The Moral Obligation of Nutrition and Hydration in the Tradition and Magisterium of the Catholic Church

Abstract

The recent publication of the fifth edition of the Ethical and Religious Directives for Catholic Health Care Services on November 17, 2009, by mandate of the United States bishops, witnessed the eruption of a controversy in the U.S. with regard to nutrition and hydration for the seriously ill and dying.¹

Among the major philosophical and moral thinkers in the field, there are some on the one hand who—out of respect for the wishes of the patient as expressed in normal situations—see no need for nutrition and hydration if such are the patient's wishes, even though they may have been expressed before the patient became ill. On the other hand, there are those who—out of respect for human dignity and with the understanding that any act of euthanasia is morally unacceptable—do not see how the interruption of life support can be acceptable unless it comes to be a burden and no longer a benefit under end-of-life conditions.

In light of all this, the present article aims to provide reflections on the nature of assisted nutrition and hydration (ANH) and the obligation to use it in cases where clinical evidence requires it, with a particular focus on the ongoing bioethical debate in the U.S.

The Terms of the Debate

For years now we have been witnessing events and debates on the topic of nutrition and hydration. Suffice it to recall the Nancy Cruzan case in December 1990, the Terry Schiavo case in March 1995, and the similar Eluana Englaro case in February 2009 in Italy. With a careful eye, we can see a clear line of thinking behind each of these events that has become increasingly complex and sophisticated.

At this point, the philosophical background supporting the idea that it is licit to interrupt assisted nutrition and hydration on the basis of the patient's own advanced directive can be found first of all in a particular emphasis on the principle of autonomy. According to J.S. Mill, the principle of autonomy is formulated as follows: do not interfere with the freedom of action of another person except when necessary to prevent harm to others.² It is well known by now that this way of thinking involves utilitarian philosophy, which has undergone a certain evolution: it has moved from the assessment of what is pleasurable and unpleasurable,³ without abandoning it, to the threefold precept of maximi zing pleasure, minimizing suffering, and broadening the sphere of personal freedoms for the greatest number of persons.⁴ This way of thinking has thereby introduced the well-known quality-of-life concept, which establishes the perspective and the goal to be attained.

This position, which I would define as classical, has developed within an increasingly well-constructed conceptual framework that employs the approach of analytical philosophy: fragmenting human actions, removing them from their natural context, and thereby reaching debatable conclusions. An example pertaining to our topic is that many countries now want assisted nutrition and hydration to be considered a medical act rather than a means of preserving life.

The Ethical and Religious Directives published by mandate of the United States Conference of Catholic Bishops, on the other hand, with a distinct ontology as a foundation, express the idea that a person is an end and never a means.

After analyzing the teachings of Sacred Scripture, the historical input of Tradition, and the authoritative contributions of the Magisterium through pontifical and episcopal teachings, I will offer some reflections that, regardless of whether assisted nutrition and hydration is a medical act or a means of preserving life, can provide us with additional insight for determining whether a patient is being approached with loving and therefore respectful intentions or with intentions of euthanasia, though they may be veiled by a hypocritical concern for the patient's own interests.

The Value of Life: Scriptural Foundations

The fact that life is a good to be preserved and always promoted can be deduced from its very origin. In fact, Scripture itself attests to the fact that life has its origin in God and that man, unlike all other created beings, has an additional gift: he is made in the image and likeness of God.

It is beautiful to see how this image and likeness is presented in the first chapter of Genesis through the signs and powers present in and endowed upon man:⁵ invisible dignity is made visible, and once visible it points back to the invisible. We see this surpassing dignity with which man is endowed in his dominion over creation and other living beings,⁶ in his ability to bring peace and serenity,⁷ and in his taking rest from work.⁸

The sacredness and therefore the inviolability of human life come from being God's gift and from man's participation in the life of the Eternal One. God Himself, the “lover of souls” (Wis 11:26), takes care of human life and demands an accounting for it: “For your own lifeblood, too, I will demand an accounting: from every animal I will demand it, and from man in regard to his fellow man I will demand an accounting for human life” (Gn 9:5). If it is true that this is considered the testo princeps⁹ grounding the inviolability of human life, it is likewise true that all of Sacred Scripture leads to the same truth through both maxims and actions.

The book of Job clearly reaffirms that God is Lord over man's life, and all created things owe Him their existence. We read the following in chapter 12: “Which of all these does not know/that the hand of God has done this?/In his hand is the soul of every living thing,/and the life breath of all mankind” (Job 12:9–10). In the first book of Samuel, we find these words: “The Lord puts to death and gives life;/he casts down to the nether world;/he raises up again” (1 Sam 2:6). The same concept is reaffirmed in the book of Deuteronomy: “It is I who bring both death and life” (Dt 32:39b).

Jesus powerfully confirms the inviolability of human life, commanding that the ancient lex talionis be overcome in order to unconditionally accept the life of others, including enemies. The gospel parable of the rich young man offers Jesus an opportunity to reaffirm the cen-trality of human life and its defense.¹⁰ The commandments that the young man cites, in fact, are listed in a specific order and not at random: first on the list is precisely “thou shalt not kill.”

In the Sermon on the Mount, Jesus demands from his disciples a righteousness which surpasses that of the Scribes and Pharisees, also with regard to respect for life….

By his words and actions Jesus further unveils the positive requirements of the commandment regarding the inviolability of life. These requirements were already present in the Old Testament, where legislation dealt with protecting and defending life when it was weak and threatened: in the case of foreigners, widows, orphans, the sick, and the poor in general, including children in the womb (cf. Ex 21:22; 22:20–26). With Jesus these positive requirements assume new force and urgency, and are revealed in all their breadth and depth: they range from caring for the life of one's brother (whether a blood brother, someone belonging to the same people, or a foreigner living in the land of Israel) to showing concern for the stranger, even to the point of loving one's enemy.…

Thus the deepest element of God's commandment to protect human life is the requirement to show reverence and love for every person and the life of every person.¹¹

The words of Psalm 8, in a breathtaking summary, lead us back to the preciousness of human life in the eyes of God: “What are humans that you are mindful of them,/mere mortals that you care for them?/Yet you have made them little less than a god,/crowned them with glory and honor” (Ps 8:5–6). We have been made little less than a god—by whose authority could we ever decide over our own life or the lives of others? Only with the authoritativeness of love that, in the words of St. Paul, “does no evil to the neighbor” (Rom 13:10).

Safeguarding Life in the Moral Tradition

The distinction between negative precepts and positive precepts, which we owe to the teachings of St. Thomas Aquinas, constitutes the foundation for the teachings of Tradition regarding medical means and means of preserving life.

In examining the natural law and Sacred Scripture, we find that certain precepts or regulations are valid always and in all circumstances. The good that they safeguard is such that it may never be violated; hence, such precepts are binding semper et pro semper. This category includes all precepts that can never be contravened in their call to avoid evil and do good. Then there are the positive precepts, which are instead valid semper sed non pro semper. They seek to guide us toward the attainment of the best possible good in a given situation. We realize that attaining the best possible good must also take into account the concrete situation in which a person finds him- or herself. No one can be expected to attain an impossible good: “ad impossibilia nemo tenetur,” as the ancient Romans affirmed. John Paul II confirms this in his encyclical letter Veritatis splendor:

The negative precepts of the natural law are universally valid. They oblige each and every individual, always and in every circumstance. It is a matter of prohibitions which forbid a given action semper et pro semper, without exception, because the choice of this kind of behavior is in no case compatible with the goodness of the will of the acting person….

On the other hand, the fact that only the negative commandments oblige always and under all circumstances does not mean that in the moral life prohibitions are more important than the obligation to do good indicated by the positive commandments.¹²

On this basis, therefore, we can say that while it is illicit always and in every circumstance to take one's own life, it is not likewise obligatory to prolong it. Safeguarding physical life is one matter, while desperately prolonging it—often at the cost of immense toil—is another.

On the basis of the principles just called to mind, moralists began to address our topic around the beginning of the sixteenth century, spurred by the advent of new surgical techniques such as amputation. While it is true that moralists in this context were more focused on developing doctrines on the use of therapeutic or medical means, it is likewise true that they also addressed the means of preserving life: specifically, nutrition and hydration.

Francisco de Vitoria (1483–1546), the celebrated commentator on the works of St. Thomas Aquinas, could be said to have laid the foundations for subsequent doctrinal development. In his Relectiones theologiae, he addresses several questions regarding the moral obligation—or lack thereof—to nourish oneself. He states:

If a sick man can take food or any form of nourishment, when there is a hope that he will live, he must do so, just as he would be required to give it to another sick person…. If his depression is so great and his appetite so diminished that he can only take food with enormous effort, almost as though it were a form of torture, then a certain impossibility must surely be recognized and he is therefore excused, at least from mortal sin, particularly where there is little or no hope that he will live.¹³

The text cited above points out two vitally important aspects: the absence of impossibility and the reasonable hope of benefit. These conditions, as Tradition maintains, must be present at the same time in order to speak of moral obligation. What is meant by the reasonable hope of benefit is clear.

Renaissance theologians worked to determine the physical or moral impossibility of a given treatment.¹⁴ They listed the unobtainability or the unusableness of a means, as well as the incompatibility of the patient's clinical condition with use of that means, as causes of physical impossibility.

Determining the causes of moral impossibility was more complex. Several of the major causes identified included extreme toil (summus labor), excessive harshness of the means (media nimia dura), certain torment (quidam cruciatus), immense pain (ingens dolor), extraordinary burden (sumptus extraordinarius), great expense of the means (media pretiosa), rarity of the means (media exquisita), and, lastly, intense fear (vehemens horror).

We can therefore summarize the traditional teachings by stating that a medical means, as well as a means of preserving life, should be considered non-obligatory when, given the subject's clinical situation,¹⁵ they do not offer a reasonable benefit and there are causes of moral or physical impossibility present. Stated the other way around, they are obligatory when their use is supported by a reasonable spes salutis (hope of benefit) and there are no causes of moral or physical impossibility present.¹⁶

Nutrition and Hydration in the Magisterium of the Church

Over the past fifty years, the topic of artificial nutrition and hydration has appeared in several documents of the ordinary pontifical magisterium, in official pronouncements by the dicasteries of the Holy See, and in pronouncements by the episcopal magisterium.

On June 27, 1981, the Pontifical Council “Cor Unum” made a pronouncement on the topic of interest with a document titled “Some Ethical Questions Relating to the Gravely Ill and the Dying.” This document contains a paragraph that explicitly addresses minimally obligatory means. It reads as follows:

The strict obligation remains, however, to pursue the use of so-called “minimal” means, which is to say, those means whose purpose under normal and habitual conditions is to maintain life (nutrition, blood transfusions, injections, etc.). Interrupting their administration would constitute, in practice, a desire to put an end to the patient's days.¹⁷

The Pontifical Academy of Sciences has also affirmed that necessary care, including nutrition and hydration, is obligatory in the event of a permanent and irreversible unconscious state, even when administered artificially.¹⁸

The 1992 Catechism of the Catholic Church addresses the topic of our study with a statement of summary at number 2279: “even if death is thought imminent, the ordinary care owed to a sick person cannot be legitimately interrupted.”¹⁹

The Charter for Health Care Workers, published by the Pontifical Council for Pastoral Assistance to Health Care Workers in 1995, addresses the issue apertis verbis at number 120, where it states that “nutrition and hydration, even if administered artificially, are part of the normal care always due to a sick person when they are not burdensome to him or her: their undue suspension could constitute a true and proper act of euthanasia.”²⁰

The Pontifical Academy for Life expressed its position on the matter in the document “Respect for the Dignity of the Dying,” published in December 2000, which states the following:

The approach to the gravely ill and the dying must therefore be inspired by the respect for the life and the dignity of the person. It should pursue the aim of making proportionate treatment available but without engaging in any form of “overzealous treatment” (cf. CCC, n. 2278). One should accept the patient's wishes when it is a matter of extraordinary or risky therapy which he is not morally obliged to accept. One must always provide ordinary care (including artificial nutrition and hydration).²¹

In the context of the pontifical magisterium, the pronouncement by John Paul II in March 2004, during a private audience granted to the participants in an international congress on the vegetative state, is certainly important to our topic. The following can be read in the address:²²

I should like particularly to underline how the administration of water and food, even when provided by artificial means, always represents a natural means of preserving life, not a medical act. Its use, furthermore, should be considered, in principle, ordinary and proportionate, and as such morally obligatory, insofar as and until it is seen to have attained its proper finality, which in the present case consists in providing nourishment to the patient and alleviation of his suffering.

The obligation to provide the “normal care due to the sick in such cases” includes, in fact, the use of nutrition and hydration. ²³

Another important document, Iura et bona, which is an expression of the ordinary pontifical magisterium, was published by the Congregation for the Doctrine of the Faith on May 5, 1980. This is the declaration that condemns euthanasia. Part IV, which addresses the proportionate use of medical means, affirms that

when inevitable death is imminent in spite of the means used, it is permitted in conscience to take the decision to refuse 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.²⁴

This text uses the expression “normal care…in similar cases,” making a clear and obvious allusion to nutrition and hydration.

The Congregation for the Doctrine of the Faith returned its attention to our topic of study with great clarity in a response to the U.S. bishops on August 1, 2007, with a connected commentary, reaffirming the sure principles for guiding the actions of both health-care personnel and family members living through these situations. The document confirms that the administration of food and water “is therefore obligatory to the extent to which, and for as long as, it is shown to accomplish its proper finality, which is the hydration and nourishment of the patient.”²⁵

The commentary by the same congregation recalls what tradition has consistently affirmed, which is that we are dealing with the positive precept of safeguarding life and, as such, we are called to act within the limits of possibility. In fact, the document reads as follows:

When stating that the administration of food and water is morally obligatory in principle, the Congregation for the Doctrine of the Faith does not exclude the possibility that, in very remote places or in situations of extreme poverty, the artificial provision of food and water may be physically impossible, and then ad impossibilia nemo tenetur. However, the obligation to offer the minimal treatments that are available remains in place, as well as that of obtaining, if possible, the means necessary for an adequate support of life. Nor is the possibility excluded that, due to emerging complications, a patient may be unable to assimilate food and liquids, so that their provision becomes altogether useless. Finally, the possibility is not absolutely excluded that, in some rare cases, artificial nourishment and hydration may be excessively burdensome for the patient or may cause significant physical discomfort, for example resulting from complications in the use of the means employed.²⁶

After having examined the magisterial teachings on the topic, we now move to the contemporary bioethical debate in the United States to which this article intends to contribute.

The Catholic Bioethical Debate in the U.S

At present there is a lively and rich bioethical debate between Catholic authors in the United States as they address various aspects of this subject. I believe it important to point out first of all the sector of the debate involving, on the one hand, doctors and theologians who maintain that medically assisted nutrition and hydration are burdensome and excessive in all cases, and on the other hand, those who maintain that administering nourishment is necessary insofar as it is not excessively burdensome to the patient.

On May 7, 1990, the Texas Conference of Catholic Bishops published a pastoral letter affirming that a person in a permanently unconscious state should be considered afflicted with a lethal pathology that, in the absence of artificial nutrition and hydration, will lead to death. They concluded that interrupting the administration of liquids and nutrients in such cases is simply a matter of not impeding the final step of a lethal pathology.²⁷

The position just described was further developed by two Dominican theologians, Kevin O'Rourke and Benedict Ashley.²⁸ They maintain, along with the Texas bishops, that a persistent vegetative state is a lethal pathology and life support is therefore to be considered futile since the person cannot pursue life's goals and purposes, which require affective and cognitive functionality. Mere physical existence therefore does not constitute a benefit for the patient according to these authors. Ashley and O'Rourke cite Pius XII's teaching in 1957 in support of their position. On that occasion, the pope affirmed that ordinary means of life support are those which do not entail an excessive burden for oneself or others. In his address, the Holy Father emphasized that life, health, and all temporal activities are subordinated to spiritual ends.²⁹ On the basis of all this, they conclude that extraordinary means are optional because they are ineffective for or constitute a grave burden in helping one attain the spiritual purpose of one's existence. Since nourishing a person in a persistent vegetative state is ineffective to this end, such means are to be considered extraordinary.³⁰

The December 1998 and January 1999 editions of the journal Ethics and Medics present William E. May's position, which involves a critique of Ashley and O'Rourke's position.³¹ In the first part, May maintains—with the support of medical literature—that a person in a persistent vegetative state has no lethal pathology; therefore, the idea that administering nutrition and hydration to such persons constitutes futile treatment is erroneous. May points out how Ashley and O'Rourke commit a serious error in their interpretation of the pontifical address by considering “extraordinary” not only those means which prevent a person from pursuing the spiritual purposes of life but also those which are ineffective in helping the person to that end. May affirms that there is a difference between preventive means and ineffective means: while the former are negative and harmful, the latter are medically and morally neutral. May continues his article by pointing out how many people who suffer from serious neurological or mental pathologies (e.g., trisomy 13) are incapable of “human acts” in the fully moral sense, yet it is right that they live. No one would affirm in such cases that any means of life support should be considered extraordinary and therefore not morally required. The author further points out that if a child afflicted with trisomy 13 were to cut his veins, hemostasis would certainly not be considered extraordinary treatment even though it is ineffective in helping to pursue the spiritual goal of life. May goes on to contest the fact that Ashley and O'Rourke do not consider physical life a good in itself or a good intrinsic to the person but rather an instrumental good for the person. He concludes that although a person has spiritual capacities that cannot be reduced to physical ones, it is no less true that the living body of a human being is that same physical person.³²

Another aspect of the lively bioethical debate is the division between those who consider the administration of artificial nutrition and hydration to be a medical treatment and those who instead consider it a means of preserving life.

The New Jersey Catholic Conference of Bishops intervened with a pronouncement in 1987 reaffirming that the administration of nutrition and hydration, which is essential to human life and distinct from medical treatment, should always be provided to the patient; indeed, interrupting nutrition and hydration is a new form of attack on human life.³³ An essay was published in the same year sharing this position: nourishment is not to be considered futile because it sustains the good of human life. The authors of this work maintained, however, that it should not constitute an excessive burden for the patient and its administration should respect the patient's physical and mental integrity.³⁴ The contribution of Germain Grisez is interesting to note in this context, since he shows that an additional good is pursued through the administration of nourishment: human solidarity.³⁵

A book by Robert Barry, O.P., followed in 1989. In cases of permanent unconsciousness, he maintained that nutrition and hydration should be considered ordinary care so long as the digestive system is able to assimilate nutrients; as such, they should never be omitted or considered a medical treatment subject to the criteria of burdensomeness or futility.³⁶ Two years later, Bishop James McHugh expressed the same idea: food and liquids are fundamental means of life support and administering them is obligatory even if it requires medical technology. The same bishop also conceded that it would not be obligatory if it were burdensome or useless in sustaining human life.³⁷ The years that followed witnessed a burgeoning of articles classifying nutrition and hydration as a form of care, not cure, underscoring the moral obligation to administer them unless they constitute an excessive burden or are completely futile. Supporters of this idea included the Pennsylvania Conference of Catholic Bishops and the Committee for Pro-Life Activities of the U.S. Conference of Catholic Bishops.³⁸

Eugene Diamond, M.D., maintains the same position. In his article published in Ethics and Medics in 1999, he first of all underscores how the insertion of a nasogastric tube constitutes a medical procedure; however, he points out, it is not radical.³⁹ Diamond further maintains that artificial nourishment does not constitute a medical procedure since it can also be performed by family members in a domestic environment. In the author's opinion, feeding a comatose patient is ordinary care.

William Dennis and Edward J. Furton follow the same line of reasoning. Citing John Paul II's 2004 address in their article published in November 2006, in which they consider the case of an anencephalic newborn, they underscore how artificial nutrition and hydration are always a natural means of preserving life and not a medical act. Consequently, they are to be considered ordinary and proportionate means in principle, and are therefore morally obligatory.⁴⁰

In June 2007, Steven R. Moore authored a response that appeared in Ethics and Medics: “Providing AHN Is a Medical Act: A Response to Dennis and Furton.”⁴¹ Moore poses two questions in his article: first, whether the insertion of a tube and the subsequent nutrition and hydration can be considered ordinary care or whether they should be considered medical interventions; second, whether the teachings of John Paul II on artificial nutrition and hydration in cases of PVS and anencephalic newborns are supported by the Catholic moral tradition.

With regard to the first question, Moore affirms that there is nothing natural in artificial nutrition and hydration. Based on the fact that it is always needed when there is an active pathology, he affirms that those who claim it is a natural means of preserving life and not a medical act ignore the pathological circumstances that demand it. He further states that there is nothing natural in making an incision in the abdominal wall and placing a feeding tube in the person's stomach, and likewise there is nothing natural about the food and liquids thereby administered insofar as they are not products of agriculture but rather of the pharmaceutical industry.

With regard to the second question the author proposes to address, he reaffirms how the Catholic tradition includes many statements by saints, theologians, and popes in support of the criterion of reasonable benefit—and therefore against excessive burdensomeness—in end-of-life medical decisions; the administration of nutrients and fluids should likewise be subject to this sort of discernment. In the body of the text, Moore's opinion emerges through the citations he provides. For patients “without consciousness,” it appears that Moore focuses on their ability to attain “spiritual purposes.” In support of this approach, he cites an article by Eberl summarizing the teachings of Aquinas, who, according to Moore, states that the human soul requires cerebral functionality in order to pursue human spiritual goods.⁴² In defense of O'Rourke's position, Moore maintains that it is unnecessary to prolong the life of patients who are no longer capable of pursuing the spiritual goals of life itself. At this point, the author asks himself whether this amounts to the acceptance of active euthanasia. Obviously not, he maintains, yet he affirms—citing O'Rourke—that the moral mandate requiring that the lives of these patients be sustained no longer applies since they are not able to carry out human acts (driven by the intellect and the will). In summary, Moore maintains that in the Catholic moral tradition there is no support for a medical obligation to provide nutrition and hydration to patients with anencephaly or similar conditions.

Dr. Dennis and Dr. Furton responded to Dr. Moore in the June 2007 issue of Ethics and Medics.⁴³ In their article, they ask themselves whether the administration of food and liquids should be considered a medical act or whether it is instead a moral act. In order to develop a proposal, they scrutinize Moore's three reasons for considering the administration of nutrition and hydration a medical act: first, Moore maintains that nutrients and liquids cannot be considered natural because they are pharmaceutical rather than agricultural products; second, he affirms that there is nothing natural in making an abdominal incision so that the person can be nourished through a tube in the stomach; third, he states that all of this cannot be considered natural because a pathology leads to the need for implementing artificial nutrition and hydration. In their conclusion, Dennis and Furton rightly recall that nutrients and liquids, even if provided through medical technology, are essential for safeguarding the human person. They recall how John Paul II did not say that the use of technical means was natural; this is beside the point. In reality, the Holy Father did not focus on the means of administering nourishment but on the fact that food is to be considered natural in itself. This leads to several considerations about the term “natural” that I will reserve for my conclusions.

An article by Gail Scoates, a member and coordinator of the St. Joseph Medical Center Ethics Committee in Bloomington, Illinois, appeared in the September 2010 edition of Ethics and Medics.⁴⁴ In line with Catholic moral tradition and the Magisterium, she reaffirms that there is an obligation to use so-called proportionate means but no obligation to use extraordinary means. In an effort to provide criteria for practical use, the author references an article by Rev. Tadeusz Pacholczyk in which he offers some criteria for use in concrete scenarios.⁴⁵ Rev. Pacholczyk maintains, in fact, that the administration of food and fluids—even by artificial means—is obligatory for all those who stand to benefit from it. He reaffirms the Church's position in support of the administration of food and fluids even by artificial means for those who are not in the terminal phase and for whom death is not imminent. If the administration of nutrition and hydration becomes burdensome, in the sense that nutrients and fluids can no longer be metabolized by the body, it is licit to withhold it; likewise, it is licit to withhold administration when the patient's subjective conditions render it extraordinary. It is explicitly required that death not occur due to the withholding of nutrition and hydration, which would be euthanasia; rather, it should be due to the progress of a pathological condition that can no longer be stopped. Indeed, life is to be defended and protected but not stubbornly clenched to the point of causing pointless suffering.

Having considered the current Catholic debate in the U.S. in broad strokes, I now wish to offer conclusions with regard to the dignity of the human person and the teachings that have consistently characterized the Catholic moral tradition and the authoritative Magisterium.

Conclusions

After having analyzed the moral teachings of the Magisterium and Church Tradition, aware of the ongoing bioethical debate, I would like to offer some final thoughts in support of directive 58 of the U.S. bishops's Ethical and Religious Directives, which communicates unconditional support for human dignity. Indeed, this dignity must always be respected and should never be violated or manipulated by schools of thought that hide behind a veil of false pietism, confusing moral good with psychological and physical good or human happiness with pleasure experienced in certain circumstances.

We are facing a scenario within American society that divides prolifers from pro-choicers, where the former maintain the inviolability of human life and the latter do not. I believe that this terminology is inaccurate because those who defend life also and above all make a choice. In this sense, they too are “pro-choice”: they promote the choice to safeguard and defend human life. This being clarified, I also believe it necessary to reaffirm the presence of a distinct euthanasic mentality that continues to spread in the wake of a glorification of patient autonomy and, along with it, the idea that a life is not worth living if it does not meet a certain quality-of-life standard.

This mentality is accompanied today by the continual proclamation of a right to die.⁴⁶ If we look at the major human rights thinkers and theorizers, it becomes apparent that a right to die makes no sense at all. As Thomas Hobbes and John Locke teach, all rights conferred upon man by nature presuppose a concerned attachment to life. All rights can be traced back to the fundamental right to life, or rather, to self-preservation. Mansfield rightly stated:

All rights are conferred upon man by nature, but are necessary because men are also subject to the unpredictability of nature. Since life is in danger, every man has an equal right to life, to the liberty that protects life and to the pursuit of happiness which is the goal of life, however fragile it is.⁴⁷

As Leon Kass rightly underscores, death is the evil I must avoid in order to enjoy any or all of my goods; my right to protect my life from death is the central pillar of law and all ethical thought of a political nature.⁴⁸ It is obvious that a right to death or a right to die cannot be grounded on this foundation. Life seeks to live and needs as much help as possible.

This does not mean that the thinkers of the modern era were not aware that people tire of living or find their existence onerous at times. Yet a diminished will to live neither excludes nor annuls the right to life nor implicates a right to die. The right to life is a question of nature and not of the will: it is within the realm of natural law, not positive law. Locke himself affirms that “the state of nature is upheld by a natural law that binds all, and reason, which is this law, teaches anyone who consults it that, since all men are equal and independent, no one should violate the life, health, liberty, and goods of another.”⁴⁹

Some maintain that Locke admits a principle of self-ownership according to which one may do whatever one wishes with oneself, including self-destruction: since life and the body are mine, I may do what I wish with them. For Locke, however, man's self-ownership actually has an inalienable characteristic: it is affirmed so that man will not be placed at the same level as his goods, and Locke makes this affirmation to ensure that man himself is not included among the shared goods available to everyone. My body and my life are mine only in the limited sense that they are not yours. They are different from alienable goods such as a house, a car, or shoes. I cannot alienate my body and my life even though I can use them as my own. In a more profound sense, my body does not belong to anyone, not even to me.

Furthermore, even if we were to admit the absurd possibility of the liberty to do whatever we want, we would soon realize that this only allows for the possibility of attempting suicide, not the right to successfully commit suicide or, worse still, the right to be assisted by others in doing so. The person designated as the death assistant has neither the duty nor the natural right to become a successful death assistant, and the liberal state, created to defend life, cannot grant a right to kill—even if death is requested. The right to die therefore cannot be grounded upon classical or traditional principles.

Later thinkers in the liberal tradition did not much change their views on the topic. Jean-Jacque Rousseau laments the evils of a civil society centered on threats against life and physical integrity. Immanuel Kant, to whom contemporary society is indebted for the concept of autonomy, requires that one act always in accordance with one's self, which is to say one's rational will. Being autonomous does not mean being irrational. For Kant, autonomy is self-governance and not doing whatever one wants.

For these reasons and many others, autonomy can never justify or ground a right to die. Indeed, it cannot be used to ground a right to be assisted by another in committing suicide—a right that would also impose an obligation on someone else, thereby limiting that individual's autonomy.

Given these premises, I wish to critique all positions that consider it licit to withdrawal nutrition and hydration from a person whose body still metabolizes them, thereby achieving their purpose of nourishment. Such actions constitute euthanasia in the true sense, which, as we know, is defined as “an action or an omission which of itself or by intention causes death, in order that all suffering may in this way be eliminated. Euthanasia's terms of reference, therefore, are to be found in the intention of the will and in the methods used.”⁵⁰

So long as the food nourishes and the fluids hydrate, therefore, it is not licit to withhold assistance. Steven R. Moore's opinion, invoking a Thomistic theology in which pursuing spiritual goals requires a functioning and conscious brain in order to support the withholding of assisted nutrition and hydration from comatose patients, seems irrelevant and is open to criticism.⁵¹ While it is true that spiritual life rests upon psychological life, it is likewise true that these are two different aspects; and the alteration or elimination of consciousness does not imply the elimination of the person, whose purpose is not achieved according to any pragmatic mentality focused on results, but rather according to the person's being. The higher purposes that Moore discusses, like O'Rourke, are not only achieved through willed and conscious acts but also and no less through other moments and phases of life and especially through the recognition of the intrinsic value of life itself, which does not come across to me in the work just cited. I personally do not share such positions, which lend themselves to a qualitative assessment of life and all of its consequences.

I believe it is necessary to clarify the meanings of the term “natural,” which are rather different in medicine and in theology. What is not natural in medical terms may in fact be so in theological terms, and what is natural in theological terms may not be so in medical terms. In the theological sense, natural means everything that pertains to the nature of man understood in a holistic sense, even if it occurs through artificial means, because it allows man to achieve his ends, first among which is self-preservation and sustenance. Metaphysics affirms that every rational substance tends to preserve itself and never to destroy itself.

Therefore, on the basis of these considerations and the discussion presented in the body of this article, I wish to vigorously reaffirm—in continuity with the moral tradition and the authoritative Magisterium—the obligation to administer assisted nutrition and hydration insofar as it attains its proper finality, which is to nourish and hydrate.

Are we not perhaps discovering that behind all of this there lies an attempt to veil a euthanasic mindset in statements that would lead us to think otherwise?

The interruption of assisted nutrition and hydration leads the patient to certain and inevitable death insofar as it does not ensure him or her true life support. The difference between refusing treatment and suspending assisted nutrition and hydration therefore seems apparent to me: in the case of the former, the person will die because of his or her pathology, which will take its natural course without medical intervention; refusing assisted nutrition and hydration, on the other hand, the person will certainly die, no longer because of his or her pathology, but rather because of dehydration and undernourishment. In principle, assisted nutrition and hydration is a proportionate means of preserving life and, as the Congregation for the Doctrine of the Faith has stated, “obligatory to the extent to which, and for as long as, it is shown to accomplish its proper finality.”⁵² This implies that “always” does not always mean “always”: by affirming that such means are obligatory in principle, the Magisterium “does not exclude the possibility that, in very remote places or in situations of extreme poverty, the artificial provision of food and water may be physically impossible,” and, perhaps even more significantly, it is not “excluded that, due to emerging complications, a patient may be unable to assimilate food and liquids, so that their provision becomes altogether useless.”⁵³ Finally, it does not rule out the possibility that such means may constitute excessive burdensomeness or cause significant physical discomfort to the patient. Always, then? No, not always: only so long as those means attain their proper finality, which is to nourish and hydrate the patient.

This does not mean that life should be exhausted or prolonged with pointless suffering. There are significant and evident differences, however, between this, which is therapeutic stubbornness, and the withholding of assisted nutrition and hydration.

In this manner, the constant teachings of Tradition are reaffirmed: there is an obligation to protect and safeguard human life which does not require exhausting or prolonging it with pointless suffering. I believe, however, that there are differences between such therapeutic stubbornness and the withholding of assisted nutrition and hydration that require careful assessment in the interest of promoting respect for the frequently invoked human dignity that is perceived, recognized, and advanced by human society and is now ensconced in all modern systems of law.