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Necessary decisions

Taking Sides for Schiavo
Like March Madness in the basketball world, participants in the debate over Terri Schiavo seemed driven to pick a team and root it on to victory, vanquishing the opponents. With her death, it’s time to put the madness behind us and attend not just to the passion but to the compassion on both sides of the debate. Both sides, after all, claimed to be on Terri’s side. Consider, then, two arguments, both Christian and both “pro-Terri.”

The first argument: We must provide food and drink for Terri. Terri might not count for much as the world counts, but she surely counts as among “the least of these” in Jesus’ parable. “In as much” as you gave food to the hungry or drink to the thirsty, Jesus said, you did it “as unto me” (Matt. 25).

To provide food and drink is simply the sort of care one human being owes another. It doesn’t matter whether the person is at home or in a hospital or in a hospice. It doesn’t matter whether food and drink are provided in a cup or in a bowl, through a straw or through a tube. Moreover, to withhold food and drink is to aim at Terri’s death, and that we must not do. We may allow some people to die sometimes when they are going to die anyway, but we may not kill them.

Even if you regard providing food and drink as medical treatment, it must still be regarded as “ordinary treatment,” not “extraordinary treatment.” The distinction depends not on whether the treatment is customarily given but on whether the benefits to the patient outweigh the burdens of the treatment to the patient. To an unconscious patient like Terri a feeding tube is hardly a burden—and the benefit is life.

If we fail to see life as a good, as a benefit to her, we have evidently accepted an unbiblical and Cartesian dualism of body and soul, reduced the self to its powers of rationality and choice, and reduced the body to being a mere container for what’s really important and valuable. Withholding food and drink may be an effective means to make certain that biologically tenacious patients die when their life is a burden to us, but it should be classified with other means of making certain people die, like blowing their brains out. Don’t do it! Don’t allow it!

I hope you find this argument compelling. I have tried to present it that way. But there is a second “pro-Terri” argument that I hope you also find compelling: We must withdraw artificial nutrition and hydration from Terri. Nasal-gastric tubes, J-tubes (feeding tubes placed directly into the intestine) and intravenous lines are medical procedures, and the same standards that apply to withholding or withdrawing of other medical procedures should apply also to artificial nutrition and hydration. Those standards must start from the recognition that caring for Terri requires respect for her integrity. Legally this respect is reflected in the right of competent patients to refuse medical treatment.

Christians regard life as a good, to be sure, but not as a second god. Remembering Jesus and following him, we can hardly make our own survival the law of our being. Christians may refuse medical care so that another may live. They may refuse medical procedures that may lengthen their days but do nothing to make those days more apt for their tasks of reconciliation or fellowship.

It is not shocking that Terri would have suggested she would not want artificial nutrition and hydration if she were in a persistent vegetative state. That decision must be honored if we would respect Terri’s Christian integrity. If there were no evidence of such a decision, or very uncertain evidence, then others would have to weigh the burdens and benefits of those medical procedures to Terri. In such cases we still may and still should withdraw artificial nutrition and hydration. If we regard the preservation of her biological life as a benefit to her, then we have evidently adopted an unbiblical vitalism, reduced her to her body and her body to a mere organism.

Moreover, although withdrawing artificial nutrition and hydration may have death as a consequence, death is not intended but accepted in that action. To insist that artificial nutrition and hydration be continued is to make Terri a prisoner of medical technology and should be classified with other imprisonments imposed without due process. Don’t do it! Don’t allow it!

What shall we say about these arguments? First, that they are not new or original. They have been articulated not just over the past 30 days but over the past 30 years among both Catholic and Protestant moral theologians.

Second, there are some important areas of agreement in these two quite different positions. Both sides agree that there is an important moral distinction between killing and allowing to die. They disagree on whether withdrawing “food and drink” (or “artificial nutrition and hydration”) is more like killing or more like letting die. Both use the language of “ordinary” and “extraordinary” to refer to the importance of weighing the burdens and benefits of treating Terri. They disagree about how to describe and weigh the benefits and burdens. Both sides agree that Terri is to be treated and cared for as an embodied self. They disagree about whether the greater risk is that she will be reduced to her capacities for rational choice or that she will be reduced to biological organism.

Third, the disagreements suggest the importance of perspective, of how we see and describe what’s going on. Do we see removing a feeding tube as the refusal to give food and drink or the withdrawal of medical technology? Do we see an embodied self being reduced to capacities for rational agency or being reduced to biological organism?

Short of an agreement about what should be decided, we ask, “Who should decide?” And short of an agreement about how to describe the case, we ask, “Who should decide how to describe what’s going on?” But now things get tricky, because how we see matters here, too. If what is going on is the refusal to provide food and drink, and if that perspective leads us to describe the case as killing, then killing is not a choice for anyone to make. To give priority to the procedural question “Who should decide?” then seems dangerously close to issuing a license to kill. Of course, the question looks innocent and reasonable when we don’t see the case in that way.

But how to see and describe the case is precisely what is at stake. So we enter a regress: “Who should decide who should decide what’s going on?” The answer to that question in our culture has frequently been the courts. The courts allocate choice-making powers to some and not to others. Sometimes there is no alternative to this move. Sometimes, as a last resort, we must simply decide who should decide. But we should not rush to the last resort. Our obligation is not just to decide who should decide but to listen to one another and to consider our own need for “corrective vision.”

The lessons are two. First, continue the conversation. The courts too often put a stop to the conversation by simply deciding who should decide. Because the patient is the one who should decide, it has become a commonplace to urge people to prepare an advance directive. I’m not sure that helps as much as commonly supposed—unless it is done in conversation with one’s community.

One context for continuing this conversation must be the churches. Churches need to be communities of moral discourse and discernment. There, in memory of Jesus, Christians learn that life is a great gift but that death is not the greatest evil. We learn that we need not use all of our resources against death, that the victory over death is finally a divine victory, not a technological victory. By listening to the stories of scripture and to the stories of Christian physicians and nurses and families that care for the dying, we may yet learn together a wisdom that can correct our vision.

The second lesson is this: appreciate ambiguity. There are situations where there are no right answers, no good answers, situations where goods collide and cannot all be chosen, where evils gather and cannot all be avoided. There may be situations—and I think there are such situations—in which it is morally appropriate to withhold medical procedures (including procedures for nutrition and hydration). That does not make death a good.

That claim, of course, discloses my sympathy with the second “pro-Terri” argument.

The first “pro-Terri” argument, however, may at least warn us against the possibility of slipping into regarding Terri as a burden and of justifying this way (or others) of eliminating our burdens by making certain that biologically tenacious patients die. Churches do not escape ambiguity, but they can remind us of God’s forgiveness and so nurture the courage to make a necessary but necessarily ambiguous decision.

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