Karl Rahner’s Theology of Dying and Death: Normative Implications for the Permanent Vegetative State Patient

Permanent Vegetative State (PVS)

Before proceeding, we must define PVS and address recent literature on its misdiagnosis. First, there is general agreement in the scientific literature on the definition of the vegetative state: ‘a clinical condition of complete unawareness of the self and the environment.’ That complete unawareness of self, by definition, prevents a PVS patient not only from experiencing pain, but also from exercising freedom and relationality in history. ⁴ In the scientific, medical, and bioethical literature, it is not always clear what the ‘P’ in PVS designates. It may designate either ‘persistent’ or ‘permanent’ vegetative state. Scientific and medical literature often distinguishes between ‘persistent,’ a diagnosis that ‘refers only to a condition of past and continuing disability with an uncertain future,’ and ‘permanent,’ a prognosis that ‘implies irreversibility.’ A person moves from a persistent to a permanent vegetative state ‘when the diagnosis of irreversibility can be established with a high degree of clinical certainty.’ ⁵ Since all clinical diagnoses and prognoses are based on clinical probabilities, not certainties, that ‘high degree of clinical certainty’ must be understood as a high degree of clinical probability. In this article, the ‘P’ in PVS will always mean permanent and PVS will always mean permanent vegetative state.

Second, recent studies have confirmed a high number of misdiagnoses of the vegetative state by relying solely upon clinical consensus. ⁶ This gives credence to John Paul’s concern—voiced in the Allocution—that ‘medical science, up until now, is still unable to predict with certainty who among patients in [the vegetative state] … will recover and who will not.’ ⁷ While the scientific studies and John Paul’s warnings are important to the discussion of ANH and the PVS patient, they do not directly impact our current discussion of freedom, action in history, and relationality and their roles and functions in a theology of dying and death. We submit two reasons for that judgment.

First, these concerns are not based on an inaccurate definition of the vegetative state; rather, they are based on whether or not PVS can be properly diagnosed in a particular patient. A recent study examined 54 patients in England and Belgium with disorders of consciousness (vegetative or minimally conscious state) to evaluate whether these patients could willfully modulate their brain activity indicating some cognition and awareness. Only five demonstrated this capacity. The study concludes that ‘careful clinical examination will result in reclassification of the state of consciousness in some of these patients.’ ⁸ We acknowledge the concerns about the diagnosis of PVS, the need to consult the sciences as research on the accuracy of diagnosis continues, and the need to expand and improve the criteria and methods for making such a diagnosis (e.g., the Coma Recovery Scale - Revised). These concerns, however, do not touch our argument in this article, for the argument becomes relevant only if and when a patient is accurately diagnosed to be in PVS.

Second, it seems that John Paul’s warning is raising the bar too high for moral decision-making. It has never been the case in the Catholic tradition that a moral agent must ‘predict with certainty’ a contingent state of affairs before making a moral judgment. The scientific literature speaks of probabilities, even high probabilities (‘a high degree of clinical certainty’), not absolute certainty; and so does the ethical literature. High numbers of misdiagnoses of PVS patients are certainly grounds for concern, and science is working to reduce this number through neurological studies and improved neurobehavioral rating scales. As this information becomes available, it will be integrated into our ethical reflections. However, the lack of these data does not prohibit us now from making moral judgments based on the data, particularities, and probabilities that are now available. If it did, the Pope would have used a stronger phrase than ‘in principle’ to describe the obligation to provide ANH for PVS patients. Besides, the scientific studies suggest that the majority of clinically diagnosed PVS cases, even those relying solely on clinical consensus, are accurate diagnoses.

Karl Rahner’s Theology of Dying and Death

The Catechism of the Catholic Church explains that, ‘because of Christ, Christian death has a positive meaning.’ Christians were buried with Christ sacramentally ‘by baptism into death, so that as Christ was raised from the dead by the glory of the Father, we too might walk in newness of life’ (Rom 6:4). ‘Physical death,’ the Catechism continues, ‘completes this “dying with Christ” and so completes our incorporation into him in his redeeming act.’ ⁹ This theology is reinforced by other Catholic doctrines: the value of freely and consciously suffering with Christ, purgatory, the universal resurrection of the dead, and eternal life. As the Preface of the Mass of Christian Burial makes plain, for Christ’s faithful ‘life is changed not ended. When the body of our earthly dwelling lies in death we gain an everlasting dwelling place in heaven.’ John Paul’s Allocution hints at this long-established theology, but gives it no substantive place in statements concerning ANH and the PVS patient. This absence makes it possible to focus on biological life as, at least, a quasi-absolute good, a position that contradicts the universal Catholic position on life, dying, and death.

In the universal Catholic tradition, death is described as the separation of the soul from the body. ¹⁰ Karl Rahner, generally accepted as one of the leading Catholic theologians of the 20th century, demonstrated an ongoing interest in the theology of death throughout his distinguished career, at a time when Catholic theology paid little attention to death. ¹¹ The theology of death he developed—a theology that is, of course, not official Catholic teaching but widespread in the contemporary Catholic theological tradition—offers a fruitful Catholic theological perspective on dying and death and the situation of the PVS patient. ¹² While affirming the traditional description of physical death, which coincides with the Catechism’s description, he finds it inadequate as a theological definition of the death of a specifically personal being. The traditional description focuses on the physical, biological death of a human person, ‘but it fails completely to indicate the specifically human element in the death of a man.’ ¹³ To correct this failure, underscoring that ‘it is man who dies,’ Rahner proposes a nuanced definition of death that is specific to the human being and has theological implications for both our understanding of the dying and death of a person and the normative implications of this understanding for issues surrounding ANH and the PVS patient. ¹⁴

Rahner’s Theological Anthropology

Three critical dimensions of Rahner’s theological anthropology are relevant to our purposes in this article: the human person is essentially free, historical, and relational. ¹⁵ We underscore the word essentially to emphasize that freedom, historicity, and relationality are not three accidental characteristics of the person in the abstract, but three essential, ontological properties that define the person in the concrete, so that if one or other or all three are lacking in the concrete, ‘the human person integrally and adequately considered’ is seriously ontologically damaged. ¹⁶ And the human person integrally and adequately considered ‘is the criterion for discovering whether an act is morally right.’ ¹⁷ Freedom, historicity, and relationality are existentials, central to the ontological definition of the human person and, therefore, central also to the definition of dying and death and to norms guiding end-of-life decisions. We consider each in turn. We introduce here something that will be important later: the damage done to a person by the loss of one or other of the existentials under discussion does not result in the total loss of human dignity. That dignity remains in the abstract, if somewhat damaged in the concrete, and that fact will be important later when we consider decisions about maintaining the PVS patient on ANH or withdrawing it.

Rahner accepts Kant’s turn toward the subject and the implications this turn has on the shift from a physical, biological definition of dying and death as a merely biological event to a person-centered definition of dying and death as a personal, free, historical, and relation-ending event. With this shift comes the need to know the person-subject in freedom, for ‘man is personal freedom.’ ¹⁸ This freedom is both categorical and transcendental or foundational. Categorical freedom is the freedom to choose particular actions: to go fishing, to read a book, to continue or discontinue ANH. Categorical freedom is the more obvious of the two freedoms in a human life. Foundational freedom—which is distinct from but related to categorical freedom as root to shoot—is the subject’s being responsible for himself. ‘In real [foundational] freedom the subject always intends himself, understands and posits himself. Ultimately, he does not do something, but does himself.’ ¹⁹ My personal foundational freedom is the ontological ground for my categorically affirming the fullness of self, neighbor, and God. ²⁰ This affirming and drawing ever closer to God in freedom and love are expressed in Catholic theology in the metaphor of the pilgrimage. ²¹

Historicity is easy to characterize: ‘In terms of his nature a man exists in space and time.’ ²² An existential characteristic of persons is that they are persons-in-the-world, embodied, mundane persons who realize themselves only in bodily existence and relationality within a human community. The human is a being whose origin, life, and death lie within the world, that is, a being who has his roots in empirical realities. The human is by nature an inescapably historical creature. An external world of other persons and other things is an essential part of our nature, and it is only in interaction in, and with, this external world that humans continuously actualize themselves and continue on their personal pilgrimage. The irretrievable loss of the ability to exercise one’s foundational and categorical freedom and relationality in history, as in the case with the PVS patient, is contrary to and damaging not only to human personality psychologically, but also to human personhood ontologically. This is the ultimate problematic of the PVS patient.

One of the things a person does to be realized essentially in history is to enter freely into mutually-realizing relationships with other persons. The human person, Rahner argues, is an essentially ‘community-building person’; qua person, the human ‘is intended for community with other persons.’ ²³ We prefer to say that, qua person, the human is intended for mutual and mutually-realizing relationship with other persons, and that such a relationship is an existential of the human person. Friendship, or contemporarily relationality, Aquinas suggests correctly, has three characteristics: benevolence, reciprocity, and mutual indwelling. ²⁴ In friendship, I seek the other’s well-being (Aquinas’ definition of love is well known, amare est velle bonum (to love is to will the good), the other responds in kind, and the result is mutual indwelling, intimacy, and self-realization. ²⁵ Friendship is among the most personally creative of human relationships.

Human freedom, which ‘actualizes one thing, the single subject in the unique totality of his history,’ historicity, which actualizes that subject in the world, and friendship which actualizes the subject in relationship with others, together existentially ground full human being, human nature and person, and human values. ²⁶ Since freedom, living history, and relationship are of the essence of the human, the permanent incapacity to exercise freedom, relationship, and living history—as in the case of the PVS patient—has normative implications for defining dying and death as natural, personal, and theological events.

Rahner’s Theology of Dying and Death as Acts of Foundational Freedom

For Rahner, since the human person is ‘both spirit and matter’ the person’s death must also exhibit this ontological dialectic that is so intrinsic and essential to the human. ²⁷ The death of a person, an embodied spirit in the world, must have both a material and a spiritual or personal aspect. The description of death as the separation of body and soul focuses on death as a biological event, defined by medical criteria. This description, however, ‘fails completely to indicate the specifically human element in the death of man.’ ²⁸ As a personal consummation of the self, dying and death cannot be experiences which are only suffered passively, though on occasion—a sudden accident, for instance, or while under sedation to control pain—dying and death are suffered passively. But death ‘must also be understood as a human act, as a deed of man, originating within.’ ²⁹

If humans are personal freedom, then it follows that persons are the ones who can and do use the resources of their own innermost nature to form themselves by their own free acts. By the exercise of this freedom, each can ‘definitively determine the shape of his life as a whole, and decide what his ultimate end is to be.’ ³⁰ Each can, that is, make a fundamental disposition of life and self, sometimes as an act of foundational freedom, but more often in acts of categorical freedom, which manifest this fundamental self-disposition in history. In historical reality, persons are dying at every moment of their lives, and every moment of life is a moment which points to and is overshadowed by death. Catholic tradition refers to this ‘always dying’ as prolixitas mortis (the long duration of death), and teaches that it is never to be forgotten. There are undoubtedly the occasions mentioned above—fatal accidents or while under sedation to control pain—when death comes to a person suddenly or unconsciously and apparently passively without any exercise of personal freedom. Such a judgment of complete passivity, however, ignores the prior and ongoing free choices that a person, dying daily, might have made and remade on the journey to death, resurrection, and the eternal presence and unimaginable hospitality of God (cf. 1 Cor 2:9).

The Catholic tradition urges prolixitas mortis on its believers, inviting them to be not only aware, but also accepting, of their mortality, not out of any morbid fear of death, but as a way to escape that fear and achieve maturity. ‘Keep death daily before your eyes,’ commands the rule of St. Benedict. ‘Remember man that thou art dust and unto dust thou shalt return,’ commanded the traditional Ash Wednesday prayer. These injunctions are intended to highlight prolixitas mortis and instill a positive and mature attitude towards dying, death, and especially life. Humans can, and frequently do, run away from their mortality, looking upon it, in Heidegger’s words, as a ‘social inconvenience’ or ‘downright tactlessness.’ ³¹ Or they can freely embrace their mortality and the finitude and limitation it imposes and, thus, realize and dispose of themselves foundationally and categorically in full freedom. Such an ongoing attitude leads, first, to the acknowledgment and acceptance of their life of relative freedom (historicity precludes absolute freedom) and, then, to courage in the face of every threat to life, including PVS. In a Catholic theological context, that of prolixitas mortis, death is never merely a passive event; it is always, at least in its daily preparation, a free and active event. ³²

As Christ’s human reality reaches its full perfection only in his freely-embraced death, so also every person is definitively posited only in death as the final and ultimately fulfilling act of freedom. The Catechism insinuates this final act of foundational freedom in more traditional theological language, teaching that the human ‘can transform his own death into an act of obedience and love toward the Father, after the example of Christ.’ ³³ That human death contains ‘this characteristic element of final decision is not at all indicated by the expression, “the separation of body and soul.”’ ³⁴ Such a free, personal, and final self-disposition can and sometimes—when the exercise of an unconscious patient’s personal freedom is no longer an option—must take place earlier than death in the physical sense. ‘Dying in the physical sense [assessed by the clinical judgment of a physician], and dying as an act of [personal, definitive] freedom need not [and for those unconscious before death cannot] coincide chronologically.’ ³⁵ The implications for the PVS patient of the distinction between personal and physical death are obvious.

As a human act, therefore, the act of dying sub prolixitate mortis is a process that is free, historical, and personal. For the PVS patient, who has irretrievably lost the ability to exercise any freedom, living history, or relationality, any free self-disposition must precede the onset of PVS, which marks the personal death that is the end of the patient’s personal pilgrimage. When there is no potential to exercise personal freedom and relationship in history, neither is there any potential to further pursue one’s personal pilgrimage to selfhood, personhood, and God; and when one’s personal pilgrimage is over, one’s personal life is over. One element of Catholic teaching about death is that death brings a person ‘a kind of finality and consummation which renders his decision for or against God, reached during the time of his bodily life, final and unalterable.’ ³⁶ The person’s biological life, over which the PVS patient has no moral control and in respect of which is, therefore, passive, may continue; personal, specifically human life, over which one has active control, has come to an end. ³⁷ With death—both physical death and, for the PVS patient, personal death in the sense we have explained—persons dispose of themselves in relation to God.

The suggestion by some commentators that the withholding or withdrawing of ANH at this point of personal death is, in fact, euthanasia is rejected by the Congregation for the Doctrine of the Faith (CDF) in its 1980 Declaration on Euthanasia. ‘One cannot impose on anyone,’ the CDF decrees, ‘the obligation to have recourse to a technique which is already in use but which carries a risk or is burdensome. Such a refusal is not the equivalent of suicide; on the contrary, it should be considered as an acceptance of the human condition, or a wish to avoid the application of a medical procedure disproportionate to the results that can be expected, or a desire not to impose excessive expense on the family or the community.’ ³⁸ The Decree remains in force and is unabrogated by the papal Allocution (as this is not directed to the universal church and, therefore, as we will explain below, not infallible). The personal condition that the CDF’s Declaration refers to is this. The normal human process of dying has reached the very specific point of personal death as we have explained it. For that process to reach the normal end of the human condition there remains biological death. The withdrawal of ANH at the point of personal death is not ‘euthanasia by omission,’ as John Paul suggested. ³⁹ It is no more, the CDF teaches, than a final acceptance of the natural human condition, religiously strengthened by the universal Catholic belief that, in death, ‘life is changed not ended.’

Nigel Biggar puts this situation concisely: for the PVS patient, ‘biological’ life continues, ‘biographical’ life ceases. ⁴⁰ An amendment of Biggar’s ‘biographical’ to ‘autobiographical’ perfectly summarizes our argument. For Christians who believe that ‘life is changed not ended,’ and that ‘the doctrine of purgatory, of the coming resurrection of the body, and the future consummation of the whole universe already indicates a further development of man towards his ultimate perfection,’ that ought not to be cause for inconsolable sadness or the desperate determination to maintain biological life at all costs. ⁴¹ In Catholic teaching, a fundamental self-disposition for God in life and in death, personal and biological, results in a dying with Christ and a raising to a new, eternal life in which one enjoys the eternal presence and unimaginable hospitality of God; a fundamental self-disposition against God results in a rejection of God and eternal damnation. ⁴² It is, at least in part, this Catholic teaching on death that sustains the universal Catholic moral tradition that physical life is not an absolute value and need not, therefore, be maintained by extraordinary or disproportionate means. ⁴³

Thus, while the basic human dignity of the PVS patient undoubtedly perdures, as we noted earlier, a critical point in daily dying has been reached, namely, the irretrievable loss of the ability to exercise human freedom, living history, and relationship, which define a person qua human person. The person’s ability to exercise freedom, history, and relationality, and thus to continue the autobiography or pilgrimage in relation to self, loved ones, and God, has ended, though the person remains biologically alive. We submit that it is in the dimensions of personal freedom, living history, and relationality that Rahner’s anthropology of dying and death provides a theological foundation for assessing John Paul II’s Allocution and the CDF’s two documents, ‘Responses to Certain Questions of the United States Conference of Catholic Bishops Concerning Artificial Nutrition and Hydration’ (hereafter Responses), and Commentary. ⁴⁴

The Allocution and Prior Catholic Tradition

A series of articles by Catholic scholars has already debated whether or not John Paul II’s Allocution reaffirmed or revised the established Catholic tradition on some technologies that are used to preserve life. ⁴⁵ We approach this question by focusing on two items: the principle guiding the administration of ANH promulgated in past magisterial documents; and the comparison of this principle with John Paul II’s Allocution and the CDF’s Responses and Commentary. The discussion requires some historical background on the Catholic tradition in question. Before that discussion, however, we briefly note another question that many consider crucial, namely, the theological authority of the Allocution. That question has already been competently examined by Kevin O’Rourke, and we are in complete agreement with his conclusion that the Allocution is not a declaration made to the universal church and, therefore, not infallible. ⁴⁶

The CDF’s ‘Instruction on the Ecclesial Vocation of the Theologian’ lists four levels of church teaching and the assent due to each. Level one is ‘when the magisterium of the church makes an infallible pronouncement and solemnly declares that the teaching is found in revelation.’ The assent called for on that level ‘is that of theological faith.’ ⁴⁷ Level four is when the magisterium prudentially intervenes ‘in questions under discussion which involve, in addition to solid principles, certain contingent and conjectural elements.’ Such statements are ‘per se not irreformable,’ and the competent theologian may raise questions about ‘the form or even the contents of magisterial interventions.’ ⁴⁸ John Paul’s Allocution ‘was not a dogmatic pronouncement on faith and morals promulgated to the universal church [level one above], but an ‘occasional speech’ to a meeting of physicians [level four above].’ ⁴⁹ The presence of ‘contingent and conjectural elements’ in his teaching in the Allocution rules out any possibility of infallibility, and any demand for theological faith on the part of believers, including theologians. After the Allocution, the questions that surround ANH and the PVS patient remain open for honest theological debate.

Traditional Principle Guiding Administration of ANH

The Catholic tradition with respect to ANH and the PVS patient prior to John Paul’s Allocution is easily stated. First, 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.’ ⁵⁰ Secondly, that presumption is not unconditional and absolute. It can ‘yield in cases where such procedures have no medically reasonable hope of sustaining [physical] life or pose excessive risks or burdens’ to either the patient or the patient’s loved ones. In disproportionate or burdensome cases, ANH can morally be withheld or withdrawn, though it cannot be withheld or withdrawn when its omission is ‘intended to cause a patient’s death.’ The direct intention to cause death would be euthanasia which, in the Catholic moral tradition, is always immoral. This universal Catholic moral tradition, which permits the moral ‘refusal of overzealous treatment,’ has a long, magisterial history. ⁵¹

This Catholic tradition was carefully enunciated by Pius XII in 1957. ‘Normally one is held to use only ordinary means—according to circumstances of persons, places, times, and culture—that is to say, means that do not involve any grave burden for oneself or another. A more strict obligation would be too burdensome for most people and would render the attainment of the higher, more important good too difficult.’ ⁵² It was repeated by the CDF in 1980. ‘Everyone has the duty to care for his/her health … But is it necessary in all circumstances to have recourse to all possible remedies? In the past, moralists replied that one is never obliged to use “extraordinary” means.’ The Congregation goes on to suggest how one might distinguish between ‘ordinary’ and ‘extraordinary’ means. One considers ‘the type of treatment to be used, its degree of complexity or risk, its cost and the possibilities of using it, and comparing these elements with the results that can be expected, taking into account the state of the sick person and his or her physical and moral resources.’ The refusal of extraordinary care is not the equivalent of suicide but ‘should be considered as an acceptance of the human condition, or a wish to avoid the application of a medical procedure disproportionate to the results that can be expected, or a desire not to impose excessive expense on the family or the community.’ ⁵³ This very same doctrine and judgment were repeated again by John Paul II in 1995. ⁵⁴

In November 2004, six months after his March Allocution that ignited the present debate, John Paul taught that ‘the possible decision either not to start or to halt a treatment will be deemed ethically correct if the treatment is ineffective or obviously disproportionate to the aims of sustaining life or recovering health. Consequently, the decision to forego aggressive treatment is an expression of respect that is due to the patient at every moment.’ ⁵⁵ The Catechism of the Catholic Church neatly sums up this universal Catholic moral tradition: ‘Discontinuing medical procedures that are burdensome, dangerous, extraordinary, or disproportionate to the expected outcome can be legitimate; it is the refusal of “over zealous treatment.” Here one does not will to cause death; one’s inability to impede it is merely accepted.’ ⁵⁶

Thomas Shannon and James Walter protest that the articulation of the Catholic end-of-life tradition as a ‘presumption in favour of providing medically assisted nutrition and hydration’ is a modern revisionist approach to that tradition. The tradition ‘from at least the 16th century through Pius XII, the Congregation for the Doctrine of the Faith in 1980, and the vast majority of moral theologians has determined this obligation by having the patient consider the benefits and burdens of the intervention to determine if they were proportionate or disproportionate.’ ⁵⁷ Only after the intervention has been judged proportionate or disproportionate can the judgment then be made that it is either ordinary and obligatory or extraordinary and non-obligatory. ⁵⁸ We agree with that judgment, but retain the language of presumption to focus on the language of the Allocution, Responses, and Commentary, which appear to abandon the 500-year-old traditional benefit/burden assessment and to suggest that ANH is ordinary care in the abstract, and, therefore, morally obligatory, prior to any benefit/burden analysis of the particular, concrete case. Once the judgment of ANH as ordinary care is made, it then is said to be morally obligatory. We ask, however, can such a medical and moral judgment be made in the abstract, or must the particular, concrete situation be taken into account, as the Catholic moral tradition insists it must be to make a moral judgment?

The Tradition, Allocution, Responses, and Commentary

In his Allocution, John Paul II writes that ‘I should like particularly to underline how the administration of food and water, even when provided by artificial means, always represents a natural means of preserving life, not a medical act. Its use, furthermore, should be considered, in principle, ordinary and proportionate, and as such morally obligatory, in so far as and until it is seen to have attained its proper finality, which in the present case consists in providing nourishment to the patient and alleviation of his suffering.’ ⁵⁹ We wish to show here, in partial disagreement with those who conjecture otherwise, both the continuity and discontinuity of this text with the Catholic moral tradition with respect to ANH and the PVS patient. ⁶⁰

John Paul’s judgment that nutrition and hydration are, ‘in principle,’ ordinary and proportionate means of preserving life, ‘insofar as and until it is seen to have attained its proper finality,’ implies, as the Catholic tradition has always held, that the moral obligation to provide food and water is not absolute and unconditional. ⁶¹ ‘In principle’ suggests, first, an abstract principle, akin to ‘Thou shalt not kill.’ It suggests, secondly, therefore, with the universal Catholic moral tradition, that the principle might have exceptions in concrete circumstances (as does ‘Thou shalt not kill’ in circumstances of just war and proportionate self-defence). The moral obligation to provide food and water to the PVS patient exists in principle and in the abstract; it might have exceptions for a particular patient in the concrete. John Paul specifies only one exception, when, for whatever reason, it does not achieve its ‘proper finality,’ which he specifies as ‘providing nourishment to the patient and alleviation of his suffering.’ But his careful ‘in principle’ suggests that there may be other circumstances for discontinuing ANH, and we may include the traditional disproportionate burdens to the patient or to the patient’s loved ones. These include biological, relational, emotional, social, spiritual, economic, and the CDF’s ‘moral’ burdens emphasized earlier.

In his November 2004 ‘Address to the Participants in the 19th International Conference of the Pontifical Council for Health Pastoral Care,’ already cited, an Address that is as authoritative as his March 2004 Allocution, John Paul II asserted that ‘the possible decision either not to start or to halt a treatment will be deemed ethically correct if the treatment is ineffective or obviously disproportionate to the aims of sustaining life or recovering health.’ ⁶² This Address, largely ignored in the current debate over ANH and the PVS patient, at the very least attenuates the judgments expressed in the Allocution. When unpacked and allied with the Allocution’s ‘in principle,’ it clearly suggests the traditional view that in some particular concrete circumstances, medical treatment might be judged extraordinary and disproportionate, and, therefore, ought to be either withheld or discontinued.

The CDF’s Responses and Commentary suggest this very same conclusion, namely, that in certain circumstances it is moral to withhold or withdraw ANH from the PVS patient. ‘Finally,’ the Commentary notes that ‘the possibility is not absolutely excluded that, in some rare cases, artificial nourishment and hydration may be excessively burdensome for the patient.’ ⁶³ It does not specify the criteria that would justify withholding or withdrawing ANH in ‘excessively burdensome’ circumstances, but the fact that the Responses and Commentary use the phrase ‘in principle’ and that the Commentary has recourse to the traditional language of ‘excessively burdensome’ suggests that extraordinary cases should be guided by a benefit/burden principle of analysis. The general benefit/burden principle represented in these documents is in continuity with the tradition. There are also, however, discontinuity with, and a substantial revision of, the tradition in four items in the documents. Those items are: the teaching that ANH ‘always represents a natural means of preserving life, not a medical act; the criteria advanced for the benefit/burden analysis; the teaching about who determines whether or not the criteria have been fulfilled; and the definition of life, dying, and death when applied to the PVS patient.’ ⁶⁴

ANH: Medical Procedure or Normal Care?

As already noted, the CDF’s Declaration on Euthanasia distinguishes between euthanasia (or suicide), which is always morally prohibited, and ‘a wish to avoid the application of a medical procedure disproportionate to the results that can be expected,’ which is morally acceptable. ⁶⁵ In the present debate about ANH and the PVS patient, moral considerations hinge on whether ANH is a medical procedure (and, therefore, subject to a benefit/burden analysis) or care (and, therefore, required ‘in principle’). In the Allocution, John Paul states that ANH is ‘a natural means of preserving life, not a medical act’ and that the withdrawal of ANH, ‘if done knowingly and willingly,’ is ‘euthanasia by omission.’ ⁶⁶ Classifying ANH as care marks a significant change from the Declaration on Euthanasia and from the universal Catholic tradition in which it is embedded. ⁶⁷ This shift is evident in an earlier statement by the Pontifical Academy of Sciences in 1985 that notes: ‘If the patient is in a permanent irreversible coma, as far as can be foreseen, treatment is not required, but all care should be lavished on him, including feeding.’ ⁶⁸ We agree with Walter. ‘Such a shift to the requirement that artificial nutrition and hydration must be used (not a presumption to be used) essentially takes the decision about this intervention out of the patient-centered approach that has so characterized the historical tradition of the past.’ ⁶⁹

While the Allocution, Responses, and Commentary all consider ANH care, the Commentary is conceptually confused and confusing, since it employs the traditional criterion of burden and makes allowance for exceptions that go beyond both the Allocution and the Responses. It states that ANH ‘always represents a natural means for preserving life, and is not a therapeutic treatment’; but then it equivocates on this assertion by noting that such means ‘in some rare cases … may be excessively burdensome for the patient.’ By labeling ANH care, but allowing exceptions on the basis of whether or not the care is excessively burdensome, the Commentary uses the language of a medical procedure subject to benefit/burden analysis. In addition, all three documents consider ANH to be, by definition, ordinary and proportionate. Traditionally, these terms resulted from an a posteriori moral judgment made by a patient or the patient’s designated power of attorney for health care on the basis of an assessment of the proportionate benefits and burdens of a particular medical treatment for the patient. The three Vatican documents replace this a posteriori moral judgment with an a priori clinical judgment on the medical technology itself; ANH, they claim, is required ‘in principle’ to provide ordinary care. ⁷⁰ The ambiguity on whether ANH is a medical procedure or care is evident in other literature as well.

The now sadly defunct Irish Council for Bioethics (ICB) took up this question in its document, ‘Is It Time for Advanced Healthcare Directives,’ and noted ‘disagreement’ among different organizations. ⁷¹ The Medical Council of Ireland (MCI), for instance, highlights the ‘basic need’ that all patients have for nutrition and hydration, but qualifies ‘that this access should be maintained wherever reasonable and practical.’ An Bord Altranais (the Irish Nursing Board) ‘advises nurses not to participate in the withdrawal or termination of ANH from an individual but to continue to provide nursing care to that person.’ The Italian National Bioethics Committee recognizes that ANH is morally obligatory ‘unless it is overly burdensome for the patient.’ Citing Catholic Health Australia, the ICB notes that John Paul II’s Allocution has been interpreted to mean that ‘ANH should be provided in all cases unless it is considered inappropriate or burdensome on the individual involved.’ Finally, the legal system in Ireland considers ANH a medical treatment. ⁷²

The American Academy of Neurology (AAN) lists ANH as a medical treatment and indicates that the decision to discontinue ANH should be made, as is every medical decision, on the basis of ‘a careful evaluation of the patient’s diagnosis and prognosis, the prospective benefits and burdens of the treatment, and the stated preferences of the patient and family.’ ⁷³ Regarding the PVS patient, it emphatically states that medical treatment, including ANH, ‘provides no benefit’ to the patient since it ‘merely prolongs or suspends the dying process without providing any possible cure.’ ⁷⁴ Many Catholic theologians concur. Medical procedures are used ‘with the intent and hope for substantive recovery’ of the patient. ⁷⁵ In the case of the PVS patient, by definition, substantive recovery is not possible; ANH merely maintains the PVS patient in biological life without any hope of ever regaining free, personal cognitive, affective, and relational capabilities. ‘When life support is removed because it does not offer hope of benefit [substantive recovery] or imposes an excessive burden, the cause of death is the pathology which is no longer abated or circumvented’ by a medical procedure. ⁷⁶ The universal Christian teaching of prolixitas mortis accepts that death is a natural part of life; humans are by nature and inescapably mortal beings. That, to some terrifying, teaching is softened and strengthened by the universal Christian doctrine of resurrection. ⁷⁷

The criteria of the traditional benefit/burden analysis, which is entirely person- and patient-centered, include biological, relational, spiritual, psychological, moral, and economic considerations, determined by the patient, the patient’s loved ones, and/or the patient’s designated power of attorney for health care. They also recognize a Catholic holistic definition of life, dying, and death. The criteria of the revised benefit/ burden analysis, which takes any decision about either withholding or withdrawing ANH out of the patient’s hands, rely solely on biological considerations, implicitly posit the physician as sole decision-maker, and focus only on biological life, dying, and death. The discontinuity between the traditional and revised principles may be demonstrated by considering the normative implications of Rahner’s theology of dying and death for ANH and the PVS patient.

Rahner’s Theology of Dying and Death: Normative Implications

What are the implications of Rahner’s distinction between death as a loss of personal freedom, relationality, and action in history and death as a loss of physical, biological life for assessing the Allocution, Responses, and Commentary? Comparing the statements in these documents with earlier patient- and person-centered magisterial statements on maintaining or withdrawing ANH, it appears that what is morally permissible in the former is dictated by an exclusive focus on death in the biological sense and in the latter by a focus on death as an act of personal, foundational, and categorical freedom. We explore this inconsistency.

In the Allocution, Responses, and Commentary, dying and death for the PVS patient are considered only as biological events in which the freedom to determine the imminence of death is assigned to a physician’s clinical judgment based on purely biological criteria. The first question of the Responses asks if the administration of food and water to the PVS patient is morally obligatory. The affirmative answer recognizes two exceptions to this obligation: first, when ANH ‘cannot be assimilated by the patient’s body’; and, secondly, when they ‘cannot be administered to the patient without causing significant physical discomfort.’ ⁷⁸ It is significant that these two exceptions to the ordinary and proportionate principles requiring the administration of ANH to the PVS patient ‘in principle,’ allowing a physician to withhold ANH, are granted on the basis of physical criteria. We repeat again that such an approach, depending on the treatment decisions of the PVS patient as expressed in a living will or by a designated power of attorney for health care, may disregard the PVS patient’s freedom and, in doing so, violate her dignity as a corporeal-spiritual person. We have already seen John Paul II’s judgment that ‘if treatment is ineffective or obviously disproportionate to the aims of sustaining life or recovering health … the decision to forego aggressive treatment is an expression of respect that is due to the patient at every moment.’

We acknowledge that there are equally competent and dedicated Catholic commentators who argue that a living will that specifies no medically assisted nutrition and hydration is, following John Paul II’s Allocution, contrary to Catholic teaching. ⁷⁹ They argue that the removal of ANH is actually euthanasia. The fact that no medical interventions are possible to reverse the permanent vegetative state and that the PVS patient will not recover and is, in our terminology, personally dead, is irrelevant to them. In our judgment, their argument elevates biological life to an almost-absolute good, and that, again in our judgment, is contrary to the long-established Catholic moral tradition.

We suggest that the determination to maintain or withdraw ANH should be made only as a result of a case-by-case analysis that recognizes that, for every human being in the long process of dying sub prolixitate mortis, dying and death are acts of foundational, categorical, and theological freedom as much as they are passive, biological acts. For Catholic believers they are also the doorway to what Pius XII called ‘the higher, more important good,’ namely, definitive entrance into the eternal presence and unimaginable hospitality of God. We further suggest that any determination about the administration or withdrawal of ANH should be made by the patient via wishes expressed in a living will, or by the patient’s freely designated power of attorney for health care in dialogue with a physician. That dialogue should be guided by the benefit/burden analysis, which includes a total consideration of the patient’s relational, biological, and economic situation. No decision should be permitted by a physician alone and on the basis only of physical, biological criteria.

The Revised Directive 58 of the USCCB’s Ethical and Religious Directives (2009) argues that ANH ‘may become excessively burdensome and therefore not obligatory in light of their very limited ability to prolong [biological] life or provide comfort.’ However, since the PVS patient ‘can reasonably be expected to live [physically] indefinitely if given such care,’ ANH is an obligation. David Jones also argues for the ‘very strong presumption’ that ANH should not be withdrawn from the fact that ‘the unconscious patient cannot experience any discomfort from the presence of the tubes.’ ⁸⁰ Any argument, however, based on the comfort or discomfort of the PVS patient misunderstands the medical reality of PVS articulated by the Multi-Society Task Force on PVS. ‘Patients in a persistent vegetative state are unaware and insensate and therefore lack the cerebral cortical capacity to be conscious of pain.’ ⁸¹ If the unconscious patient cannot experience any discomfort from the presence of tubes, neither can such a patient experience any discomfort from the absence of tubes and the nutrition and hydration they deliver.

There is another issue involved in the assignment of responsibility for administering or withdrawing ANH exclusively to a physician’s clinical assessment. It is by the medical imperative that many modern physicians live: it mandates that if we can prolong biological life then we ought to prolong it. Such an imperative is at variance not only with the ancient Catholic moral tradition on end-of-life issues but also with the more ancient medical tradition evidenced by Hippocrates, who urges physicians ‘not to treat those who are “overmastered” by disease, recognizing that “in such cases medicine is powerless.”’ ⁸² An exclusively physical approach to the question of withholding or withdrawing ANH from the PVS patient impinges not only on the dying patient’s personal freedom, perhaps previously exercised in a living will or by a designated power of attorney for health care, but also on our inviolable human dignity. Any action that disregards the patient’s personal freedom, especially when this has been categorically expressed in a living will or by a power of attorney for health care, violates human dignity and treats the patient in an undignified way that is inconsistent with Catholic teaching on our body–spirit identity.

It disregards the patient’s foundational freedom of moral self-determination, the freedom to dispose totally and definitively of oneself, and places it in the hands of a physician. To be sure, the physician has a crucial role in aiding the patient or, more accurately, in the case of a PVS patient without a living will, the patient’s designated power of attorney for health care to discern a morally acceptable course of medical treatment. As Rahner notes, however, ‘when [the physician] accepts a sick person as patient he accepts the duty to serve a person and his total and entire life history.’ ⁸³ The person and one’s total and entire life history, however, cannot be reduced to the purely biological dimension of being, but must also include the emotional, relational, spiritual, moral, and freedom-in-history dimensions. All these dimensions are intrinsic aspects of the patient’s total and entire life history and provide the context in which to exercise freedom and relationality in the form of free and informed decisions regarding final self-disposition. It is clear, of course, that in concrete circumstances the PVS patient cannot exercise any freedom in the physical act of death. Daily free choices, however, sub prolixitate mortis, and especially the categorically free and informed decision to leave a living will or a designated power of attorney for health care indicating that a patient wishes to withdraw ANH if in PVS, can be an exercise of such freedom.

Cardinal Rigali and Bishop Lori argue that, while a living will allows for the exercise of ‘free and informed health care decisions,’ this only applies to the extent that the decision ‘does not contradict Catholic principles.’ ⁸⁴ We agree, but with two caveats. The first is that what those Catholic principles are is indicated not by an uncritical reading of non-traditional, contingent, conjectural, and, therefore, non-infallible papal language, but by a careful hermeneutic of that language in the context of the established universal Catholic moral tradition. Any presumed contradiction, we submit, arises only from a questionable reading of both the traditional and suggested revised Catholic principle guiding the administration of ANH. The second caveat—perhaps more to the point in a discussion that concerns the PVS patient—is that any contradiction arises both from the prioritization of biological over personal death and the shifting of the freedom to discern the application of Catholic moral principles from a conscientious patient and/or the patient’s designated power of attorney for health care to a physician. The problem is exacerbated when the physician is mandated to consider only the patient’s physical condition and not the patient in his ‘total and entire life history.’ A physician who exercises the freedom to declare that ANH ‘cannot be administered to the patient without causing significant physical discomfort’ is basing the assessment and judgment on purely physical criteria and, therefore, in relation to the total and entire human person, is acting reductionistically.

The exclusive prioritization of physical considerations that trump all other considerations, including relational, psychological, spiritual, moral, and economic ones, indicates the methodological reductionism of the revised benefit/burden principle that emphasizes dying and death primarily as biological and medical events. In the Allocution, Responses, and Commentary, the moral justification for withholding or withdrawing ANH from the PVS patient is based exclusively on physical criteria, though the Commentary does mention that ‘in principle’ it does not exclude the physical impossibility of administering ANH (as in the cases of ‘very remote places’ or ‘extreme poverty’). This reductionism is in stark contrast to the original tradition that allowed for a benefit/burden analysis that included physical, emotional, relational, spiritual, moral, and economic considerations and resulted in a free decision by the patient and/or the patient’s designated health care proxy.

The reductionist prioritization, not the absolutization as William May incorrectly suggests, of the biological over the personal is further reflected in the Responses’ judgment on the ‘proper finality’ of ANH, described as ‘the hydration and nourishment of the patient.’ ⁸⁵ Sustaining biological life is certainly a finality of ANH for the PVS patient, but it cannot equally be argued that ANH alone sustains personal life. We respectfully disagree with all those who claim, including John Paul II in his Allocution, that the PVS patient ‘remains a person in the full sense of the term.’ ⁸⁶ We do not disagree in the abstract that the patient remains a person and retains all the dignity due to a person but, we submit, in the particular concrete circumstances of unfreedom, inaction in history, and unrelationality, the patient is far from a person ‘in the full sense of the term.’ In terms of the philosophy of death and dying we have articulated, ontologically, in terms of what essentially constitutes the specificity of the fully human person, the PVS patient has suffered the irretrievable loss of the capacity to exercise freedom, relationality, and living history, dimensions of personhood that are integral to fullness.

Foregoing or withdrawing ANH from the PVS patient is not tantamount to abandoning the person. It is, rather, simply accepting the fact that the person has come to the end of a specifically personal life and should not be impeded from taking the final, natural, biological step. ⁸⁷ The patient has permanently lost essential components of the full human person, namely, the rational, affective, relational, spiritual, and moral capabilities that distinguish specifically human animals from lower animals. We respectfully disagree with those who, despite their protestations to the contrary, argue, on the basis of a philosophy which prioritizes biological over personal life, against the position we have just articulated. ⁸⁸ For the PVS patient, personal death has already taken place, though biological death has not. We propose that the ‘proper finality’ of ANH must be assessed in terms of the personal as much as the physical, and we further propose that when it is assessed in terms of the personal, it does not attain any personal finality in the PVS patient.

There is another, seldom-mentioned theological problem with having a physician make an assessment on purely biological grounds as to whether a PVS patient should be continued or discontinued on ANH. It is a problem we have hinted at several times throughout this article and now explain. ‘The human person, created in the image of God,’ the Catechism teaches, ‘is a being at once corporeal and spiritual.’ ⁸⁹ This corporeal–spiritual, body–soul composition of human persons is a universal and ongoing Catholic doctrine. To assess human persons only physically and bodily, even unconscious PVS patients who are not in a position to object, far from treating them with dignity—as is commonly asserted by those who read John Paul’s Allocution to mean that ANH must never be withdrawn from the PVS patient—is to treat them as something less than the personal, spiritual beings that they are. It is to treat them not as the someones they truly are, albeit damaged, but as somethings, as objects which have nothing to say about themselves or their treatment and care. It is to treat them not with the dignity due to human beings but with the indignity that is always involved in treating persons as objects. This is especially true in the case in which the PVS patient has already exercised freedom and either left specific instructions in a living will to withhold or withdraw ANH if in PVS or designated a power of attorney for health care to make such a decision. In the case in which the patient has not exercised this freedom by leaving a living will or designating a power of attorney, her exclusively physical assessment by a physician with respect to continuing or withdrawing ANH is still objectively unreasonable, and, therefore, also objectively immoral. Biological life, to repeat again, is not an absolute value. Valuing and respecting the expressed decision of a free, competent, person with a well-informed conscience, expressed in a living will or by a designated power of attorney for health care, is an absolute value.

Earlier, traditional magisterial teachings on ANH defend our proposal. In the CDF’s 1980 Declaration on Euthanasia, we note the following: ‘it pertains to the conscience either of the sick person, or of those qualified to speak in the sick person’s name, or of the doctors, to decide, in the light of moral obligations and of the various aspects of the case.’ ⁹⁰ The Declaration also clarifies the nature of the moral obligations: ‘One cannot impose on anyone the obligation to have recourse to a technique which is already in use but which carries a risk or is burdensome. Such a refusal is not the equivalent of suicide; on the contrary, it should be considered as an acceptance of the human condition, or a wish to avoid the application of a medical procedure disproportionate to the results that can be expected, or a desire not to impose excessive expense on the family or the community.’ ⁹¹ That traditional Catholic teaching has not been superseded by John Paul’s Allocution, nor by the CDF’s Responses and Commentary.

Conclusion

In this article, we have done essentially three things. First, we have articulated a Catholic theology of dying and death; secondly, we have analyzed John Paul II’s 2004 Allocution on ‘Life Sustaining Treatments and the Vegetative State’ and the CDF’s Responses and Commentary explicating that Allocution; thirdly, we have debated the normative implications of this theological theory and these documents for the issue of ANH and the PVS patient. We have argued that John Paul II’s Allocution and the CDF’s Responses and Commentary give priority to dying and death as biological events, disregard the patient’s freedom to determine dying and death as acts of personal freedom, transfer that freedom implicitly to the clinical judgment of a physician, and suggest only reductionist, physical criteria to determine how that freedom will be exercised. We have also argued that to assess any corporeal–spiritual, body–soul being (which the universal Catholic tradition holds the human being to be) on only bodily, physical grounds, is to treat a patient with indignity and is objectively unreasonable and, therefore, objectively immoral.

Earlier magisterial statements, which had long become traditional, give priority to dying and death as a free, personal choice, recognize that foundational and categorical freedom are to be exercised by the patient or the patient’s designated power of attorney for health care and the patient’s physician in dialogue, and consider the moral determination to maintain or withdraw ANH to be the outcome of a benefit/burden analysis in light of relational, emotional, spiritual, moral, medical, and economic considerations. The shift in focus from active dying and death as acts of personal freedom sub prolixitate mortis to dying and death as passive, biological events, and the prioritizing of biological life over personal life, is a distortion of a genuinely Catholic theology of dying and death and a distorted application of traditional Catholic principles guiding the administration of ANH for the PVS patient. That the shift has been prescribed in response to a papal pronouncement founded on ‘contingent and conjectural elements,’ and, therefore, owed due respect but not absolute, theological faith, suggests that the proposed shift has been hasty and is open to reconsideration. ⁹²

We conclude with a reflection from our personal experience. Jesuit moralist Richard McCormick once recounted that he asked a group of people if they would be led to question the Catholic belief in resurrection in a ward of PVS patients on feeding tubes. Some of them responded that, instead of questioning belief in resurrection, they would be led to the judgment: ‘see how they love one another.’ Having been in that same situation, we fully understand and, indeed, were ourselves tempted to that same response. Reflecting, however, on the traditional Catholic position on death as a change not an end and as the doorway to God’s eternal presence and unimaginable hospitality, we came to a different judgment: ‘see how they selfishly comfort themselves and deny the patient’s personal human condition and spiritual possibility.’ ⁹³