(Cross-posted from Musing's musings.)

This post has been coming on for a while. It was the Terri Schiavo mess that caralyzed it, but that's hardly the only reason it's been on my mind. This has not been a great spring for me, for my family, or for my circle of friends. My friend and spiritual director lost a seven-year battle with cancer in February, just weeks after my stepfather had to have double bypass surgery, and subsequently suffered a very small stroke. And just before Easter, a friend of mine who was Fr. Stephen's primary caregiver (and probably his best friend) had to take her husband to the emergency room, where he was diagnosed with a 100% blockage of his left anterior descending coronary artery (a condition known in the trade as "the widowmaker" which is usually detected only at autopsy).

Fortunately for all concerned, the two latter gentlemen both underwent successful surgeries and are recuperating nicely (although one of them is definitely, and the other is possibly, getting on his wife's nerves). But all the time I've spent in hospitals and nursing homes, or hearing stories of how other people close to me were spending time there, has definitely brought a few end-of-life issues to my mind.

I already have both a living will and a limited medical power of attorney on file. I felt it was a reasonable precaution to take before I made my second pilgrimage to Israel in 2000, given the fact that the second intifada had started barely a month before we left. And since I was going to see my lawyer to update my will anyway, I was able to kill three sets of legal documents with one set of visits.

Something the Schiavo case brought up, however, and which was briefly touched on in NPR's report this afternoon on the linkage between Schiavo's situation and that of the pope, was exactly what constituted "extraordinary" lifesaving measures. The distinction is a fairly important one at least in Catholic moral theology, because a Catholic is only permitted to refuse the extraordinary measures. Ordinary or routine matters are non-negotiable.

The pope, it is alleged, has determined that the provision of food and water, even if through a feeding tube, constitutes a routine measure and cannot legitimately be refused (or removed, if the practitioner is Catholic). It is worth noting, however, that while I have seen and heard this allegation several times, no one has ever provided a citation for the document in which the pope's claim was made, or referenced the speech or allocution in which he made it. I haven't been able to find it in the Vatican's online archive of papal documents, though I also haven't been looking for it very hard lately--too many other things on my mind.

If the reports are in fact an accurate summary of the pope's position, it may turn out to be yet another thing on which he and I will have to agree, charitably, to disagree. I cannot dismiss his reasoning out of hand: I have to read it first, check his sources, and devote some thought and some prayer to the issue, at a bare minimum, before I can begin to think about dissenting. That's also standard Catholic doctrine, though understandably not one beloved of His Germanic Eminence Josef Cardinal Ratzinger.

From my own perspective, as a person of faith who is also trained in logic and reasoning (and who has a fair background in medical science as well), it is difficult for me to see how the pope could legitimately classify the artificial provision of food and water as a routine measure of care and not an extraordinary one--at least in any case where the artificial provision of nutrition and hydration was the only way the patient was ever going to be able to receive it.

We can start by noting that the kind of permanent feeding tube that was removed 10 days ago from Terri Schiavo requires a surgical intervention before it can be used. Other extraordinary measures, such as artificial respiration or electrocardiac shock, do not. (Though it is usual to perform a tracheotomy, such as was performed on the pope last month, when the patient is going to be on a respirator for a prolonged period of time, this is not a requirement to start the therapy.)

Second, if food and water are classified as basic necessities of life (which they are, in the normal course of affairs), it is hard to see how cutting off a patient's oxygen or air (as is done when a ventilator is turned off) could legitimately be deemed a morally permissible act (which it is). Of food, water, and air, the one that is most necessary to life is undoubtedly air. Cut off our air supply for even a few minutes and we shuffle off this mortal coil. It takes days or weeks to die from a lack of water or food.

There can be no question that a feeding tube constitutes an artificial life-support measure in a person such as Terri Schiavo who is in a permanent vegetative state. One consequence of the tremendous damage to Schiavo's brain is that she lacks control over most (if not all) voluntary functions--including the act of swallowing. Once the food or water has been swallowed, the autonomic or involuntary nervous system takes over the job of moving it down the esophagus, into the stomach, through the intestines, and then out again. But to get the process started requires a conscious act. Less than a century ago, when a person got to that stage, s/he was done for. There was no way to prolong his or her life past the point where the kidneys shut down or the body wasted away after consuming its own resources.

Granted, this is 2005, not 1915. We can do tremendous things with medical science, even routinely, that would have been considered virtually miraculous back then. But the $64,000 question is whether we are morally obligated to do something, especially something that unquestionably constitutes an artificial intervention in a natural process (i.e., dying), simply because we can.

I would have to argue, and the Catholic Church would normally agree with me, that because we can is never a morally sufficient argument for doing anything. We can, after all, destroy the world through self-inflicted nuclear holocaust. I haven't heard anybody arguing that was all of a sudden a moral imperative. Why should the provision of a feeding tube be any different? (Not that I'm making a facile equation of the two, mind you, but the principle is the same in both cases.)

It seems obvious to me that the provision of nutrition and hydration through a feeding tube is both morally permissible and morally required when the paralysis or inability to eat normally is only temporary, or as long as there is some reasonable hope that recovery is possible--assuming, of course, that the patient had not specifically directed that such treatment was not to be undertaken in the first place. But once it becomes obvious that the condition is not temporary, or that recovery is no longer reasonably to be hoped for, it should also be morally plausible to suspend the treatment.

There are a number of bases from which to conclude that the removal of a feeding tube under such circumstances is morally permissible. The first and simplest of these is the principle of the double effect. The removal of the feeding tube will of course inevitably result in the death of the patient, who is unable to take nourishment on his or her own. But so long as this is not a directly intended end, the action is morally permissible.

Another plausible base on which to build a case is the question of limited resources. Full-time nursing care for someone in a permanent vegetative state does not come cheaply: circa $80,000 a year for Terri Schiavo alone (at least that is the figure that has been bandied about the blogs these last few days). If we had infinite resources, we could of course provide for those needs and we would have a moral obligation to do so. But we aren't even close to having infinite resources, and the money is only the last and least of the resources in question. We don't have adequate facilities for long-term care, we don't have an adequate pool of highly trained staff to operate the facilities we already do have, let alone all the ones we would need to do an adequate job for everybody who needed this kind of intensive care.

I would never dare to suggest that lack of wherewithal (financial or otherwise) could constitute a morally sufficient reason to withhold or remove medical treatment automatically. That is the bugaboo the Weepublicans (and some Catholics) brandish before the public whenever people start talking about end-of-life issues such as refusal of extraordinary measures or euthanasia), but it is the reddest of red herrings. If resources can be found to cover the costs of such care, and its provision is not otherwise removing scarce medical resources from the pool available to treat others in need of those services, by all means, let the treatment continue. But do we really want to legislate or moralize ourselves into a situation where we as a nation (or we as individuals, whether alone or in groups--in such things as insurance pools, for example) are going to be required to provide absolutely any medical procedure any patient needs, for as long as the patient needs it? Because if we go down that road, my friends, there are going to be an awful lot of other things we're going to have to give up (like all those billions of dollars we don't actually have in the till that the Maximum Doofus is sending over to Iraq every day).

Of course, the simplest solution to the problem is to have as many people as possible make advance directives for their care if they should ever wind up in a situation analogous to that of Terri Schiavo. That's one of the rare silver linings inside the dark cloud that hangs over the poor woman's last few days on this earth: by all accounts, filings of wills and living wills and medical powers of attorney are significantly up all across the country. People are talking about the case--and expressing their own feelings on being kept alive through artificial means--at dinner tables and in offices, with friends and family, on a level probably never seen before, and perhaps never to be seen again.