Artificial Nutrition and Hydration for Persons in a State with Disorders of Consciousness
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Artificial Nutrition and Hydration for Persons in a State with Disorders of Consciousness - an Updated Study in Theological Ethics Applied to Three Moral Cases. Bachelor of Philosophy and Theology Matteus C.G. Collvin Candidate number: 1100 Supervisors Professor and Doctor of Theology Kenneth R. Overberg, S.J. Professor and Doctor of Philosophy Erik T. Åkerlund This Master’s Thesis is carried out as a part of the education at MF Norwegian School of Theology and is therefore approved as a part of this education. MF Norwegian School of Theology, 2016, Spring term AVH 5010, Thesis for Master of Theology (60 ECTS) Master’s degree in Theology Table of Contents Abstract……………………………………………………………………………………………. 6 1. Introduction ……………………………………………………………………….. 7 1.1 Aim…………………………………………………………………………………….. 7 1.2 Outline………………………………………………………………………………….. 8 1.3 Literature review and material for my own research……………………………… 9 1.4 Potential problems…………………………………………………………………… 10 1.5 Expected outcome……………………………………………………………………. 11 2. Why? A Background: A context of a cultural conflict…………………………………… 12 2.1 Deontological Vitalism……………………………………………………………… 12 2.2 Teleological Pessimistic Utilitarianism……………………………………………. 13 2.3 The Catholic moral tradition…………………………………………………..…… 15 2.3.1 The human person………………………………………………………… 17 2.3.2 The sanctity of life……………………………………………………….… 18 2.3.3 The basic good of life………………………………………………..……. 18 2.3.4 The qualities of life…………………………………………………..……. 19 3. Whom it is about: Three Moral Cases concerning ANH……………………………….. 21 3.1 Aruna Shanbaug………………………………………………………………….…. 21 3.2 Vincent Lambert…………………………………………………………………….. 23 3.3 Terry Wallis………………………………………………………………………….. 27 !2 4. Catholic moral history of allowing to die……………………………………………..….. 29 4.1 Ancient history………………………………………………………………….……. 29 4.2 Before Pius XII………………………………………………………………..………. 30 4.3 Pius XII…………………………………………………………………..……..…..… 31 4.4 In the spirit of Vatican II…………………………………………………………….. 32 4.5 John Paul II…………………………………………………………..…………….… 36 4.6 After John Paul II…………………………………………………….………………. 43 4.7 Actual research……………………………………………………………………….. 46 5. What it is about: Catholics, Nutrition and Hydration…………………………………… 54 5.1 Defining consciousness…………………………………………………………….,. 54 5.2 Coma………………………………………….……………………………………….. 55 5.3 The vegetative state………………………………………………………………..… 56 5.4 Minimally conscious state………………………………………………………….. 60 5.5 Nutrition: in the bible and elsewhere……………………………………………… 62 5.6 Artificial Nutrition and Hydration………………………………………………… 63 6. How to investigate in theological ethics: is ANH proportionate to what it achieves? 66 6.1 A real ethics…………………………………………………………………………… 66 6.2 A real decision……………………………………………………………………..…. 69 6.3 Conscience……………………………………………………………………………. 71 6.4 The principle of proportionality……………………………………………………. 73 6.5 Longing and striving - a theological point of view………………………….…… 73 6.6 Different actual positions in Catholic moral theology…………………………… 74 6.7 Proportionate to what?……………………………………………………………… 77 6.7.1 Proportionate and disproportionate or ordinary and extra-ordinary… 79 6.7.2 Burdens and benefits………………………………………………………. 80 6.7.3 Objective frame of reference and subjective perceptions or preferences 81 6.8 Human flourishing………………………………………………………………….. 83 6.9 The method used: what seems the most pertinent way of treating this issue… 84 !3 7. What would it mean if foregoing or withdrawing ANH were equal to euthanasia?.. 88 7.1 Arguments in favor of euthanasia………………………………………………….. 88 7.2 Arguments against euthanasia…………………………………………………….. 90 7.3 Purpose and intent………………………………………………………………….. 92 7.4 Terminal illness………………………………………………………………………. 95 7.5 Palliative sedation…………………………………………………………………… 95 8. What else: Who is deciding?………………………………………………………………… 97 8.1 Autonomy…………………………………………………………………………….. 97 8.2 Respect for the patients will………………………………………………………… 98 8.3 Informed or presumed consent or permission…………………………………… 98 8.4 Advance directives………………………………………………………………..…. 99 8.5 Proxies……………………………………………………………………………….. 100 8.6 The responsibility of the doctors……………………………………………..…… 101 8.7 Church authority…………………………………………………………………… 101 8.7.1 Canon Law………………………………………………………………… 103 8.8 The virtue of epikeia………………………………………………………………… 103 8.9 Social justice………………………………………………………………………… 104 9. When to forego and when to withdraw - is there any difference at all?…………..… 107 9.1 Excessive over-zealous unreasonable obstinacy………………………………… 107 9.2 Futility…………………………………………………………………………..…… 108 9.3 Imminently dying………………………………………………………………….. 109 9.4 Omissions……………………………………………………………………….…… 110 10. Where is the main point?………………………………………………………………..… 112 10.1 Physical and biotechnical improvements or an overall condition of health… 112 10.2 Curing…………………………………………………………………………….… 114 10.3 Caring………………………………………………………………………….…… 114 10.4 A person’s human condition…………………………………………………..… 115 !4 11. An advice to the persons involved with the three cases………………………………. 117 11.1 Aruna Shunbaug………………………………………………………………….. 117 11.2 Vincent Lambert…………………………………………………………………… 120 11.3 Terry Wallis………………………………………………………………………… 125 12. Conclusion………………………………………………………………………………..… 127 12.1 Summary…………………………………………………………………………… 127 12.2 A reception disclaimer……………………………………………………….…… 128 12.3 Further considerations…………………………………………………………… 128 Bibliography……………………………………………………………………………………. 130 !5 Abstract The Catholic Church has, over the past decade, given clear signals in the official teaching that one should not withdraw the artificial supply of nutrition and hydration from a person in a permanent vegetative state because this is not a medical treatment, but a basic human right. This master thesis considers not only the historical development, but above all the past decade's research, to investigate the advantages that the artificial supply of nutrition and hydration provide, in proportion to the burden placed on the unconscious patients. The thesis reflects on how strictly the Catholic Church's teaching should be interpreted, in light of the moral theological tradition, and the insights of the new findings. Deeper insights into different degrees of consciousness judged to be relevant to the ethical evaluation of three moral cases are of special interest. !6 1. Introduction Let us imagine that your old good friend or relative is in a bed at the hospital and seems barely if at all able to communicate with the outside world. It turns out after a while that you are this person’s closest relative. There is no one left alive who is closer kin to this person than you. The hospital asks you now how you wish to proceed. Would you like the treatment to continue? Would you like to prolong the life-saving assistance such as food or drink? Would you consider caring for this person alone or who else would provide care for him or her? Would you like to let this person die as painlessly as possible? Would you even consider helping this patient to die as smoothly and quickly as possible to relieve him or her of any painful experiences? What ought you be doing? People are concerned about how dying patients are cared for, especially since the 1970s when euthanasia and physician-assisted suicide began gaining wider support. Some people are frightened to be either the executioner or executed if nutrition and hydration are removed during their illness or that of their dear ones. There has been an intense debate within the Catholic moral theology whether it seems morally right or not to continue the artificial nutrition and hydration (ANH) in cases where the patient has a serious brain injury and disorders of consciousness (DOC) that includes both patients in a vegetative state (VS) and those in a minimally conscious state (MCS). This is an intricate question needing careful reflection. This thesis aims to give some ethical advice and guidance built on current research on the issue along with the traditional teachings of the Church. 1.1 Aim The purpose with this master’s thesis is to investigate whether contemporary research provides clearer ethical guidelines for when to provide artificial nutrition and hydration (ANH) to people in a state with disorders of consciousness. !7 1.2 Outline After the introduction stated both the purpose and focus of the thesis, in chapter two the thesis presents the philosophical-ethical contradiction between wanting to preserve human life at any cost and the individual's autonomy over his or her life. The thesis will adopt an intermediate position in accordance with Catholic tradition and develop what this means. Chapter three contains a presentation of three moral cases, which are related to the ethical problem of the thesis. One could say that the thesis focuses on the second of the three moral cases. The two other moral cases give to some extent the limits of the second case. Everything that is written could be read with this prism: what does it say about the second case. In chapter four the chronological history of ethical attitudes will be delineated regarding eating and drinking at the end of life, mainly in the Catholic Church's sphere of thought. In chapter five an overview of the scientific question is presented. It serves also as an introduction for those who have not reflected on this specific ethical problem before. Chapter six explains what a proportionate approach means and how it will be used on the master thesis' problem. Chapter seven describes illusory similarities and real differences between the master thesis' issue and the question of whether euthanasia