Our People

Why do people who can no longer exercise rational autonomy still matter?

Summary of a paper given to the Catholic Bioethics in the Public Forum, Symposium of the International Association of Catholic Bioethicists
Order of Malta and the John Paul II Institute for Marriage and the Family, Melbourne

By Most Rev. Anthony Fisher OP
Auxiliary Bishop of Sydney
27 June 2005

1. Civilization after Schiavo?

If the test of a civilization is how it treats its weakest and most vulnerable members, cases like that of Terri Schiavo are emblematic of much more than just the care of a particular cognitively impaired person. Important arguments in philosophy and culture—once recognized as being about metaphysics and religion—are now played out as healthcare battles, often in the courts and media, generally with much heat and little light. The enthusiasm of some to discontinue assisted feeding, or to prevent it from beginning in the first place (via advanced directives or other protocols), comes from several quarters. One is euthanasist pure and simple: by the time people need long-term assistance with nutrition and hydration they are presumed to be better off dead. Another set of motives are economic and logistical, as it is concluded that such patients are not deserving of finite health resources and other energies. But also at play here is concern with respect for the dignity and free will of patients, their right to say no to being over-treated and perhaps their right just to say no. We all recognize the profound importance of being able to choose for oneself on a basis of information and deliberation what should happen to us and being able to enact this decision. But often in public rhetoric and practice today this concern for freedom has become an idolatry of the will.

Bioethical talk of ‘autonomy’ is code for a multi-faceted concept carrying within it a mini-history of philosophical speculation on anthropology, social life and ethics. After detailing something of the history of the autonomy idea I argue in my full paper that it has been severely impoverished by liberalism at the very time that its importance has been exaggerated. My story of Ronald Dworkin’s granny who life was mere ‘white noise’ shows the slide from ‘no autonomy’ to ‘no rights’. Autonomy-personism asserts that people who lack autonomy are not persons: thus Terri Schiavo was described by her guardian’s lawyer as a houseplant. Real respect for those who will never again be free choosers and for those around them who can still have sensations and preferences requires withdrawing any life-sustaining care and even, more actively, hurrying up their deaths. Dworkin is one champion and Peter Singer another of a bioethic descending from John Stuart Mill. Liberals advance at least two, not entirely compatible, reasons for not feeding those who lack rational autonomy. One is the view that what really matters in life is ‘doing it my way’: being able to pick and revise my own values and life-plans, make my own choices, satisfying my own preferences. Another is that what matters in life is maximizing good sensations or fulfilled preferences and minimizing bad sensations or unfulfilled preferences. Both views accommodate rationality to preference rather than vice versa.

In liberal cultures much popular (and some professional) talk of autonomy has slipped (without much opposition) from an appeal to reason to a much reduced appeal to wants. This is not to deny that autonomy properly understood matters. Most of us take the possession and frequent exercise of rational autonomy for granted; we abhor the prospect of its future reduction; and we miss it deeply when it is compromised in ourselves or someone we care about. It is distressing to think of having to live, possibly for years on end, without being able to exercise reason and will. But can we move from the idea that ‘rational autonomy matters very much’ to the claim that ‘people only matter because of their rational autonomy’ and to the conclusions that such people are better off dead and may be neglected to death?

Entering this contemporary fray came Pope John Paul II in Veritatis Splendor, Evangelium Vitæ and the 2004 Allocution on the care of those in a so-called ‘vegetative state’. Careful to make the necessary distinctions between euthanasia by an action or omission on the one hand and appropriate pain relief or non-treatment on the other, he taught that euthanasia is always wrong and is symptomatic of that deep malaise in the West which he famously tagged ‘the culture of death’. Catholic teaching, he recognized, has never required the prolongation of life at all costs; ‘heroic’, ‘extraordinary’ or very burdensome treatments may properly be foregone, especially when death is clearly imminent and inevitable, ‘so long as the normal care due to the sick person in similar cases is not interrupted’. Until his 2004 allocution he did not unpack this term ‘normal care’, but the 1995 Vatican Charter for Health Professionals had already defined it to include ‘feeding and hydration, if needs be artificially assisted’. In his several writings he unmasked as ‘false mercy’, ‘the height of arbitrariness’ and ‘injustice’ the judgment that some people have a ‘virtually sub-human’ quality of life, that their life is ‘no benefit’ and their death ‘no loss’, deciding ‘who ought to live and who ought to die’.

In his 2004 Address John Paul insisted that severely cognitively impaired people should not be demeaned by tags or behaviour that imply they are less than human. In the face of such tendencies he strongly reaffirmed “that the intrinsic value and personal dignity of every human being do not change, no matter what the concrete circumstances of his or her life. A man, even if seriously ill or disabled in the exercise of his highest functions, is and always will be a man, and he will never become a ‘vegetable’ or an ‘animal’. Even our brothers and sisters who find themselves in the clinical condition of a [so-called] vegetative state retain their human dignity in all its fullness. The loving gaze of God the Father continues to fall upon them, acknowledging them as his sons and daughters, especially in need of help.” The ‘fundamental good’ of life, the Pope reminded us, cannot be outweighed by quality of life or cost considerations, and positive measures must be taken to support such people and their loved ones.

John Paul’s teaching and the long tradition on which it builds puts the Church very much at odds with the view of some contemporary philosophers, theologians, lawmakers and health professionals. At the heart of it is a very different view of the human person and of respect for persons, of what is treatment, what is appropriate treatment, and what other kinds of care are appropriate. It is to these matters I turn in part 2 of my paper.

2. Philosophical account of why those who cannot exercise rational autonomy still matter

One common response to liberal claims about those lacking (the present exercise of) rational autonomy has been an appeal to human dignity. In its popular form it offers a kind of simple progress from the proposition that ‘all human beings have dignity’ to the claim that ‘human life is inviolable’ to the conclusion ‘there is a duty to feed (even artificially) all human beings’. But this requires some unpacking.

A strong case has been made for the first proposition: that from the first moments to the last of a human being’s existence, he has human dignity because he is of his very nature the kind of being that has reason and free will (as well as bodiliness, society, emotions, immortality…)—whether or not he can exercise those capacities at any particular moment. Even when handicap renders a person unlikely ever again (in this life) to exercise rational autonomy, therefore, he retains his nature and so his inestimable value.

In my paper I suggest that the alternate view—that  someone unable to exercise one of their capacities is thereby not a ‘someone’ any longer—is prima facie a piece with those least edifying corners of ancient or more recent discrimination in ethics and politics. What is new today—though it might be said to go back to Ockham—is the denial that there are natures and thus that there is any necessary commonality between us and the severely cognitively impaired. Whether anyone is ‘one of us’ is all a matter of power, affection, identification, word games, world views. Whom we decide to include in ‘the commonwealth of persons’ is as arbitrary as national borders, and as every Australian knows, you can arbitrarily vary your borders and exclusion zones if you want to keep someone out. Though Singer complains of speciesism in talk of human dignity and seeks to expand the category of those for whom we should have respect to include higher order animals, he and Dworkin in fact join a long line of elitists who say that “you only have dignity or rights if you are like me”; the new group of subhuman or subpersonal outsiders, the ‘vegetables’, are not like us. But to the view that patients with ‘PVS’ and like conditions are not us we might ask: if we could introduce genes or drugs or tissues to restore brain function and so the exercise of rational autonomy to a patient, would we regard this as correcting a handicap or creating a new being; as therapy or conception? Would we use the same name for the patient after the procedure? If we would be curing rather than creating or transubstantiating someone here, then there would be a someone being cured: a damaged person who was there all along.

Alasdair MacIntyre, in the most recent of his sequence of profound books, argues against the elitist account of human personhood by arguing very persuasively that we are fundamentally dependent beings and that this dependence is not just chronologically but logically and ontologically prior to our independence or autonomy. Reflecting upon our nature as physical, biological beings, MacIntyre also argues that our ethics must be grounded in our bodily, animal nature. Here he joins Aristotle, Aquinas, John Paul II, Mary Midgley, John Finnis, Germain Grisez, Robert George, and others who have argued that the body and bodily life are not merely instruments somehow distinct from and serving ‘the real me’, ‘the self’ or, as Richard Rorty calls it, my ‘mind-stuff’. These writers demonstrate that mind-stuff approaches not only necessarily presuppose an indefensibly dualist conception of the human person, but also adopt a radically denatured anthropology. Human beings are rational animals, living organisms, not angels or spirits connected or disconnected in some way to an animal body; they are their bodies; their life is bodily life. Deliberately to end the life of their bodies is to kill their person.

Some people recognize that all human beings are equally persons, but deny they are entitled to equal respect, care and protection. Humanity is divided, then, not into ‘persons’ and ‘non-persons’ but ‘persons who count’ and ‘persons who don’t’. Thus a particular class of human beings might legitimately be denied food and water, allowed to die of hunger or thirst, and the bystanders be told by law and medical ethics that that’s OK. But for the healthy so openly to violate or neglect those who suffer—whether against their wills, without their wills, or by forming their wills so that they themselves condone the violation—looks rather like a new form of an old disrespect for humanity. Though we are usually more careful today not to use the language of ‘moron’ and ‘untermensch’, ‘subhuman’ or ‘inhuman’, we share with some previous societies a readiness to reverse the proper protectiveness of the strong for the weak. The Schiavo case demonstrates that in contemporary Western ‘civilization’ sickness, which always meant vulnerability, now means an even greater vulnerability: susceptibility to action and neglect aimed at worsening the condition, even to the point of destroying the sick person, precisely because they are sick.

Those who argue for personhood but against equal protection and care for all persons are forced to disguise it with all sorts of sobriquets: ‘in the patient’s own best interests’, ‘safeguarding their dignity’, ‘avoiding unnecessary suffering’, ‘just easing along the inevitable’, ‘letting nature take its course’, ‘she would not have wanted to go on in this way’ and so on. But it is not hard to see that what is really at issue here is usually not so much respect for the cognitively impaired person but for the more autonomous, more powerful and more vocal bystanders. Nor do homicidal acts or omissions become right simply by becoming policies or by getting the victims to sign the death warrants: in many ways that seems to me only to aggravate the evil at stake.

But is the life of every human being really to be regarded as inviolable? Various cases have been made for this moral claim. One begins with the idea that life is a basic and not merely an instrumental human good and argues that the ‘natural law’ precepts to preserve life and not to take human life are determinations of the basic good of life. I suggest in my full paper that that life is a basic or intrinsic good of human persons explains many of our claims, actions and institutions and is the basis of our taboo against killing: directly to deprive a person of life, therefore, is prima facie to deny him a good that is properly his and always to do him a harm.

A few qualifications are in order here. To say that life is a basic human good is not to say that the prolongation of life is reasonably to be pursued by everybody, at all times and in all circumstances, at whatever cost to themselves and others, and by whatever means; nor does it mean that life is the only value or the most important value or an absolute value. There will often be good reasons to do things which protect or prolong life: the good of life itself, the goods life enables, responsibilities to others especially dependents etc. But there may well concurrently be good reasons not to do so: great burdens of various kinds for the person whose life would be prolonged or for those who would be engaged in their care, the risks involved and opportunity costs, etc.

Furthermore, to say that life is a basic good is not to say that we tend to desire it by itself. People want not merely to live but to live well, exercising amongst other things their rational autonomy in choices that contribute to their happiness and that of others. On the face of it this might seem to suggest once again that life is merely an instrumental good. But one would not expect people to want to participate in any single basic good, abstracted from the range of ends which together constitute true flourishing. Truth, beauty, work, play: none of these goods would be appealing by itself in an existence (were that possible) deprived of all other goods. No one wants to suffer ‘PVS’ or dementia, and no decent person wants to see anyone else living like that: the goods of life (continuing), health (diminished) and love (received) are very inadequately instantiated in such a person’s life, and all the other goods are absent or at least not experienced consciously. Nonetheless, even the severely cognitively impaired are living human beings: their life is their very reality as persons and as such remains a good, even if it is not consciously enjoyed by them and however little it appeals to us; their death is a harm which diminishes the human community as well as them. This explains why we still care for such people: such care ensures their continued participation in whatever goods of which they can still be subjects; it maintains our bonds of interpersonal communion or solidarity with them; it expresses our benevolence and respect for them as members of the human family. It also explains why we do not harm such people: we do not kill them or bury them alive, exploit them by live organ-harvesting or experimentation, sexually abuse them, throw them on the garbage heap, or otherwise subject them to indignity.

But how are we to face ineradicable suffering, when we’ve tried all we reasonably can to combat pain, disease and dying? When a fix is impossible, our consumer culture stands in gaping incomprehension, goes into denial, withdraws its support, and/or marginalizes those who cannot be fixed so that the rest can carry on undisturbed. The fact is that there are evils we cannot ‘solve’ in any simple, morally acceptable way, and that call forth much that is most noble in the human spirit: patient endurance, perseverance, fortitude, even heroism on the part of patients, doctors, families and communities. Sometimes more patience will be asked of the bystanders than the patients themselves, and impatience will be at the heart of the decision to stop feeding.

Starving or dehydrating someone to death by obstructing them from obtaining food and water or by failing to provide it when they depend on us to receive it, has always been considered not only killing but a particularly egregious form of killing. Why is that? I think it is because food and water are not only sources but symbols of life and community. To deny things which are so basic to someone is not only to deny them a need but deliberately to deny their humanity and all solidarity with them. Some claim that food and water are treatments and treatments can be denied if doctors or guardians say so. But as Pope John Paul II pointed out in his 2004 allocution, food and water are not medical treatments, even when medical help is necessary for their delivery; they are part of that ordinary care we provide for ourselves or that is provided for us by family members or sometimes nurses when we are weak. To recategorize food and water as treatments so as to excuse their withdrawal reduces medicine to nominalism and medical ethics to sophistry.

3. Theological account of why those who cannot exercise rational autonomy still matter

In the third part of my paper I consider such theological concepts as ‘the image of God’, ‘the sanctity of life’ and the religious duty to feed. All religion is bound up in some way with feeding, feasting and fasting. Religion teaches the mystical, communitarian and symbolic dimensions of offering, eating and abstaining. Feeding the hungry is required in every major religion and appears almost antiphonally as a charge in Judaism and Christianity. God’s good gifts of food and drink are to be shared with others. Only the knave and the fool, according to Isaiah, “utter error about the Lord, fail to feed the hungry or deprive the thirsty of drink”. To stand by and do nothing while another starves is the very antithesis of religion that succours and sacrifices precisely so that the spiritual advantages of food are made more fully available to the hungry.

But what was and is different about the Christian religion here? In my full paper I have argued that Jesus’ nick-name “glutton and a drunkard” was not merely a complaint about a petty vice or even a lack of seriousness about religion. It implied Jesus was a sluggard, a useless eater, who would come to nothing and so deserved to be denied food, even killed. Such a charge could only hope to stick because Jesus was in fact an enthusiast for his food and drink. The Gospels record many feeding stories involving Jesus and the turning points of Jesus’ life are marked by eating and drinking: beginning with turning water into wine; signifying by multiplying loaves and fishes; ending with the miraculous haul of fish—all  of these miracles of divine extravagance, a foretaste of the longed-for messianic banquet. As his ministry came to its climax, he took his closest friends aside for a last meal, investing the Passover Seder with new significance: his own Pasch memorialized and perpetuated in the Eucharist. Before returning to the Father he dined again with disoriented disciples in Emmaus, with confused apostles at the Sunday gathering and with his nearest and dearest at the lakeside breakfast in Galilee.
 
When he wanted to describe the kingdom of God, or the afterlife, or forgiveness, or ministry, or himself, time and again he chose images of food and drink, feasts and parties. In my paper I list the veritable pantry upon which Jesus draws in his teaching. I argue that attitudes to food and drink have implications that run deep for our theology of creation and eschatology, incarnation and redemption, sacramentality and spirituality, politics and ethics. Our attitudes with respect to whom we feed and our ‘practices’ with respect to how we feed them also say something powerful about both them and us. To refuse to feed or water someone is to excommunicate them, to place them outside the pale of human friendship and deserving, to deny them the status of brother and sister. This is why Christ made whether you feed and water the needy a test of communion and ultimately of salvation: to refuse them food and drink is to refuse them fraternity and ultimately to refuse the God who made them your brother or sister.

Whom Jesus fed and with whom he sat at feeding time was also highly significant. Jesus’ critics complained about the company he kept at table. He was, it seems, altogether too inclusive, bringing even people who were ritually impure, morally dubious or socially outcast into relationship with him. Most of them were far from powerful, fully autonomous, beautiful or successful. Though none suffered from ‘PVS’, one at least was actually dead before he raised and fed her! Such inclusivity was, of course, deliberate and it was subversive. So were the rôle reversals: ‘the hungry filled with good things while the rich go empty away’; a prodigal son feasting while his law-abiding brother excommunicates himself; the high and mighty self-excluded from the wedding banquet while the tramps are dragged in from the highways and byways; the Master washing his disciples’ feet before dinner and promising to serve them at table; the rich man in hell while the starved one goes to Abraham’s bosom. Jesus’ feeding miracles undermined the system of public patronage and were quickly read as political. And finally, in the Eucharistic texts we find the most striking teaching of Christ about food or through food: for here he is the food. A more comprehensive overturning of ‘power eating’ would be hard to imagine. Far from using the feast to exercise control, Jesus makes himself the waiter and the meal, emptying himself of all pretensions to power at the very moment when all authority is given him in heaven and on earth. And at the moment of his glorification he one more joins all those who hunger and thirst as he cries out from the Cross ‘I thirst’.

“You give them something to eat yourselves!” Jesus commanded. The Church must be the very stomach with which Christ still feels splangchnizomai, the gut-wrenching compassion he once felt for the hungry crowd. Here I think we come to the heart of what is described so clinically in our bioethics documents as ‘the presumption in favour of feeding’ and it is a ‘presumption’ at the heart of the mission of the Church. Christians are called to feel stomach-churning pity for the physically or spiritually hungry and to respond by feeding them what they need. And that was precisely what the early Christians did, taking up collections of food and money to distribute to the poor, even appointing specialists—the deacons—to ensure this happened. The spectacular take-off of Christianity in the Græco-Roman world was in a large part due to its special appeal to the poor and the hungry. “See how these Christians love each other!” people said in astonishment. Their simple, egalitarian, compassionate approach had a tremendous kerygmatic effect. No longer did racial, ethnic, cultural, citizenship, social or gender differences mark the boundaries of moral concern and obligation: now people of every class and background were to be loved for themselves, as children of God and claimants on his followers’ concern. The distribution of food and other alms to the poor preached more powerfully than the words of Peter and Paul; and it preached the subversive inclusiveness of the nobodies in this new ‘kingdom of God’.

In due course the Christian virtue of hospitalitas meant the erection of the first hospices, poor houses, soup kitchens and feeding stations, in local churches and monasteries, along the way to the Holy Land, and later the great institutions such as the chivalric orders of hospitallers, Catholic hospitals, orphanages, Vinnies conferences, Caritas and the rest. So much that we now take for granted might never have happened without Matthew chapter 25 and a whole Bible full of charges to feed the hungry and give drink to the thirsty. In the process it changed not only how the starving were treated but also how they were viewed: even the lives of the least were sacred.

So much for the Christian duty to feed: what about the sanctity of life doctrine supposedly behind it? All too often ‘sanctity of life’ is contrasted with ‘quality of life’, as if Christians want longer, low-grade lives and seculars want better if shorter lives. Neither is true of course: most people, religious or not, want long, good-quality lives for themselves and those they care about. Where quality-of-life talk does mark a real difference is where some argue that those below a certain quality-of-life threshold do not command the same respect and care as those above it; here sanctity-of-life talk functions, much like dignity talk, to insist that all human lives qua sacred equally deserve care and respect; and, much like inviolability talk, to insist that even low-quality lives should not be deliberately shortened. Another way of reading sanctity-of-life talk is as a call to a greater reverence for human beings than that demanded by secular ‘dignity’ and ‘inviolability’ talk. I suggest that sanctity talk has most bite at the margins, i.e. when it is hardest to hold on to the principle of not killing the innocent. Take, for instance, the philosophers’ chestnut of the man in the burning car who cannot be rescued and begs to be put out of his misery; or the (rather more common) example of a couple considering abortion because their child has anencephaly. Even those who hold to the infinite value and inviolability of the human person are tempted to make exceptions in such hard cases. The contrary tug in such people or in others, against killing even in awful circumstances, could be plain superstition, stubbornness or insensitivity. But it might be due to something else, and that something else is called ‘sanctity of life’. It is a quality in the valuer as much as in the person valued, the kind of reverence so many of our saints who saw Christ present in the most desperate of people and hung around to help.

[In my full paper I give several examples of this, including my sister in St Dominic, St Catherine of Siena. Her ‘street ministry’ to the most hopeless cases, the lepers, those dying of plague, those on death row, was marked by a willingness to persevere in care even when feelings of repugnance and impotence inclined her to flee. Furious at the moral evil of the system in sent young men to die on the executioner’s block and at the natural evil of a world in which young women and children died of plague, she went to remonstrate with Christ on the Cross. The corpus responded to her: “Turn around and see who it is I love enough to die for.” And turning around she saw all the halt and the lame, as well as the privileged and the perfect, the victims and their persecutors, all. Her task, she knew, was to expand the range of those she loved and to persevere in her care for them, no matter how repugnant she found them at times and no matter how little she felt she could do.]

That ability to reverence those we find repugnant and to care for those for whom we feel we can do nothing is, I think, where sanctity of life talk really bites. And it is here that the notion of the imago Dei also comes in. The saints see the image of God in those they nurse. St Catherine’s talk about God being pazzo d’amore, drunk or insane with love for us, and about our catching that madness from him, cut in precisely as the condition of her lepers became hopeless, as their bodies and spirits disintegrated, as they faded out of consciousness or were dying, when all she could do was give them basic care and wait. It is in those very cases that I think the liberal account of why people matter and the Christian one most radically diverge. For Mill, Dworkin and Singer, human persons matter because of sentience and mobility, preferences, hopes and plans, reason and choices, language and social interaction—all the stuff of rational autonomy. For Christians, while all those things matter, what makes people so valuable is: their creation in the very image of God (as the kinds of beings who will ordinarily exercise not only rational autonomy, but unitive love and other capacities); their restoration to that likeness despite their brokenness by the redemptive sacrifice of Christ; their sharing human nature with a God who became man so that men might become as gods; the graces they receive and enact in this life in good (not merely free) choices; and the destiny to which they are called in heaven. And as Alasdair MacIntyre and Stanley Hauerwas have demonstrated, it is often the ‘profoundly disabled’ who best draw our attention to what we really value—or should really value—in the human person: their intrinsic, metaphysical nobility rather than their presently apparent, contingent abilities.

What I am suggesting, then, is that the Christian notion of the sanctity of life is more than secular dignity and inviolability dressed up in religious poetry. With the eyes of faith one comes to see every human being, including, indeed especially, those most desperate, repugnant, beyond help, as the image of God, as the suffering Christ, as Temples of the Holy Spirit, worthy not just of ‘respect and care’ but of a ‘mad’ love akin in some ways to worship. Indeed the ‘weaker’, ‘less respectable’, ‘low quality-of-life’ people are precisely the parts of the Body of Christ for whom all Christians should demonstrate particular sympathy and protectiveness. On this account directly to kill or neglect-to-death an innocent human being involves more than the loss of that person and all they mean to others, more than the harm it does the killer and his community—though it does indeed involve all those losses. Killing or abandoning someone to death is also, and ultimately, a kind of desecration of the sacred, an attack upon the God of whom the victim is an icon. So says Paul, quoting the wisdom literature and recalling no doubt Jesus’ command to love even your enemies: “if your enemy is hungry, feed him; if he is thirsty give him drink”. That, I think, is why the early Church put murder with apostasy as the most horrendous crimes: not just because both are very bad (for there are many, very bad sins), but because to kill is not merely to do an injustice but directly to attack the Author of Life, to usurp his rôle, and so to sin against faith, hope and love. Talk of sanctity of life tries, however limpingly, to capture something of the reverence or awe that religion has before the mystery of life and death, and something of the shudder down the spine the Christian feels at the thought of killing any human being, even one in desperate straits.

A theological counterpart to the ‘autonomy-personism’ of liberal philosophers is what we might call ‘spiritual-acts-personism’. This view holds that the human person is capable of many acts but that those directed towards securing the goods of the body (nourishment, exercise, health…) or of social life (peace, friendship, prudent choice…) are intrinsically inferior to, merely instrumental for and entirely ordered towards ‘spiritual acts’ (thought, contemplation, understanding, worship…). According to this view keeping someone alive when he can no longer perform spiritual acts is at best pointless, because life has lost its point. It may even cruel, as we are depriving the person of ‘release’ and delaying their entry into heaven. In my paper I headline seven lines of arguments which might be run against this view. Amongst them is the thought that if heaven is the presumed end of the person with serious cognitive impairment—and that is a highly presumptuous—and if denying tube-feeding to such a person is a kindness, it is hard to see why spoon feeding should not also be stopped. I also wonder whether it can it be presumed that those suffering from ‘PVS’ or like conditions have no ‘spiritual experiences’ or whether it is right to assume that the ‘suffering’ of such people is purposeless for them and for others.

But no one wants to live that way! Of course not. As I argued above, there are umpteen awful situations which we would not want to be in or want others we loved to be in. But to say that is a very different matter to saying that our life (or theirs) would no longer be ‘worth living’; that we (or they) would lose our ‘dignity’ or that our life (or theirs) would lose its ‘sanctity’; that others should then hasten our deaths or neglect to give us even basic care. To put it another way: is the action of a Mother Teresa or Catherine of Siena irrational, even cruel, if it lengthens ‘the kind of life no-one would want for themselves or those they loved’? When John Paul contrasts the ‘false pity’ that kills with ‘the way of love and true mercy’, he recognizes that in the face of ‘the supreme confrontation with suffering and death’, many will be tempted ‘to give up in utter desperation’; but then what is really called for is ‘companionship, sympathy and support in the time of trial… help to keep on hoping when all human hopes fail.’.

4. Some practical conclusions

What are the practical implications of these different views of whether those who cannot exercise rational autonomy still matter? I have written elsewhere about what I think are the four positions commonly adopted by ethicists, health professionals and others on the question of whether such people should be fed with medical or nursing assistance. I have called them the “Never Feed View”, the “Always Feed View”, the “Seldom Feed View” and the “Usually Feed View”. I have argued that the Catholic magisterium has consistently proposed the “Usually Feed View” and repudiated both a ‘vitalism’ that would feed even when this no longer works or works only at a grave burden to the patient or others, and a euthanasist approach that denies food when the patient is judged better off dead. Everyone is entitled at least to food, clothing, shelter, sanitation, company and prayer. So if they need help with achieving nutrition or hydration (or clothing or sanitation) and it can easily be given them, then it should normally be given. Even persons suffering ‘PVS’ or like conditions have the right to such ‘basic’, ‘natural’, ‘normal’ or ‘minimal’ care as John Paul II called assisted nutrition and hydration in these cases. But as the Pope pointed out, this kind of care is (only) ‘in principle’ obligatory as long as it achieves its ‘proper goal’ of nourishing or comforting. Thus the Catholic tradition, like the Hippocratic one, has long held such interventions inappropriate: where the patient has died; where the patient is imminently dying; where the delivery of such nutrition and hydration is futile: i.e. it is ineffective in feeding, hydrating or comforting the patient; where the mode of delivery is too burdensome for the patient; or where the mode of delivery places an unreasonable burden upon others. This means that sometimes it will be appropriate to withdraw assisted nutrition and hydration. But it also means that prima facie assisted nutrition and hydration should be given to those suffering ‘PVS’ or like conditions. One way of examining our intentions here might be to ask: if patients suffering ‘PVS’ or dementia could be adequately fed and hydrated by spoon or with a simple and cheap patch, would we? If our instinct is still ‘no’ then our reason for withholding tube feeding is not one of the ones traditionally recognised in medicine and nursing.

To label ‘PVS’ and like patients as ‘dying’ or as having a ‘lethal pathology’ and to call withholding food and water from them ‘allowing a natural dying process to proceed’ is confused and inclines people to unethical behaviour. How can someone like Terri Shiavo who, if she had been fed, would probably have lived for years be said to have been dying? Is ‘dying’ simply a tag we use for a special class of patients who will, once so labelled, be denied basic care and so die sooner rather than later? Even if we resolve why people who lack the exercise of rational autonomy matter and whether and how we should feed them, there will be more to do for such people, as John Paul pointed out. There is likewise more we could say in this debate. I hope this paper is a good starter.