Amazing life-sustaining technologies developed in the 1960s that, while welcomed, raised the specter that patients might be maintained on machines well past their “time to die” (Eccl 3:2).  The 1976 case of Karen Ann Quinlan, who was in a “persistent vegetative state” (PVS) and supported by a respirator, made national news when the highest court in New Jersey authorized her father to have the respirator removed. In 1990, the United States Supreme Court, in the case of Nancy Ann Cruzan, upheld a state law that declared that when there is “clear and convincing evidence” that a patient in PVS would want to have artificial nutrition and hydration withdrawn, doing so would not be contrary to the Constitution.

These and several other legal cases in which medical technology has maintained patients in a limbo between life and death have brought increased attention to the question of how long we are morally required to keep people near death or in PVS alive by means of medical measures.

To address such questions, a resolution was passed by the 70th General Convention of the Episcopal Church in 1988 stating that “there is no moral obligation to prolong the act of dying by extraordinary means ...”  The decision to withhold or withdraw treatment, the resolution declared, “should ultimately rest with the patient or the patient’s surrogate decision makers ...”  It also indicated that, when persons are in a comatose state with no reasonable hope of recovery, church members should seek the counsel of members of the church community “in contemplating the withholding or removing of life-sustaining systems, including hydration and nutrition.” 

Church reports

Two reports were published in the next few years, one from the Diocese of Washington and the other from an End-of-Life Task Force of the church.  These explained the view developed four centuries ago within the Roman Catholic tradition and adopted by many other Christian traditions that treatment is “extraordinary” and need not be used when it would impose grave burdens on a patient without offering significant benefits. 

What counts as a significant burden? Treatment is gravely burdensome for several different sorts of reasons: It will not reverse the underlying condition and return a person to a state of health; it will leave him or her radically disfigured; it will create great pain and suffering; it will require the person to travel great distances; or it will bankrupt a family.  The burdens of such treatment would have to be outweighed by overwhelming benefits if treatment were to be considered “ordinary” and morally required. 

What is it like to be in PVS?  According to the American Academy of Neurology, the cerebral cortex of those in PVS has been irreparably damaged, leaving them with no conscious awareness of their surroundings.  Because their brain stem, which controls their reflex responses, continues to function, they still breathe, have wake-sleep cycles, respond to loud noises and even laugh and cry – but for no apparent reason.

PVS is considered permanent after three months.  The number of well-documented cases of recovery after this time is excruciatingly small.  PVS differs from a “prolonged coma,” in which people with severe brain damage seem asleep and utterly unaware of the world around them.  Those in such a coma may respond to treatment and recover consciousness.  In general, comatose persons who recover do so gradually within two to four weeks.

Must tube feedings be given for an indefinite period of time to those in PVS because they cannot swallow on their own? That depends on whether tube feedings are considered akin to feeding a person food and water by mouth or more like a medical treatment similar to blood transfusions or the delivery of medication though an IV line. 

Prevailing view

The prevailing view within the Anglican tradition is that tube feedings are forms of medical treatment that can be ended, much as respirator use can be ended, when they amount to burdensome or “extraordinary” treatment.  The Lambeth Conference of 1998 declared that to sustain a person in PVS with artificial nutrition and hydration constitutes a medical intervention.  The End-of-Life Task Force of the General Convention stated in 2000 that:

“Certainly, depriving the weak of needed food and drink is a paradigmatic case of individual and social sin within the Christian tradition.  Even so, we must recognize that having a synthetic protein compound pumped directly into the intestine by skilled medical personnel is not the same as eating and drinking with friends.  It is a qualitatively different act from feeding a patient with a cup and spoon.”

The task force concluded that providing artificial nutrition and hydration is a medical intervention that can be ended when it amounts to invading a person’s body with disproportionately burdensome and ultimately futile treatment.  This is not a form of euthanasia, or intentional killing, which was rejected by the 1988 General Convention and subsequent reports.  The intention when artificial nutrition is withdrawn is to stop burdensome and futile measures and allow the underlying disease to take its course. 

Death is the foreseen and regretted outcome; it is not actively and gleefully willed. Will the patient die in suffering? Hospice physicians tell us that those who are approaching death often stop eating and drinking and die in comfort.  They do not complain of experiencing hunger and thirst.  Indeed, if they are given tube feedings, they can experience swelling and considerable discomfort. It is important, though, to provide them with measures to overcome a dry mouth and other forms of palliative care.

A decision about the morally appropriate use of artificial nutrition and hydration calls for discernment of the ends and purposes to be honored in a person’s living and dying. 

Christians are not “vitalists” who maintain that life is an end that must be maintained as long as possible, regardless of the burdens on the patient and family.  Instead, we have a responsibility to address decisions about whether to continue tube feedings for those near death and in PVS prayerfully, mindful of the love, concern and grace of God and the unique dignity and worth of each person.