NEW YORK—As the director of such well-known films as The Sting and Butch Cassidy and the Sundance Kid lay dying in the care of a Catholic hospice, a private-duty nurse and a pro-life advocate were fighting to make sure he was being treated with dignity.

George Roy Hill, 81, died Dec. 27. He was under the care of his doctors and the hospice program of Cabrini Medical Center, a Manhattan Catholic hospital, in mid-December in his Fifth Avenue home when his family decided to stop his artificial feeding.

The family made the decision based on Hill's living will, said Louisa Hill, his ex-wife and health care proxy.

Hill had suffered for several years from Parkinson's disease. Because the Parkinson's disease interfered with his ability to breathe normally, Louisa Hill explained, he had a tracheotomy, an opening in the trachea made through the neck. The Parkinson's disease also hampered Hill's ability to swallow, requiring him to receive his food artificially through a stomach tube.

According to Louisa Hill, the Parkinson's disease was causing Hill to suffer from a great deal of congestion in his lungs, which had to be suctioned out frequently.

After the artificial feeding stopped, Louisa Hill said Hill's lungs seemed less congested and needed to be pumped out less frequently. He was “resting peacefully,” she said in a Dec. 6 interview. Hill was expected to die any day.

Louisa Hill acknowledged that a former nurse of Hill's, Heather Ward, “disagreed with the decision to follow the living will.” Louisa Hill said she felt “harassed” because Ward had encouraged “every little agency” to look into the Hill case.

Ward, on the other hand, feared the withdrawal of nutrition was not medically or ethically justified. She fought to ensure that Hill would continue to receive food by protesting to Cabrini as well as to the Archdiocese of New York, the New York Police Department, the Manhattan District Attorney's Office and the Adult Protective Services agency.

None of her protests succeeded.

Ward resigned as Hill's private duty nurse as an objection to the family's decision to stop artificial feeding, she said. For the past four years she had been taking care of Hill for 12 hours a day, five to seven days a week, she said. She described Hill as “very handsome,” with a “distinctive smile,” short gray hair and “beautiful gray eyes.”

“I told [the family] he's not an animal,” she said.

The case raises questions about whether a Catholic institution was unjustifiably “starving Hill to death,” said Chris Slattery, the co-founder of the Legal Center for the Defense for Life who was assisting Ward in the matter.

Medical Ethics

In resolving questions of medical ethics, Catholic hospitals are obligated to follow the Ethical and Religious Directives for Catholic Health Care Services issued by the U.S. Conference of Catholic Bishops. According to the directives, “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.”

“We should not assume that all or most decisions to withhold or withdraw medically assisted nutrition and hydration are attempts to cause death,” states a resource paper issued in 1992 by the Secretariat for Pro-Life Activities of the bishops' conference.

Withdrawal of nutrition and hydration might be justified when “the patient [is] imminently dying, whether feeding takes place or not” or when the feeding procedure is “of limited usefulness to the patient or unreasonably burdensome for the patient and the patient's family or caregivers,” according to the resource paper.

However, “the harsh reality is that some who propose withdrawal of nutrition and hydration from certain patients do directly intend to bring about a patient's death,” the resource paper adds. Nutrition and hydration “are sometimes withdrawn not because a patient is dying but precisely because a patient is not dying (or not dying quickly) and someone believes it would be better if he or she did,” it cautions.

Although no one at Cabrini was willing to comment on whether the withdrawal of Hill's artificial feeding was justifiable, other ethicists at prominent Catholic hospitals indicated that it might be morally defensible to withhold nutrition from patients with Parkinson's disease who are being artificially fed, such as Hill.

“A feeding tube does not necessarily prolong life or prevent aspiration” of food into the lungs, said Franciscan Brother Daniel Sulmasy, a physician who chairs the department of ethics of St. Vincent's Hospital-Manhattan and New York Medical College. A person with advanced Parkinson's disease could suffer from as many as five episodes of aspiration pneumonia from food being aspirated into the lungs, he said.

“Nutritional intervention doesn't always improve survival,” said Dr. Christopher Comfort, chairman of the ethics committee at Calvary Hospital, a Catholic institution for the terminally ill located in the Bronx, in agreement. “Incidents of aspiration pneumonia don't fall in patients with gastrostomy [stomach] tubes.”

A diagnosis of end-stage Parkinson's disease can be “as terminal a diagnosis as a diagnosis of cancer,” Comfort added. Under those circumstances, continued nutrition and hydration “may make a difference only in terms of hours or days.”

The resource paper explains that even where “the shortening of the patient's life is one foreseeable result” of withdrawing nutrition and hydration, “this kind of decision should not be equated with a decision to kill” where the primary purpose of the withdrawal is to ease the patient.

Value of Life

According to Conventual Franciscan Father Germain Kopaczynski, director of education at the National Catholic Bioethics Center, “the Church's teaching is very much on the side of life—when in doubt, choose life.”

“The paramount consideration is that God is Lord of life and death,” and we “can't put God aside and say in this case God's will is not as the family wishes,” he added. On the other hand, “no one wants to see people suffer,” he said, so the Church must balance “pastoral and doctrinal concerns” on this issue.

According to Father Kopaczynski, the directives are “a summary of authentic Catholic teaching” and are “as good as you could get given the medical realities—there are so many situations that might arise.” Nonetheless, some Catholic medical institutions “would not be as strict as other facilities or might understand the directives in a different way.”

According to Tom Marzen, general counsel of the National Legal Center for the Medically Dependent and Disabled, the directives of the bishops' conference do not provide clear enough guidance in specific situations. Marzen has been involved in approximately 100 lawsuits contesting the withdrawal of treatment such as nutrition and hydration.

Marzen said he thinks as a practical matter there is “no careful analysis of the legitimate burdens and benefits” to the patient with respect to continued artificial feeding.

“Some benefits are more important than others,” he said, “like staying alive.”

Marzen fears many Catholics and Catholic hospitals, like the rest of society, have lost the sense of the “absolute value of human life, the sanctity of life.”

Avenues of Protest

With respect to the Hill case, Marzen explained that from a legal standpoint it is often very difficult to protest a decision made by a health care proxy such as Louisa Hill. This does not mean that a person protesting such a decision has no recourse, however.

Catholic hospitals can and do refer patients to other doctors or transfer them to other facilities if their wishes or their family's wishes do not accord with the directives, explained Comfort of Calvary Hospital. Moreover, if patients or their families during the admitting process make requests that violate the directives, Calvary will not admit the patient, he said.

Additionally, “a physician or nurse told to participate in a course of action that he or she views as clearly immoral has a right and responsibility either to refuse to participate in this course of action or to withdraw from the case, and he or she should be given the opportunity to express the reasons for such refusal in the appropriate forum,” the bishops' conference resource paper states.

In accordance with these principles, Hill's former nurse Ward refused to participate in the withdrawal of artificial feeding from Hill. Through Slattery, she attempted to express her reasons for this refusal to Cabrini.

Cabrini has a procedure for people to protest medical decisions on ethical and religious grounds, according to Belinda Conway, vice president of missions, who has responsibility for ethical matters at Cabrini.

The hospital has “an ad hoc ethics committee that meets and reviews specific patients' situations,” Conway said. The patient's treating physician or a person directly involved in the patient's care can ask for a meeting of the ad hoc ethics committee, she said.

Mary Cooke, who is director of Cabrini Hospice and a member of Cabrini Medical Center's standing ethics committee, said anyone at the medical center would have access to the ad hoc ethics committee. She said if a private-duty nurse wished to address the ad hoc ethics committee, Cooke would ask the committee if it was possible.

Slattery said he contacted Cooke on Ward's behalf to protest the treatment of Hill but that Cooke did not inform him of a procedure that would allow someone to contest a medical decision on ethical grounds. Instead, he said, she characterized Slattery's and Ward's activities as interfering in a private decision and refused to take action.

Cooke refused to comment on why she did not mention the committee to Slattery when he called on behalf of Ward.

Slattery also contacted Margaret Kranz, senior vice president of legal services and general counsel to Cabrini, he said. According to Slattery, Kranz likewise failed to mention the ad hoc ethics committee and instead expressed the concern that Ward was revealing confidential medical information of a patient.

Kranz was unavailable for comment.

Question of Oversight

The interpretation of the directives is ultimately up to the local bishops, said Richard Doerflinger, deputy director of the Secretariat for Pro-Life Activities of the U.S. Conference of Catholic Bishops.

A bishop has the authority to determine whether a medical institution in his diocese can continue to call itself Catholic. He can also keep an institution from claiming tax-exempt status in the name of the Church, Doerflinger said.

Dr. Karl Adler, Cardinal Edward Egan's delegate for health care in the Archdiocese of New York, said the archbishop would consider ordering an institution not to call itself Catholic if that institution violated the directives. To seek the aid of the archdiocese, a person would simply need to “write a letter to Cardinal Egan with a cc to myself,” he said.

Adler, who is also chairman of the archdiocese's Catholic Healthcare System of hospitals, is not aware of any such complaints. In particular, the Hill case had not come to his attention.

Ward and Slattery met twice with officials from the Archdiocese of New York's Family Life/Respect Life Office, however, and were told that Cardinal Egan was informed of the situation, Slattery said.

According to Louisa Hill, someone at the archdiocese called Hill's family; she did not say who or what the person said.

Neither Cardinal Egan's office nor archdiocesan spokesman Joseph Zwilling would comment on what action it took and whether it had an official position on the matter.

Katharine Smith Santos writes from Garden City, New York.