Markkula Center of Applied Ethics

"Church Autonomy" in Medical Ethical Decision Making

By Nicole Van Groningen

This article is a reflection on an Ethics Center presentation, " Nutrition, Hydration, and Patients in a Permanent Vegetative State: Has the Vatican Changed the Rules:" with panelists Margaret R. McLean, Center director of biotechnology and health care ethics, and Gerald Coleman, S.S., Vice President, Corporate Ethics, Daughters of Charity Health System, held April 29, 2008.

The Ethics at Noon discussion of patients in a persistent vegetative state (PVS) revolved around the March 2004 allocution in which Pope John Paul II declared that Catholics have a moral obligation to provide artificial nutrition and hydration (ANH) to patients in PVS. This declaration challenged previous church teaching that there were certain "moral impossibilities" that could arise in caring for your life. For instance, humans would not be required to preserve their lives if it necessitated eating expensive foods or suffering tremendous pain. Moreover, Pope Pius XII asserted in 1957 that only "ordinary means" need be taken to preserve one's life. What has changed recently, however, is the definition of "ordinary means." According to Pope John Paul II, the administration of artificial hydration and nutrition (ANH) is basic, natural, and ordinary. It should therefore be provided to patients in PVS.

The biggest ethical concern inherent in this discussion of the administration of ANH in PVS patients is the issue of autonomy.1 In the American medical context, patient autonomy is perhaps valued over all else. As such, health care providers tend to favor treatments that are in alignment with the patient's wishes. But in PVS patients, it is impossible to determine what those wishes are, and surrogate decision makers cannot always make decisions representative of the patient's true desires.

In the health care setting, conflicts in autonomy can arise between patients (or their surrogate decision makers) and physicians. But for Catholics, there may be a conflict in autonomy between the patient and the church. Although the patient would like to be in control of his or her medical care and end of life decisions, the recent declaration that it is morally obligatory to administer ANH to persons in PVS limits this autonomy.

During the lecture, I found myself contemplating the idea of "church autonomy" in medical decision making. Although it is true that many personal medical decisions are heavily influenced by religion, we are not accustomed to thinking of churches and religions as having ultimate authority in health care decisions. Is this what the Catholic Church seems to be striving for? Other religions, such as the Jehovah's Witnesses, have made similar demands. Considering this, it seems appropriate to think of religion as more than a mere influence in a patient's decision-making process, but rather as an institution claiming its own autonomous place in the decision making circle that we ordinarily recognize as comprised of only patients, surrogate decision makers, and health care providers.

While some interpret the Pope's declaration that ANH should be administered as doctrine, others claim it is just a pastoral suggestion. If it were, in fact, an opinion, then this teaching would probably only serve as guidance in helping patients make PVS-related decisions. But if it is true doctrine, it seems that my idea of "church autonomy" is one that merits real reflection and discussion.

1Patient autonomy is the right patients have to make their own medical decisions without physicians or other health care workers attempting to influence or coerce them. Physicians, too, can exercise autonomy by refusing to perform procedures with which they do not agree.

Nicole Van Groningen was the valedictorian of the SCU class of 2008. At Santa Clara, she majored in physics and minored in religious studies. She is currently working at St. Jude Children's Research Hospital in Memphis, TN while applying to medical schools for a joint degree in medicine and public health.

July 2008

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