The US Conference of Catholic Bishops released an “Ethical and Religious Directive” this month that would ban any Catholic hospital, nursing home or hospice program from removing feeding tubes or ending palliative procedures of any kind, even when the individual has an advance directive to guide their end-of-life care. The Bishops’ directive even notes that patient suffering is redemptive and brings the individual closer to Christ.
The Catholic bishops have become more involved in political fights in recent years, particularly the issue of abortion coverage and immigration provisions in the current health care debate. This has caused a schism in the American Catholic community, which bubbled to a head yesterday with Rep. Patrick Kennedy (D-RI) being denied communion because of his position on choice.
More quietly, however, the Church has staked out a radical position on end-of-life care, without patients of the 565 Catholic hospitals and other Catholic care facilities even knowing about it. As Barbara Coombs Lee, president of Compassion and Choices, an advocacy group, put it, “When a patient goes to one of these facilities, they don’t know that they’re choosing Catholic dogma. The bishops see the hospitals as an extension of their ministry.”
The “Ethical and Religious Directives for Catholic Health Care Services” put out by the Catholic bishops would build upon an elocution given in the wake of the controversial Terri Schiavo case, where the US Congress stepped in to keep Schiavo alive despite her persistent vegetative state and the wishes of her husband to end care. The papal elocution did state that the permanently unconscious should always have access to a feeding tube, but it did not have the force of doctrinal law behind it. “There was always some wiggle room” for Catholic care facilities, said Coombs Lee. Catholics were allowed to use something called a “benefit/burden balance” to determine the ethical, moral and compassionate result in any individual case.
Now, that wiggle room is gone. In the new directive, the bishops state that it is unethical and immoral to withhold or withdraw a feeding tube from patients, whether in cases of permanent unconsciousness, comas, or even cases of advanced dementia when the patient is unable to feed themselves.
This substitutes the wishes of the bishops for the stated wishes of families and the patients themselves, said Coombs Lee. Even if the family can produce an advance directive or living will, Catholic hospitals and nursing homes would be expected to maintain the feeding tubes. In addition, all Catholic health care workers are required by their faith to continue palliative care, according to the document. The directive even addresses patients. “These are directives for you, from the church,” said Coombs Lee.
In many cities, this means that every hospital or medical care facility will not allow the withdrawal of a feeding tube. “In Spokane, Washington, if you don’t get Catholic health care, you don’t get health care,” Coombs Lee said. “In Eugene, Oregon, if you don’t get Catholic health care, you don’t get health care.” Coombs Lee characterized it as a kind of entrapment, with a sense of “my house, my rules.” If a patient’s family wanted to comply with an advance directive, they would have to leave the Catholic care facility, adding a level of stress and disruption to the already difficult time of aggrievement. “Decisions on feeding tubes are hard enough without adding this extra adversity,” said Coombs Lee.
Coombs Lee believes that this could create “300,000 Terri Schiavo cases,” the number being equal to the number of feeding tubes inserted in the United States each year.
The Catholic Hospital Association disagrees. Their statement responding to the Bishops’ Ethical and Religious Directive says that:
However, the Directive explains that this obligation ceases and the measures become “morally optional” when the measures cannot reasonably be expected to prolong the patient’s life or when they become excessively burdensome. (This provision incorporates into the Directive the teaching of Pope John Paul II and the Congregation for the Doctrine of the Faith regarding medically assisted nutrition and hydration to persons in a persistent vegetative state. Catholic health care facilities have already addressed the implications of these statements).
The Directive also distinguishes between patients in a chronic state and those who are dying. This distinction has implications for the use of medically administered nutrition and hydration. For dying patients, medically administered nutrition and hydration may no longer be of benefit and may, in fact, impose significant burdens.
Compassion & Choices says that this language distinguishing between those cases where artificial nutrition is “excessively burdensome” appears nowhere in the Bishops’ directive. Furthermore, while the CHA says the directive only applies to those patients being kept alive by a feeding tube, that is precisely their function. As Coombs Lee puts it, “Feeding tubes keep people in chronic states like PVS and advanced dementia alive… Feeding tubes are not indicated for people actively dying and they are rarely inserted in any institution, Catholic or not.”
A 60Minutes piece this weekend looked at the cost of dying in America, showing that Medicare paid $50 billion in the last two months of patients’ lives in 2008. Compassion & Choices focuses on the suffering at the end of life, not federal dollars, but they agree in general with the portrait shown by 60 Minutes. Incredibly, suffering is one of the selling points in the Catholic Bishops’ directive. “It’s quite specific about the role of suffering in Christian dogma,” Coombs Lee explained. “It says that suffering is redemptive, that it’s part of Christ’s passion. So they are pretty clear on their concern for the suffering of the patient.”
The end of life issue became very controversial in the health care debate, over fears that Congress was creating so-called “death panels.” However, these secret “suffering panels” put in by Catholic hospitals are being done without much fanfare at all. “People need to know,” said Coombs Lee, “when they commit themselves to a hospital, that they are submitting to a Catholic ministry, in the eyes of the Bishops.”