WASHINGTON — Pope John Paul II's recent statement about feeding patients intravenously settled an intra-Church debate on the topic, says the U.S. bishops' conference.

But Catholic hospitals want to dialogue about the meaning of the Pope's words before they determine how to implement them.

On March 20, the Holy Father said providing food and water to patients in a persistent vegetative state is “morally obligatory” and withdrawing feeding tubes constitutes “euthanasia by omission.”

“For this particular class of patients, there was an unsettled debate,” said Richard Doerflinger, deputy director of pro-life activities for the U.S. Conference of Catholic Bishops. “The bishops' conference was certainly recommending feeding these patients, but that was not at the level of papal teaching. Now it is. This clarifies but does not radically change the situation.”

In 2001, the U.S. bishops published the fourth edition of “Ethical and Religious Directives for Catholic Health Care Services,” which outline ethical standards of behavior and provide authoritative guidance on certain moral issues in medicine. Diocesan bishops are expected to enforce the directives in their dioceses.

The directives say 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.” Caregivers are to follow instructions set out in advance by people who do not want life-prolonging medical treatments as long they don't conflict with Catholic moral teachings.

Doerflinger said he expects the ethical and religious directives will be updated with the Pope's directives and sent to the bishops' conference for their approval within a year.

Father Michael Place, president of the Catholic Health Association of the United States — which represents 624 Catholic hospitals across the country — refused to be interviewed by the Register. But in a prepared statement he stopped short of saying when policies would be changed because of the Pope's statements.

“This will require dialogue,” said the statement, “especially with regard to practical implications for those patients who are not in a persistent vegetative state.”

The Pope's remarks came during a Vatican symposium on caring for people who are incapacitated. John Paul took issue with the medical terminology used to describe people in so-called “persistent vegetative states.”

No matter how ill someone is, “he is and will always be a man, never becoming a vegetable or animal,” the Pope told members of the international congress organized by the Pontifical Academy for Life and the International Federation of Catholic Medical Associations.

At a March 16 press conference at the opening of the conference “Life-Sustaining Treatments and the Vegetative State: Scientific Advances and Ethical Dilemmas,” Bishop Elio Sgreccia, vice president of the Pontifical Council for Life, refuted the position that “when a person loses the use of reason, he or she ceases to be a person, and then there is the possibility of interrupting feeding and hydration in order to facilitate his or her death.”

Catholic teaching emphasizes that as long as a human being is alive, he or she is a person with a right to receive care, the bishop said.

“As long as they are absorbed by the body and are beneficial to the patient,” he said, nutrition and hydration must be provided.

He said feeding and hydration of vegetative patients is a duty both from an ethical point of view — it makes possible the preservation of the good of life — and a medical point of view, since in the present state of scientific knowledge it is not possible to know ahead of time if these patients will be cured.

The bishop added that a person could not deny himself food and water — through a will — should he fall into a vegetative state, as that would be “suicide.”

The Catholic Health Association has put together materials for member hospitals to encourage study and dialogue.

The package includes a chart showing how Catholics justified denying food and water to patients before the Pope's teaching.

“The chart [which is the result of the work of a small group of Catholic theologians and ethicists who advise Catholic Health Association staff] compares the current understanding of many in the Church of the Church's teaching regarding medically administered nutrition and hydration with what seems to be contained in the papal allocution,” an association statement provided to the Register stated.

“Further study and clarification of the papal allocution could result in slight or substantive revision of the preliminary analysis contained in the chart.”

Michigan-based Trinity Health System issued a statement saying it will continue to follow the ethical and religious directives but “would not care to speculate on the implications of the Pope's message; however, we anticipate that there are implications. That discussion … will be taken up by the bishops and others whom we depend upon for expert counsel in such matters.”

Presumption for Life

In a so-called “vegetative state,” patients are awake but not aware of themselves or their environment. The patient is in a persistent vegetative state if the state continues for a month. After a year without improvement, he is considered to be in a permanent vegetative state.

Providing food and water to such patients should be considered natural, ordinary and proportional care — not artificial medical intervention as many ethicists and health-care professionals have argued, the Pope said.

“Death by starvation or dehydration is, in fact, the only possible outcome as a result of [withdrawal of nutrition and hydration.] In this sense it ends up becoming in effect, if done knowingly and willingly, euthanasia by omission,” the Holy Father said.

The ethical and religious directives say there should be a presumption in favor of feeding for all patients who need it, Doerflinger explained.

“That statement remains true, but the Pope is saying that presumption is quite strong. He's saying that as long as it fulfills its goal of providing nourishment effectively and alleviating suffering, then this is the general rule and you need a serious reason to depart from that rule.”

But James Drane, a professor of clinical bioethics at Edinboro University of Pennsylvania, said he felt “shock and disbelief” when reading the Holy Father's directives because he believes they contradict centuries of Catholic moral teaching.

According to Drane, Spanish theologians from as far back as the 16th century — including Jesuit philosopher Francisco Suárez — held that “no one was required to do everything possible to save a life, especially when the life was compromised quality-wise or in the dying process.”

“It's the pro-life agenda that I see driving this alteration of a sound and respectful Catholic tradition, which has been accepted by the American legal system, by all of the professional associations and has become mainline bioethics,” said Drane, a former priest suspended in the 1960s from a teaching position at St. John's Seminary in Little Rock, Ark., after criticizing the Church's position on contraception.

Dissenting ethicists such as Drane think John Paul has gone too far because they believe feeding people in a vegetative state is of no benefit to that person, Doerflinger said.

They believe “the benefit of feeding is to restore people to health or to support life that is capable of human cognitive acts,” he said.

Drane agrees with that assessment, saying that feeding tubes should be removed from patients such as Terri Schiavo, the brain-damaged Florida woman at the center of legal battles regarding removal of her feeding tube.

“The only thing I see complicating the Schiavo case is the controversy in the family,” he said. Schiavo's husband, Michael, has sought permission to remove the feeding tube that keeps his wife alive.

Terri Schiavo suffered massive brain damage 14 years ago. Some doctors have diagnosed her as being in a “persistent vegetative state” — a diagnosis her parents adamantly reject, saying their daughter is responsive to other people. She breathes on her own but requires a tube to provide nutrition and hydration.

For some patients, however, nutrition and hydration is not a benefit said Dominican Father Albert Moraczewski, the first president of the National Catholic Bioethics Center near Boston. This needs to be clarified. Perhaps: “For some patients food and water can no longer be assimilated by the body, in which case feeding tubes fail to provide needed nutrition.”

The Pope's directives allow for a feeding tube to be removed in such a case What case?. “When a person is dying, a lot of functions stop,” Father Moraczewski said. “Consequently, the body is not metabolizing food and water properly.”

The Holy Father likely chose to clarify Church teaching on this subject because of the denigration of the human person in many countries, including Holland, where euthanasia is legal, Father Moraczewski said.

“We tend to deal with seriously handicapped individuals — physically and mentally handicapped especially — as if they were non-persons,” he said. “But it's still a human being even if the manifestations are not obvious.”

Patrick Novecosky writes from Ann Arbor, Michigan.