Dr. Chris Kahlenborn is an internist in Altoona, Pennsylvania.
He serves as president of the Polycarp Research Institute (www.polycarp.org).
He spoke with Tim Drake about the dynamics and ethics of denying a person
nutrition and hydration.
What happens to a person when he or she is denied food
The first thing is that after 2-3 days you get extremely
dehydrated. That results in a lot of changes in the body. Your mucous membranes
and your skin get very dry. Your mouth cracks. It’s very uncomfortable.
Your urine becomes very concentrated and acidic, making it uncomfortable
Then your heart rate increases, your blood pressure decreases,
and after about the third day, your kidneys start to develop problems. When
the kidneys are damaged enough, they cannot get rid of the poison in the
body. Blood urea nitrogen (BUN) builds up. The effect that this has on the
body is to give you a type of lethargy, and has an almost anesthetic effect.
It can also result in seizures. The poison builds up and drives the person
towards unconsciousness after a period of days. The cause of death is usually
seizures or cardiac arrhythmia because of an electrolyte imbalance.
That sounds painful.
The initial part of the process is pretty painful. Imagine
playing a tennis match and not grabbing your Gatorade. Try not drinking
anything for a day or two and you would get a sense of what it would feel
like. You could say that the person eventually gets comfort, but it’s
after a lot of pain.
Is the denial of nutrition and hydration a standard practice
in health care?
It’s happening daily in hospitals, in hospices, in
homes. It happens most often with patients who have Alzheimer’s or
who have suffered bad strokes. It’s happening, yet no one is doing
anything about it. Patients are often being denied stomach tubes per the
Medical professionals are using the term “artificial
nutrition and hydration” to say it’s not natural. They are arbitrarily
calling it artificial partly because the means of getting food into you
require assistance. Yet, if you use that definition, babies should be starving
too, because every baby needs our help in order to be fed.
Are Catholic medical professionals condoning this?
They are split. The Catholic Medical Association (www.cathmed.org)
has an excellent statement currently on their web site: it reads:
In March 2004, Pope John Paul II addressed an international
congress of health care professionals convened in Rome to discuss the scientific
advances and ethical dilemmas in the vegetative state. In the statement
by the Vicar of Christ, “Life Sustaining Treatments and Vegetative
State,” he declares clearly and unequivocally that “the sick
person in a vegetative state still has the right to basic health care…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…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.”
This papal statement makes it absolutely clear that the withdrawal
of food and water from Mrs. Schindler-Schiavo constitutes euthanasia, a
gravely immoral act. We would add furthermore, that it represents a violation
of her constitutionally protected right to life and a violation of her religious
freedom as a Catholic.
They would argue rather strongly that food and hydration
should be provided unless it’s harmful or death is imminent. Some
physicians have a pretty loose definition of imminent. For some that’s
an hour or two; for others it’s six months. Death is imminent for
all of us.
Are there times when the denial of nutrition or fluids
The way I see it, there should always be some form of hydration.
There may be a time in medicine when you don’t have to place a stomach
tube, but fluids should be continued to keep a person comfortable and to
assist in hydration. If someone has metastatic cancer and has only a few
hours or days to live, you wouldn’t have to put in a stomach tube,
but the person should be kept comfortable with I.V. fluids.
About the only case I can see where you might withhold fluids
for a certain time would be congestive heart failure, but that’s only
temporary. It would be pretty hard to find a case where you wouldn’t
give a person fluids. In almost every case, nutrition should be given.
If a person has an injury, such as a chemical burn of the
esophagus, and cannot eat any more, everyone would say that the person should
be given a stomach tube. Yet, when you have a person with Alzheimer’s,
some people will say that they have lived their life and can slowly die
of starvation by failing to place a stomach tube. When you do that, you’re
basing the entire decision upon intellectual ability and worth. If you take
IQ out of it, you would treat the two people the same. If you argue that
someone can’t process the food otherwise, they should be given a stomach
tube, then you need to give it to everyone. I’ve never seen anyone
who could challenge that argument.
Many of these arguments are similar to the abortion argument.
What is the Catholic Church’s position with regard
to nutrition and hydration?
Nutrition and hydration should always be given, unless it’s
directly harmful to the patient as noted by Pope John Paul II above.
Advance directives and living wills have become quite
common. What do you see as the danger of such directives?
They are greatly misunderstood and greatly abused. My feeling
is that the legal profession takes advantage of people’s fears to
rack up the money. Most lay Catholics have no clue what the Church’s
teaching is. They sign living wills all the time. Such directives often
go against Catholic Church teaching. When you have a 30-year-old’s
directive saying he or she doesn’t want food or water, or antibiotics,
or blood products, that usually represents a gross misunderstanding of Church
teaching. Most of the time, you should be getting those things. So many
times people are signing something that is against Church teaching.
I’m not saying they are always wrong. You could have
a carefully thought out “loving will” that focuses on the things
that you do want, rather than the things that you don’t want. It’s
better not to get into specifics, or there is the potential to be taken
advantage of by lawyers. I helped one gentleman who was slowly dying to
create a positive “loving will.” It said that he did want food
and hydration and consultation with someone before he died.
In the case of Terri Schiavo, why is the denial of nutrition
and hydration wrong?
It’s wrong in any circumstance, regardless of whether
she said she didn’t want it or her husband says she didn’t want
it. It’s inherently evil to deny food and water to anyone unless it’s
going to make the person worse or death is within a few hours. It’s
independent from what she or her husband has said.
What of someone in a “persistent vegetative state”
Even in the case of someone in a persistent vegetative state,
the Pope has said that the person should get food and water.
The definition of the persistent vegetative state is basically
a person whose brain has been affected so that they make or perform no conscious
or purposeful action. You can’t make them follow a command, in theory.
They do not talk.
My problem is that you don’t know what is happening
inside a person, of if they will be changing. Some people in a vegetative
state have progressed to higher levels. The Pope has said that you should
receive food and hydration, even in that state. There is a real black and
Do you know whether it’s permissible to starve an
animal in the state of Florida?
That would be considered cruelty to animals. The Nazis tortured
St. Maximilian Kolbe by trying to starve him. I think he lived for about
12 days. In the end, they gave him an injection of carbolic acid. Most people
would say that you wouldn’t do that to an animal.
Tim Drake is a staff writer with the National Catholic Register,
and author of the book “Young and Catholic: The Face of Tomorrow’s
Church” (Sophia Institute Press, 2004). He writes from Saint Joseph,
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