VENTILATORS VERSUS FOOD AND WATER
Before affirming that patients in a persistent vegetative state ought to be provided with food and water, even when delivered by artificial means, the Vatican consulted widely, especially among physicians. That consultation was added to the already robust discussion among philosophers and theologians on the moral obligations connected with the provision of food and water to patients in debilitated states.
The discussion continues, but now with some settled parameters. Patients who are in a cognitively disabled state should generally receive food and water; the refusal to provide these basic necessities is, in effect, euthanasia by omission. No one has ever died of the persistent vegetative state. When deprived of food and water these patients die of dehydration and starvation.
A Challenge to the Teaching
One of the challenges posed to the Church concerning this judgment is how to distinguish assisted nutrition and hydration from the use of a ventilator. There are many similarities between the two, and yet the provision of food and water by artificial means is considered a form of ordinary care and usually obligatory, while the provision of oxygen through ventilatory support is not. Often, ventilatory support can be set aside as a measure of extraordinary means.
How are we to distinguish between these two apparently similar procedures? Both involve the provision of a basic necessity to a patient who retains the innate capacity to assimilate these fundamental goods of our physical nature. The patient who is unable to swallow retains the ability to digest food, just as the patient who is unable to breathe retains the ability to respire.
At first glance, this similarity would seem to undermine the moral distinction between food and water and ventilatory support. How can two such similar procedures, when subjected to moral analysis, lead to opposite conclusions?
There is, in fact, a very significant difference between them. In the case of ventilatory support, the apparatus must not only provide oxygen to the lungs but also mechanically operate them. Strictly speaking, there is air in the lungs of those who are unable to breathe. The problem is that they are not able to draw that air into the alveoli for the purposes of respiration. To draw oxygen in, the lungs must inhale. The ventilator forces the lungs to inhale and exhale.
This is unlike tube feeding. Here the tube provides food and water which the body readily assimilates on its own, without the tube taking over any function of the body. So long a a steady supply of food and water is provided, it will be consumed and will provide the patient with continued life. Although the same is true with the use of a ventilator, the fact is that this apparatus also replaces the breathing function. One cannot simply supply air to the lungs. The lungs must be inflated and deflated mechanically.
One of the ways of determining whether a particular medical procedure or treatment is an ordinary or extraordinary means is to ask whether it replaces a vital bodily function. The replacement of such a function, especially with an external apparatus, is likely to be, in many cases, an excessive burden.
Ventilatory support is rightly viewed as an ordinary means of treatment for a variety of patients. Placing a young person who has suffered a serious accident on temporary ventilatory support is a good example of what is rightly judged to be ordinary means of treatment. But an elderly person at the end of life, for whom ventilatory support will permanently replace the breathing function, has no obligation to submit to this procedure.
A Key Difference
As ventilators improve, their debilitating side effects will be lessened. Many patients today are on long-term ventilatory support. This is all to the good. Nonetheless, it is difficult to see how, even in the best of circumstances, the use of a ventilator would ever become a morally obligatory means of care, as is the provision of food and water. We cannot be bound to an external machine.
So the key difference between the provision of food and water via tube and the provision of oxygen via ventilatory support is that one replaces a bodily function and the other does not. This is why one procedure is routinely judged an ordinary means of care while the other is sometimes judged to be an extraordinary measure.
by Edward J. Furton, MA, PhD, Editor
ETHICS AND MEDICS
The National Catholic Bioethics Center
Volume 36, Number 6, June 2011