Prayer is an Act of Faith
Patricia Fossarelli's excellent article, “Outcomes of Intercessory Prayer for Those Who Are Ill” (Linacre Quarterly 78.2 [May 2011]), should put to rest the notion that the efficacy of prayer can be measured scientifically. Prayer is an act of faith and operates in a spiritual realm that is inaccessible to scientific measurement.
Prayer is not primarily something we do; it is an opening of the heart to the action of God upon ourselves and others. It is superstitious to think we can manipulate God to grant our wills or desires by going through certain formulas of “prayer.” Rather, true prayer is always modeled on the prayer of Our Lord in the Garden of Gethsemane: “Lord, if it be thy will, let this cup pass from me, but not my will but thine be done” (Mt 26:39).
Was this prayer of the Son of God efficacious? Not if the measured end point was the “successful” accomplishment of the request. The cup of suffering did not pass from Christ; he drank it to the dregs. But did his prayer help him to accept and carry out the will of the Father? Evidently so, to the salvation of the world.
Does God answer all our prayers? Yes, He does, but sometimes the answer is “no.” He is our loving Father, who loves us more than we love ourselves. He does not give us a snake if we ask for a fish, but he might give us a fish if we ask for a snake.
“Thou shalt not put the Lord thy God to the test” (Mt 4:7).
William G. White, M.D.
Past-President, Catholic Medical Association Franklin Park, Illinois
The Term “End of Life”
The issue of assisted nutrition and hydration continues to challenge all of us. The February 2011 issue of The Linacre Quarterly contained a very helpful article by Marie Hilliard from the National Catholic Bioethics Center and an excellent editorial by John Travaline and Fr. Thomas Berg.1 There was also an article on end-of-life care by Michael Gloth, in which he discusses assisted nutrition and hydration. His comments give the misleading impression that assisted nutrition and hydration is of no benefit and thus should not be used. Gloth writes: “For example, with artificial feeding, there are no studies showing overall benefit or even survival in prolonged artificial feeding in conscious patients.”2
After reading the article, one could easily come away with the mistaken impression that assisted nutrition and hydration should never be used in end-of-life care. As Travaline and Hilliard explain earlier in the same issue, this is far from the case. In fact, as Catholic physicians we should see assisted nutrition and hydration as ordinary care to which every patient in principle is entitled. While there are appropriate exceptions, assisted nutrition and hydration should be the default position. Whenever possible and unless there is a clear contraindication, assisted nutrition and hydration should be offered and provided. To put it more simply, we should not allow our patients to die of dehydration or starvation, as is becoming commonplace in secular medicine.
Contrary to Gloth's assertion, there is evidence of medical benefit from assisted nutrition and hydration in end-of-life care. In patients with end-stage dementia, A.S. Brett has pointed out: “Of course [PEG tubes] prolong life in the subgroup of patients with no oral intake.”3 There are also benefits from assisted nutrition and hydration in some end-of-life patients with ALS, severe stroke, and malignancies.4 The research regarding assisted nutrition and hydration must be interpreted with great caution as it is often agenda driven and biased against use of assisted nutrition and hydration. In 2009 I published an analysis of the limitations of such research on assisted nutrition and hydration in patients with dementia.5 One difficulty is in the way the term “end of life” is used. It is important to distinguish the patient who is actively dying from the patient who has weeks or months to live. It may be appropriate and beneficial to provide assisted nutrition and hydration for the latter but not the former. There are also methodological problems with research at the end of life. To my knowledge, there are no double-blind, prospective trials regarding the benefits of assisted nutrition and hydration at the end of life. Indeed, how would one conduct such a trial?
Unfortunately, Gloth fails to even mention Church teaching on the subject of assisted nutrition and hydration. Providing assisted nutrition and hydration is clearly beneficial to many patients at the end of life, and failure to provide it may constitute euthanasia by omission. In fact, death by dehydration is often promoted by some as an alternative to euthanasia or physician-assisted suicide.6 As Dr. Gloth points out, “All of us will die” (80). Yet, we should not die of dehydration or starvation because we were denied ordinary care in the mistaken belief that it would not be beneficial.
John Howland, M.D.
St. Luke's Health Center Southbridge, Massachusetts
Dr. Gloth Responds
The interest shown by Dr. Howland regarding my article “Faith in Practice: End of Life and the Catholic Medical Professional,”1 is greatly appreciated. I am also grateful for the opportunity to respond to him and to address some misconceptions expressed in the letter. Such problems often arise when a reader goes beyond the scope of the article. In this case, Dr. Howland writes that the article gave “the misleading impression that assisted nutrition and hydration is of no benefit and thus should not be used.” Such erroneous impressions reside within the interpretation of the reader. In fact, no such claim is made in the article, and the article does not address the far broader term of “assisted nutrition and hydration,” which can include manual feeding assistance by a caregiver. Dr. Howland has concerns with one focus of the article, i.e., the use of feeding tubes in conscious patients at the end of life and the lack of benefit in only that specific circumstance. From this, Dr. Howland extrapolates that one could “come away with the mistaken impression that assisted nutrition and hydration should never be used in end-of-life care.” I agree that such an interpretation would indeed be a mistake, and the article certainly and purposefully avoids such an apocryphal claim.
Dr. Howland's letter actually errs in multiple arenas, all from conjecture extending beyond statements made in the actual article. As indicated above, the first error comes in the interpretation that there is no role for artificial nutrition or hydration. The article addresses artificial feeding very specifically and deliberately states that “there are no studies showing overall benefit or even survival in prolonged artificial feeding in conscious patients“ (emphasis added). The references provided by Dr. Howland give no well-designed trials to refute that claim. For example, the reference to E. Bruera et al. refers to a study of IV hydration in dehydrated individuals for a brief, two-day period only, certainly not the prolonged IV nutrition expressed in my article.2 The A.S. Brett reference is not a study at all, but rather a letter to the editor regarding a study by D.E. Meier et al. showing lack of survival benefit from feeding tubes in patients with advanced dementia.3
The second error is in Dr. Howland's statement that “as Catholic physicians we should see artificial nutrition and hydration as ordinary care to which every patient in principle is entitled.” He seems to acknowledge this error with the sentence that immediately follows, “While there are appropriate exceptions, artificial nutrition and hydration should be the default position” (emphasis added). One small, but important, point in my article addressed the common scenario wherein a feeding tube is as likely, or more so, to cause harm as to provide any benefit. As such, there is an ethical and professional obligation to do no harm, which would preclude the use of feeding tubes in such circumstances. Such scenarios are relatively common, and I believe that careful reading of the article delineates this with sufficient references to studies with admirable methodology. Presumably, such relatively common scenarios would fall into the category of an “appropriate exception” to what Dr. Howland would otherwise consider “the default position.” It is discouraging to see orders given to withhold feeding in patients due to aspiration, and then to have families or patients told that without a feeding tube starvation will result. It is erroneous to equate withholding a feeding tube with withholding food.
Indeed, nothing in Dr. Howland's letter makes a legitimate case contrary to the facts in the article, only to what appears to be a misinterpretation or extrapolation from what was actually stated in the article. The statements in the article must be taken out of context to have any relation to concerns expressed by Dr. Howland. I can only address and attempt to clarify points actually made in the article. There is, of course, nothing to indicate that withholding food or water would be advocated.
Finally, let me close with an excerpt from my article, the quote related to Catholic doctrine as articulated in Blessed John Paul II's encyclical Evangelium vitae:
By euthanasia in the true and proper sense must be understood an action or omission which by its very nature and intention brings about death, with the purpose of eliminating all pain”; such an act is always “a serious violation of the law of God, since it is the deliberate and morally unacceptable killing of a human person. (n. 65)4
F. Michael Gloth III, M.D., F.A.C.P.
Baltimore, Maryland
Soul Stirring Hippocratic Oath
I am responding to Patrick Riley's editorial “The Import of an Oath,” in the November 2010 issue of The Linacre Quarterly.
I am an ob/gyn physician in active practice, and I relished his article on the Oath of Hippocrates. I am encouraged that someone else “gets it.” His comments were spot on.
Doctors abandoned the Oath of Hippocrates when abortion became legal and now take a watered-down version of … something. Some medical school classes now write their own statement. No one calls current recitations an oath.
Mr. Riley discussed trust and the Oath. Modern medicine now rewards a doctor who violates the Oath. The Oath states that I, as a doctor, must “prescribe regimens for the good of my patients according to my ability and my judgment.” But because doctors are now required by corporations, hospitals, and the government to follow a one-size-fits-all approach to medical care, a doctor's loyalty switches from the patient to the protocol. Doctors who adhere to these guidelines receive more pay, but it will not be long before punishment will follow non-compliance. A small cadre of doctors, administrators, and accountants determine these protocols. The doctors who determine these protocols are most often university types who have never worked “in the trenches,” so to speak. Even now, a doctor who goes outside a protocol finds himself or herself reporting to a committee to explain why. With these “cookbooks” for medical care, doctors are motivated by money to abandon their medical judgment, a requirement of the Oath, and follow the recipe. Doctors following a protocol may order tests they think are not necessary in their medical judgment or, worse, not order a test they would normally order if they were using their judgment.
Doctors who abandon the Oath for money do not deserve trust.
Mr. Riley mentions cynicism as a result of abandoning the Oath. How true. A doctor who takes the Oath swears to “preserve the purity of my life and my arts.” Truly, this statement leaves no room for cynicism or disrespect, traits all too common in today's doctors. Most doctors do not practice with care and concern both inside and outside the patient's room. (Inside the room: “So, we will have you see the dietician about your weight.” Outside the room: “I can't believe she is so fat and dirty! It's disgusting!”).
Because the Oath has been relegated to the dustbin of history by modern medical ethicists, patients are left at the mercy of doctors who may or may not have a concept of right and wrong, doctors who decide right and wrong on the fly, doctors who put “society's good” above the good of the patient being treated. Doctors can now hide behind the power of the protocol to deny care. We can say to patients that we no longer do certain tests, prescribe certain medicines, or perform certain surgeries or procedures for patients because the protocol, or “best practice” says so.
Consequently, patients may be denied care because of age, diagnosis, condition, weight, or other reasons because the denial of care is deemed the “medically best treatment.” The protocol will be the means of ushering in rationing to save money for the good of society. Death, or denial of treatment, is the ultimate cost containment.
Also, with the electronic medical record (EMR) and the HIPPA Privacy Law (HIPPA actually undermines the privacy of confidential medical records), the Oath's admonition to “keep secret” and to “never reveal” patient information becomes a sham. An abundance of eyes now view patient records without the patient's permission. Medical records travel with the speed of the Internet. I've had a patient ask that I establish a separate paper record for her problems rather than have them on the EMR to be viewed by so many.
I could go on, of course, about other aspects of the Oath, such as transcendence, the necessity of a belief in God and accountability to God; the moral aspect of medicine and the existence of right and wrong; the commitment to eschew abortion and euthanasia; the admonition to do no harm; the requirement of practitioner integrity and the covenantal relationship between doctor and patient.
Mr. Riley's journey through the value of the Oath stirred my soul. Thank you, Mr. Riley.
Matthew Anderson, M.D.
White Bear Lake, Minnesota
The Fullness of Marital Union
In his article titled “The Missing Premise in the HIV-Condom Debate” in this issue (Linacre Quarterly 78 [2011]: 401–414), Stephen Napier addresses the question of whether the use of condoms always corrupts the conjugal act by making it the kind of act that would not consummate a marriage. The question ultimately boils down to: a) whether the use of a condom always represents a choice by the couple for the husband not to inseminate his wife, meaning a choice not to ejaculate in her vagina; and b) whether this lack of insemination is immoral.
The author concludes in the negative for both.
Concerning the first, the author points out that a choice not to inseminate might not be what is going on in the minds of the couple. The author says that “the order of practical reasoning may diverge from the order of causality.” The point seems to be that while a condom is the cause of the sperm not being deposited in the vagina, this is not the way the couple are thinking about the whole thing. The author says “not-inseminating, then, cannot be a proper object of choice; it is not something they aim at.” Now, I find this hard to believe since the prevention of insemination seems to be exactly what the couple want, as a necessary stepping stone to the further goal of preventing the transmission of disease. In this way, it truly is different from the question of whether the couple choose to sterilize the conjugal act. I am somewhat confident that the object of choice is not contraception (as Fr. Rhonheimer concludes). I am much less confident that it is not a choice against insemination. This is because the sterilizing effect really is further from the intention than the choice not to inseminate.
By saying that “the order of practical reasoning may diverge from the order of causality” and “not-inseminating, then, cannot be a proper object of choice, it is not something they [the couple] aim at,” the author seems to be giving all the weight to intention and none to the objective facts of the action when it comes to describing the object of choice. While it is true that different moralists place more emphasis on one than on the other (for example, Germain Grisez favors intention, Janet Smith favors objective criteria) it seems true that we can never place all the weight only on intention. There comes a moment when, despite what the actor might say about his intention, the object of his action is something different. The action can no longer hold the weight of the purported intention. We could perhaps express this “scholastically” by saying that the “matter” of the action is no longer disposed to receive the “form'” of the intention.
Often, when this line is crossed can only be judged by prudence, but not necessarily by the prudence of the actors themselves. We need the judgment of the most prudent person we can find! Without claiming to be that person, my sense is that, whatever the couple profess they are choosing, in the scenario under scrutiny here, they have chosen not to inseminate.
But this leads us to the second question. Is this choice not to inseminate wrong, in the sense of: does it corrupt the marital act? Or, as the author puts it, “the task for the proponent of the Canon Law argument is to pick out a good that is impugned in conjugal acts that are non-inseminating.”
The obvious response to this is that intentional non-insemination is a moral evil because it represents a voluntary failure to achieve the unitive end of the marital act. The author counters this by noting that the “one flesh union” of marital intercourse is a union based on becoming one principle of procreation. I agree wholeheartedly with this. This is why anal sex does not bring about a one flesh union. Now this means that the evil of non-insemination has been reduced to the evil of sterilizing the intercourse; and, as we have seen, if Fr. Rhonheimer is correct (and both the author and I assume he probably is), the use of a condom in such cases is not a choice for contraception.
However, it is clear that the canonical tradition does make a distinction between condoms and oral contraception when it comes to consummation. The use of the latter does not preclude consummation.
The reason for this distinction could be purely practical. Imagine the canonist were to say that oral contraception prevents consummation, and that a man seeks an annulment on grounds of non-consummation. He says their sexual intercourse was non-consummating because his wife took oral contraceptives; but she denies always or regularly taking them. What then? At least when a condom is used both parties know for certain the conjugal act was sterilized and non-consummative. There can be no dispute.
However, I do not think we should exclude the possibility that the canonical distinction is more significant than that, and in some sense providential. Insemination entails the husband leaving something of himself in his wife. Any normal couple would only consider the conjugal act complete when this has happened. Therefore, it seems that to intend not to do this is to intend not to have a complete conjugal union.
Is this, in the words of the author, “a reductionistic-physicalistic” view of the conjugal act?
I do not think so. Would not it be true to say that the fullness of union is achieved in being one principle of procreation, but the beginning is truly found in insemination? Experience—even illicit experience—seems to verify this. The reason many couples choose to use oral contraception rather than condoms often does not come down to simply a matter of effectiveness but rather to the experience that condoms put a barrier between the body of the man and the body of the woman. The dissatisfaction that attends this experience is not about pleasure but about failing to experience intimacy, that is, union.
Lastly, if insistence on insemination can be dismissed as “a reductionistic-physicalistic” view of the conjugal act, it seems to me that coitus interruptus would be a permissible means for preventing the transmission of sexually transmitted diseases, including AIDS. According to the logic of the author, this would not entail a deformation of the unitive dimension of conjugal intercourse (because it is not a choice against procreation but for disease prevention); but surely this is going too far. Where is the moment of union in coitus interruptus?
In conclusion, there seems to be a profound truth embedded in the demands of the canonist—one that truly protects the unitive end of conjugal intercourse.
William Newton, Ph.D.
Trumau, Austria
Notes
Marie T. Hilliard, Ph.D., R.N., “Utilitarianism Impacting Care of Those with Disabilities and Those at Life's End,” Linacre Quarterly 78 (2011): 59–71; John M. Travaline, M.D., and Rev. Thomas V. Berg, Ph.D., “Perspectives on Directive 58,” Linacre Quarterly 78 (2011): 8–12.
F. Michael Gloth III, M.D., “Faith in Practice: End-of-Life Care and the Catholic Medical Professional,” Linacre Quarterly 78 (2011): 78.
A. S. Brett, “Dementia, Gastrostomy Tubes, and Mortality,” Archives of Internal Medicine 161 (2001): 2385–2386.
H. Mitsumoto et al., “Percutaneous Endoscopic Gastrostomy (PEG) in Patients with ALS and Bulbar Dysfunction,” Amyotrophic Lateral Sclerosis and Other Motor Neuron Disorders 4 (2003): 177–185; S. Sartori et al., “Cost Analysis of Long Term Feeding by Percutaneous Endoscopic Gastrostomy in Cancer Patients in an Italian Health District,” Support Care Cancer 4 (1996): 21–26; T. Morita et al., “Determinants of Sensation of Thirst in Terminally Ill Cancer Patients,” Support Care Cancer 9 (2001): 177–186; E. Bruera et al., “Effects of Parenteral Hydration in Terminally Ill Cancer Patients—A Preliminary Study,” Journal of Clinical Oncology 23 (2005): 2366–2371; B. Norton et al., “A Randomised Prospective Comparison of Percutaneous Endoscopic Gastrostomy and Nasogastric Tube Feeding after Acute Dysphagic Stroke,” British Medical Journal 312 (1996): 13–16; A. James et al., “Long-Term Outcome of Percutaneous Endoscopic Gastrostomy Feeding in Patients with Dysphagic Stroke,” Age and Ageing 27 (1998): 671–676.
J. Howland, “A Defense of Assisted Nutrition and Hydration in Patients with Dementia,” National Catholic Bioethics Quarterly 9 (2009): 697–710.
F. Miller et al., “Voluntary Death: A Comparison of Terminal Dehydration and Physician-Assisted Suicide,” Archives of Internal Medicine 128 (April 1, 1998): 559–562.
F.M. Gloth III, “Faith in Practice: End of Life and the Catholic Medical Professional,” Linacre Quarterly 78 (2011): 72–81.
E. Bruera et al., “Effects of Parenteral Hydration in Terminally Ill Cancer Patients—A Preliminary Study,” Journal of Clinical Oncology 23 (2005): 2366–2371.
A.S. Brett, “Dementia, Gastrostomy Tubes, and Mortality,” Archives of Internal Medicine 161 (2001): 2385–2386. D.E. Meier, J.C. Ahronheim, J. Morris, S. Baskin-Lyons, R.S. Morrison, “High Short-Term Mortality in Hospitalized Patients with Advanced Dementia: Lack of Benefit of Tube Feeding,” Archives of Internal Medicine 161 (2001): 594–599.
Quoted in Pope John Paul II, address to the International Congress on “Life-Sustaining Treatments and Vegetative State: Scientific Advances and Ethical Dilemmas,” March 20, 2004, n. 4, http://www.vatican.va/holy_father/john_paul_ii/speeches/2004/march/documents/hf_jp-ii_spe_20040320_congress-fiamc_en.html.