Artificial Hydration and Nutrition

Question: My mother is 92-years-old and has lung cancer that has metastasized to her liver and brain. She has been declared incompetent and terminal by her physicians. She has stopped eating and her physicians have asked the family to consider inserting a feeding tube in her to give her nourishment. Are we required to insert a feeding tube?


Traditional moralists made a clear distinction between allowing-to-die, which entails foregoing disproportionate means where death is foreseen but not directly intended and direct killing by euthanasia. Allowing a patient to die by foregoing aggressive, non-beneficial treatments is not only morally permissible, but it is treating the patient with dignity and respect. The decision is based on the fact that physiological existence no longer offers these patients any hope at all of pursuing those goods for which human life is the fundamental condition. I would conclude that if the family believes that the feeding tube is burdensome and does not offer a reasonable hope of benefit for their mother, then the feeding tube would not need to be inserted. One option would be to place their mother in hospice or move toward palliative care only.

This position is supported by the tradition of the Catholic Church. The history of the Catholic Church’s position on the ordinary-extraordinary means distinction dates back to the 16th century Dominican moralists. The Dominican moralists, followed the tradition of the Church that states human life is a good but not an absolute good. As a relative good, one’s duty to preserve it is a limited duty. While a person has freedom over his or her life, one is never permitted to directly take one’s life. The issue becomes to what extent is one obligated to preserve one’s life. The traditional understanding of ordinary-extraordinary means remained basically unchallenged until the mid-1900s with the advent of advances in medicine and technology. How to apply the early distinction of ordinary-extraordinary means to issues like oxygen and feeding tubes, especially with permanently unconscious patients became hotly debated as early as the 1950s. Jesuit moralist Gerald Kelly was one of the first to examine this issue critically. He defined ordinary means of preserving life as “all medicines, treatments, and operations, which offer a reasonable hope of benefit for the patient and which can be obtained and used without excessive expense, pain, or other inconvenience.” Extraordinary means would be “all medicines, treatments, and operations, which cannot be obtained or used without excessive expense, pain, or other inconvenience, or which, if used, would not offer a reasonable hope of benefit” (Kelly, Medico-Moral Problems, 1957). The distinctive element of Kelly’s interpretation is that it is a patient-centered, quality-of-life approach which is consistent with how the 16th-century-Dominican moralists viewed this distinction. Kelly concludes that no person is morally obligated to use any means, and this would include natural or artificial means, that does not offer a reasonable hope of ameliorating the patient’s condition.

A contemporary understanding of the ordinary-extraordinary means distinction was given in the 1980 Congregation for the Doctrine of the Faiths’ Declaration on Euthanasia. The Declaration follows the tradition on the ordinary-extraordinary means distinction since the 16th century, which is based on the effect of the treatment on the patient or those responsible for the care of the patient. The Declaration reminds us of the duty one has to care for one’s own life and to seek such care for others. But there are limits to this obligation. One needs to judge the means used by “studying the type of treatment to be used, its degree of complexity or risk, its cost and the possibilities of using it, and comparing these elements with the result that can be expected, taking into account the state of the sick person and his or her physical and moral resources” (Congregation for the Doctrine of the Faith, “Declaration on Euthanasia,” 1980). The Declaration goes on to give four examples: patients are permitted to use experimental, advanced medical techniques, which may be a service to humanity; patients may interrupt treatments if they fall short of expectations; the refusal of a technique that is in use and carries a risk or is burdensome is not equivalent to suicide; finally, when death is imminent in spite of the means used, it is permitted in conscience to make the decision to refuse forms of treatment that would only secure a precarious and burdensome prolongation of life, so long as the normal care due to the sick person in similar cases is not interrupted (Congregation for the Doctrine of the Faith, 1980). Finally, the Congregation for the Doctrine of the Faith reflects the traditional teaching when it writes: “Life is a gift from God, and on the other hand death is unavoidable; it is necessary, therefore, that we, without in any way hastening the hour of death, should be able to accept it with full responsibility and dignity” (Congregation for the Doctrine of the Faith, 1980). The only real change is that the document realizes that the terms ordinary and extraordinary are imprecise as terms in regards to the rapid advancement of medicine and technology. More precise terms would be proportionate and disproportionate (Congregation for the Doctrine of the Faith, 1980).

The U. S. Conference of Catholic Bishop’s fourth edition of the Ethical and Religious Directives for Catholic Health Care Services (ERDs) provide authoritative ethical guidance for all those working in Catholic Health Care facilities. The introduction to Part 6 states the more restrictive standard: “These statements agree that hydration and nutrition are not morally obligatory either when they bring no comfort to a person who is imminently dying or when they cannot be assimilated by the person’s body” (United States Catholic Conference of Bishops, Introduction-Part 6, 2001). Directive 58 states clearly that, “There should be a presumption in favor of providing nutrition and hydration to all patients, including patients who require medically assisted nutrition and hydration, as long as this is of sufficient benefit to outweigh the burdens involved to the patient” (United States Catholic Conference of Bishops, 2001). This directive follows the traditional understanding of the ordinary-extraordinary means distinction, in which the benefits-burdens are understood broadly relative to the patient.