"You shall know the truth, and the truth shall make you odd." ~Flannery O'Connor

Tuesday, December 18, 2007

Death by qualification

On August 1, the CDF issued a responsum about the use of "artificial nutrition and hydration" (ANH) for patients in a "permanent vegetative state" (PVS). Given the controversy surrounding the case of Terry Schiavo in 2005, and Pope John Paul II's controversial 2004 allocution on the broader topic, I was surprised that the responsum went largely unnoticed outside the Catholic professional circles most closely concerned with such matters. In my own post on the document, where I revealed my personal as well as intellectual interest, I argued that the teaching conveyed by the responsum is not a matter of opinion but a logical corollary of the settled, ordinary teaching of the Church. It should be received as such by all Catholics. But I am not at all surprised that what is not a matter of opinion in principle is becoming one in fact. The document's reception seems to be killing the teaching with qualifications—the kind of qualifications that can be and are used to justify killing the most vulnerable of patients.

A very good example of what I'm referring to is an article in the December 7 issue of Commonweal by a Franciscan brother, Daniel P. Sulmasy, who "holds the Sisters of Charity Chair in Ethics at St. Vincent’s Hospital in New York City" and is "also professor of medicine and director of the Bioethics Institute of New York Medical College." This man is well-placed to influence Catholic clergy as well as health-care professionals, and I have no doubt he does so. He is concerned, at least prima facie, to uphold orthodox Catholic teaching. Yet whether by design or merely in effect—I don't know, and it hardly matters—Sulmasy's article reduces the responsum's utility to next-to-nothing. It does so by how he interprets the Vatican's motives and how he reduces the teaching's scope of application.

First we are told that the responsum must be read in its cultural and political "context." That seems fair enough; after all, even the dogmatic definitions of the Church can be adequately interpreted only by taking their original contexts into account. Thus:

The Vatican’s interest in PVS is also driven by its reaction to utilitarianism-especially in English-speaking nations and particularly in Australia, where philosophical utilitarian ethics is perhaps most radical. Utilitarian philosophers have argued in scholarly journals that it would be more morally appropriate to conduct painful experiments on human beings in PVS than on dogs or porpoises, since those in PVS cannot feel pain and have ceased to be persons. This is not a view that is congenial to Catholic thinking and a group of very influential prelates has pressed for doctrinal responses to such utilitarian claims.

That is true and important. To understand the teaching's value, it's important to know what sort of prevalent moral philosophy the teaching's premises oppose. But Sulmasy goes on to observe, at some length, that the Vatican's stance is motivated partly by both "pro-life extremists" within the Church and by a European culture of health care that is supposedly more "paternalistic" than the American. Now even supposing for argument's sake that such motives were at work, their relevance to the question of the responsum's truth and value is at best dubious; for in general, the truth of a rationally argued-for proposition is independent of the motives one might have for asserting the proposition. Yet Sulmasy actually adduces such motives as part of a critique, as though they somehow undermined the value, if not actually the truth, of the responsum's teaching. And by lumping the latter two motives—if in fact they are among the motives—together with the first as part of the document's "context," the first is conditioned by rhetorical association with them. Hence the difficulty: Sulmasy insinuates, without actually claiming, that the CDF stance is just a matter of opinion—one that might well have been left unexpressed by Vatican officials, and might even have been different from what it is, if the motives he cites had not been present. While that might not be the message Sulmasy wants to convey, he ought to know that it's the message many will readily hear. That's both because it is what they're disposed to hear and because there's nothing to discourage such a disposition in Sulmasy's discussion of "context." So this kind of writing is irresponsible on the part of a man in his position.

Sulmasy also reduces the teaching's scope of application not by denying what it says, but by giving such weight to exceptional cases as to make it seem purely a matter of judgment, on the part of those responsible for a PVS patient's care, whether or not ANH could constitute unduly burdensome and thus "extraordinary" or "disproportionate" treatment. To see the difficulty, contrast the last two paragraphs of the CDF's own nota (commentary) on the responsum with Sulmasy's conclusion.

The nota says (emphasis added):

When stating that the administration of food and water is morally obligatory in principle, the Congregation for the Doctrine of the Faith does not exclude the possibility that, in very remote places or in situations of extreme poverty, the artificial provision of food and water may be physically impossible, and then ad impossibilia nemo tenetur. However, the obligation to offer the minimal treatments that are available remains in place, as well as that of obtaining, if possible, the means necessary for an adequate support of life. Nor is the possibility excluded that, due to emerging complications, a patient may be unable to assimilate food and liquids, so that their provision becomes altogether useless. Finally, the possibility is not absolutely excluded that, in some rare cases, artificial nourishment and hydration may be excessively burdensome for the patient or may cause significant physical discomfort, for example resulting from complications in the use of the means employed.

These exceptional cases, however, take nothing away from the general ethical criterion, according to which the provision of water and food, even by artificial means, always represents a natural means for preserving life, and is not a therapeutic treatment. Its use should therefore be considered ordinary and proportionate, even when the "vegetative state" is prolonged.

Not much wiggle room there. Now, zeroing in on the used of the phrase "in principle" by both the responsum and the nota, Sulmasy begins thus:

...the CDF statement ratifies the views of an international group of Catholic bioethicists who in July 2004 argued that the words “in principle” in the papal allocution did not mean “exceptionless,” but rather the opposite. This is crucial because in the ordinary/extraordinary-means tradition, one cannot make an a priori exceptionless declaration that a particular treatment is ordinary. A treatment that is ordinary in one set of circumstances may be extraordinary in another. The CDF’s response and accompanying commentary declare that its teaching about feeding tubes in PVS must be located squarely within this tradition.

Again, that is true. But in response to concerns about whether Church teaching about using ANH in PVS patients has "changed" to a confusing extent, Sulmasy says (I have added the bullets and accompanying syntactical changes—ML):

What, then, has changed? It seems to me that the proper way for clinicians, hospitals, and families to interpret the CDF statement is to understand it as saying that IF
  • a patient is in the rare state known as PVS
  • has not left any advance directive
  • is otherwise young and healthy
  • the government or an insurance carrier is paying or one is independently wealthy
  • it is not reasonable to construe that the patient is suffering
  • and if there are no apparent complications
then, other things being equal, one cannot justify the removal of the feeding tube merely because one is morally certain that the patient cannot recover. In such a “thick” description of the circumstances, the believing community’s authoritative voice has judged that this treatment should be considered ordinary. I suspect that previously many of us would have taken a good-faith determination by the family that the patient would not want to live if unable to recover as sufficient to judge the feeding tube extraordinary. The Vatican has now declared that more justification is required.

The irony here is exquisite. In the very course of affirming that the Vatican has clarified the full rigor of the teaching, Sulmasy so qualifies the teaching's scope that, if his analysis is broadly accepted, the teaching will make virtually no practical difference to current clinical practice in Catholic or any other institutions. Other paragraphs, especially his closing ones, continue in the same vein. Thus, a CDF document meant as a reaffirmation of the strongly-worded doctrinal clarification issued by the previous pope is reduced to a wan reminder that a bit more justification than some have found enough is required for dehydrating and starving a PVS patient to death.

This is how the Enemy uses theologians despite their best intentions. Cynicism and subtlety choke off the Spirit of life. Intelligent Catholics, beware.
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