Bioethics in Faith and Practice, Volume 2, Number 1

6 Smith ⦁ ANH and PVS Patients 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. 5 The version of Directive 58 in ERD5 reads as follows: 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 (e.g., the ‘persistent vegetative state’) who can reasonably be expected to live indefinitely if given such care. 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, for example resulting from complications in the use of the means employed.’ For instance, as a patient draws close to inevitable death from an underlying progressive and fatal condition, certain measures to provide nutrition and hydration may become excessively burdensome and therefore not obligatory in light of their very limited ability to prolong life or provide comfort. 6 As is apparent from a comparison of these two versions of Directive 58, the 2009 version departs from the ‘presumption’ approach to providing ANH to patients found in the 2001 version by creating an obligation that applies ‘in principle’ to all patients, even those in PVS. The reasons for this change are discussed further below, but certainly the papal allocution in 2004 from Pope John Paul II cited below was a strong influence. The reasons for the difference are also reflected in the changes made in the text of the Introduction section to Part 5 of ERD 4 and the corresponding part of ERD 4 . 7 Both ANH and PVS have been discussed extensively in the bioethics literature by secular thinkers and by thinkers of Catholic 8 and other faith traditions , 9 so the constraints of time and space require both brevity and the use of certain definitions, limitations and assumptions. In this effort, I have adopted the distinction made by John C. Harvey regarding the two main causes of PVS: (a) cases caused by physical head trauma or poisoning; and (b) cases caused when “an individual develops cardiac standstill and anoxia (lack of oxygen) for a period longer than six or seven minutes before resuscitation is accomplished. ” 10 According to Harvey, persons in PVS who fall under (a) do not necessarily have a fatal condition, but those who fall under (b) always have such a condition . 11 I have also adopted the definition of PVS included in the comprehensive statement resulting from the work of the Multi-Society Task Force on the Persistent Vegetative State, as published in the New England Journal of Medicine in 1994 ( NEJM ), as follows: The vegetative state is a clinical condition of complete unawareness of the self and the environment, accompanied by sleep-wake cycles, with either complete or partial preservation of hypothalamic and brain-stem autonomic functions. In addition, patients in a vegetative state show no evidence of sustained, reproducible, purposeful, or voluntary behavioral responses to visual, auditory, tactile, or noxious stimuli; show no evidence of language comprehension or expression; have bowel and bladder incontinence; and have variably preserved cranial-nerve and spinal reflexes. We define persistent vegetative state