Vatican CDF on Nutrition to
Patients in Vegetative State
"Responses to Certain Questions of the
United States Conference of
Concerning Artificial Nutrition and Hydration."
"A Person With Fundamental Human Dignity"
VATICAN CITY, SEPT. 14, 2007 (Zenit.org).- Here is the note published
today by the Congregation for the Doctrine of the Faith entitled
"Responses to Certain Questions of the United States Conference of
Catholic Bishops Concerning Artificial Nutrition and Hydration."
* * *
First question: Is the administration of food and water (whether by
natural or artificial means) to a patient in a "vegetative state"
morally obligatory except when they cannot be assimilated by the
patient's body or cannot be administered to the patient without causing
significant physical discomfort?
Response: Yes. The administration of food and water even by artificial
means is, in principle, an ordinary and proportionate means of
preserving life. It is therefore obligatory to the extent to which, and
for as long as, it is shown to accomplish its proper finality, which is
the hydration and nourishment of the patient. In this way suffering and
death by starvation and dehydration are prevented.
Second question: When nutrition and hydration are being supplied by
artificial means to a patient in a "permanent vegetative state," may
they be discontinued when competent physicians judge with moral
certainty that the patient will never recover consciousness?
Response: No. A patient in a "permanent vegetative state" is a person
with fundamental human dignity and must, therefore, receive ordinary
and proportionate care which includes, in principle, the administration
of water and food even by artificial means.
* * *
The Supreme Pontiff Benedict XVI, at the audience granted to the
undersigned cardinal prefect of the Congregation for the Doctrine of
the Faith, approved these responses, adopted in the Ordinary Session of
the Congregation, and ordered their publication.
Rome, from the Offices of the Congregation for the Doctrine of the
Faith, Aug. 1, 2007.
William Cardinal Levada
Angelo Amato, S.D.B.
Titular Archbishop of Sila
Commentary on Artificial
Hydration and Nutrition
The Sick "Have the Right to Basic Health Care"
VATICAN CITY, SEPT. 14, 2007 (Zenit.org).- Here is a commentary issued
today by the Congregation for the Doctrine of the Faith on "Responses
to Certain Questions of the United States Conference of Catholic
Bishops Concerning Artificial Nutrition and Hydration."
* * *
The Congregation for the Doctrine of the Faith has formulated responses
to questions presented by His Excellency the Most Reverend William S.
Skylstad, president of the United States Conference of Catholic
Bishops, in a letter of July 11, 2005, regarding the nutrition and
hydration of patients in the condition commonly called a "vegetative
The object of the questions was whether the nutrition and hydration of
such patients, especially if provided by artificial means, would
constitute an excessively heavy burden for the patients, for their
relatives, or for the health care system, to the point where it could
be considered, also in the light of the moral teaching of the Church, a
means that is extraordinary or disproportionate and therefore not
The address of Pope Pius XII to a congress on anesthesiology, given on
Nov. 24, 1957, is often invoked in favor of the possibility of
abandoning the nutrition and hydration of such patients. In this
address, the Pope restated two general ethical principles. On the one
hand, natural reason and Christian morality teach that, in the case of
a grave illness, the patient and those caring for him or her have the
right and the duty to provide the care necessary to preserve health and
On the other hand, this duty in general includes only the use of those
means which, considering all the circumstances, are ordinary, that is
to say, which do not impose an extraordinary burden on the patient or
on others. A more severe obligation would be too burdensome for the
majority of persons and would make it too difficult to attain more
important goods. Life, health and all temporal activities are
subordinate to spiritual ends. Naturally, one is not forbidden to do
more than is strictly obligatory to preserve life and health, on
condition that one does not neglect more important duties.
One should note, first of all, that the answers given by Pius XII
referred to the use and interruption of techniques of resuscitation.
However, the case in question has nothing to do with such techniques.
Patients in a "vegetative state" breathe spontaneously, digest food
naturally, carry on other metabolic functions, and are in a stable
situation. But they are not able to feed themselves. If they are not
provided artificially with food and liquids, they will die, and the
cause of their death will be neither an illness nor the "vegetative
state" itself, but solely starvation and dehydration.
At the same time, the artificial administration of water and food
generally does not impose a heavy burden either on the patient or on
his or her relatives. It does not involve excessive expense; it is
within the capacity of an average health care system, does not of
itself require hospitalization, and is proportionate to accomplishing
its purpose, which is to keep the patient from dying of starvation and
dehydration. It is not, nor is it meant to be, a treatment that cures
the patient, but is rather ordinary care aimed at the preservation of
What may become a notable burden is when the "vegetative state" of a
family member is prolonged over time. It is a burden like that of
caring for a quadriplegic, someone with serious mental illness, with
advanced Alzheimer's disease, and so on. Such persons need continuous
assistance for months or even for years. But the principle formulated
by Pius XII cannot, for obvious reasons, be interpreted as meaning that
in such cases those patients, whose ordinary care imposes a real burden
on their families, may licitly be left to take care of themselves and
thus abandoned to die. This is not the sense in which Pius XII spoke of
Everything leads to the conclusion that the first part of the principle
enunciated by Pius XII should be applied to patients in a "vegetative
state": in the case of a serious illness, there is the right and the
duty to provide the care necessary for preserving health and life. The
development of the teaching of the Church's magisterium, which has
closely followed the progress of medicine and the questions which this
has raised, fully confirms this conclusion.
The Declaration on Euthanasia, published by the Congregation for the
Doctrine of the Faith on May 5, 1980, explained the distinction between
proportionate and disproportionate means, and between therapeutic
treatments and the normal care due to the sick person: "When inevitable
death is imminent in spite of the means used, it is permitted in
conscience to take 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" (Part IV).
Still less can one interrupt the ordinary means of care for patients
who are not facing an imminent death, as is generally the case of those
in a "vegetative state"; for these people, it would be precisely the
interruption of the ordinary means of care which would be the cause of
On June 27, 1981, the Pontifical Council Cor Unum published a document
entitled "Some Ethical Questions Relating to the Gravely Ill and the
Dying," in which, among other things, it is stated, "There remains the
strict obligation to administer at all costs those means which are
called 'minimal': that is, those that normally and in usual conditions
are aimed at maintaining life (nourishment, blood transfusions,
injections, etc.). The discontinuation of these minimal measures would
mean in effect willing the end of the patient's life" (No. 2.4.4.).
In an address to participants in an international course on forms of
human preleukemia on Nov. 15, 1985, Pope John Paul II, recalling the
Declaration on Euthanasia, stated clearly that, in virtue of the
principle of proportionate care, one may not relinquish "the commitment
to valid treatment for sustaining life nor assistance with the normal
means of preserving life," which certainly includes the administration
of food and liquids. The Pope also noted that those omissions are not
licit which are aimed "at shortening life in order to spare the patient
or his family from suffering."
In 1995 the Pontifical Council for Pastoral Assistance to Health Care
Workers published the Charter for Health Care Workers, paragraph 120 of
which explicitly affirms: "The administration of food and liquids, even
artificially, is part of the normal treatment always due to the patient
when this is not burdensome for him or her; their undue interruption
can have the meaning of real and true euthanasia."
The Address of John Paul II to a group of bishops from the United
States of America on a visit "ad limina," on Oct. 2, 1998, is quite
explicit: Nutrition and hydration are to be considered as normal care
and ordinary means for the preservation of life. It is not acceptable
to interrupt them or to withhold them, if from that decision the death
of the patient will follow. This would be euthanasia by omission (cf.
In his address of March 20, 2004, to the participants of an
international congress on "Life-sustaining Treatments and the
Vegetative State: Scientific Progress and Ethical Dilemmas," John Paul
II confirmed in very clear terms what had been said in the documents
cited above, clarifying also their correct interpretation. The Pope
stressed the following points:
1) "The term permanent vegetative state has been coined to indicate the
condition of those patients whose 'vegetative state' continues for over
a year. Actually, there is no different diagnosis that corresponds to
such a definition, but only a conventional prognostic judgment,
relative to the fact that the recovery of patients, statistically
speaking, is ever more difficult as the condition of vegetative state
is prolonged in time" (No. 2).
2) In response to those who doubt the "human quality" of patients in a
"permanent vegetative state," it is necessary to reaffirm 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'" (No. 3).
3) "The sick person in a vegetative state, awaiting recovery or a
natural end, still has the right to basic health care (nutrition,
hydration, cleanliness, warmth, etc.), and to the prevention of
complications related to his confinement to bed. He also has the right
to appropriate rehabilitative care and to be monitored for clinical
signs of possible recovery. I should like particularly to underline how
the administration of water and food, even when provided by artificial
means, always represents a natural means of preserving life, not a
medical act. Its use, furthermore, should be considered, in principle,
ordinary and proportionate, and as such morally obligatory, to the
extent to which, and for as long as, it is shown to accomplish its
proper finality, which in the present case consists in providing
nourishment to the patient and alleviation of his suffering" (No. 4).
4) The preceding documents were taken up and interpreted in this way:
"The obligation to provide the 'normal care due to the sick in such
cases' (Congregation for the Doctrine of the Faith, Declaration on
Euthanasia, p. IV) includes, in fact, the use of nutrition and
hydration (cf. Pontifical Council Cor Unum, "Some Ethical Questions
Relating to the Gravely Ill and the Dying," No. 2, 4, 4; Pontifical
Council for Pastoral Assistance to Health Care Workers, Charter for
Health Care Workers, No. 120).
The evaluation of probabilities, founded on waning hopes for recovery
when the vegetative state is prolonged beyond a year, cannot ethically
justify the cessation or interruption of minimal care for the patient,
including nutrition and hydration. Death by starvation or dehydration
is, in fact, the only possible outcome as a result of their withdrawal.
In this sense it ends up becoming, if done knowingly and willingly,
true and proper euthanasia by omission" (No. 4).
Therefore, the responses now given by the Congregation for the Doctrine
of the Faith continue the direction of the documents of the Holy See
cited above, and in particular the Address of John Paul II of March 20,
2004. The basic points are two.
It is stated, first of all, that the provision of water and food, even
by artificial means, is in principle an ordinary and proportionate
means of preserving life for patients in a "vegetative state": "It is
therefore obligatory, to the extent to which, and for as long as, it is
shown to accomplish its proper finality, which is the hydration and
nourishment of the patient."
It is made clear, secondly, that this ordinary means of sustaining life
is to be provided also to those in a "permanent vegetative state,"
since these are persons with their fundamental human dignity.
When stating that the administration of food and water is morally
obligatory in principle, the Congregation for the Doctrine of the Faith
does not exclude the possibility that, in very remote places or in
situations of extreme poverty, the artificial provision of food and
water may be physically impossible, and then "ad impossibilia nemo
However, the obligation to offer the minimal treatments that are
available remains in place, as well as that of obtaining, if possible,
the means necessary for an adequate support of life. Nor is the
possibility excluded that, due to emerging complications, a patient may
be unable to assimilate food and liquids, so that their provision
becomes altogether useless. Finally, the possibility is not absolutely
excluded that, in some rare cases, artificial nourishment and hydration
may be excessively burdensome for the patient or may cause significant
physical discomfort, for example resulting from complications in the
use of the means employed.
These exceptional cases, however, take nothing away from the general
ethical criterion, according to which the provision of water and food,
even by artificial means, always represents a natural means for
preserving life, and is not a therapeutic treatment. Its use should
therefore be considered ordinary and proportionate, even when the
"vegetative state" is prolonged.
 Terminology concerning the different phases and forms of the
"vegetative state" continues to be discussed, but this is not important
for the moral judgment involved.