Understanding Catholic Teaching About Artificial Nutrition and Hydration in the Light of Previous Church Teachings and the Catholic Moral Tradition

(This is a research paper. It is longer and more detailed than the “Reflections” on this page. Please enjoy.)

Introduction

In their article, “Artificial Nutrition and Hydration: The Evolution of Ethics, Evidence, and Policy,” Howard Brody, Laura D. Hermer, Larry D. Scott, L. Lee Grumbles, Julie E. Kutac, and Susan D. McCammon (Brody et al.) declare that “Since Shiavo, the Catholic position on [artificial nutrition and hydration (ANH)] has become difficult for outsiders clearly to discern.”[I] Referring to a formulation in Pope John Paul II’s March 2004 “Address to Participants in the International Congress on ‘Life Sustaining Treatments and the Vegetative State: Scientific Advances and Ethical Dilemmas’” and the August 2007 “Responses to Certain Questions of the USCCB Concerning Artificial Nutrition and Hydration” of the Congregation for the Doctrine of the Faith (CDF), they claim, “The Church’s reaction to Shiavo threatened to remove ANH from the proportionate / disproportionate calculus by designating ANH ‘in principle’ always as ordinary care.”[ii] They refer to this as a “shift in Catholic teaching,” implying that “the hierarchy’s official position . . . that no shift in thinking has occurred” should be regarded as dubious and claim that the position that “argues for continuing to access ANH within the proportionate / disproportionate framework” is “a dissenting position.”[iii]

Contrary to the claims of Brody et al., I will argue that the Catholic Church’s recent teachings are in continuity with previous Catholic teaching and with the Catholic moral tradition. I will show how Pope John Paul II’s distinction between “a natural means of preserving life” and “a medical act” (emphases original) was anticipated in previous Catholic teaching and tradition, and how this distinction does not preclude but rather informs the practical judgment about whether ANH[iv] should be considered ordinary and proportionate or extraordinary and disproportionate in a given circumstance.

The teachings of John Paul II in 2004 and the CDF in 2007, which Brody et al. refer to as characterizing Catholic teaching on ANH “since Shiavo,” have to do with the use of ANH for persons in a so-called “persistent vegetative state” (PVS). There has been much discussion about how these teachings might apply to persons suffering from other life-threatening or debilitating conditions. I am not engaging in that discussion. My purpose, rather, is to show that these teachings are consistent with previous Catholic doctrine and tradition and intelligible in terms of what Brody et al. call “the proportionate / disproportionate calculus.”

Recent Catholic Teachings Regarding ANH

In Pope John Paul II’s 2004 Address, the portion of the text to which Brody et al. refer reads as follows:

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 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.[v]

Pope John Paul II’s teaching on the morality of ANH is further articulated in other passages in this address. He states that the “person in a vegetative state . . . has the right to basic health care (nutrition, hydration, cleanliness, warmth, etc.)” and, quoting the CDF’s Declaration on Euthanasia, declares, “The obligation to provide the ‘normal care due to the sick person in such cases’ includes, in fact, the use of nutrition and hydration.”[vi]

In 2007, this teaching of was reaffirmed by the CDF, which stated in its Responses, “The administration of food and water even by artificial means is, in principle, an ordinary and proportionate means of preserving life. It 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.”[vii] The CDF also attached a commentary to its Responses in which, after articulating possible exceptions to that norm, it states,

These exceptional cases, however, take nothing away from the general ethical criterion, according to which the provision of water and food, even by artificial means, always represents a natural means for preserving life, and is not a therapeutic treatment. Its use should therefore be considered ordinary and proportionate, even when the ‘vegetative state’ is prolonged (emphases original).[viii]

The United States Conference of Catholic Bishops (USCCB) has echoed these teachings in its Ethical and Religious Directives for Health Care Workers, in which it states,

In principle, there is an obligation to provide patients with food and water, including medically assisted nutrition and hydration for those who cannot take food orally. This obligation extends to patients in chronic and presumably irreversible conditions (e.g. the “persistent vegetative state”) who can reasonably be expected to live indefinitely if given such care.

It continues, quoting the 2007 CDF Commentary, “Medically assisted nutrition and hydration become morally optional when they cannot reasonably be expected to prolong life or when they would be ‘excessively burdensome for the patient or [would] cause significant physical discomfort.’”[ix]

In the course of articulating these teachings, Pope John Paul II and the CDF both make reference to previous Church teachings. The commentary to the CDF Responses affirms, “The Responses now given by the Congregation of the Doctrine of the Faith continue the direction of the documents of the Holy See cited above.”[x] The documents cited are: Pope Pius XII’s 1957 Address to an International Congress of Anesthesiologists, The 1980 CDF Declaration on Euthanasia, a 1981 document of the Pontifical Council Cor Unum titled Some Ethical Questions Related to the Gravely Ill and the Dying, a 1985 address of Pope John Paul II, the 1995 Charter for Health Care Workers of the Pontifical Council for Pastoral Assistance to Health Care Workers, another address of Pope John Paul II in 1998, and the 2004 address that we have already considered. There, as we have already had occasion to quote, Pope John Paul II makes reference to the CDF’s Declaration on Euthanasia. He also refers to the 1981 Cor Unum document and the 1995 Charter for Health Care Workers.

Continuity of Recent Teachings with Previous Church Teachings

The claims of Pope John Paul II and the CDF that their more recent teachings are in continuity with previous Church teachings can be verified by examination of the respective documents. In citing the 1957 Address of Pope Pius XII, the 2007 CDF Commentary acknowledges that “it is often invoked in favor of the possibility of abandoning the nutrition and hydration of [patients in a vegetative state].”[xi] That may be because, in addition to the principle that patients and caregivers have “the right and duty in case of serious illness to take the necessary treatment for the preservation of life and health,” Pope Pius XII sets forth the general principle that “normally one is held to use only ordinary means . . . that do not involve any grave burden for oneself or another.”[xii] It is easy to imagine how some might conclude from this teaching that ANH involves grave burdens and is therefore not an ordinary means. However, the CDF Commentary points out that Pius XII’s teachings “referred to the use and interruption of techniques of resuscitation.” It contrasts this with the “stable situation” of the person in a vegetative state. It also states that “the artificial administration of water and food generally does not impose a heavy burden . . . but is rather ordinary care aimed at the preservation of life” When prolonged over time for a person in a vegetative state, “It is a burden like that of caring for a quadriplegic [or] someone with serious mental illness.” According to the Commentary, “Everything leads to the conclusion that the first part of the principle enunciated by Pius XII should be applied to patients in a ‘vegetative state’: in case of serious illness, there is the right and the duty to provide the care necessary for preserving health and life.”[xiii]

The CDF’s 1980 Declaration on Euthanasia states, “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.”[xiv] Like the teaching of Pope Pius XII, the CDF’s teaching is subject to interpretations that identify ANH as securing “precarious and burdensome prolongation of life.”[xv] However, the 2007 CDF Commentary points out that, in general, PVS patients “are not facing imminent death” and that, if normal care for the dying should not be interrupted, “still less can one interrupt the ordinary means of care” for PVS patients. In his 2004 Address, Pope John Paul II quotes the phrase “normal care due to the sick person,” saying that it “includes, in fact, the use of nutrition and hydration.”[xvi]

The 1981 Pontifical Council Cor Unum document, after affirming that “a doctor must follow the wishes of a sick person who refuses [extraordinary] measures,” states,

There remains the strict obligation to apply under all circumstances those therapeutic measures which are called ‘minimal’: that is, those which are normally and customarily used for the maintenance of life (alimentation, blood transfusions, injections, etc.). To interrupt these minimal measures would, in practice, be equivalent to wishing to put an end to the patient’s life.[xvii]

The 2007 CDF Commentary quotes the first sentence of this passage without further comment. Pope John Paul II’s 2004 Address refers to this passage parenthetically to support his inclusion of nutrition and hydration in the category “normal care.”

The 2007 CDF Commentary also quotes a 1985 address of Pope John Paul II, claiming that,

[The address] stated clearly that, in virtue of the principle of proportionate care, one may not relinquish ‘the commitment to valid treatment for sustaining life nor assistance with the normal means of preserving life,’ which certainly includes the administration of food and liquids. The Pope also noted that those omissions are not licit which are aimed ‘at shortening life in order to spare the patient or his family from suffering.’”[xviii]

The 1995 Charter for Health Care Workers quotes the passage from the 1980 Declaration on Euthanasia that includes the proscription against interrupting “the normal care due to the sick person.” It then states, “The administration of food and liquids, even artificially, is part of the normal treatment always due to the patient when this is not burdensome for him: their undue suspension could be real and properly so-called euthanasia.”[xix] In his 2004 Address, Pope John Paul II makes reference to this document when he affirms that nutrition and hydration are to be considered “normal care.”

Finally, the 2007 CDF Commentary recalls a 1998 address of Pope John Paul II in which he teaches that “nutrition and hydration are to be considered as normal care and ordinary means for the preservation of life: it is not acceptable to interrupt them or withhold them, if from that decision the death of a patient with follow. This would be euthanasia by omission.”[xx]

All of these documents either affirm or presume that ordinary life-sustaining care should be provided to the sick and that, when death is imminent and/or extraordinary means have been declined, a basic level of life-sustaining care should be maintained. Several documents affirm, and none deny,[xxi] that this care should include nutrition and hydration. What is added in the Church’s recent teachings is the specification that nutrition and hydration are to be considered basic forms of care even when artificially administered. That is nowhere denied in the teachings we have surveyed and is explicitly affirmed in the “pre-Shiavo” 1995 Charter for Health Care Workers. This specification could reasonably be characterized as a development of the Church’s teaching. It is not reasonable to call it a “shift in thinking,” much less a “reaction to Shiavo.”

Continuity of Recent Teachings with the Catholic Moral Tradition

In considering the Catholic moral tradition concerning the necessity of providing nutrition and hydration to the sick, we begin with teachings of Thomas Aquinas (1226-1274). In his Commentary on 2 Thessalonians, Aquinas writes, “A man has the obligation to sustain his body, otherwise he would be a killer of himself . . . by precept, therefore, he is bound to nourish his body and likewise, we are bound to all the other items without which the body cannot live.”[xxii] This obligation is fundamental for and continually restated in the Catholic moral tradition after Aquinas. Also relevant for our discussion is Aquinas’ teaching on the finality of pleasurable goods, including food and drink. In his Summa Theologiae, he states that “pleasurable objects that are at man’s disposal are directed to some necessity of this life as to their end.”[xxiii]

Francisco de Vitoria (1443-1546) follows in the tradition of Aquinas and applies his teachings to medical situations. He writes, 

If a sick man can take food or nourishment with some hope of life, he is held to take the food . . . [but] if there is such consternation in the appetitive power that only with the greatest effort . . . can the sick man take food . . . he is excused . . .  A similar case does not exist in reference to food and drugs. For, food is per se a means ordered to the life of the animal and it is natural, drugs are not: man is not held to employ all the possible means for conserving his life, but the means which are per se intended for that purpose.[xxiv]

Vitoria also says that “medicine per se is intended also by nature for health, but since [its effectiveness] rarely can be certain, therefore they are not to be condemned of mortal sin who have universally declared abstinence from drugs.”[xxv] Daniel Cronin, in his extensive treatment of the Catholic moral tradition on the subject of “the necessity of using the ordinary means of conserving life and the lawfulness of shunning the extraordinary means,” remarks that “the teaching of Vitoria had tremendous influence.”[xxvi]

Tomás Sánchez (1550-1610) writes that “It is licit to fast and abstain from common foods . . . as long as the food necessary for the nourishment and conservation of the individual is taken . . . [intending] only to use means directed by nature for sustenance and not to prolong life, to which no one is bound.”[xxvii]

In a 1950 article, Gerald Kelly states that authorities including Alphonsus Liguori (1696-1787) “seem to hold that no remedy (emphasis original) is obligatory unless it offers a reasonable hope of checking or curing disease.”[xxviii] Kelly asks, “May all artificial means be considered as remedies; or must they be distinguished into those which are intended as cures for disease . . . and those which are primarily designed to supplant a natural means of sustaining life[?]”[xxix] Kelly admits that “there might be room for the distinction if we were discussing this question on a merely speculative basis.” On the basis of “a prudent, human evaluation of the factors involved,” however, he concludes that “all artificial means of sustaining life seem to be remedies.”[xxx] Regarding intravenous feeding, Kelly draws the conclusion that it is “in itself an ordinary means” but “one may not immediately conclude that it is obligatory.”[xxxi] Considering that intravenous feeding for a person in a terminal coma does not confer “any real benefit,” he gives the opinion that “apart from very special circumstances, the artificial means not only need not but should not be used.”[xxxii]

In this brief survey of the Catholic moral tradition concerning the provision of nutrition and hydration to the sick, we recognize an earlier development of the Church’s teachings on the obligation to sustain bodily life and how that obligation applied to nutrition and hydration. We find the teaching that food and drink are ordered to the need for bodily sustenance. We also find the emergence of a distinction between sustaining life by means of food that is natural and per se ordered to bodily health, and by means of drugs or medicinal remedies that are not naturally ordered to bodily health in the same way. In Gerald Kelly, we find a prominent Catholic moral theologian whose conclusions about ANH diverge from the recent teachings of the Church. I think it significant, however, that he recognizes a distinction between artificial life-sustaining measures “intended as cures for disease” and those meant “to supplant a natural means of sustaining life,” and considers intravenous feeding “an ordinary means.” These are precisely the reasons given in recent Church teachings to support the conclusion that, for patients in a “vegetative state,” ANH is, in principle, obligatory. In conclusion, while the Catholic moral tradition is neither static nor uniform, we can recognize in it the development of principles and distinctions that underlie the Church’s recent teachings concerning the necessity of providing nutrition and hydration to the sick.

The Distinction Between “a Natural Meansof Preserving Life” and “a Medical Act

In surveying the Catholic doctrine and tradition concerning the necessity of providing nutrition and hydration to the sick, it is instructive to observe how the distinction between “a natural means of preserving life” and “a medical act” in Pope John Paul II’s 2004 Address, and between “a natural means of preserving life” and “a therapeutic treatment” in the 2007 CDF Commentary, is so extensively anticipated. Vitoria distinguishes between food and drugs. Sánchez distinguishes between what sustains life and what prolongs life. Kelly distinguishes between natural means of sustaining life and remedies or cures for disease. The CDF Declaration on Euthanasia distinguishes between normal care and forms of treatment. The Cor Unum document distinguishes between minimal measures and extraordinary measures. In the 1995 Charter for Health Care Workers and in the 1985 and 1998 addresses of Pope John Paul II cited above, normal care that should not be interrupted is, at least implicitly, distinguished from other care that may be interrupted. When making this distinction in his 2004 Address, John Paul II, in addition to using the term “natural means of preserving life,” quotes the term “normal care due to the sick” (from the CDF’s Declaration on Euthanasia), uses the seemingly equivalent term “minimal care” (used in the Cor Unum document), and cites the 1995 Charter for Health Care Workers. The Pope clearly means to emphasize that the distinction he makes between “a natural means of preserving life” and “a medical act” is in continuity with previous Church teaching and, by extension, with the Catholic moral tradition in which that teaching is grounded.

What is notable about this distinction is not only the fact of its repeated affirmation in Catholic doctrine and tradition, but also the ways in which it is understood in by those who affirm it. I suggest that the meaning of this distinction in the Catholic moral tradition can be articulated in three ways.

Firstly, it means that the moral necessity of employing seperate life-sustaining measures must be considered separately. It may be rightly determined that some or all forms of curative medical treatment are futile or extraordinary and may therefore by discontinued. That would not mean that forms of life-sustaining care that are “normal,” “natural,” or “minimal” may also be discontinued.

Secondly, this distinction means that life-sustaining measures that are “normal,” “natural,” or “minimal” are to be considered differently than those that are “medical,” “therapeutic,” or “curative” because they have a different finality. Aquinas says nutrition and hydration are ordered to the needs of this present life. Vitoria says food is per se ordered to animal life and drugs are not. Sánchez says some things are naturally directed to sustenance and some are not. Kelly’s distinction between natural means of sustaining life and remedies for disease implies the same difference in finality. This difference is not as evident in the Church teachings preceding Pope John Paul II’s 2004 Address that we surveyed. In that Address, however, Pope John Paul II emphasizes it. His use of the term “natural means” as distinct from “a medical act” already suggests this difference in finality. Then, having stated that the use of ANH should be considered, in principle, obligatory, he specifies that this is the case “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 2007 CDF Responses similarly state that ANH is “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.”

Thirdly, this distinction does not mean that life-sustaining measures that are “normal,” “natural,” or “minimal” are always obligatory and immune from case-by-case prudential judgments to the contrary. Vitoria says that a sick person is excused of the obligation to take food when it is a cause of consternation and great difficulty. The Charter for Health Care Workers says that the normal treatment of administering food and water is due to a patient only when it is not burdensome. Pope John Paul II’s 2004 Address and the CDF’s 2007 Responses both qualify the judgment that ANH should be considered ordinary, proportionate, and obligatory with the caveat “in principle.” In its Commentary, the CDF explains:

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 . . . the artificial provision of food and water may be physically impossible. . . Nor is the possibility excluded that, due to emergency complications, a patent 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.[xxxiii]

Natural Means of Preserving Life” as Proportionate “In Principle”

Brody et al. claim that recent Catholic teachings have “threatened to remove ANH from the proportionate / disproportionate calculus by designating ANH ‘in principle’ always as ordinary care.” A reexamination of those teachings light of their context within Catholic doctrine and tradition will demonstrate the falsity of that claim.

Pope John Paul II, in his 2004 Address, designated ANH as “in principle, ordinary and proportionate, and as such morally obligatory” because, it would seem, of his prior designation of ANH as “always represent[ing] a natural means of preserving life, not a medical act.” We should note that, in Pope John Paul II’s Address, the qualifier “always” applies to ANH as “a natural means,” not to ANH as “ordinary care” as Brody et al. misstate. ANH, according to John Paul II, is always a natural means of preserving life that should be considered in principle ordinary and proportionate. The CDF, in its 2007 Commentary, essentially says the same thing. There, however, the causal connection between these two affirmations is explicit: “[ANH] always represents a natural meansfor preserving life, and is not a therapeutic treatment. Its use should therefore (emphasis mine) be considered ordinary and proportionate.” In order to understand this, let us consider what it means, in the context of Catholic doctrine and tradition, to say that a means of preserving life is ordinary and proportionate.

According to the USCCB, “A person has a moral obligation to use ordinary or proportionate means of preserving his or her life.” And, “Proportionate means are those that in the judgment of the patient offer a reasonable hope of benefit and do not entail an excessive burden.”[xxxiv] Determining whether a potentially life-preserving means is morally obligatory involves a judgment about the proportionality of its expected benefits and burdens. As we have seen, the distinction made by Pope John Paul II in his 2004 Address and anticipated in Catholic doctrine and tradition does not mean that “a natural means of preserving life” is always morally obligatory. Whether “a natural meansof preserving life” is or is not morally obligatory must be determined in each case. But is that judgment to be made by considering the proportionality of expected benefits and burdens? And if so, how is a judgment about “a natural means of preserving life” different than a judgment about “a medical act”?

The answers to these questions are given in the Catholic doctrines and traditions that we have surveyed. Like “a medical act,” “a natural means of preserving life” like food and water can be burdensome, even unduly so to the degree that it is disproportioned to its benefits and no longer morally obligatory. Vitoria explicitly recognized this, as did the 1995 Charter for Health Care Workers and the CDF’s 2007 Commentary. The benefits of “a natural means of preserving life,” however, are to be reckoned differently according to its different finality. From Aquinas to John Paul II, the Catholic tradition recognizes the finality of nutrition and hydration as the nourishment that sustains bodily life. “A medical act,” by contrast, has a different finality. It is ordered to the restoration of bodily health. These different means of preserving life are beneficial to the extent that they fulfill their purpose or attain their finality. When “a medical act” does not attain its finality, it is no longer beneficial. When the degree to which it attains its finality is, in the judgment of the patient, disproportionate to the burdens it imposes, it is no longer obligatory. Even when this is so, however, the morality of providing “a natural means of preserving life” must be considered separately. Such a means would remain beneficial, ordinary, and proportionate so long as it continued to attain its finality and were not unduly burdensome.

Recent Catholic teachings have not “threatened to remove ANH from the proportionate / disproportionate calculus.” Rather, their distinction between “a natural means of preserving life” and “a medical act” informs that calculus so that the benefits of different kinds of life-sustaining measures can be correctly identified and rightly proportioned to the burdens they impose. Contrary to Brody et al., arguments in favor of “continuing to assess ANH within the proportionate / disproportionate framework” are not what characterize dissenting positions. Dissenting positions are those that would apply that calculus while ignoring the distinction between “a natural means of preserving life” and “a medical act.”

Conclusion

In conclusion, and contrary to the claims of Brody et al., the Catholic Church’s recent teachings about artificially administered nutrition and hydration are in continuity with previous Church teaching and with the Catholic moral tradition. Moreover, the distinction in those teachings between “a natural means of preserving life” and “a medical act” informs and does not preclude the practical judgment about whether artificially administered nutrition and hydration should be considered ordinary and proportionate or extraordinary and disproportionate in a given circumstance.


[i]Howard Brody, Laura D. Hermer, Larry D. Scott, L. Lee Grumbles, Julie E. Kutac, and Susan D. McCammon, “Artificial Nutrition and Hydration: The Evolution of Ethics, Evidence, and Policy,” Journal of General Internal Medicine, March 5, 2011, 1056,

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3157529/pdf/11606_2011_Article_1659.pdf.

[ii]Ibid.

[iii]Ibid.

[iv]I will use the term “artificial nutrition and hydration” or “ANH” for the sake of convenience. I do not intend to suggest that this term is the most accurate or appropriate for describing of the set of procedures it denotes.

[v]John Paul II, Address to the Participants in the International Congress on “Life-Sustaining Treatments and Vegetative State: Scientific Advances and Ethical Dilemmas (March 20, 2004), n. 4.

[vi]Ibid, n. 4.

[vii]Congregation for the Doctrine of the Faith, Responses to Certain Questions of the Unites States Conference of Catholic Bishops Concerning Artificial Nutrition and Hydration (August 1, 2007).

[viii]Congregation for the Doctrine of the Faith, Commentary on Responses to Certain Questions of the Unites States Conference of Catholic Bishops Concerning Artificial Nutrition and Hydration (National Catholic Bioethics Quarterly 8.1, Spring, 2008), 124.

[ix]United States Conference of Catholic Bishops, Ethical and Religious Directives for Catholic Health Care Services, 6thed. (Washington, DC: United States Conference of Catholic Bishops, 2018), n. 58.

[x]Congregation for the Doctrine of the Faith, Commentary, 127.

[xi]Ibid, 124.

[xii]Pius XII, Address to an International Congress of Anesthesiologists (National Catholic Bioethics Quarterly 9.2, Summer 2009), 329.

[xiii]Congregation for the Doctrine of the Faith, Commentary, 124-125.

[xiv]Congregation for the Doctrine of the Faith, Declaration on Euthanasia (May 5, 1980), n. 4.

[xv]Peter Gummere writes in “Assisted Nutrition and Hydration in Advanced Dementia of the Alzheimer’s Type: An Ethical Analysis” (National Catholic Bioethics Quarterly 8.2., Summer 2008), that “in deciding whether or not to withdraw a specific modality of treatment at end of life, including ANH, the Sacred Congregation for the Doctrine of the Faith counsels in the Declaration on Euthanasia, ‘When inevitable death is imminent . . . it is permitted in conscience to make 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 the sick person in similar cases is not interrupted’” (293-294). Similarly, Patrick Guinan in “Is Assisted Nutrition and Hydration Always Mandated?: The Persistent Vegetative State Differs from Dementia and Frailty” (National Catholic Bioethics Quarterly10.3., Autumn 2010) writes in a table titled “Church Statements on Assisted Nutrition and Hydration” that the “Statement” of the Declaration on Euthanasia is, “Refusal of ANH is permitted” (483). I cannot find any warrant for these allegations in the text of this document.

[xvi]Congregation for the Doctrine of the Faith, Commentary, 125.

[xvii]Pontifical Council Cor UnumEthical Questions Regarding the Fatally Ill and the Dying (June 27, 1981), n. 2.4.4.,

http://www.academiavita.org/_pdf/magisterium/councils/pontifical_council_cor_unum/fatally_ill_and_dying.pdf

[xviii]Congregation for the Doctrine of the Faith, Commentary, 125-126.

[xix]The Pontifical Council for Pastoral Assistance to Health Care Workers, The Charter for Health Care Workers (1995), n. 120, http://www.ewtn.com/library/CURIA/PCPAHEAL.HTM#4

[xx]Congregation for the Doctrine of the Faith, Commentary, 126.

[xxi]See note xv.

[xxii]Daniel A. Cronin, Conserving Human Life: Part I, 2.1., quoting Aquinas, Commentary on 2 Thessalonians.

http://ldysinger.stjohnsem.edu/@books1/Cronin/Cronin_Conserving_Life.pdf

[xxiii]ST II-II q.141, a. 6.

[xxiv]Cronin, Conserving Human Life: Part I, 2.2., quoting Vitoria, Relectio de Temperantia, n. 1.

[xxv]Ibid.

[xxvi]Cronin, Conserving Human Life: Part I, 2.2.

[xxvii]Cronin, Conserving Human Life: Part I, 2.2., quoting Sánchez, Consilia seu opuscula moralia, Tom. II, Lib. V, Cap. 1, dub. 33.

[xxviii]Gerald Kelly, “The Duty of Using Artificial Means of Preserving Life” (Theological Studies 11.2, May 1, 1950), 207.

[xxix]Ibid, 213.

[xxx]Ibid.

[xxxi]Ibid, 218.

[xxxii]Ibid, 220.

[xxxiii]Congregation for the Doctrine of the Faith, Commentary, 127.

[xxxiv]United States Conference of Catholic Bishops, Ethical and Religious Directives, n. 57.

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