Pulling the Plug

After giving them the entire synopsis of the Gospel for the first eleven chapters of his letter to the Romans, St. Paul tells the Christians to be “transformed by the renewal of your mind” (Romans 12:2).  In essence he is telling them that the Gospel ought to penetrate into every single dimension of their lives.  This is the role of the Church as Teacher—to show us just how deeply the Gospel penetrates all areas of our lives and how we can act as “heirs of God and joint heirs with Christ” (Romans 8:17) in all things.  For converts coming into the Church, it is often the Catholic intellectual tradition that makes the Church herself attractive because it reveals truth as an integrative whole—incorporating not just divine Revelation, but philosophy, science and even psychology all leading us to the One Who is Truth itself.  There may be no single area where this integration is more obvious than in the Church’s teaching on end of life.

Modern medicine is plagued by the problem that there is no strictly scientific way in which to determine when someone has died.  St. John Paul II in an Address to the Eighteenth Meeting of the Transplantation Society in 2000 acknowledged this difficulty when he said:

“…the death of the person is a single event, consisting in the total disintegration of that unitary and integrated whole that is the personal self. It results from the separation of the life-principle (or soul) from the corporal reality of the person. The death of the person, understood in this primary sense, is an event which no scientific technique or empirical method can identify directly.”

In defining death as the separation of the soul from the body, it is obvious that it cannot be determined empirically since the soul is non-material in nature.  Furthermore, as the Holy Father pointed out death is not a process but the definite termination of the life of the person.  What this means is that not all parts of the body die at the same time (fingernails and hair continue to grow for example).  Further complicating this is the fact that through ventilators and heart pumps the person can appear to be alive almost indefinitely.  In summary, it seems at best that medicine can only develop a set of criteria that makes the fact that death has occurred very likely.

Despite the fact that no empirical method can identify when death actually occurs, it is possible to apply Thomistic principles in order to create a criterion for death and leave it to modern medicine to determine what clinical signs may be used to obtain moral certainty that death has occurred.

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To understand these principles, we must first look at the Catholic understanding of the human soul.  Technically speaking the soul is simply the animating principle of each living thing.  In other words, there is no such thing as a living being that does not have a soul.  There are three different types of souls that exist in a nested hierarchy of sorts.  First there is a vegetative soul that has the capacity for growth, assimilate nutrition and reproduction.  A sensitive soul has all the capacities of the vegetative soul plus has the capacity for locomotion and perception.  Finally the intellectual soul has all the capacities of the other two plus the capacity for rational thought.

It is also necessary to examine what we mean when say that “the soul is in the body.”  When a spiritual principle is “in” a material principle it really means that the spiritual principle is operating upon it.  But the human soul does not operate upon each part of the body directly.  When I will to raise my hand, it is not my will that operates directly on my arm, but instead it operates on a “primary organ” through which the soul “moves” or “operates” the body’s other parts.    Although St. Thomas thought this organ was the heart, modern biology tells us that this organ is the brain.  His philosophy was solid, he just lacked the necessary biological knowledge to be more precise.

With this understanding of the human soul and its action upon the human body serving as a foundation, we can now apply this to the practical question of when death occurs.  To say that the soul “has left” the body is to say that the soul is no longer acting upon the body.  Because the union of body and soul is a substantial one, this can only occur when it is no longer able to operate on the body because of a permanent defect in the primary organ (the brain).  This is the basis for the Church’s support of the “neurological criteria” for ascertaining death.

The problem of course is that medically speaking, “neurological criteria” for determining death means different things to different people, but the Church has a very specific understanding of this criteria.  Returning to St. John Paul II’s 200 address, he says, “…in establishing, according to clearly determined parameters commonly held by the international scientific community, the complete and irreversible cessation of all brain activity (in the cerebrum, cerebellum and brain stem).”  This is the so-called “whole brain death.”

To see why this must be so, we can return to St. Thomas’ teachings on the human soul.  The human soul operates in three different capacities—rational, sensitive, and vegetative.  Although we have a single soul, not all these capacities need to be exercised for the soul to be present (think of when we are asleep for example).  Even if the higher capacities can no longer be exercised because of brain damage, the soul is still present and operating in its vegetative capacity.  In other words, when the vegetative capacity can no longer be exercised, we can be morally certain that the soul has left the body and the person may be declared dead.

The person who still has vegetative powers is still in fact alive and loses none of their dignity as a person.  They may be in what is defined medically as a (Permanent) Vegetative State (PVS), but they are still a person and entitled to the care that we afford all people who are incapacitated in some way.  This care includes things such as bathing, warmth, turning them to avoid bedsores, pain relief and most importantly providing food and water.

These basic elements of care are distinct from medical treatments (which are interventions made to return someone to health or cure disease) and are never optional.  There is a tendency within some medical communities to treat those in PVS as if they are already dead and only the body is left.  This leads to the practice of removing nutrition and hydration from them; a practice that was rejected by the CDF in their 2007 document Responses to Certain Questions of the USCCB Concerning Artificial Nutrition and Hydration.  In a very clear manner it was taught that

“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. 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.”

This is why the Church so vociferously opposed the ruling in the Terry Schiavo case.  While she was in a PVS and very unlikely to ever regain use of her higher faculties, she was not dying.  Instead her cause of death was dehydration and starvation.  Unfortunately there are cases every single day that do not garner the same national attention, that still require our attention.  All too often when confronted with what appears only to be a medical decision, families defer to unethical doctors.  “Pulling the plug” is always a moral decision and one that we can make well when we value and attempt to see the truth of the Church’s teachings.

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