Editor’s Note: The following is a moral analysis intended to help form the reader’s conscience. It is not intended, nor should it be construed, as medical or legal advice.  

Q. Is it ethical to remove the feeding tube from a person who has been in a vegetative state for two years, if doing so will result in her death?  

A. The short response to your question is “No,” this would not be morally permissible solely on the grounds that two years have passed or that the patient is in a so-called vegetative state. However, there may be other circumstances when refusing or removing a feeding tube is morally permissible. Let us explain.  

The bioethical principle often called the “Principle of Ordinary and Extraordinary Means” helps a patient or his health-care proxy determine which medical options are ordinary or proportionate (must be accepted or continued) and which options are extraordinary or disproportionate (may be refused or discontinued). The principle entails case-specific judgments by the patient or patient’s proxy informed by the hope of benefit and the burdensomeness of an intervention. As such, there is no definitive list of which means are always ordinary and which are always extraordinary.  

Different patients in similar clinical situations may come to different moral judgments about whether an intervention is ordinary. Benefits and burdens can also include nonphysical considerations such as allowing an opportunity for a final good-bye (benefit) or significant financial expense (burden). Some moral theologians even argue that any intervention offered to the patient is ordinary until the patient has received sacramental forgiveness of mortal sins, which can come through confession or anointing of the sick (when the patient is incapable of confession). 

Special consideration must be given to the provision of food and water — even when delivered through artificial means like a feeding tube or intravenous tube (IV) — because of the fundamental duty to provide basic human care to our neighbor. This duty remains in principle when a patient is in a so-called persistent vegetative state (PVS) or any other neurological condition that involves little or no responsiveness.  

When the nutrition and hydration accomplishes its purpose, it is considered beneficial. The benefit of medically assisted nutrition and hydration (ANH) is not determined based on whether the patient will regain functions or recover, but simply on whether it will nourish and hydrate the patient. There would be no benefit, for example, if the patient is unable to assimilate the nutrition and hydration — and so it could be declined.  

Even when the patient is able to assimilate the ANH, it may nonetheless become morally optional if it causes excessive burdens. An example might be recurring infection at the site of tube insertion. It also becomes optional when death is truly imminent, but imminent death can be determined only rarely in practice. Imminent death means that the physician has moral certitude that the patient will die within hours, or perhaps within a day or two, from a definite pathological condition such as an aggressive cancer. The key here is that death is expected to result from the underlying illness and not from starvation or dehydration. 

We can see a detailed explanation of the Principle of Ordinary and Extraordinary Means in the “Ethical and Religious Directives for Catholic Health Care Services” (ERDs), published by the U.S. Conference of Catholic Bishops, which state: 

“A person has a moral obligation to use ordinary or proportionate means of preserving his or her life. Proportionate means are those that in the judgment of the patient offer a reasonable hope of benefit and do not entail an excessive burden or impose excessive expense on the family or the community” (56).  

“A person may forgo extraordinary or disproportionate means of preserving life. Disproportionate means are those that in the patient’s judgment do not offer a reasonable hope of benefit or entail an excessive burden, or impose excessive expense on the family or the community” (57). 

The ERDs also give practical application of this teaching to patients in a so-called PVS: 

“In principle, there is an obligation to provide patients with food and water, including medically assisted nutrition and hydration for those who cannot take food orally. This obligation extends to patients in chronic and presumably irreversible conditions (e.g., the ‘persistent vegetative state’) who can reasonably be expected to live indefinitely if given such care. Medically assisted nutrition and hydration become morally optional when they cannot reasonably be expected to prolong life or when they would be ‘excessively burdensome for the patient or [would] cause significant physical discomfort, for example resulting from complications in the use of the means employed.’ For instance, as a patient draws close to inevitable death from an underlying progressive and fatal condition, certain measures to provide nutrition and hydration may become excessively burdensome and therefore not obligatory in light of their very limited ability to prolong life or provide comfort” (58). 

These directives articulate the consistent moral teaching of the Catholic Church on this matter, which was reaffirmed most recently in the 2020 letter Samaritanus Bonus from the Congregation (now Dicastery) for the Doctrine of the Faith.  

“In particular, required basic care for each person includes the administration of the nourishment and fluids needed to maintain bodily homeostasis, insofar as and until this demonstrably attains the purpose of providing hydration and nutrition for the patient. [Nutrition and hydration] are instead forms of obligatory care of the patient, representing both a primary clinical and an unavoidable human response to the sick person. Obligatory nutrition and hydration can at times be administered artificially, provided that it does not cause harm or intolerable suffering to the patient” (3). 

For other examples of this consistency, Pope St. John Paul II wrote about the moral obligation in principle to provide ANH to patients, including those in a so-called PVS, in a 2004 address. And that was reaffirmed by the Congregation for the Doctrine of the Faith in its 2007 “Responses to Certain Questions Concerning Artificial Nutrition and Hydration” and in the corresponding commentary.  

We hope this response is helpful as you continue to ask the Lord for his graces and wisdom through prayer and the sacraments. The Catechism of the Catholic Church reminds us that “in the formation of conscience the Word of God is the light for our path,” and we must assimilate it in faith and prayer. We must also examine our conscience before the Lord’s cross. “We are assisted by the gifts of the Holy Spirit, aided by the witness or advice of others, and guided by the authoritative teachings of the Church” (1785).