Forced Feedings: The Bishops and Artificial Nutrition and Hydration.
The new directive, more definitive than previous church teachings, also appears to apply broadly to any patient with a chronic illness who has lost the ability to eat or drink, including victims of strokes and people with advanced dementia.
Catholic medical institutions are bound to honor the bishops' directive, issued late last year, as they do church teachings on abortion and birth control. Officials are weighing how to interpret the guideline in various circumstances.
What happens, for example, if a patient's advance directive, which expresses that individual's end-of-life wishes, conflicts with a Catholic medical center's religious obligations?
Gaetjens, 65, said she did not know of the bishops' position until recently and finds it difficult to accept.
"It seems very authoritarian," said the Evanston, Ill., resident. "I believe people's autonomy to make decisions about their own health care should be respected."
Part of the reason the Catholic church gets away with making these decisions for patients is because so few know how Catholic health care is regulated, by the church. About the history of this new policy on artificial nutrition and hydration, the case of Terri Schiavo is cited, an event that I would say is one of the primary roots of the church's recent restrictions:
The guideline addresses the cases of people such as Terri Schiavo, a Catholic woman who lived for 15 years in a persistent vegetative state, without consciousness of her surroundings. In a case that inspired a national uproar, Schiavo died five years ago, after her husband won a court battle to have her feeding tube removed over the objections of her parents.
The directive's goal is to respect human life, but some bioethicists are skeptical.
"I think many [people] will have difficulty understanding how prolonging the life of someone in a persistent or permanent vegetative state respects the patient's dignity," said Dr. Joel Frader, head of academic pediatrics at Children's Memorial Hospital in Chicago and professor of medical humanities at Northwestern University.
The church's view is that giving food and water through a feeding tube is not a medical intervention but basic care, akin to keeping the patient clean and turned to prevent bedsores, he said.
Pope John Paul II articulated the principle in a 2004 speech, and the Congregation for the Doctrine of the Faith, an arm of the Vatican, expanded on it in a 2007 statement.
The new guideline incorporates those positions in Directive 58 of the U.S. bishops' Ethical and Religious Directives for Catholic Health Care Services.
There are several important exceptions. For one, if a person is actively dying of an underlying medical condition, such as advanced diabetes or cancer, inserting a feeding tube is not required.
"When a patient is drawing close to death from an underlying progressive and fatal condition, sometimes measures that provide artificial nutrition and hydration become excessively burdensome," said Erica Laethem, a director of clinical ethics at Resurrection Health Care, Chicago's largest Catholic health-care system.
A second exception has to do with bodily discomfort. If infection develops repeatedly at the site of the feeding tube, for instance, artificial nutrition and hydration can be refused or discontinued, Catholic ethicists agree.
A third exception is allowed when inserting or maintaining a feeding tube becomes "excessively burdensome" for a patient.
Under traditional Catholic teachings, patients may refuse medical interventions when anticipated burdens outweigh potential benefits.
"Decisions are made case by case," and that will continue, said Ron Hamel, senior director of ethics at the Catholic Health Association of the United States.
Of particular concern is whether Catholic medical centers will honor an advance directive stating broadly that a person does not want a feeding tube inserted.
Compassion & Choices, a group that supports the right of dying people to end their lives, suggested the potential for conflict is significant.
"Now, [Catholic] hospitals and nursing homes have no choice but to enforce Catholic doctrine universally over patient wishes," the group's president, Barbara Coombs Lee, wrote on her blog.
But most ethicists said they do not see a significant problem. Disagreements, they say, usually can be resolved by discussing people's end-of-life concerns, such as fear of being abandoned, fear of living in pain or fear of becoming entirely dependent on others.
It is rare for people to be very specific about their wishes.
"I have never seen an advance directive that says, 'If I am in a persistent vegetative state, I ask that you withdraw food and water,' " Laethem said.
The bishops' guidelines specify that patients' "advance directives are to be followed, so long as they do not contradict Catholic teachings," said John Haas, president of the National Catholic Bioethics Center. How those teachings will be interpreted has yet to be resolved.