The recent events surrounding the case of Terri Schiavo have highlighted the moral implications of end-of-life care. Among the issues raised by Terri's parents against the withdrawal of her feeding tube was that doing so would be “euthanasia” and, as such, would violate their daughter's Roman Catholic religious beliefs. The emotionally charged rhetoric and the political posturing in this case drowned out both rational discourse and historical memory. Politicians and even a few bishops and cardinals were quick to join the parents in denouncing the removal of Terri Schiavo's feeding tube as “euthanasia” or “murder.” However, the interpretation of the Catholic position on the sanctity of life that led to that moral judgment is not in line with the centuries-long Catholic position on end-of-life care.

The Schindler family's perception of Catholic teaching is understandable, particularly in light of the late Pope John Paul II's speech regarding the care of patients in a persistent vegetative condition in which the pontiff declared: “The administration of water and food, even when provided by artificial means, always represents a natural means of preserving life, not a medical act … and as such is morally obligatory” (John Paul II, 2004). That statement is the basis for the Schindler family's belief that the denial of these basic needs constitutes murder.

The parents' position is highly problematic, however, because it is incompatible with 450 years of consistent Catholic moral teaching regarding the measures by which one should preserve life. In 1595, Domingo Bañez expounded upon the foundational views of the moralist Francisco de Vitoria by drawing the distinction between “extraordinary” and “ordinary” means of preserving life (McCarthy, 1980). Examples of extraordinary measures include those procedures that incur excessive cost, pain, or burden or lack substantial benefit to the patient. If these conditions are met, there is no obligation to utilize such “disproportionate” measures to sustain life.

That the doctrine has continued unchanged to the present day is seen in the Vatican's 1980 “Declaration on Euthanasia,” which states: “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 [or euthanasia]; on the contrary, it should be considered as an acceptance of the human condition” (Sacred Congregation for the Doctrine of the Faith, 1980).

The broader context for this teaching is the Catholic understanding of life and death. Within the Catholic tradition, life is understood as a gift from God, one we hold in responsible stewardship and trust. We are created by God, and in the words of Mahler's Resurrection Symphony, “We have come from God and to God we must return.” Life is thus a good, but not an absolute good. The absolute good for which we have been created is not this life, but the ultimate goal of union with God in eternal life.

Death in this context is not an evil to be avoided at all cost, but the calling at some point in time of each of us back to God. This teaching is best summed up in a recent pastoral letter on death and dying by Archbishop John J. Myer in which he writes:

Because life is God created and thus sacred, we are morally obliged to care for and sustain it within its created purpose. As Richard McCormick notes in his classic essay, “To Save or Let Die,” that obligation is fulfilled when the purpose and goal of creation—relationship with others and through those relationships to God—has been exhausted (McCormick, 1974). Without a capacity for on-going relationship, the human task of striving for union with God through active love of neighbor has been completed.

Because life if not an absolute good, but one oriented to a spiritual end, the duty to sustain it is a limited one. What are the limits the Catholic moral heritage have discerned on the obligation to preserve life? The Vatican Declaration puts it succinctly: “In the past moralists have replied that one is never obliged to use ‘extraordinary’ means.” But as the Declaration makes clear, the confusion, abuse, and misuse of that term has rendered it less precise in our age, and so it might be preferable and more accurate to speak of “proportionate” and “disproportionate” means.

In making an assessment on proportionate means—which the Vatican Declaration states belongs “to the conscience either of the sick person or those qualified to speak in the sick person's name”—consideration must be made of “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.”

When a decision is made that the burden of the treatment outweighs the benefits to this specific patient given his or her medical condition and the spiritual, financial, and physical resources available to that patient, it is, in the Vatican's words, “permitted with the patient's consent to interrupt these means.” “Such a refusal,” says the Declaration, “is not the equivalent of suicide [or euthanasia]; on the contrary, it should be considered 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.” That being so, there is no need to undergo “forms of treatment that would only secure a precarious and burdensome prolongation of life so long as the normal care due to the sick person in similar cases is not interrupted.”

The Vatican's Declaration is a summary of the centuries-long tradition of the Church on the duty to preserve life. That tradition began with the teachings of Domingo Soto in the 16th century that religious superiors could only require their subjects to use medicine that could be taken without too much difficulty. The most famous formula for that limitation was the distinction first proposed in 1595 by Domingo Bañez between “extraordinary” and “ordinary” means, by which was meant measures proportionate to one's condition or state in life.

The clearest statement of that teaching is found in the Relations Theologicae by the 16th-century Dominican moralist Francisco DeVitoria. In a commentary on the obligation to use food to preserve life, DeVitoria asks: “Would a sick person who does not eat because of some disgust for food be guilty of a sin equivalent to suicide?” His reply: “If the patient is so depressed or has lost his appetite so that it is only with the greatest effort that he can eat food, this right away ought to be reckoned as creating a kind of impossibility, and the patient is excused, at least from mortal sin, especially if there if little or no hope of life” (DeVitoria, 1587).

DeVitoria provides an everyday example of the type of “delicate treatment” that would be beyond what one is obliged to employ to preserve life: “Chickens and partridges, even if ordered by the doctor, need not be chosen over eggs and other common items, even if the individual knew for certain that he could live another 20 years by eating such special foods.” If this was true of hens and partridges in DeVitoria's time, how much the more so today for total parenteral nutrition, feeding gastrostomies, nasogastric tubes, and other artificial means of providing alimentation?

That DeVitoria's views were neither unique nor subsequently abandoned is best seen in an essay on “The Duty of Using Artificial Means of Preserving Life” published in Theological Studies in 1950 by the widely respected Jesuit moralist Gerald Kelly (Kelly, 1950). Kelly was concerned with the same questions that confronted us in the Schiavo case: Is there a moral obligation to continue intravenous feeding of an irreversibly comatose patient? After a thorough survey of the prior teachings on the subject, Kelly finds that the authors hold that “no remedy is obligatory unless it offers a reasonable hope of checking or curing a disease (Nemo ad inutile tenetur).” From this Kelly concludes that no one is obliged to use any means—natural or artificial—if it does not offer a reasonable hope of overcoming the patient's condition.

Kelly's application of the principle is instructive. He immediately asks if all artificial means are remedies, or are some, such as intravenous feeding, merely designed to supplant a natural means of sustaining life? He quickly dismisses the speculative difference as irrelevant and insists that in the world of sick people, all artificial means of sustaining life are remedies for some diseased or defective condition. Kelly specifically applies this holding to the use of oxygen or intravenous feeding to sustain life in the so-called hopeless cases. His response is quite direct: “There is no obligation of using these things, unless they are needed to allow time for the reception of the sacraments.”

Practical application of principles is the mark of a moralist, and Kelly provides us with two cases—cases nearly identical to questions raised in Schiavo. In his first example, a terminally ill cancer patient's painful death is being prolonged by intravenous feeding. With such therapy, the patient could survive several more weeks. The physician stops the intravenous feeding, and the patient dies soon thereafter. As is true in the present disputes, the commentators were divided over whether the intravenous feedings constituted an “ordinary” or “extraordinary” means of preserving life. Kelly concedes that one could consider the treatment as “ordinary.” But one must still determine if the patient is obliged to undergo it. Kelly's answer is straightforward and clear: “Since the prolonging of life is relatively useless, the patient may refuse the treatment.” Further, he argues that if the patient is so racked with pain he is unable to speak for himself, “the relatives and physicians may reasonably presume that he does not wish the intravenous feeding” and licitly discontinue it.

In the second case, Kelly goes even further. When asked if oxygen and intravenous feeding must be used to extend the life of a patient in a terminal coma—the term in use at the time for what we now call a permanent vegetative condition—he replies: “I see no reason why even the most delicate professional standard should call for their use. In fact, it seems to me that, apart from very special circumstances, the artificial means not only need but should not be used, once the coma is reasonably diagnosed as terminal. Their use creates expense and nervous strain without conferring any real benefit.”

A 1958 doctoral dissertation at the Gregorian University in Rome, “The Moral Law in Regard to the Ordinary and Extraordinary Means of Preserving Life,” by Daniel A. Cronin (the now retired Archbishop of Hartford) provides the most authoritative historical study of this topic (Cronin, 1958). After a review of over 50 moral theologians, from Aquinas to those writing in the early 1950s, Cronin concludes that the church's teaching is consistent in its view: “Even natural means, such as taking of food and drink, can become optional if taking them requires great effort or if the hope of beneficial results (spes salutis) is not present.” For the patient whose condition is incurable, Cronin writes, “even ordinary means, according to the general norm, have become extraordinary [morally dispensable] for the patient and [so] the wishes of the patient, expressed or reasonably interpreted, must be obeyed.” Cronin's retrospective analysis of the tradition firmly established that the moralists have always held that no means—including food or water—can be said to be absolutely obligatory regardless of the patient's status.

That approach has likewise been taken in official guidelines on the use of nutrition and fluids issued by the Roman Catholic Bishops of Texas (Bishops of Texas, 1990). The Texas bishops outline the reasoning in the Vatican's Declaration and then apply it to the patient in a persistent vegetative state (PVS). Their analysis of such patients differs substantially from those who would describe such patients as “unconscious but non-dying.” The Texas bishops describe the PVS patient as “human beings” who “are stricken with a lethal pathology which, without artificial nutrition and hydration, will lead to death.” If there is evidence the now irreversibly comatose patient would not want to be maintained by artificial nutrition and fluids, these may be forgone or withdrawn. Such an action, in the bishops' understanding, “is not abandoning the person. Rather, it is accepting the fact that the person has come to the end of his or her pilgrimage and should not be impeded from taking the final step.”

This subordination of physiological concerns to the patient's spiritual needs and obligations is the hallmark of authentic Catholic thinking. It is based on a clear and careful reiteration of the ethical assumptions upon which medicine and the efforts to treat people have been based—“to prolong living in order to pursue the purpose of life.” The burden a person would experience in striving to obtain the purpose of life—not the burden associated with the means to prolong it—is and traditionally has been the focus of Catholic moral concern.

It is this bedrock teaching of theology on the meaning of life and death—neither of which in the Christian framework ought to be made absolute—and not a misplaced debate on the casuistry of means that should guide our judgments on the difficult and sometimes trying decisions cast up by modern medical technology. To do otherwise—or to count mere vegetative existence as a patient-benefit—it so let slip one's grasp on the heart of Catholic tradition in this matter. It is that tradition, developed over centuries of living out the Gospel message on the meaning of life and death, that is and ought to be the source of the Catholic Church's teaching on the use of nutrition and fluids.

The United States Catholic bishops in 2001 developed a set of national norms that incorporate those teaching and propulgated them as The Ethical and Religious Directives to guide physicians in the care of patients in Catholic hospitals (United States Conference of Catholic Bishops, 2001). Two such directives are of immediate consequence. Directive 57 states: “A person may forgo means that in the patient's judgment do not offer a reasonable hope of benefit, or entail an excessive burden, or impose excessive expense on the family or community.” This directive gives the patient the right to choose, even if that choice is accepting death. The second of these, Directive 58, reads: “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 the patient.” Such language implies that there are situations where the presumption on the use of artificial nutrition and hydration is reputable. The tradition provides the examples of such situations.