I accept in particular the death that is destined for me, with all the pains that may accompany it. – St. Alphonsus Liguori
Two months ago we saw that food and water are routinely withheld from patients in Canadian hospitals. Last month we examined the attitudes of the groups and organizations most concerned with this practice.
Now we are ready to ask the basic question: What stand should the pro-life person take?
It is easy to answer: Always feed. With most other important questions, the easy answer is generally not the right one. In this case, however, this is precisely the answer we shall give, but for a reason which is not immediately apparent and which it is crucial to understand.
Let us review the best arguments of those who would permit the withholding or withdrawal of food and water.
When treating a terminally ill person, our principal aim should be to make him comfortable; to allow him to die as peacefully, as naturally, and with as much control over the end of his earthly life as possible. Up to a certain point, artificially provided nutrition and hydration support this aim. In addition, they provide a focus for the bond between patient and caregiver.
However, shortly before death some major physiological changes occur. As the patient becomes weaker, he displays an increasing indifference to food and drink. His fluid levels decrease, accompanied often by electrolyte excess and acidness. He may vomit frequently, and may experience internal bleeding and gastrointestinal fluid loss.
The “terminal dehydration” which this causes is a natural function of the dying process, and benefits the patient in many ways. First, there is less need for the bedpan, urinal, or catheter, and little bed-wetting. The diminished gastrointestinal fluid level reduces vomiting. A decrease in pulmonary secretions reduces congestion and coughing. There may be relief from choking or drowning sensations as a result of lowered pharyngeal secretions.
There may also be a significant reduction in the pressure around tumors as body fluids surrounding them are re-absorbed. And there is evidence that at this stage, reduced fluid levels and increased electrolytes serve as a natural anesthesia for the central nervous system. Finally, at 24 to 48 hours before death the patient undergoes total kidney failure, making it impossible for the body to process liquids. Fluids supplied artificially at this stage seem to accumulate in the pulmonary system, causing pulmonary swelling.
The provisions of hydration during the last few days, then, can reverse the beneficial effects of natural dehydration, thus leading to increased vomiting, the need for frequent urinating or the insertion of a catheter, difficulty in coughing and breathing, and the need for both lung and stomach suction tubes to drain excess fluids.
Intravenous therapy during the last phase of a terminal illness is thus, in the pro-withholding mind, a cruel intervention in the natural act of dying, short-circuiting the process by which the body eases itself into its final moments. It disrespects the integrity of the dying person, prolongs his agony, and causes unnecessary pain.
Directly opposed to this position is that of the pro-lifer who insists that nutrition and hydration must be given to all patients in all circumstances as long as there is life in the body. After all, he argues, food and water are the basic building blocks of life; not to provide them is to condemn the patient to death by starvation. And even if such a death could be proven to be less painful than the slower disintegration caused by the disease itself (which has not been done), we would still not have the right to initiate an action which would inevitably lead to death from another cause.
There are serious difficulties with both these positions. On the one hand, those who would allow withholding fail to distinguish clearly between death from natural causes and that from starvation. While they often say that they do not want to prolong dying, what they would permit in fact is the replacement of a lingering, medically complicated and perhaps uncomfortable death with one that is simple, fast, possibly painless, and easy to manage.
But this is exactly the argument used by the proponents of euthanasia. What could be simpler, faster, less painful, and easier to control than a lethal injection? What more sensitive to the wish of the dying person to be relieved of his misery, and to the needs of his family. What more accepting of his impending death?
What more humane? If a painless death is the main objective of palliative care, there is little distinction among methods to achieve it – whether passive or active.
On the other hand, the “always feed” pro-life position fails in at least three ways to deal with the real situation of the dying person.
First, although it attempts to provide basic human care, and although it may in fact prevent fever, parched mouth, and the drying out to the respiratory tract, stomach lining, and brain cells, it does not take sufficient account of the physiology of dying. As the body begins to “shut itself down,” normal approaches to care may no longer apply. What formerly nourished it may now cause acute distress. As in the treatment of healthier patients, “listening to the body” is a wise medical approach.
Secondly, it may tend to obscure the “acceptance of the human condition” of which the 1980 Vatican Declaration on Euthanasia speaks. All of us must stand at the gates of death with empty hands – and, what is often worse, permit our loved ones to stand there with us. Trying too hard to prevent the inevitable may lead to difficulty in accepting it “with full responsibility and dignity … in the light of human values, and (as) Christians even more so in the light of faith” (Declaration).
Thirdly, the pro-life person must be wary of raising bulwarks where none need to be raised. Our energies are often directed at righting wrongs which are so entrenched that sometimes we seem like a legion of Don Quixotes. But this does not mean that we are obliged to wage war against the laws of human nature in our zeal to promote respect for life. Where real evil exists, we must fight it with all our strength. But we must be careful that, in our concern about feeding the dying, we do not transform an issue on which there are many medical and ethical opinions (and on which we can perhaps have less impact than elsewhere) into a rallying point for the pro-life movement. What to do?
With the contradictory voices of medical, ethical, and theological experts confusing us; with the Church yet to teach authoritatively on the subject of euthanasia; with the frightening example of the Netherlands before us and ominous court decisions from the United States at our side; and with no way of avoiding what will surely be the most important moral issue of the 1990’s – what do we, as committed pro-lifers, do?
We insist on nutrition and hydration until natural death for the following reasons:
First, the leaders of the euthanasia movement are well-educated, committed, and patient. They have 77 per cent of the Canadian public on their side (a public woefully uninformed about the implications of euthanasia). They have the support of the Law Reform Commission, many Canadian doctors, and, of course, the media. They know that it is simply a matter of time before they are successful in opening the doors of Canadian law to active euthanasia.
What use are they likely to make of a pro-life position approving the withholding/withdrawal of nutrition and hydration “in some cases?” Will they be sensitive to the distinction between IV therapy before and after kidney failure? Will they respect the right of a permanently comatose person to receive nourishment for decades, if necessary, until natural death occurs? Will they treat that provision as an obligation, whatever the patient’s previously expressed wish or that of his family?
Secondly, these same leaders have, almost to a man, denied three fundamental principles of human existence, principles which, as we said last month, are among the foundation stones of western civilization. These are:
- There is a God.
- Each human life comes from Him, and must be protected until He decides to take it.
- No one therefore has the right to take human life, even his or her own.
Denial of these principles leads inevitably to acceptance of abortion, euthanasia and suicide. Conversely, to permit any of these three evils is tacitly to support the principles from which they flow. The euthanasia mentality is inescapably atheist.
Lastly, it is impossible to speak about death without discussing the Christian view of suffering. Those readers who are Christians will accept this view as true; those who are not will understand the necessity of dealing with it, if only for the immense influence it has had and continues to have on so many people.
Christians accept death, and the suffering which accompanies it, as just punishment allowed by God for the original sin of our race and for our own personal sins. Although they are evils, suffering and death can be transformed into supernatural goods through faith, compunction, humility, and charity. In this way they become means of purification and of growth in love.
While the Christian need not choose them voluntarily he should certainly accept them with resignation when they come, for it is part of the eternal plan for the glory of God and his own salvation. Just as the Christian does not consider it a terrible thing to die, so he does not consider it terrible to suffer, praying only that he not be asked to suffer beyond his means.
And, while it may be a “hard saying,” this same principle applies to our loved ones as well. It is not easy to make a decision which may cause additional discomfort, and a possible prolonging of the dying process for our father or mother, our husband or wife, or even our own child. Such a decision seems to cry out against nature. But so does death itself; so do the myriad diseases against which we hurl all the weapons of our modern medical technology.
What is our conclusion, then? Just this: that, even though in individual cases and at specific stages of illness it may be permissible (never obligatory) to withhold or withdraw nutrition and hydration, the consequences of permitting it, at this point in the euthanasia campaign, would be so disastrous that the common good demands that exceptions should not be allowed.
For the sincere non-believer, this approach will be justified solely on the basis that it is right to place the lives of many over the comfort of a relative few. For the Christian, it will be ennobled by the realization that this is a particularly concrete and symbolic way of laying down his life for his friends. For, since he does not wish to avoid suffering so much as sin, whatever additional pain this decision may involve will be transfigured in that love which proved itself most forcefully on the Cross.
In the real medical world, prudent drug therapy can manage almost any pain associated with terminal illness. It may be, then, that our own difficulty in watching a loved die is greater than that experienced by the dying person himself. Nevertheless, even if in some cases this is not true, we must not weaken our resolve to uphold the dignity of all human life as worth preserving – even in the midst of pain and confusion and in the shadow of death.
If at some future time the world has an unexpected fit of reason and can clearly distinguish between nutrition withdrawal as “letting go in peace” on the one hand and “aiming to kill” on the other, the pro-life person will have no difficulty in allowing the removal or non-insertion of feeding and intravenous tubes. Until then, however, aware that wholesale active euthanasia lies in wait just around the corner, he or she will resolutely refuse any action which could further lessen society’s respect for every human life.
I am indebted to Joyce Zerwekh, RNC, M.A., and to Dr. Stephen Cox, for their brief but careful studies of the physiology of dehydration; and to Fr. Albert Moraczewski, O.P., Ph.D., for his insight into the probable abuse of a legitimate moral stand by the euthanasia movement.
Next month we will try to answer the question: “What do we do about this?”