Bioethics in Faith and Practice, Volume 2, Number 1

10 Smith ⦁ ANH and PVS Patients euthanasia, PAS and PAD. Letting die may take many forms, such as complying with a ‘do not resuscitate’ (DNR) order for a terminal patient where no measurable benefit can be gained from using a particular procedure, while a positive harm may result if action is taken in contravention of the DNR order ( e.g., puncturing the lungs of an elderly and infirm patient by resuscitation efforts). Therefore, while the ordinary- extraordinary distinction may seem strained, it remains a useful tool in analyzing bioethical dilemmas, perhaps particularly when considering whether to provide or withdraw ANH from a PVS patient. If ANH is withdrawn from a PVS patient and the patient dies, “Death comes not from the lack of tube feeding but from the underlying pathology that placed the person in that condition…the original pathology [is allowed] to take its natural course of events. ” 51 Presumption or Obligation? When comparing Directive 58 in ERD4 and ERD5, it is clear that ERD4’s contemplation that this area may be one “requiring further reflection ” 52 has been replaced with the certainty of the language of obligation in ERD5. Directive 58 in ERD4’s formulation speaks in the language of presumption of providing ANH, “so long as this [providing ANH] is of sufficient benefit to outweigh the burdens involved to the patient.” 53 In ERD5’s formulation, however, the sufficient benefit standard is removed in favor of a standing obligation to provide ANH, except in very limited circumstances where ANH would be “excessively burdensome” or involve “significant physical discomfort”, especially where ANH has “very limited ability to prolong life or provide comfort.” 54 Although perhaps intended to end the prior debate among Catholic thinkers on this issue, that debate continues. Further dialogue on this issue is not only desirable, but also necessary for us to “remain attuned to the progressive revelation of Christ throughout history.” 55 For example, Richard McCormick observes that ANH “are not required for persons diagnosed as irreversibly in a PVS… [because it] is not a benefit to the patient and therefore is not in the patient’s best interests. ” 56 Providing ANH for PVS patients in most instances is essentially futile care and not mandatory. 57 In this context, we should not conflate continuation of biological existence with conferring a ‘benefit’ on a patient who is no longer a sentient being in any real sense. O’Rourke 58 likewise focuses on the lack of actual benefit provided by ANH to the PVS patient. He also reminds us about the principle of double effect, benefit and double effect being two areas where proponents of the view espoused by a literal reading of Directive 58, such as William E. May, 59 either ignore or attempt to define away. 60 May finds a ‘benefit’ to be conferred by using ANH merely because biological existence continues for the PVS patient, conflating mere ‘existence’ with ‘life’ in the context of what is found in PVS from the NEJM article cited above, a “…clinical condition of complete unawareness of the self and the environment…” 61 In Directive 58 (ERD4), the Catholic tradition allowed a balancing of interests, including whether the benefit of a particular intervention would be sufficient to outweigh its burdens. In Directive 58 (ERD5), unless the phrase ‘in principle’ may be read as qualifying the obligation to provide ANH to all PVS patients, the historic benefits-burdens analysis has seemingly been abandoned. At a minimum, at least when read on its own and without applying any limiting effect at all to the ‘in principle’ preamble, the new Directive 58 has conflated benefit with effect, because while routinely providing ANH on an indefinite basis to PVS patients may continue their biological existence, no practical benefit is thereby conferred on these patients . 62 Considerable resources would be devoted to providing care that is useless, futile or perhaps even harmful. As O’Rourke has also observed, a formulation equivalent to new Directive 58 ignores issues of cost and the inherent burden imposed upon families and societies, 63 all such issues being important components of CST in its emphasis on the greater good and the prudent use of scarce resources, such as health care, in ways that will benefit the society at large. Although defining the limits of morally obligatory heath care interventions is certainly not easy, 64 perhaps