CNS STORY: Schiavo case raises issue of advance medical directives

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CNS Story:

SCHIAVO-DECISIONS Mar-29-2005 (990 words) Backgrounder. With photos. xxxn

Schiavo case raises issue of advance medical directives

By Agostino Bono
Catholic News Service

WASHINGTON (CNS) -- The family fight over the fate of Terri Schindler Schiavo, a severely brain-damaged woman, has raised the issue of drafting instructions outlining a person's wishes if he or she were unable to make health care decisions.

These instructions are known as advance medical directives or living wills. They can provide general guidelines, specify do's and don'ts regarding treatment and, in an addendum, name a health care proxy to make decisions based on the wishes of the patient.

For Catholics, the moral debates surrounding Schiavo's situation also raise questions regarding the use of feeding tubes to sustain the life of a person diagnosed as comatose or in a persistent vegetative state. Can a Catholic leave instructions that a feeding tube not be used given the strong statements by Vatican and U.S. church officials opposing the removal of the tube from Schiavo?

On the feeding tube issue, Catholic experts in bioethics have differing opinions as to the circumstances that could justify removing a feeding tube or instructing that one not be inserted.

The prevailing position, based on a 2004 speech by Pope John Paul II, is that the tube is a must for someone in a persistent vegetative state as food and water are part of basic care. But not all moral theologians are in accord that the pope significantly changed church teaching that life does not have to be artificially prolonged if it provides no benefit to the patient and is an excessive burden on the family.

Schiavo's case "underscores the importance of completing written advance directives, even given their limitations, and a durable power of attorney for health care," said a statement issued by the Catholic Health Association March 18.

The drawn-out legal fighting over Schiavo was facilitated because she left no written instructions about her care if she were no longer able to make decisions. Michael Schiavo, her husband and legal guardian, said she would want the tube removed. Her parents said she would want to remain alive based on her Catholic faith.

Several doctors have testified in Florida courts that Schiavo is in an irreversible vegetative state. Her parents, Mary and Bob Schindler, have said other doctors dispute this diagnosis.

Dominican Father Kevin O'Rourke, Christian ethics professor at the Neiswanger Institute for Bioethics and Health Policy at the medical school of Loyola University in Chicago, said it would be morally permissible to draft an advance directive saying a feeding tube should not be inserted or should be removed if a person is diagnosed as in an irreversible vegetative state.

As with any medical diagnosis, this is subject to error but the diagnosis provides moral certainty, he said.

"If a Catholic in an advance directive says no to artificial hydration and nutrition, he is saying that if he becomes comatose this will be too much of a burden for the family," said Father O'Rourke.

However, the tube cannot be removed if the purpose is euthanasia, "the direct killing of a suffering person," he said.

"But you can't define euthanasia by the physical result of the act," he said. "The moral object or the purpose of the act has to be to kill someone."

Edward Furton, specialist in medical ethics at the National Catholic Bioethics Center in Philadelphia, disagreed.

"An advance directive that makes blanket statements that food and water be removed from a brain-damaged or persistent vegetative state patient is not appropriate for Catholics," said Furton.

Someone in a persistent vegetative state "deserves food and water," he said.

This has been the stated position of Vatican and U.S. church officials regarding the Schiavo case.

It is based on a 2004 papal speech to an international meeting on life-sustaining treatments in which Pope John Paul said that "the administration of water and food, even when provided by artificial means, always represents a natural means of preserving life, not a medical act."

The pope added that such provision of food and water "should be considered, in principle, ordinary and proportionate, and as such morally obligatory" as long as the aim "consists in providing nourishment to the patient and alleviation of his suffering."

As the removal of Schiavo's feeding tube neared, a top Vatican bioethicist, Bishop Elio Sgreccia, called any removal of the feeding tube from Schiavo "direct euthanasia."

Furton said that it would be morally permissible to remove a feeding tube if the tube was causing more harm than good. Cases he cited include:

-- The body is not assimilating food and water.

-- The tube is causing infection.

-- The patient is disturbed and constantly removes the tube.

Regarding advance directives, Richard Doerflinger, deputy director of the U.S. bishops' Secretariat for Pro-Life Activities, said that while the church "generally" honors the requests of a person the church would "not honor a statement that is suicidal."

Advance directives should be looked at carefully and along with putting wishes in writing people should name a proxy decision-maker who understands what the individual would want, he said.

Furton also advocated naming a health care proxy aware of a person's wishes and the role faith plays in that person's decision-making.

"The advance directive should be a supplement to the proxy. It is better to have someone who knows your situation to decide for you rather than have people go through a menu of items you once checked off and then decide," he said.

His organization offers draft advance directive and health care proxy forms as guidelines for Catholics. The draft advance directive states that a person wants decisions guided by Catholic moral teachings and it lists important end-of-life documents issued by the Vatican and the U.S. bishops.

Furton cautioned that one form does not fit every situation as each state has separate requirements for what constitutes a legally binding document.

Many state bishops' conferences offer draft forms based on state law.

- - -

Contributing to this story was Jean Gonzalez in Orlando, Fla.

END

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