| U.S. News

The persistent vegetative state strips away all human consciousness, and thus poses a harrowingly clear moral question: When the only thing left is biological life itself, does that life still possess transcendent value that must be maintained – even if it means years, perhaps decades, beyond realistic hope of recovery? Does human dignity depend on some degree of recognizable human personality, or is it biological existence itself that counts?

Today’s debate is fueled by the Western drift toward euthanasia and physician-assisted suicide, as well as the mounting costs of health care. For those who insist that life must always be preserved, the nightmare scenario is that whole classes of disabled people may come to be seen as expendable because it’s considered too expensive or bothersome to keep them alive – that a noble-sounding “right to die” could turn into an implicit duty to die.

The latest turn came Sept. 14, when the Vatican’s doctrinal office responded to two questions from the bishops of the United States. In essence, the Vatican held that artificial nutrition and hydration for patients in a persistent vegetative state is a basic requirement of human dignity and is almost always obligatory. The ruling confirmed the content of a speech from Pope John Paul II in March 2004, in which he took the same position.

Supporters hail the ruling as a courageous blow against a “culture of death”; critics charge that it reverses centuries of careful moral reflection on the distinction between ordinary and extraordinary care, and may add to the suffering of families and caregivers facing anguished decisions about when to fight on and when to let go.

Limited scope

Generally speaking, patients enter a persistent vegetative state one of two ways: either through trauma such as a car accident or a beating; or through severe loss of oxygen to the brain caused by conditions such as an eating disorder, a stroke or a drug overdose. Because cases involving trauma are thought to have a better chance of recovery, it usually takes 12 months to make a diagnosis of a persistent vegetative state for a trauma patient, six months in other situations. After that length of time, most doctors regard the chances of recovery as remote or nonexistent.

Medical sources say there are perhaps 15,000 patients in the United States in a persistent vegetative state, and an additional 100,000 in what’s known as a “minimally conscious state,” with some level of awareness. Aside from impaired consciousness, patients in both conditions are generally stable and able to live for years, barring other illnesses, if given nutrition and hydration and other basic care. (One American woman, for example, lived more than 37 years after falling into a coma at age 6.) After a lengthy period of hospitalization to verify the diagnosis, most patients are discharged to nursing homes or other facilities for long-term care.

One important point about the Vatican’s ruling, according to experts, is that it applies exclusively to the persistent vegetative state, and therefore does not mean that all Catholics who can’t eat on their own are required to use a feeding tube, even if they’re in the final stages of a terminal illness.

Nor does the ruling mean that the obligation to use a feeding tube is airtight even for patients in a vegetative condition. It recognizes three exceptions: when the patient’s body can no longer assimilate food or water; when use of the tube causes “significant physical discomfort”; and in a remote or impoverished location when use of a feeding tube is impossible. (The last point hints at one reality of the debate over end-of-life care, which is that it tends to be a preoccupation of affluent Western societies that can afford life-extending technology. There’s little discussion of the persistent vegetative state in developing nations, where the more urgent bioethical issues generally concern inequitable global distribution of health-care resources.)

However limited in scope, the ruling nevertheless closes a door in Catholic debate that had earlier remained open. Prior to John Paul’s address in 2004, some Catholic theologians and bishops believed that food and water could be withdrawn even in the absence of the three exceptions noted above, on the grounds that prolonging physical life without hope of recovery imposes needless burdens on both patients and caregivers. That option has now been rejected.

Living in limbo

St. Joseph Sister Jean deBlois of the Aquinas Institute in St. Louis, a nurse and an expert in bioethics, knows firsthand how difficult these cases can be. In 2000, she was consulted by the wife of Steven Becker, a father of three young sons who entered a vegetative state in March 2000 following surgery to relieve pressure on his brain.

Two and a half months later, doctors at St. John’s Mercy Medical Center in St. ...