BALTIMORE — The U.S. bishops have moved to tighten guidelines governing the care of patients in a persistent vegetative state.

While acknowledging deep divisions within the medical community and the public at large over accepted standards for withdrawing nutrition and hydration for patients with chronic, irreversible medical conditions, the bishops overwhelmingly approved a revision to the “Ethical and Religious Directives for Catholic Health Care Services” that echoes the Vatican’s stance on end-of-life issues.

The revision has relevance particularly now, when the country is debating a reform of the health-care delivery and finance system. Various proposed legislation has included what some characterize as “death boards,” rationing care to the elderly and chronically ill, or a stipulation that physicians who exceed a certain spending quota in the care of elderly patients will receive a reduced reimbursement from the government.

The change affirms the obligation of institutions and caregivers to provide artificial hydration and nutrition to such patients. The altered language incorporates two key “clarifications” on the proper care for such patients: Pope John Paul II’s March 2004 address to the participants in the international congress on “Life-Sustaining Treatments and Vegetative State: Scientific Advances and Ethical Dilemmas” and the Congregation for the Doctrine of the Faith’s August 2007 “Responses to Certain Questions of the United States Conference of Catholic Bishops Concerning Artificial Nutrition and Hydration.”

“In principle, there is an obligation to provide patients with food and water, including medically assisted nutrition and hydration for those who cannot take food orally. This obligation extends to patients in chronic and presumably irreversible conditions ... who can reasonably be expected to live indefinitely if given such care,” states the relevant passage from Article 58 in the USCCB directive.

The revised directive qualifies the obligation to provide care, noting that “medically assisted nutrition and hydration become morally optional when they cannot reasonably be expected to prolong life or when they would be ‘excessively burdensome for the patient or [would] cause significant physical discomfort.’”

Bishop William Lori of Bridgeport, Conn., the chairman of the USCCB doctrine committee that supervised the revision, expressed his satisfaction with the bishops’ strong backing.

“We certainly wanted to make it clear that providing food and water is part of ordinary care, that food and water should not be denied just because a patient has lost the use of his faculties for an extended period of time,” he explained.

‘In Principle’

Bishop Lori also noted that the changed language rejects the argument — made by some bioethicists who support the withdrawal of such care on quality-of-life grounds — that the denial of care does not “cause” death; rather the “underlying pathology” is responsible for the cessation of life. “We’ve saying that position is untenable,” said Bishop Lori.

He acknowledged that the Terri Schiavo case had raised concerns within the Church about the shift in cultural attitudes regarding end-of-life issues.

“In secular culture, there is a prevailing quality-of-life ethic that wrongly concludes that people who have lost their ability to engage their higher powers are a burden and that their life is not worth living,” he said. “The Church is speaking prophetically in this area, even in the very sober language of the directives.”

Catholic health-care professionals, concerned about the pressure on Catholic hospitals and nursing homes to define tube feeding as medically burdensome and thus optional, welcomed the revision.

“Increasingly, Catholic hospitals, under the advice of well-meaning bioethicists have chosen to withdraw nutrition and hydration in such cases,” noted Dr. Louis Greschi, president of the Catholic Medical Association and a urologist based in Baltimore. The Catholic Medical Association, along with the Catholic Health Association, the National Catholic Bioethics Center and the National Catholic Partnership on Disability, contributed to the USCCB review.

Greschi applauded the bishops’ refusal to accommodate arguments that justified the withdrawal of care by blaming the patient’s resulting death on the “underlying pathology” rather than the caregiver’s action.

“If the PVS patient is otherwise stable, then the withdrawal of food and water is the cause of their death. That’s what should go on the death certificate, but it doesn’t. We disagree with that practice.”

But Greschi said he was uncomfortable with one phrase included in the guidelines: “In principle, there is an obligation to provide patients with food and water.” That phrase appeared in the clarification issued by the Congregation for the Doctrine of the Faith, but Greschi worries that it might provide a loophole for bioethicists who support the withdrawal of such care on quality-of-life grounds or who view tube feeding as “extraordinary means.”

“‘In principle’ doesn’t need to be there,” Greschi argued. “You can’t make the provision of such care an absolute, but the exceptions are noted. I’d prefer a straightforward statement: ‘There is an obligation to provide the care.’”

Theologians Divided

Some theologians have argued that medically assisted feeding poses financial burdens to patients, their families or the state and thus should be optional. But Capuchin Father Thomas Weinandy, executive director of the USCCB Secretariat for Doctrine, observed that in “the United States, Western Europe and Eastern Europe, it’s reasonable to view assisted feeding as ordinary care” and thus obligatory.

Catholic Medical Association members have registered ethical concerns about the use of advance directives by patients who may not understand or accept the ethical requirement to provide such care. If an advance directive states that the patient does not wish to be maintained by artificial feeding, then physicians and hospitals must abide by that decision. If the directive violates Catholic moral teaching, patients or their surrogates are asked to find a new hospital or nursing home.

Greschi noted that the revised directives could become an issue at some hospice programs where patients may only receive feeding by mouth. But he applauded the hierarchy’s clear language: “The more the directives are tightened up, the more we are helped. We need the support of the bishops to take our stand, because there are plenty of theologians leaning the other way.”

Before the bishops’ meeting, Bishop Lori confirmed that the revision was necessary “particularly since the recent clarifications by the Holy See have rendered untenable certain positions that have been defended by some Catholic ethicists.” However, in an interview following the bishops’ vote, Bishop Lori would not identify the “Catholic ethicists” he had in mind.

In the Feb. 13, 2009, issue of Commonweal magazine, a group of directors of bioethics programs at Jesuit universities, calling themselves the Consortium of Jesuit Bioethics Programs, published a critique of papal teaching on the necessity of providing food and water. They urged the U.S. bishops to mainain the ERDs as they were, arguing, among other things, that papal teaching is out of touch with American medical and legal realities.

In June, a group of bioethicists, moral theologians and philosophers wrote a response to the Jesuit statement in Ethics and Medics, a journal of the National Catholic Bioethics Center. “Feeding disabled people is not a medical treatment, even though a medical procedure may be required,” they wrote. “It is a form of care owed to all persons, including patients in a PVS.”

In addition, in the November-December 2007 edition of Prospect, a publication of the Catholic Health Association, Dominican Father Kevin O’Rourke, a professor at Neiswanger Institute for Bioethics and Health Policy at Loyola University Chicago, co-wrote an article that challenged the Congregation for the Doctrine of the Faith’s clarification, including the position that artificial hydration and nutrition was generally obligatory.

“The CDF proposes that if ANH [assisted nutrition and hydration] is removed, the cause of death ‘will be neither an illness nor the “vegetative state” itself, but solely starvation and dehydration.’ Here, the CDF offers an interpretation of what kind of act constitutes euthanasia. This interpretation is at odds with the traditional teaching of moral theology,” contended Father O’Rourke.

Asked for his response to the revised directive, Father O’Rourke declined to comment.

Are some Catholic bioethicists and health-care professionals likely to resist the new standards for treatment? Bishop Lori noted that the ball was in the bishops’ court.

“I have one Catholic hospital in my diocese, and I meet regularly with the leadership of the hospital to discuss the implementation of all the ERDs. There are suggestions afloat abroad that some sort of an audit instrument might be developed. Perhaps that is a good suggestion. But it’s up to the bishop in each diocese to make sure the ERDs are being followed.”

“I hope the revised language will encourage a dialogue that will result in greater unity on this issue,” he added. “But this is not simply a matter of taking an abstract position. This is really a teaching that has direct effect on how we live out our respect for the life and dignity of the human person who is chronically ill or in the persistent vegetative state.”

Joan Frawley Desmond writes from Chevy Chase, Maryland.