Is It Wrong to Cut Off Feeding?

By Richard N. Ostling

After he suffered a ruptured aneurysm of the brain in 1983, Massachusetts Fireman Paul Brophy lapsed into what doctors judged to be a vegetative state. Before his illness, Brophy had told friends that he would never want to live in a coma. "If I'm ever like that, just shoot me," he said. "Pull the plug." Accordingly, when Brophy failed to respond to therapy, his wife Patricia asked hospital officials to remove the feeding tube that kept him alive. They refused on ethical grounds, and she then filed suit, asserting that her husband had a right to die a natural death. The result: a landmark ruling last September from the Supreme Judicial Court of Massachusetts ordering removal of the feeding tube. Eight days after it was taken away, Brophy died.

Who was right -- Brophy's wife or the hospital? Should the sanctity of human life override suffering, indignity, even a patient's own wishes? Such agonizing dilemmas were at the heart of two days of discussions in Boston last week by 70 health administrators and scholars from 28 states and Canada. Their topic: the morality of removing feeding tubes. The meeting's sponsor was the Catholic Health Association, whose membership includes 615 hospitals that admit 6 million patients a year and 267 nursing homes that care for 74,000 aged patients.

The controversy over feeding tubes, said J. Stuart Showalter, of CHA's legal department, is becoming one of the most perplexing ethical issues of the 1980s and '90s. Declared he: "Emotions rise, rhetoric becomes strident, and even among the experts there is no consensus." The problem is especially thorny for Roman Catholic institutions, because many right-to-lifers are demanding new laws against what they see as killing by "starvation." Aiming occasional barbs at the strict pro-life stance, most of those who met in Boston insisted that Catholic tradition accepts an end to feeding in medically hopeless cases.

The dispute will heat up shortly, when the New Jersey Supreme Court rules on a suit filed by the family of Nancy Ellen Jobes, asking for the removal of a feeding tube from the 31-year-old comatose woman. A contentious brief in the Jobes case was filed by New Jersey's Catholic bishops. In the view of several Boston participants, the document distorts church tradition by opposing the withdrawal of nutrition under any circumstances.

An estimated 10,000 comatose Americans who cannot swallow are now kept alive by feeding tubes, usually inserted into the stomach directly or through the nose. The claim that such patients -- or proxies acting on their behalf -- have the right to halt nutrition was endorsed a year ago by both the American Medical Association and the American Bar Association. Seriously debilitated but conscious patients who are unable to swallow are claiming the same right. Last month a Colorado court granted a no-feeding request from a patient who was conscious but paralyzed from the neck down. He died two weeks ago.

The deep disagreements were sharply pointed up by the 4-to-3 Brophy decision in the Massachusetts high court. The majority, deeming feeding tubes too "intrusive," declared that medical advances require a distinction between death as traditionally conceived and "death in which the body lives in some fashion but the brain (or a significant part of it) does not." One of the minority judges accused his colleagues of consigning Brophy to a "gruesome death," and another said the court was improperly endorsing mercy killing and suicide.

Dominican Theologian Kevin O'Rourke, director of the Center for Health Care Ethics at St. Louis University, declared at the CHA conference that since the 16th century, Catholic thinkers have allowed withholding of life support in some cases. O'Rourke and others cite a 1957 speech in which Pope Pius XII said , that life-sustaining methods are morally required only when they "do not involve any grave burdens for oneself or another."

Such thinking played a significant role in the famous 1976 New Jersey Supreme Court case that permitted the Catholic parents of comatose Karen Ann Quinlan to have her respirator removed. The Quinlans' lawyer, Paul Armstrong, also a Catholic, was among the Boston conferees. He has noted that since the Quinlan ruling, many Americans have come to view kidney dialysis, cancer chemotherapy and the use of respirators as treatments that can be halted if they become too burdensome physically, emotionally and financially. When such methods are onerous and have a minimal chance of success, Catholic moral theologians term them "extraordinary," meaning that there is no obligation to perform them.

But feeding may present a different issue, one with which experts on ethics, especially Catholics, are currently struggling. Is a surgically implanted nourishment tube similar to optional forms of medical technology, or is it more akin to the simple providing of food and water for the sick, which is a moral requirement for everyone? The New Jersey bishops' brief in the Jobes case insists that medical treatments are wholly different from food and fluids, which "are basic to human life." Nutrition, say the bishops, "must always be provided to a patient." But as the CHA experts saw it, neither the Vatican nor the U.S. bishops' conference takes such an absolute stand.

Among the nonreligious participants in the Boston deliberations was Attorney Burke Balch of the National Legal Center for the Medically Dependent and Disabled, based in Indianapolis. In an interview, Balch insisted that all human lives are equally valuable, however handicapped the individual. He is concerned that the feeding debate is part of America's "gradual but steady progression" since the 1970s toward "acceptance of the idea that lives judged to be of poor quality are better off not being lived." He also fears that the fine distinctions that Catholic theology tries to make between mercy killing and being allowed to die "naturally" may evaporate in the public arena. "After all," says Balch, "if someone is going to starve to death two or three weeks after the tube is removed, why not just give him a painless injection now?"