by the government to withdraw food and water with the intent to cause the death of a patient. A public appeal from more than 700 Italian physicians asked for Eluana to be spared an intentional death. Eluana met her death at the hands of her father, who won court permission to deny her basic care.

In light of Eluana’s fate, Italy’s recent decision to legalize intentional death-seeking seems to have been passively accepted by many Italians for some time. Nonetheless, Pope Francis spoke against the spirit of the Italian parliament’s decision in advance of their vote in his November remarks to the Pontifical Academy for Life. Pope Francis stated plainly that even when one cannot “guarantee healing or a cure, we can and must always care for the living, without ourselves shortening their life,” reiterating that “euthanasia, which is always wrong … [intends] to end life and cause death.”

Advance Directives, to the extent that they enable a mentally and physically competent person to outline their authentic and life-affirming medical wishes in advance of situations where their judgement may be compromised, can be good and useful instruments for ensuring that health care be life-affirming and not needlessly extraordinary in nature. What makes Italy’s Advance Directive law so troublesome is its embrace of a euthanasia logic that permits, or even encourages, patients to fatally deny themselves food and water, and further its aggression and violence against the conscience rights of physicians and health care workers whose right to dissent is not recognized. Every one of those more than 700 physicians who appealed for Eluana’s right to basic treatment may one day be forced to choose between intentionally bringing about the death of another Eluana, on the one hand, or being branded an extremist and consequently forced out of medicine, on the other.

Whether one is Catholic, or Protestant, or secular and unreligious, it represents a distortion of medicine’s purpose to conflate Advance Directives and the principle of medical planning with the ability to self-deny or to be denied food and water, which represents neither a costly nor an exotic form of care.

At the true end of life, the human body becomes incapable of metabolizing food and water, which is ultimately why the issue of “food and water” – as if it were an “end of life” issue by its nature – is disingenuous. Characterizing food and water as necessarily an “end of life” issue is a distortion of the reality facing millions of persons reliant on feeding tubes throughout the world each year. A young and recovering alcoholic, for instance, may be reliant on food and water by feeding tube for many months, or even years. In no traditional sense would this person be facing a fundamentally “end of life” issue, yet legislation like Italy’s encourages both the public and the patient to consider such situations in a much more fatalistic way—in a way almost certain to degrade a vulnerable patient’s will to live.

In societies that still officially oppose suicide and recognize the need to offer crisis counseling and emergency support to men and women captured by often fleeting moments of suicidal thinking, we should take the same approach of offering life-affirming care to medically vulnerable patients. Indeed, the daily lives of vulnerable patients may in fact be more consistently grinding on their will to live, especially in cultures like Italy’s whose law now rhetorically implies questions like, “Why not put a permanent end to anxiety? To periodic suffering? To moments of discomfort? To the need for rehabilitation?”

Italy’s parliament should do better by allowing for advance directive planning that fosters a will to live among vulnerable patients, continues to proscribe intentional life-taking, and cultivates life-affirming clinical environments where the conscience rights of physicians and health care workers are paramount in service of medicine’s basic purpose to cure, heal and comfort.


Bobby Schindler is President of the Terri Schiavo Life & Hope Network and an associate scholar at Charlotte Lozier Institute. Tom Shakely is Executive Director of the Terri Schiavo Life & Hope Network.