Answer to questions from the American Episcopal conference
In September answers given by the Congregation have been published for the
Doctrine of the Faith to questions from the American Episcopal Conference
regarding artificial nutrition and hydration of patients in “vegetative
state” or in ″permanent vegetative state”. The questions have been presented
few months Terri Schiavo died, in Florida, who was a patient diagnosed in
“permanent vegetative state” for some fifteen years, and whose question of
stopping tube-feeding gave rise to an international debate.
A moral obligation?
Both questions were about the morally mandatory character of water and food
administration to "vegetative state” patient, and the possibility to
interrupt food and hydration when these are provided by artificial routes to
a “permanent vegetative state” patient. The Congregation answered that it
was morally mandatory in general to give food and water, even through
artificial routes, to the “vegetative state” patient and that food and water
administered to patient through artificial routes must not be interrupted
for “permanent vegetative state” patient. A comment was added, reminding
particularly that the answers from the Congregation are in line with several
documents of Holy See, among other a speech by John Paul II of 20th March
2004. How to understand these answers?
The “vegetative state” patient is a
patient who emerges from coma and whose respiratory and cardiovascular
systems work autonomously. We observe an alternation of periods of opening
and closing movements of eyes, but the patient does not give any perceptible
signs of consciousness of himself and of his environment. The “Vegetative
state” is considered as “permanent″ when it lasts more than one year. Indeed,
the possibilities of evolution are then almost null. The average life
expectancy of these patients varies from 2 to 5 years. The “vegetative
state” patient is thus in a very reduced life state and really dependant.
Nevertheless, he is not ″in imminent danger of death″. His situation
is not that of an end-of-life patient, but rather that of a patient
seriously handicapped needing a “continuous assistance during months or
even years”. It is very difficult to assess the pain of these patients.
Families and caregivers
However, it is clear that the fact to have a relative in a “vegetative
state” which lasts in time is a ″notable responsibility″ for the
family. The accompaniment of these patients and their family is often heavy
to do for caregivers. Above all it is from this event of families and
caregivers that emerges more or less consciously the question of the
opportunity to maintain food and hydration for these patients. A question of
social solidarity is added: is it justified that the society treats and
pays, on a long term basis, for these patients whereas they are
apparently not conscious? The Congregation agrees to listen to these
questions and gives clear and measured answers.
Care responding to a vital need
From one hand, food and hydration, even by artificial route, are not seen as
a “resolutive therapy”, in other words, a treatment aimed at caring the
patient, but care responding to a vital need. It is a
″proportioned″ care insofar as it "does
generally not impose a heavy responsibility for the patient, or for his
relatives. It does not have excessive costs; it is suitable for all health
systems of medium level; it does not require hospitalisation and it is
proportioned to reach its objective: preventing the patient from dieing of
inanition and dehydration″.
Euthanasia by omission
From another hand, if food or liquids are not administered artificially to
these patients, even in “permanent vegetative state” they die, and then the
″cause of death is not a disease or a “vegetative state”, but only the
fact of inanition and dehydration″. It is really about euthanasia by
omission, that is to say “an omission which, of itself or by intention;
kills instead of relieving pain″ 1. It would consist in
considering the patient himself as a too heavy responsibility of which we
dispose of by leaving them dying. Some are going until challenging ″the
human quality″ of patients in ″permanent vegetative state″, under the
pretext they have no more conscious relationship with their relatives and
their environment. But personal life does not limit to conscious life. From
another hand, if the relationship is essential for welcoming the patient, it
is not a founder relationship of personal dignity. The comment cited by John
Paul II: ″the intrinsic value and the personal dignity of any human being
do not change, whatever the concrete conditions of his life. A man, even if
he is seriously ill or disabled in the exercise of his highest functions, is
and will always be a man, and will never become “a vegetal″ or a ″animal″.
The exceptions
The answers from the Congregation are worth ″in general″. The comment tends
to mention a certain number of exceptions: material impossibility to ensure
an artificial administration of food and drink ″in some very remote and
extremely poor regions″, impossibility of the patient to assimilate food
and drink, excessive hardness or ″serious privation at physical level″
(we can think about infectious risks related to nutrition by artificial
route) for the patient.
In France
Reminding this ethical behaviour is timely whereas in our country, some
people think they can lawfully interrupt food and water administration for
patients in "vegetative state". They rely on the article 3 of Léonetti law
stipulating that the ill patient may refuse not only ″a treatment″, but also
″any treatment″, the report of the motives explaining that such provision ″would
implicitly affect the right to refuse artificial nutrition, this being
considered by European Council of Doctors and its theologists as a treatment”.
Even more, this document of the Congregation for the Doctrine of the Faith
undoubtedly encourages those who are involved for years at the service of
these patients and their families. In France, a ministry circular of 2002,
invites Regional Hospitalisation Agencies to implement units with some long
term welcoming beds adapted to patients in ″chronic vegetative state″.
Moreover, resuscitators work for preventing these states through the
development of technical tools of prognosis. The quasi certainty of an
evolution towards the “vegetative state” would allow an unreasonable
obstinacy in intensive care.
1. Catéchisme de l’Eglise catholique, n°2277
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The Agency of biomedicine has just published its 2006 annual activity
report, first full exercise of the Agency, marked in particular by the
decree of 6 February 2006 giving it competence to deliver authorisations of
research on embryos and embryonic stem cells.
Research on embryo
The report reminds that obtaining embryonic stem cells involves the
destruction of the embryo, now at the fifth day after fertilisation, hence
the ethical interrogations. In 2006, 30 authorisations of research were
granted to 14 teams. Taking into account the works authorised within the
framework of the transitory disposition implemented by the law of 2004 (exceptional
authorisation of embryo import for research), 32 protocols of research and
70 authorisations have been granted in 2 years. The report details all these
protocols of research among which one establishes men/mice models in order
to study the infection by HIV. The first publication of results of one of
these teams which works on the differentiation of embryonic stem cells into
cardiac cells intervened in June 2006, in the journal Stem Cells,
congratulates Carine Camby, general director of the Agency.
Non-heart-beating organ sampling
The first samplings on non-heart-beating donators have been performed in
2006. in order to increase the number of organs available for grafts, organ
samplings on non-heart-beating subjects, in other words, dead of cardiac
arrest and not of brain death, is possible since the
decree of 2nd August 2005,
which authorises particularly medical teams to develop means of organ
preservation waiting for the interview with the relatives. At the end of
2005, the protocol concerning the sampling of kidneys on non-heart-beating
dead patients was validated and 9 volunteer hospitals are testing the
feasibility (La Pitié, Bicêtre, Saint Louis, Lyon, Nancy, Strasbourg,
Marseille, Nantes and Bordeaux). In December 2006, a first non-heart-beating
sampling took place successfully in the civil hospices of Lyon. Several
others followed in Lyon, Paris and Angers. In 2007, the liver sampling
should also start, after elaboration of a medical protocol.
Cord blood grafts
If the increase of the number of placental blood grafts carries on, with an
objective of fast doubling the number of preserved units, the figures are
still very low: 5,737 units of placental blood are now preserved in France,
of which 626 new in 2006, whereas 252,000 units are preserved in the whole
international banks. The report underlines that ″the therapeutic
prospects are considerably extended regarding placental blood grafts, also
the increasing number of placental blood grafts in adults imposes the update
of development strategy of French network for placental blood".
Preimplantation diagnosis
In 2005, 193 couples were treated, in the three authorised centres of Paris,
Montpellier and Strasbourg, 134 transfers of at least 1 disease free embryo
have been counted, and 32 women delivered 39 born-alive babies.
Medical termination of pregnancy
6,441 medical terminations of pregnancy (MTP) were performed in 2005, or an
increase by 7.5% compared to 2004. 60% of these MTP are performed before 22
weeks of amenorrhea and 6.5% beyond 31 weeks of amenorrhea. Despite the
release of a certificate of medical termination of pregnancy, 411 couples
wished to maintain the pregnancy: 56.1% of the pregnancies thus maintained
gave an infant alive at the last follow-up visit, 15.2%, its fetal death in
utero and 28.7%, its early or delayed neonatal death.
The figures of the MAP with donor
In 2005, 19,026 children are born from MAP techniques, which represents 2.4%
of the 807,400 births recorded in France, or 1 child out of 40. Among them,
1 child out of 625 born in 2005 have been conceived with donors (317 with
sperm donation within the framework of a in vitro fertilization, 900
infants after artificial insemination with sperm from donor, or 11% of the
whole artificial inseminations performed in 2005 and 100 with oocyte
donation.
Stored embryos
At 31st December 2005, 14,460 embryos were preserved, of which over 55,000
(39.3%) "without parental project" known and thus a priori "available" for
research.
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