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NUTRITION and HYDRATION

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CURE / CARE

BASIC CARE:

• NUTRITION
• HYDRATION
• SHELTER
• HUMAN INTERACTION

SWALLOW TEST (THICKENED FLUIDS)

MEDICALLY ASSISTED N/H

ENTERAL NUTRITION (EN) (GI TRACT)

NUTRITION / HYDRATION (N/H)

PARENTERAL NUTRITION (PN) (LINE; PORT)

ENTERAL NUTRITION (TUBE FEEDING):

• NASO-GASTRIC TUBE (NG TUBE)
• NASO-JEJUNAL TUBE (NJ TUBE)
• PERCUTANEOUS ENDOSCOPIC GASTROSTOMY (

PEG

)

EXAMPLES
OF

ENTERAL
ACCESS

NPO = NOTHING PER ORAL (6-12 HRS)

PURPOSE:

• PREVENT ASPIRATION PNEUMONIA

• UNDERGO GENERAL ANESTHESIA

• WEAK SWALLOWING REFLEX

• GASTRO-INTESTINAL BLEEDING OR BLOCKAGE

PARENTERAL NUTRITION (INTRAVENOUS = IV):

• PARTIAL PARENTERAL NUTRITION (PPN)
• TOTAL PARENTERAL NUTRITION (TPN)

VASCULAR ACCESS
TO

PARENTERAL
NUTRITION

(VENOUS CIRCULATION)

TPN solutions :

• Concentrated
• can cause thrombosis of peripheral veins
• central venous catheter usually required

TPN not used routinely in patients with an intact GI tract

disadvantages:

• It causes more complications
• It does not preserve GI tract structure and function as well (PERISTALSIS)
• It is more expensive

Indications

TPN may be the only feasible option for patients who do not have a
functioning GI tract or who have disorders requiring complete bowel rest.

NUTRITION / HYDRATION

IN PRINCIPLE, ORDINARY CARE

MEDICALLY ASSISTED N/H
ENTERAL NUTRITION (EN) (GI TRACT)
NUTRITION / HYDRATION (N/H)
PARENTERAL NUTRITION (PN) (LINE; PORT)

PEG

ERD 56. 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.

ERD 57. 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.

ERD 58. There should be a
presumption in favor of providing
nutrition and hydration to all
patients, including patients who
require medically assisted nutrition
and hydration, as long as this is of
sufficient benefit to outweigh the
burdens involved to the patient.

N/H, IN PRINCIPLE, ARE ORDINARY MEANS OF LIFE SUPPORT

2 EXCEPTIONS:

• WHEN N/H CAN NO LONGER BE ABSORBED OR ASSIMILATED

• WHEN, IN THE ESTIMATION OF THE DYING PATIENT,

N/H BECOMES AN EXCESSIVE BURDEN

CASE STUDY: TERRY (SCHINDLER) SCHIAVO

(1963 – 2005; AGED 41)

TERRI SCHIAVO TIMELINE

“QUALITY OF LIFE” (SUBJECTIVE)

“SANCTITY OF LIFE” (OBJECTIVE)

SACRED QUALITY OF HUMAN LIFE

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Ethicaland Religious Directives for

Catholic Health Care

Services

Sixth Edition

UNITED STATES CONFERENCE OF CATHOLIC BISHOPS

Ethical and Religious Directives for Catholic Health Care Services, Sixth Edition

This sixth edition of the Ethical and Religious Directives for Catholic Health Care Services was

developed by the Committee on Doctrine of the United States Conference of Catholic Bishops (USCCB)

and approved by the USCCB at its June 2018 Plenary Assembly. This edition of the Directives replaces

all previous editions, is recommended for implementation by the diocesan bishop, and is authorized for

publication by the undersigned.

Msgr. J. Brian Bransfield, STD

General Secretary, USCCB

1970 by the Confraternity of Christian Doctrine, Washington, DC, 20017 and are used by permission of

Digital Edition, June 201

reserved. No part of this work may be reproduced or transmitted in any form or by any means, electronic

or mechanical, including photocopying, recording, or by any information storage and retrieval system,

without permission in writing from the copyright holder.

Ethical and Religious Directives for Catholic Health Care Services, Sixth Edition

Contents

4 Preamble

6 General

Introduction

PART ONE

The Social Responsibility of

Catholic

Health Care

Services

PART TWO

The Pastoral and Spiritual

Responsibility of Catholic

Health Care

PART THREE

The Professional-Patient Relationship

PART FOUR

Issues in Care for the Beginning of Life

PART FIVE

Issues in Care for the Seriously Ill

and Dying

PART SIX

Collaborative Arrangements with

Other Health Care Organizations and Providers

27 Conclusion

Ethical and Religious Directives for Catholic Health Care Services, Sixth Edition

Preamble
Health care in the United States is marked by extraordinary change. Not only is there

continuing change in clinical practice due to technological advances, but the health care system

in the United States is being challenged by both institutional and social factors as well. At the

same time, there are a number of developments within the Catholic Church affecting the

ecclesial mission of health care. Among these are significant changes in religious orders and

congregations, the increased involvement of lay men and women, a heightened awareness of

the Church’s social role in the world, and developments in moral theology since the Second

Vatican Council. A contemporary understanding of the Catholic health care ministry must take

into account the new challenges presented by transitions both in the Church and in American

society.

Throughout the centuries, with the aid of other sciences, a body of moral principles has

emerged that expresses the Church’s teaching on medical and moral matters and has proven to

be pertinent and applicable to the ever-changing circumstances of health care and its delivery. In

response to today’s challenges, these same moral principles of Catholic teaching provide the

rationale and direction for this revision of the Ethical and Religious Directives for Catholic

Health Care Services.

These Directives presuppose our statement Health and Health Care published in 1981.1

There we presented the theological principles that guide the Church’s vision of health care,

called for all Catholics to share in the healing mission of the Church, expressed our full

commitment to the health care ministry, and offered encouragement to all those who are

involved in it. Now, with American health care facing even more dramatic changes, we

reaffirm the Church’s commitment to health care ministry and the distinctive Catholic identity

of the Church’s institutional health care services.2 The purpose of these Ethical and Religious

Directives then is twofold: first, to reaffirm the ethical standards of behavior in health care that

flow from the Church’s teaching about the dignity of the human person; second, to provide

authoritative guidance on certain moral issues that face Catholic health care today.

The Ethical and Religious Directives are concerned primarily with institutionally based

Catholic health care services. They address the sponsors, trustees, administrators, chaplains,

physicians, health care personnel, and patients or residents of these institutions and services.

Since they express the Church’s moral teaching, these Directives also will be helpful to Catholic

professionals engaged in health care services in other settings. The moral teachings that we

profess here flow principally from the natural law, understood in the light of the revelation

Christ has entrusted to his Church. From this source the Church has derived its understanding

of the nature of the human person, of human acts, and of the goals that shape human activity.

The Directives have been refined through an extensive process of consultation with bishops,

theologians, sponsors, administrators, physicians, and other health care providers. While providing

standards and guidance, the Directives do not cover in detail all of the complex issues that confront

Catholic health care today. Moreover, the Directives will be reviewed periodically by the United

States Conference of Catholic Bishops (formerly the National Conference of Catholic Bishops), in

the light of authoritative church teaching, in order to address new insights from theological and

Ethical and Religious Directives for Catholic Health Care Services, Sixth Edition

medical research or new requirements of public policy.

The Directives begin with a general introduction that presents a theological basis for the

Catholic health care ministry. Each of the six parts that follow is divided into two sections. The

first section is in expository form; it serves as an introduction and provides the context in which

concrete issues can be discussed from the perspective of the Catholic faith. The second section is

in prescriptive form; the directives promote and protect the truths of the Catholic faith as those

truths are brought to bear on concrete issues in health

care.

Ethical and Religious Directives for Catholic Health Care Services, Sixth Edition

General Introduction
The Church has always sought to embody our Savior’s concern for the sick. The gospel

accounts of Jesus’ ministry draw special attention to his acts of healing: he cleansed a man

with leprosy (Mt 8:1-4; Mk 1:40-42); he gave sight to two people who were blind (Mt 20:29-

34; Mk 10:46-52); he enabled one who was mute to speak (Lk 11:14); he cured a woman who

was hemorrhaging (Mt 9:20-22; Mk 5:25-34); and he brought a young girl back to life (Mt

9:18, 23-25; Mk 5:35-42). Indeed, the Gospels are replete with examples of how the Lord

cured every kind of ailment and disease (Mt 9:35). In the account of Matthew, Jesus’ mission

fulfilled the prophecy of Isaiah: “He took away our infirmities and bore our diseases” (Mt

8:17; cf. Is 53:4).

Jesus’ healing mission went further than caring only for physical affliction. He touched

people at the deepest level of their existence; he sought their physical, mental, and spiritual

healing (Jn 6:35, 11:25-27). He “came so that they might have life and have it more

abundantly” (Jn 10:10).

The mystery of Christ casts light on every facet of Catholic health care: to see Christian

love as the animating principle of health care; to see healing and compassion as a continuation

of Christ’s mission; to see suffering as a participation in the redemptive power of Christ’s

passion, death, and resurrection; and to see death, transformed by the resurrection, as an

opportunity for a final act of communion with Christ.

For the Christian, our encounter with suffering and death can take on a positive and

distinctive meaning through the redemptive power of Jesus’ suffering and death. As St. Paul

says, we are “always carrying about in the body the dying of Jesus, so that the life of Jesus

may also be manifested in our body” (2 Cor 4:10). This truth does not lessen the pain and fear,

but gives confidence and grace for bearing suffering rather than being overwhelmed by it.

Catholic health care ministry bears witness to the truth that, for those who are in Christ,

suffering and death are the birth pangs of the new creation. “God himself will always be with

them [as their God]. He will wipe every tear from their eyes, and there shall be no more death

or mourning, wailing or pain, [for] the old order has passed away” (Rev 21:3-4).

In faithful imitation of Jesus Christ, the Church has served the sick, suffering, and dying in

various ways throughout history. The zealous service of individuals and communities has

provided shelter for the traveler; infirmaries for the sick; and homes for children, adults, and

the elderly.3 In the United States, the many religious communities as well as dioceses that

sponsor and staff this country’s Catholic health care institutions and services have established

an effective Catholic presence in health care. Modeling their efforts on the gospel parable of

the Good Samaritan, these communities of women and men have exemplified authentic

neighborliness to those in need (Lk 10:25-37). The Church seeks to ensure that the service

offered in the past will be continued into the future.

While many religious communities continue their commitment to the health care ministry,

lay Catholics increasingly have stepped forward to collaborate in this ministry. Inspired by the

example of Christ and mandated by the Second Vatican Council, lay faithful are invited to a

broader and more intense field of ministries than in the past.4 By virtue of their Baptism, lay

Ethical and Religious Directives for Catholic Health Care Services, Sixth Edition

faithful are called to participate actively in the Church’s life and mission.5 Their participation

and leadership in the health care ministry, through new forms of sponsorship and governance

of institutional Catholic health care, are essential for the Church to continue her ministry of

healing and compassion. They are joined in the Church’s health care mission by many men

and women who are not Catholic.

Catholic health care expresses the healing ministry of Christ in a specific way within the

local church. Here the diocesan bishop exercises responsibilities that are rooted in his office as

pastor, teacher, and priest. As the center of unity in the diocese and coordinator of ministries

in the local church, the diocesan bishop fosters the mission of Catholic health care in a way

that promotes collaboration among health care leaders, providers, medical professionals,

theologians, and other specialists. As pastor, the diocesan bishop is in a unique position to

encourage the faithful to greater responsibility in the healing ministry of the Church. As

teacher, the diocesan bishop ensures the moral and religious identity of the health care

ministry in whatever setting it is carried out in the diocese. As priest, the diocesan bishop

oversees the sacramental care of the sick. These responsibilities will require that Catholic

health care providers and the diocesan bishop engage in ongoing communication on ethical

and pastoral matters that require his attention.

In a time of new medical discoveries, rapid technological developments, and social change,

what is new can either be an opportunity for genuine advancement in human culture, or it can

lead to policies and actions that are contrary to the true dignity and vocation of the human

person. In consultation with medical professionals, church leaders review these developments,

judge them according to the principles of right reason and the ultimate standard of revealed

truth, and offer authoritative teaching and guidance about the moral and pastoral

responsibilities entailed by the Christian faith.6 While the Church cannot furnish a ready

answer to every moral dilemma, there are many questions about which she provides

normative guidance and direction. In the absence of a determination by the magisterium, but

never contrary to church teaching, the guidance of approved authors can offer appropriate

guidance for ethical decision making.

Created in God’s image and likeness, the human family shares in the dominion that Christ

manifested in his healing ministry. This sharing involves a stewardship over all material

creation (Gn 1:26) that should neither abuse nor squander nature’s resources. Through science

the human race comes to understand God’s wonderful work; and through technology it must

conserve, protect, and perfect nature in harmony with God’s purposes. Health care

professionals pursue a special vocation to share in carrying forth God’s life-giving and

healing work.

The dialogue between medical science and Christian faith has for its primary purpose the

common good of all human persons. It presupposes that science and faith do not contradict

each other. Both are grounded in respect for truth and freedom. As new knowledge and new

technologies expand, each person must form a correct conscience based on the moral norms

for proper health care.

Ethical and Religious Directives for Catholic Health Care Services, Sixth Edition

PART ONE

The Social Responsibility of Catholic Health Care Services

Introduction

Their embrace of Christ’s healing mission has led institutionally based Catholic health care

services in the United States to become an integral part of the nation’s health care system.

Today, this complex health care system confronts a range of economic, technological, social,

and moral challenges. The response of Catholic health care institutions and services to these

challenges is guided by normative principles that inform the Church’s healing ministry.

First, Catholic health care ministry is rooted in a commitment to promote and defend

human dignity; this is the foundation of its concern to respect the sacredness of every human

life from the moment of conception until death. The first right of the human person, the right

to life, entails a right to the means for the proper development of life, such as adequate

health care.7

Second, the biblical mandate to care for the poor requires us to express this in concrete

action at all levels of Catholic health care. This mandate prompts us to work to ensure that our

country’s health care delivery system provides adequate health care for the poor. In Catholic

institutions, particular attention should be given to the health care needs of the poor, the

uninsured, and the underinsured.8 Third, Catholic health care ministry seeks to contribute to

the

common good.

The common good is realized when economic, political, and social

conditions ensure protection for the fundamental rights of all individuals and enable all to

fulfill their common purpose and reach their common goals.

Fourth, Catholic health care ministry exercises responsible stewardship of available health

care resources. A just health care system will be concerned both with promoting equity of

care—to assure that the right of each person to basic health care is respected—and with

promoting the good health of all in the community. The responsible stewardship of health care

resources can be accomplished best in dialogue with people from all levels of society, in

accordance with the principle of subsidiarity and with respect for the moral principles that

guide institutions and persons.

Fifth, within a pluralistic society, Catholic health care services will encounter requests for

medical procedures contrary to the moral teachings of the Church. Catholic health care does

not offend the rights of individual conscience by refusing to provide or permit medical

procedures that are judged morally wrong by the teaching authority of the Church.

Directives

1. A Catholic institutional health care service is a community that provides health care to

those in need of it. This service must be animated by the Gospel of Jesus Christ and

guided by the moral tradition of the Church.

2. Catholic health care should be marked by a spirit of mutual respect among caregivers that

disposes them to deal with those it serves and their families with the compassion of Christ,

sensitive to their vulnerability at a time of special need.

Ethical and Religious Directives for Catholic Health Care Services, Sixth Edition

3. In accord with its mission, Catholic health care should distinguish itself by service to and

advocacy for those people whose social condition puts them at the margins of our society

and makes them particularly vulnerable to discrimination: the poor; the uninsured and the

underinsured; children and the unborn; single parents; the elderly; those with incurable

diseases and chemical dependencies; racial minorities; immigrants and refugees. In

particular, the person with mental or physical disabilities, regardless of the cause or

severity, must be treated as a unique person of incomparable worth, with the same right to

life and to adequate health care as all other persons.

4. A Catholic health care institution, especially a teaching hospital, will promote medical

research consistent with its mission of providing health care and with concern for the

responsible stewardship of health care resources. Such medical research must adhere to

Catholic moral principles.

5. Catholic health care services must adopt these Directives as policy, require adherence to

them within the institution as a condition for medical privileges and employment, and

provide appropriate instruction regarding the Directives for administration, medical and

nursing staff, and other personnel.

6. A Catholic health care organization should be a responsible steward of the health care

resources available to it. Collaboration with other health care providers, in ways that do

not compromise Catholic social and moral teaching, can be an effective means of such

stewardship.

7. A Catholic health care institution must treat its employees respectfully and justly. This

responsibility includes: equal employment opportunities for anyone qualified for the task,

irrespective of a person’s race, sex, age, national origin, or disability; a workplace that

promotes employee participation; a work environment that ensures employee safety and

well-being; just compensation and benefits; and recognition of the rights of employees to

organize and bargain collectively without prejudice to the common good.

8. Catholic health care institutions have a unique relationship to both the Church and the

wider community they serve. Because of the ecclesial nature of this relationship, the

relevant requirements of canon law will be observed with regard to the foundation of a

new Catholic health care institution; the substantial revision of the mission of an

institution; and the sale, sponsorship transfer, or closure of an existing institution.

9. Employees of a Catholic health care institution must respect and uphold the religious

mission of the institution and adhere to these Directives. They should maintain

professional standards and promote the institution’s commitment to human dignity and the

common good.

Ethical and Religious Directives for Catholic Health Care Services, Sixth Edition

PART TWO

The Pastoral and Spiritual Responsibility of

Catholic Health Care

Introduction

The dignity of human life flows from creation in the image of God (Gn 1:26), from

redemption by Jesus Christ (Eph 1:10; 1 Tm 2:4-6), and from our common destiny to share a

life with God beyond all corruption (1 Cor 15:42-57). Catholic health care has the

responsibility to treat those in need in a way that respects the human dignity and eternal

destiny of all. The words of Christ have provided inspiration for Catholic health care: “I was

ill and you cared for me” (Mt 25:36). The care provided assists those in need to experience

their own dignity and value, especially when these are obscured by the burdens of illness or

the anxiety of imminent

death.

Since a Catholic health care institution is a community of healing and compassion, the care

offered is not limited to the treatment of a disease or bodily ailment but embraces the physical,

psychological, social, and spiritual dimensions of the human person. The medical expertise

offered through Catholic health care is combined with other forms of care to promote health

and relieve human suffering. For this reason, Catholic health care extends to the spiritual

nature of the person. “Without health of the spirit, high technology focused strictly on the

body offers limited hope for healing the whole person.” 11 Directed to spiritual needs that are

often appreciated more deeply during times of illness, pastoral care is an integral part of

Catholic health care. Pastoral care encompasses the full range of spiritual services, including a

listening presence; help in dealing with powerlessness, pain, and alienation; and assistance in

recognizing and responding to God’s will with greater joy and peace. It should be

acknowledged, of course, that technological advances in medicine have reduced the length of

hospital stays dramatically. It follows, therefore, that the pastoral care of patients, especially

administration of the sacraments, will be provided more often than not at the parish level, both

before and after one’s hospitalization. For this reason, it is essential that there be very cordial

and cooperative relationships between the personnel of pastoral care departments and the local

clergy and ministers of care.

Priests, deacons, religious, and laity exercise diverse but complementary roles in this

pastoral care. Since many areas of pastoral care call upon the creative response of these

pastoral caregivers to the particular needs of patients or residents, the following directives

address only a limited number of specific pastoral activities.

Directives

10. A Catholic health care organization should provide pastoral care to minister to the

religious and spiritual needs of all those it serves. Pastoral care personnel—clergy,

religious, and lay alike—should have appropriate professional preparation, including an

understanding of these Directives.

Ethical and Religious Directives for Catholic Health Care Services, Sixth Edition

11. Pastoral care personnel should work in close collaboration with local parishes and

community clergy. Appropriate pastoral services and/or referrals should be available to all

in keeping with their religious beliefs or affiliation.

12. For Catholic patients or residents, provision for the sacraments is an especially important

part of Catholic health care ministry. Every effort should be made to have priests assigned

to hospitals and health care institutions to celebrate the Eucharist and provide the

sacraments to patients and staff.

13. Particular care should be taken to provide and to publicize opportunities for patients or

residents to receive the sacrament of Penance.

14. Properly prepared lay Catholics can be appointed to serve as extraordinary ministers of

Holy Communion, in accordance with canon law and the policies of the local diocese.

They should assist pastoral care personnel—clergy, religious, and laity—by providing

supportive visits, advising patients regarding the availability of priests for the sacrament

of Penance, and distributing Holy Communion to the faithful who request it.

15. Responsive to a patient’s desires and condition, all involved in pastoral care should

facilitate the availability of priests to provide the sacrament of Anointing of the Sick,

recognizing that through this sacrament Christ provides grace and support to those who

are seriously ill or weakened by advanced age. Normally, the sacrament is celebrated

when the sick person is fully conscious. It may be conferred upon the sick who have lost

consciousness or the use of reason, if there is reason to believe that they would have asked

for the sacrament while in control of their faculties.

16. All Catholics who are capable of receiving Communion should receive Viaticum when

they are in danger of death, while still in full possession of their faculties.

17. Except in cases of emergency (i.e., danger of death), any request for Baptism made by

adults or for infants should be referred to the chaplain of the institution. Newly born infants

in danger of death, including those miscarried, should be baptized if this is possible.13 In

case of emergency, if a priest or a deacon is not available, anyone can validly baptize.14 In

the case of emergency Baptism, the chaplain or the director of pastoral care is to be

notified.

18. When a Catholic who has been baptized but not yet confirmed is in danger of death, any

priest may confirm the person.

19. A record of the conferral of Baptism or Confirmation should be sent to the parish in which

the institution is located and posted in its baptism/confirmation registers.

20. Catholic discipline generally reserves the reception of the sacraments to Catholics. In

accord with canon 844, §3, Catholic ministers may administer the sacraments of Eucharist,

Penance, and Anointing of the Sick to members of the oriental churches that do not have

Ethical and Religious Directives for Catholic Health Care Services, Sixth Edition

full communion with the Catholic Church, or of other churches that in the judgment of the

Holy See are in the same condition as the oriental churches, if such persons ask for the

sacraments on their own and are properly disposed.

With regard to other Christians not in full communion with the Catholic Church, when

the danger of death or other grave necessity is present, the four conditions of canon 844,

§4, also must be present, namely, they cannot approach a minister of their own

community; they ask for the sacraments on their own; they manifest Catholic faith in these

sacraments; and they are properly disposed. The diocesan bishop has the responsibility to

oversee this pastoral practice.

21. The appointment of priests and deacons to the pastoral care staff of a Catholic institution

must have the explicit approval or confirmation of the local bishop in collaboration with

the administration of the institution. The appointment of the director of the pastoral care

staff should be made in consultation with the

diocesan bishop.

22. For the sake of appropriate ecumenical and interfaith relations, a diocesan policy should

be developed with regard to the appointment of non-Catholic members to the pastoral care

staff of a Catholic health care institution. The director of pastoral care at a Catholic

institution should be a Catholic; any exception to this norm should be approved by the

diocesan bishop.

Ethical and Religious Directives for Catholic Health Care Services, Sixth Edition

PART THREE

The Professional-Patient Relationship

Introduction

A person in need of health care and the professional health care provider who accepts that

person as a patient enter into a relationship that requires, among other things, mutual respect,

trust, honesty, and appropriate confidentiality. The resulting free exchange of information

must avoid manipulation, intimidation, or condescension. Such a relationship enables the

patient to disclose personal information needed for effective care and permits the health care

provider to use his or her professional competence most effectively to maintain or restore the

patient’s health. Neither the health care professional nor the patient acts independently of the

other; both participate in the healing process.

Today, a patient often receives health care from a team of providers, especially in the

setting of the modern acute-care hospital. But the resulting multiplication of relationships does

not alter the personal character of the interaction between health care providers and the

patient. The relationship of the person seeking health care and the professionals providing that

care is an important part of the foundation on which diagnosis and care are provided.

Diagnosis and care, therefore, entail a series of decisions with ethical as well as medical

dimensions. The health care professional has the knowledge and experience to pursue the

goals of healing, the maintenance of health, and the compassionate care of the dying, taking

into account the patient’s convictions and spiritual needs, and the moral responsibilities of all

concerned. The person in need of health care depends on the skill of the health care provider to

assist in preserving life and promoting health of body, mind, and spirit. The patient, in turn,

has a responsibility to use these physical and mental resources in the service of moral and

spiritual goals to the best of his or her ability.

When the health care professional and the patient use institutional Catholic health care,

they also accept its public commitment to the Church’s understanding of and witness to the

dignity of the human person. The Church’s moral teaching on health care nurtures a truly

interpersonal professional-patient relationship. This professional-patient relationship is never

separated, then, from the Catholic identity of the health care institution. The faith that inspires

Catholic health care guides medical decisions in ways that fully respect the dignity of the

person and the relationship with the health care professional.

Directives

23. The inherent dignity of the human person must be respected and protected regardless of the

nature of the person’s health problem or social status. The respect for human dignity

extends to all persons who are served by Catholic health care.

24. In compliance with federal law, a Catholic health care institution will make available to

patients information about their rights, under the laws of their state, to make an advance

Ethical and Religious Directives for Catholic Health Care Services, Sixth Edition

directive for their medical treatment. The institution, however, will not honor an advance

directive that is contrary to Catholic teaching. If the advance directive conflicts with

Catholic teaching, an explanation should be provided as to why the directive cannot be

honored.

25. Each person may identify in advance a representative to make health care decisions as his

or her surrogate in the event that the person loses the capacity to make health care

decisions. Decisions by the designated surrogate should be faithful to Catholic moral

principles and to the person’s intentions and values, or if the person’s intentions are

unknown, to the person’s best interests. In the event that an advance directive is not

executed, those who are in a position to know best the patient’s wishes—usually family

members and loved ones—should participate in the treatment decisions for the person who

has lost the capacity to make health care decisions.

26. The free and informed consent of the person or the person’s surrogate is required for

medical treatments and procedures, except in an emergency situation when consent cannot

be obtained and there is no indication that the patient would refuse consent to the

treatment.

27. Free and informed consent requires that the person or the person’s surrogate receive all

reasonable information about the essential nature of the proposed treatment and its

benefits; its risks, side-effects, consequences, and cost; and any reasonable and morally

legitimate alternatives, including no treatment at all.

28. Each person or the person’s surrogate should have access to medical and moral

information and counseling so as to be able to form his or her conscience. The free and

informed health care decision of the person or the person’s surrogate is to be followed so

long as it does not contradict Catholic principles.

29. All persons served by Catholic health care have the right and duty to protect and preserve

their bodily and functional integrity.16 The functional integrity of the person may be

sacrificed to maintain the health or life of the person when no other morally
permissible means is available.

30. The transplantation of organs from living donors is morally permissible when such a

donation will not sacrifice or seriously impair any essential bodily function and the

anticipated benefit to the recipient is proportionate to the harm done to the donor.

Furthermore, the freedom of the prospective donor must be respected, and economic

advantages should not accrue to the donor.

31. No one should be the subject of medical or genetic experimentation, even if it is

therapeutic, unless the person or surrogate first has given free and informed consent. In

instances of nontherapeutic experimentation, the surrogate can give this consent only if the

experiment entails no significant risk to the person’s well-being. Moreover, the greater the

Ethical and Religious Directives for Catholic Health Care Services, Sixth Edition

person’s incompetency and vulnerability, the greater the reasons must be to perform any

medical experimentation, especially nontherapeutic.

32. While every person is obliged to use ordinary means to preserve his or her health, no

person should be obliged to submit to a health care procedure that the person has judged,

with a free and informed conscience, not to provide a reasonable hope of benefit without

imposing excessive risks and burdens on the patient or excessive expense to family or

community.

33. The well-being of the whole person must be taken into account in deciding about any

therapeutic intervention or use of technology. Therapeutic procedures that are likely to

cause harm or undesirable side-effects can be justified only by a proportionate benefit to

the patient.

34. Health care providers are to respect each person’s privacy and confidentiality regarding

information related to the person’s diagnosis, treatment, and care.

35. Health care professionals should be educated to recognize the symptoms of abuse and

violence and are obliged to report cases of abuse to the proper authorities in accordance with

local statutes.

36. Compassionate and understanding care should be given to a person who is the victim of

sexual assault. Health care providers should cooperate with law enforcement officials and

offer the person psychological and spiritual support as well as accurate medical

information. A female who has been raped should be able to defend herself against a

potential conception from the sexual assault. If, after appropriate testing, there is no

evidence that conception has occurred already, she may be treated with medications that

would prevent ovulation, sperm capacitation, or fertilization. It is not permissible,

however, to initiate or to recommend treatments that have as their purpose or direct effect

the removal, destruction, or interference with the implantation of a fertilized ovum.

37. An ethics committee or some alternate form of ethical consultation should be available to

assist by advising on particular ethical situations, by offering educational opportunities,

and by reviewing and recommending policies. To these ends, there should be appropriate

standards for medical ethical consultation within a particular diocese that will respect the

diocesan bishop’s pastoral responsibility as well as assist members of ethics committees to

be familiar with Catholic medical ethics and, in particular, these Directives.

Ethical and Religious Directives for Catholic Health Care Services, Sixth Edition

PART FOUR

Issues in Care for the Beginning of Life

Introduction

The Church’s commitment to human dignity inspires an abiding concern for the sanctity of

human life from its very beginning, and with the dignity of marriage and of the marriage act

by which human life is transmitted. The Church cannot approve medical practices that

undermine the biological, psychological, and moral bonds on which the strength of marriage

and the family depends.

Catholic health care ministry witnesses to the sanctity of life “from the moment of

conception until death.” 20 The Church’s defense of life encompasses the unborn and the care

of women and their children during and after pregnancy. The Church’s commitment to life is

seen in its willingness to collaborate with others to alleviate the causes of the high infant

mortality rate and to provide adequate health care to mothers and their children before and

after birth.

The Church has the deepest respect for the family, for the marriage covenant, and for the

love that binds a married couple together. This includes respect for the marriage act by which

husband and wife express their love and cooperate with God in the creation of a new human

being. The Second Vatican Council affirms:

This love is an eminently human one. . . . It involves the good of the whole person. . . .

The actions within marriage by which the couple are united intimately and chastely are

noble and worthy ones. Expressed in a manner which is truly human, these actions

signify and promote that mutual self-giving by which spouses enrich each other with a

joyful and a thankful will.

Marriage and conjugal love are by their nature ordained toward the begetting

and educating of children. Children are really the supreme gift of marriage and

contribute very substantially to the welfare of their parents. . . . Parents should

regard as their proper mission the task of transmitting human life and educating those

to whom it has been transmitted. . . . They are thereby cooperators with the love of

God the Creator, and are, so to speak, the interpreters of that love.

For legitimate reasons of responsible parenthood, married couples may limit the number

of their children by natural means. The Church cannot approve contraceptive interventions

that “either in anticipation of the marital act, or in its accomplishment or in the development

of its natural consequences, have the purpose, whether as an end or a means, to render

procreation impossible.”23 Such interventions violate “the inseparable connection, willed by

God . . . between the two meanings of the conjugal act: the unitive and procreative

meaning.”

With the advance of the biological and medical sciences, society has at its disposal new

technologies for responding to the problem of infertility. While we rejoice in the potential for

Ethical and Religious Directives for Catholic Health Care Services, Sixth Edition

good inherent in many of these technologies, we cannot assume that what is technically

possible is always morally right. Reproductive technologies that substitute for the marriage

act are not consistent with human dignity. Just as the marriage act is joined naturally to

procreation, so procreation is joined naturally to the marriage act. As Pope John XXIII

observed:

The transmission of human life is entrusted by nature to a personal and conscious act and

as such is subject to all the holy laws of God: the immutable and inviolable laws which

must be recognized and observed. For this reason, one cannot use means and follow

methods which could be licit in the transmission of the life of plants and animals.25

Ethical and Religious Directives for Catholic Health Care Services, Sixth Edition

Because the moral law is rooted in the whole of human nature, human persons, through

intelligent reflection on their own spiritual destiny, can discover and cooperate in the plan of

the Creator.

Directives
38. When the marital act of sexual intercourse is not able to attain its procreative purpose,

assistance that does not separate the unitive and procreative ends of the act, and does not

substitute for the marital act itself, may be used to help married couples conceive.

39. Those techniques of assisted conception that respect the unitive and procreative meanings

of sexual intercourse and do not involve the destruction of human embryos, or their

deliberate generation in such numbers that it is clearly envisaged that all cannot implant and

some are simply being used to maximize the chances of others implanting, may be used as

therapies for infertility.

40. Heterologous fertilization (that is, any technique used to achieve conception by the use of

gametes coming from at least one donor other than the spouses) is prohibited because it is

contrary to the covenant of marriage, the unity of the spouses, and the dignity proper to

parents and the child.

41. Homologous artificial fertilization (that is, any technique used to achieve conception using

the gametes of the two spouses joined in marriage) is prohibited when it separates

procreation from the marital act in its unitive significance (e.g., any technique used to

achieve extracorporeal conception).

42. Because of the dignity of the child and of marriage, and because of the uniqueness of the

mother-child relationship, participation in contracts or arrangements for surrogate

motherhood is not permitted. Moreover, the commercialization of such surrogacy

denigrates the dignity of women, especially the poor.

43. A Catholic health care institution that provides treatment for infertility should offer not

only technical assistance to infertile couples but also should help couples pursue other

solutions (e.g., counseling, adoption).

44. A Catholic health care institution should provide prenatal, obstetric, and postnatal services

for mothers and their children in a manner consonant with its mission.

45. Abortion (that is, the directly intended termination of pregnancy before viability or the

directly intended destruction of a viable fetus) is never permitted. Every procedure whose sole

immediate effect is the termination of pregnancy before viability is an abortion, which, in its

moral context, includes the interval between conception and implantation of the embryo.

Catholic health care institutions are not to provide abortion services, even based upon the

principle of material cooperation. In this context, Catholic health care institutions need to be

Ethical and Religious Directives for Catholic Health Care Services, Sixth Edition

concerned about the danger of scandal in any association with abortion

providers.

46. Catholic health care providers should be ready to offer compassionate physical,

psychological, moral, and spiritual care to those persons who have suffered from the

trauma of abortion.

47. Operations, treatments, and medications that have as their direct purpose the cure of a

proportionately serious pathological condition of a pregnant woman are permitted when

they cannot be safely postponed until the unborn child is viable, even if they will result in

the death of the unborn child.

48. In case of extrauterine pregnancy, no intervention is morally licit which constitutes a direct

abortion.31

49. For a proportionate reason, labor may be induced after the fetus is viable.

50. Prenatal diagnosis is permitted when the procedure does not threaten the life or physical

integrity of the unborn child or the mother and does not subject them to disproportionate

risks; when the diagnosis can provide information to guide preventative care for the mother

or pre- or postnatal care for the child; and when the parents, or at least the mother, give

free and informed consent. Prenatal diagnosis is not permitted when undertaken with the

intention of aborting an unborn child with a serious defect.32

51. Nontherapeutic experiments on a living embryo or fetus are not permitted, even with the

consent of the parents. Therapeutic experiments are permitted for a proportionate reason

with the free and informed consent of the parents or, if the father cannot be contacted, at

least of the mother. Medical research that will not harm the life or physical integrity of an

unborn child is permitted with parental consent.33

52. Catholic health institutions may not promote or condone contraceptive practices but

should provide, for married couples and the medical staff who counsel them, instruction

both about the Church’s teaching on responsible parenthood and in methods of natural

family planning.

53. Direct sterilization of either men or women, whether permanent or temporary, is not

permitted in a Catholic health care institution. Procedures that induce sterility are

permitted when their direct effect is the cure or alleviation of a present and serious

pathology and a simpler treatment is not available.34

54. Genetic counseling may be provided in order to promote responsible parenthood and to

prepare for the proper treatment and care of children with genetic defects, in accordance

with Catholic moral teaching and the intrinsic rights and obligations of married couples

regarding the transmission of life.

Ethical and Religious Directives for Catholic Health Care Services, Sixth Edition

PART FIVE

Issues in Care for the Seriously Ill and Dying

Introduction

Christ’s redemption and saving grace embrace the whole person, especially in his or her

illness, suffering, and death.35 The Catholic health care ministry faces the reality of death with

the confidence of faith. In the face of death—for many, a time when hope seems lost—the

Church witnesses to her belief that God has created each person for eternal life.36

Above all, as a witness to its faith, a Catholic health care institution will be a community

of respect, love, and support to patients or residents and their families as they face the reality

of death. What is hardest to face is the process of dying itself, especially the dependency, the

helplessness, and the pain that so often accompany terminal illness. One of the primary

purposes of medicine in caring for the dying is the relief of pain and the suffering caused by it.

Effective management of pain in all its forms is critical in the appropriate care of the dying.

The truth that life is a precious gift from God has profound implications for the question

of stewardship over human life. We are not the owners of our lives and, hence, do not have

absolute power over life. We have a duty to preserve our life and to use it for the glory of

God, but the duty to preserve life is not absolute, for we may reject life-prolonging procedures

that are insufficiently beneficial or excessively burdensome. Suicide and euthanasia are never

morally acceptable options.

The task of medicine is to care even when it cannot cure. Physicians and their patients

must evaluate the use of the technology at their disposal. Reflection on the innate dignity of

human life in all its dimensions and on the purpose of medical care is indispensable for

formulating a true moral judgment about the use of technology to maintain life. The use of

life-sustaining technology is judged in light of the Christian meaning of life, suffering, and

death. In this way two extremes are avoided: on the one hand, an insistence on useless or

burdensome technology even when a patient may legitimately wish to forgo it and, on the

other hand, the withdrawal of technology with the intention of causing death.37

The Church’s teaching authority has addressed the moral issues concerning medically

assisted nutrition and hydration. We are guided on this issue by Catholic teaching against

euthanasia, which is “an action or an omission which of itself or by intention causes death, in

order that all suffering may in this way be eliminated.” 38 While medically assisted nutrition

and hydration are not morally obligatory in certain cases, these forms of basic care should in

principle be provided to all patients who need them, including patients diagnosed as being in a

“persistent vegetative state” (PVS), because even the most severely debilitated and helpless

patient retains the full dignity of a human person and must receive ordinary and proportionate

care.

Directives
55. Catholic health care institutions offering care to persons in danger of death from illness,

Ethical and Religious Directives for Catholic Health Care Services, Sixth Edition

accident, advanced age, or similar condition should provide them with appropriate

opportunities to prepare for death. Persons in danger of death should be provided with

whatever information is necessary to help them understand their condition and have the

opportunity to discuss their condition with their family members and care providers. They

should also be offered the appropriate medical information that would make it possible to

address the morally legitimate choices available to them. They should be provided the

spiritual support as well as the opportunity to receive the sacraments in order to prepare

well for death.

56. 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.39

57. 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.

58. 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.40 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.” 41 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.

59. The free and informed judgment made by a competent adult patient concerning the use or

withdrawal of life-sustaining procedures should always be respected and normally

complied with, unless it is contrary to Catholic moral teaching.

60. Euthanasia is an action or omission that of itself or by intention causes death in order to

alleviate suffering. Catholic health care institutions may never condone or participate in

euthanasia or assisted suicide in any way. Dying patients who request euthanasia should

receive loving care, psychological and spiritual support, and appropriate remedies for pain

and other symptoms so that they can live with dignity until the time of natural death.42

61. Patients should be kept as free of pain as possible so that they may die comfortably and

Ethical and Religious Directives for Catholic Health Care Services, Sixth Edition

with dignity, and in the place where they wish to die. Since a person has the right to

prepare for his or her death while fully conscious, he or she should not be deprived of

consciousness without a compelling reason. Medicines capable of alleviating or suppressing

pain may be given to a dying person, even if this therapy may indirectly shorten the person’s

life so long as the intent is not to hasten death. Patients experiencing suffering that cannot

be alleviated should be helped to appreciate the Christian understanding of redemptive

suffering.

62. The determination of death should be made by the physician or competent medical

authority in accordance with responsible and commonly accepted scientific criteria.

63. Catholic health care institutions should encourage and provide the means whereby those

who wish to do so may arrange for the donation of their organs and bodily tissue, for

ethically legitimate purposes, so that they may be used for donation and research after

death.

64. Such organs should not be removed until it has been medically determined that the patient

has died. In order to prevent any conflict of interest, the physician who determines death

should not be a member of the transplant team.

65. The use of tissue or organs from an infant may be permitted after death has been

determined and with the informed consent of the parents or guardians.

66. Catholic health care institutions should not make use of human tissue obtained by direct

abortions even for research and therapeutic purposes.43

Ethical and Religious Directives for Catholic Health Care Services, Sixth Edition

PART SIX

Collaborative Arrangements with

Other Health Care Organizations and Providers44

Introduction

In and through her compassionate care for the sick and suffering members of the human family,

the Church extends Jesus’ healing mission and serves the fundamental human dignity of every

person made in God’s image and likeness. Catholic health care, in serving the common good,

has historically worked in collaboration with a variety of non-Catholic partners. Various factors

in the current health care environment in the United States, however, have led to a multiplication

of collaborative arrangements among health care institutions, between Catholic institutions as

well as between Catholic and non-Catholic institutions.

Collaborative arrangements can be unique and vitally important opportunities for

Catholic health care to further its mission of caring for the suffering and sick, in faithful

imitation of Christ. For example, collaborative arrangements can provide opportunities for

Catholic health care institutions to influence the healing profession through their witness to the

Gospel of Jesus Christ. Moreover, they can be opportunities to realign the local delivery system

to provide a continuum of health care to the community, to provide a model of a responsible

stewardship of limited health care resources, to provide poor and vulnerable persons with more

equitable access to basic care, and to provide access to medical technologies and expertise that

greatly enhance the quality of care. Collaboration can even, in some instances, ensure the

continued presence of a Catholic institution, or the presence of any health care facility at all, in a

given area.

When considering a collaboration, Catholic health care administrators should seek first to

establish arrangements with Catholic institutions or other institutions that operate in conformity

with the Church’s moral teaching. It is not uncommon, however, that arrangements with

Catholic institutions are not practicable and that, in pursuit of the common good, the only

available candidates for collaboration are institutions that do not operate in conformity with the

Church’s moral teaching.

Such collaborative arrangements can pose particular challenges if they would involve

institutional connections with activities that conflict with the natural moral law, church teaching,

or canon law. Immoral actions are always contrary to “the singular dignity of the human person,

‘the only creature that God has wanted for its own sake.’”45 It is precisely because Catholic

health care services are called to respect the inherent dignity of every human being and to

contribute to the common good that they should avoid, whenever possible, engaging in

collaborative arrangements that would involve them in contributing to the wrongdoing of other

providers.

The Catholic moral tradition provides principles for assessing cooperation with the

wrongdoing of others to determine the conditions under which cooperation may or may not be

Ethical and Religious Directives for Catholic Health Care Services, Sixth Edition

morally justified, distinguishing between “formal” and “material” cooperation. Formal

cooperation “occurs when an action, either by its very nature or by the form it takes in a concrete

situation, can be defined as a direct participation in an [immoral] act . . . or a sharing in the

immoral intention of the person committing it.”46 Therefore, cooperation is formal not only when

the cooperator shares the intention of the wrongdoer, but also when the cooperator directly

participates in the immoral act, even if the cooperator does not share the intention of the

wrongdoer, but participates as a means to some other end. Formal cooperation may take various

forms, such as authorizing wrongdoing, approving it, prescribing it, actively defending it, or

giving specific direction about carrying it out. Formal cooperation, in whatever form, is always

morally wrong.

The cooperation is material if the one cooperating neither shares the wrongdoer’s

intention in performing the immoral act nor cooperates by directly participating in the act as a

means to some other end, but rather contributes to the immoral activity in a way that is causally

related but not essential to the immoral act itself. While some instances of material cooperation

are morally wrong, others are morally justified. There are many factors to consider when

assessing whether or not material cooperation is justified, including: whether the cooperator’s act

is morally good or neutral in itself, how significant is its causal contribution to the wrongdoer’s

act, how serious is the immoral act of the wrongdoer, and how important are the goods to be

preserved or the harms to be avoided by cooperating. Assessing material cooperation can be

complex, and legitimate disagreements may arise over which factors are most relevant in a given

case. Reliable theological experts should be consulted in interpreting and applying the principles

governing cooperation.

Any moral analysis of a collaborative arrangement must also take into account the danger

of scandal, which is “an attitude or behavior which leads another to do evil.”47 The cooperation

of a Catholic institution with other health care entities engaged in immoral activities, even when

such cooperation is morally justified in all other respects, might, in certain cases, lead people to

conclude that those activities are morally acceptable. This could lead people to sin. The danger

of scandal, therefore, needs to be carefully evaluated in each case. In some cases, the danger of

scandal can be mitigated by certain measures, such as providing an explanation as to why the

Catholic institution is cooperating in this way at this time. In any event, prudential judgments

that take into account the particular circumstances need to be made about the risk and degree of

scandal and about whether they can be effectively addressed.

Even when there are good reasons for establishing collaborative arrangements that

involve material cooperation with wrongdoing, leaders of Catholic healthcare institutions must

assess whether becoming associated with the wrongdoing of a collaborator will risk undermining

their institution’s ability to fulfill its mission of providing health care as a witness to the Catholic

faith and an embodiment of Jesus’ concern for the sick. They must do everything they can to

ensure that the integrity of the Church’s witness to Christ and his Gospel is not adversely

affected by a collaborative arrangement.

Ethical and Religious Directives for Catholic Health Care Services, Sixth Edition

In sum, collaborative arrangements with entities that do not share our Catholic moral

tradition present both opportunities and challenges. The opportunities to further the mission of

Catholic health care can be significant. The challenges do not necessarily preclude all such

arrangements on moral grounds, but they do make it imperative for Catholic leaders to undertake

careful analyses to ensure that new collaborative arrangements—as well as those that already

exist—abide by the principles governing cooperation, effectively address the risk of scandal,

abide by canon law, and sustain the Church’s witness to Christ and his saving message.

While the following Directives are offered to assist Catholic health care institutions in

analyzing the moral considerations of collaborative arrangements, the ultimate responsibility for

interpreting and applying of the Directives rests with the diocesan bishop.

Directives

67. Each diocesan bishop has the ultimate responsibility to assess whether collaborative

arrangements involving Catholic health care providers operating in his local church involve

wrongful cooperation, give scandal, or undermine the Church’s witness. In fulfilling this

responsibility, the bishop should consider not only the circumstances in his local diocese

but also the regional and national implications of his decision.

68. When there is a possibility that a prospective collaborative arrangement may lead to serious

adverse consequences for the identity or reputation of Catholic health care services or entail

a risk of scandal, the diocesan bishop is to be consulted in a timely manner. In addition, the

diocesan bishop’s approval is required for collaborative arrangements involving institutions

subject to his governing authority; when they involve institutions not subject to his

governing authority but operating in his diocese, such as those involving a juridic person

erected by the Holy See, the diocesan bishop’s nihil obstat is to be obtained.

69. In cases involving health care systems that extend across multiple diocesan jurisdictions, it

remains the responsibility of the diocesan bishop of each diocese in which the system’s

affiliated institutions are located to approve locally the prospective collaborative

arrangement or to grant the requisite nihil obstat, as the situation may require. At the same

time, with such a proposed arrangement, it is the duty of the diocesan bishop of the diocese

in which the system’s headquarters is located to initiate a collaboration with the diocesan

bishops of the dioceses affected by the collaborative arrangement. The bishops involved in

this collaboration should make every effort to reach a consensus.

70. Catholic health care organizations are not permitted to engage in immediate material

cooperation in actions that are intrinsically immoral, such as abortion, euthanasia, assisted

suicide, and direct sterilization.48

71. When considering opportunities for collaborative arrangements that entail material

cooperation in wrongdoing, Catholic institutional leaders must assess whether scandal49

might be given and whether the Church’s witness might be undermined. In some cases, the

risk of scandal can be appropriately mitigated or removed by an explanation of what is in

fact being done by the health care organization under Catholic auspices. Nevertheless, a

Ethical and Religious Directives for Catholic Health Care Services, Sixth Edition

collaborative arrangement that in all other respects is morally licit may need to be refused

because of the scandal that might be caused or because the Church’s witness might be

undermined.

72. The Catholic party in a collaborative arrangement has the responsibility to assess

periodically whether the binding agreement is being observed and implemented in a way

that is consistent with the natural moral law, Catholic teaching, and canon law.

73. Before affiliating with a health care entity that permits immoral procedures, a Catholic

institution must ensure that neither its administrators nor its employees will manage, carry

out, assist in carrying out, make its facilities available for, make referrals for, or benefit

from the revenue generated by immoral procedures.

74. In any kind of collaboration, whatever comes under the control of the Catholic institution—

whether by acquisition, governance, or management—must be operated in full accord with

the moral teaching of the Catholic Church, including these Directives.

75. It is not permitted to establish another entity that would oversee, manage, or perform

immoral procedures. Establishing such an entity includes actions such as drawing up the

civil bylaws, policies, or procedures of the entity, establishing the finances of the entity, or

legally incorporating the entity.

76. Representatives of Catholic health care institutions who serve as members of governing

boards of non-Catholic health care organizations that do not adhere to the ethical principles

regarding health care articulated by the Church should make their opposition to immoral

procedures known and not give their consent to any decisions proximately connected with

such procedures. Great care must be exercised to avoid giving scandal or adversely

affecting the witness of the Church.

77. If it is discovered that a Catholic health care institution might be wrongly cooperating with

immoral procedures, the local diocesan bishop should be informed immediately and the

leaders of the institution should resolve the situation as soon as reasonably possible.

Ethical and Religious Directives for Catholic Health Care Services, Sixth Edition

Conclusion
Sickness speaks to us of our limitations and human frailty. It can take the form of infirmity

resulting from the simple passing of years or injury from the exuberance of youthful energy. It

can be temporary or chronic, debilitating, and even terminal. Yet the follower of Jesus faces

illness and the consequences of the human condition aware that our Lord always shows

compassion toward the infirm.

Jesus not only taught his disciples to be compassionate, but he also told them who should

be the special object of their compassion. The parable of the feast with its humble guests was

preceded by the instruction: “When you hold a banquet, invite the poor, the crippled, the

lame, the blind” (Lk 14:13). These were people whom Jesus healed and loved.

Catholic health care is a response to the challenge of Jesus to go and do likewise. Catholic

health care services rejoice in the challenge to be Christ’s healing compassion in the world

and see their ministry not only as an effort to restore and preserve health but also as a spiritual

service and a sign of that final healing that will one day bring about the new creation that is

the ultimate fruit of Jesus’ ministry and God’s love for us.

Ethical and Religious Directives for Catholic Health Care Services, Sixth Edition

Notes

1. United States Conference of Catholic Bishops, Health and Health Care: A Pastoral Letter of the

American Catholic Bishops (Washington, DC: United States Conference of Catholic Bishops,

1981).

2. Health care services under Catholic auspices are carried out in a variety of institutional settings (e.g.,

hospitals, clinics, outpatient facilities, urgent care centers, hospices, nursing homes, and parishes).

Depending on the context, these Directives will employ the terms “institution” and/or “services” in

order to encompass the variety of settings in which Catholic health care is provided.

3. Health and Health Care, p. 5.

4. Second Vatican Ecumenical Council, Decree on the Apostolate of the Laity (Apostolicam

Actuositatem) (1965), no. 1.

5. Pope John Paul II, Post-Synodal Apostolic Exhortation On the Vocation and the Mission of the

Lay Faithful in the Church and in the World (Christifideles Laici) (Washington, DC: United States

Conference of Catholic Bishops, 1988), no. 29.

6. As examples, see Congregation for the Doctrine of the Faith, Declaration on Procured Abortion

(1974); Congregation for the Doctrine of the Faith, Declaration on Euthanasia (1980);

Congregation for the Doctrine of the Faith, Instruction on Respect for Human Life in Its Origin and

on the Dignity of Procreation: Replies to Certain Questions of the Day (Donum Vitae)

(Washington, DC: United States Conference of Catholic Bishops, 1987).

7. Pope John XXIII, Encyclical Letter Peace on Earth (Pacem in Terris) (Washington, DC: United

States Conference of Catholic Bishops, 1963), no. 11; Health and Health Care, pp. 5, 17-18;

Catechism of the Catholic Church, 2nd ed. (Washington, DC: Libreria Editrice Vaticana–United

States Conference of Catholic Bishops, 2000), no. 2211.

8. Pope John Paul II, On Social Concern, Encyclical Letter on the Occasion of the Twentieth

Anniversary of “Populorum Progressio” (Sollicitudo Rei Socialis) (Washington, DC: United

States Conference of Catholic Bishops, 1988), no. 43.

9. United States Conference of Catholic Bishops, Economic Justice for All: Pastoral Letter on Catholic

Social Teaching and the U.S. Economy (Washington, DC: United States Conference of Catholic

Bishops, 1986), no. 80.

10. The duty of responsible stewardship demands responsible collaboration. But in collaborative

efforts, Catholic institutionally based health care services must be attentive to occasions when the

policies and practices of other institutions are not compatible with the Church’s authoritative

moral teaching. At such times, Catholic health care institutions should determine whether or to

what degree collaboration would be morally permissible. To make that judgment, the governing

boards of Catholic institutions should adhere to the moral principles on cooperation. See Part Six.

11. Health and Health Care, p. 12.

12. Cf. Code of Canon Law, cc. 921-923.

13. Cf. ibid., c. 867, § 2, and c. 871.

14. To confer Baptism in an emergency, one must have the proper intention (to do what the Church

intends by Baptism) and pour water on the head of the person to be baptized, meanwhile

pronouncing the words: “I baptize you in the name of the Father, and of the Son, and of the

Ethical and Religious Directives for Catholic Health Care Services, Sixth Edition

Holy Spirit.”

15. Cf. c. 883, 3º.

16. For example, while the donation of a kidney represents loss of biological integrity, such a donation

does not compromise functional integrity since human beings are capable of functioning with only

one kidney.

17. Cf. directive 53.

18. Declaration on Euthanasia, Part IV; cf. also directives 56-57.

19. It is recommended that a sexually assaulted woman be advised of the ethical restrictions that

prevent Catholic hospitals from using abortifacient procedures; cf. Pennsylvania Catholic

Conference, “Guidelines for Catholic Hospitals Treating Victims of Sexual Assault,” Origins 22

(1993): 810.

20. Pope John Paul II, “Address of October 29, 1983, to the 35th General Assembly of the World

Medical Association,” Acta Apostolicae Sedis 76 (1984): 390.

21. Second Vatican Ecumenical Council, Pastoral Constitution on the Church in the Modern World

(Gaudium et Spes) (1965), no. 49.

22. Ibid., no. 50.

23. Pope Paul VI, Encyclical Letter On the Regulation of Birth (Humanae Vitae) (Washington, DC:

United States Conference of Catholic Bishops, 1968), no. 14.

24. Ibid., no. 12.

25. Pope John XXIII, Encyclical Letter Mater et Magistra (1961), no. 193, quoted in Congregation for

the Doctrine of the Faith, Donum Vitae, no. 4.

26. Pope John Paul II, Encyclical Letter The Splendor of Truth (Veritatis Splendor) (Washington, DC:

United States Conference of Catholic Bishops, 1993), no. 50.

27. “Homologous artificial insemination within marriage cannot be admitted except for those cases in

which the technical means is not a substitute for the conjugal act but serves to facilitate and to help

so that the act attains its natural purpose” (Donum Vitae, Part II, B, no. 6; cf. also Part I, nos. 1, 6).

28. Ibid., Part II, A, no. 2.

29. “Artificial insemination as a substitute for the conjugal act is prohibited by reason of the voluntarily

achieved dissociation of the two meanings of the conjugal act. Masturbation, through which the

sperm is normally obtained, is another sign of this dissociation: even when it is done for the purpose

of procreation, the act remains deprived of its unitive meaning: ‘It lacks the sexual relationship called

for by the moral order, namely, the relationship which realizes “the full sense of mutual self-giving

and human procreation in the context of true love” ’ ” (Donum Vitae, Part II, B, no. 6).

30. Ibid., Part II, A, no. 3.

31. Cf. directive 45.

32. Donum Vitae, Part I, no. 2.

33. Cf. ibid., no. 4. (Washington, DC: United States Conference of Catholic Bishops, 1988), no. 43.

34. Cf. Congregation for the Doctrine of the Faith, “Responses on Uterine Isolation and Related

Matters,” July 31, 1993, Origins 24 (1994): 211-212.

35. Pope John Paul II, Apostolic Letter On the Christian Meaning of Human Suffering (Salvifici

Doloris) (Washington, DC: United States Conference of Catholic Bishops, 1984), nos. 25-27.

Ethical and Religious Directives for Catholic Health Care Services, Sixth Edition

36. United States Conference of Catholic Bishops, Order of Christian Funerals (Collegeville, Minn.:

The Liturgical Press, 1989), no. 1.

37. See Declaration on Euthanasia.

38. Ibid., Part II.

39. Ibid., Part IV; Pope John Paul II, Encyclical Letter On the Value and Inviolability of Human Life

(Evangelium Vitae) (Washington, DC: United States Conference of Catholic Bishops, 1995),

no. 65.

40. See Pope John Paul II, Address to the Participants in the International Congress on “Life-

Sustaining Treatments and Vegetative State: Scientific Advances and Ethical Dilemmas” (March

20, 2004), no. 4, where he emphasized that “the administration of water and food, even when

provided by artificial means, always represents a natural means of preserving life, not a medical

act.” See also Congregation for the Doctrine of the Faith, “Responses to Certain Questions of the

United States Conference of Catholic Bishops Concerning Artificial Nutrition and Hydration”

(August 1, 2007).

41. Congregation for the Doctrine of the Faith, Commentary on “Responses to Certain Questions of

the United States Conference of Catholic Bishops Concerning Artificial Nutrition and Hydration.”

42. See Declaration on Euthanasia, Part IV.

43. Donum Vitae, Part I, no. 4.

44. See: Congregation for the Doctrine of the Faith, “Some Principles for Collaboration with non-

Catholic Entities in the Provision of Healthcare Services,” published in The National Catholic

Bioethics Quarterly (Summer 2014), 337-40.

45. Pope John Paul II, Veritatis Splendor, no. 13.

46. Pope John Paul II, Evangelium Vitae, no. 74.

47. Catechism of the Catholic Church, no. 2284.

48. While there are many acts of varying moral gravity that can be identified as intrinsically evil, in the

context of contemporary health care the most pressing concerns are currently abortion, euthanasia,

assisted suicide, and direct sterilization. See Pope John Paul II’s Ad Limina Address to the bishops

of Texas, Oklahoma, and Arkansas (Region X), in Origins 28 (1998): 283. See also “Reply of the

Sacred Congregation for the Doctrine of the Faith on Sterilization in Catholic Hospitals”

(Quaecumque Sterilizatio), March 13, 1975, Origins 6 (1976): 33-35: “Any cooperation

institutionally approved or tolerated in actions which are in themselves, that is, by their nature and

condition, directed to a contraceptive end . . . is absolutely forbidden. For the official approbation of

direct sterilization and, a fortiori, its management and execution in accord with hospital regulations,

is a matter which, in the objective order, is by its very nature (or intrinsically) evil.” This directive

supersedes the “Commentary on the Reply of the Sacred Congregation for the Doctrine of the Faith

on Sterilization in Catholic Hospitals” published by the National Conference of Catholic Bishops on

September 15, 1977, in Origins 7 (1977): 399-400.

49. See Catechism of the Catholic Church: “Anyone who uses the power at his disposal in such a way

that it leads others to do wrong becomes guilty of scandal and responsible for the evil that he has

directly or indirectly encouraged” (no. 2287).

Sheet2

) to provide nutrition and hydration. Police report

PEG

1992

1998

2000

2000 GREER

REMOVE PEG

2001 SCHINDLERS

2001 MICHAEL

2001 GREER

2001 SCHINDLERS

2001 GREER

2001

JD LAZZARA

2001

4/23/01

SCHINDLERS

4/26/01

MICHAEL

2DCA

GREER

2DCA

MICHAEL

FL SUPREME

FED CT

14-Nov-03

29-Mar-04

31-Aug-04

18-Feb-05

House Democrats and Republicans hold news conferences.

1963

BORN

3-Dec-63

Theresa (Terri) Marie Schindler is born in Pennsylvania.

10-Nov-84

1984

MARRIED

Terri Schindler, 20, and Michael Schiavo, 21, are married at Our Lady of Good Counsel Church in Southhampton, Pennsylvania. The union is now among the “celebrity marriages” featured at About.com, a Website about marriage.

(20 Y/O)

1986

The couple move to St. Petersburg, where Ms. Schiavo’s parents had retired.

25-Feb-90

1990

COLLAPSE

Ms. Schiavo suffers cardiac arrest, apparently caused by a potassium imbalance and leading to brain damage due to lack of oxygen. She was taken to the Humana Northside Hospital and was later given a percutaneous endoscopic gastrostomy (

PEG

12-May-90

(26 Y/0)

Ms. Schiavo is discharged from the hospital and taken to the College Park skilled care and rehabilitation facility.

18-Jun-90

Court appoints Michael Schiavo as guardian; Ms. Schiavo’s parents do not object.

30-Jun-90

Ms. Schiavo is transferred to Bayfront Hospital for further rehabilitation efforts.

Sep-90

Ms. Schiavo’s family brings her home, but three weeks later they return her to the College Park facility because the family is “overwhelmed by Terri’s care needs.”

Nov-90

Michael Schiavo takes Ms. Schiavo to California for experimental “brain stimulator” treatment, an experimental “thalamic stimulator implant” in her brain.

Jan-91

The Schiavos return to Florida; Ms. Schiavo is moved to the Mediplex Rehabilitation Center in Brandon where she receives 24-hour care.

19-Jul-91

Ms. Schiavo is transferred to Sable Palms skilled care facility where she receives continuing neurological testing, and regular and aggressive speech/occupational therapy through 1994.

May-92

Ms. Schiavo’s parents, Robert and Mary Schindler, and Michael Schiavo stop living together.

Aug-92

1992

1/4 M AWARD

Ms. Schiavo is awarded $250,000 in an out-of-court medical malpractice settlement with one of her physicians.

Nov-92

1 M AWARD

The jury in the medical malpractice trial against another of Ms. Schiavo’s physicians awards more than one million dollars. In the end, after attorneys’ fees and other expenses, Michael Schiavo received about $300,000 and about $750,000 was put in a trust fund specifically for Ms. Schiavo’s medical care.

(750Th TRUST)

14-Feb-93

Michael Schiavo and the Schindlers have a falling-out over the course of therapy for Ms. Schiavo; Michael Schiavo claims that the Schindlers demand that he share the malpractice money with them.

29-Jul-93

Schindlers attempt to remove Michael Schiavo as Ms. Schiavo’s guardian; the court later dismisses the suit.

1-Mar-94

First guardian ad litem, John H. Pecarek, submits his report. He states that Michael Schiavo has acted appropriately and attentively toward Ms. Schiavo.

6-May-97

Michael Schiavo’s attorney Deborah Bushnell writes to the Circuit Court to request that the Schindlers receive notice of all filings in the guardianship proceeding, in anticipation of a forthcoming request to withdraw Ms. Schiavo’s PEG tube.

May-98

~1990

INFIDELITY

Michael Schiavo was in a relationship with Jodi Centonze, and had fathered their first child. He said he chose not to divorce his wife and relinquish guardianship because he wanted to ensure her final wishes (not to be kept alive in a PVS) were carried out.

1998

MICHAEL

Michael Schiavo petitions the court to authorize the removal of Ms. Schiavo’s PEG tube; the Schindlers oppose, saying that she would want to remain alive. The court appoints Richard Pearse, Esq., to serve as the second guardian ad litem for Ms. Schiavo.

PET PEG OUT

20-Dec-98

TERRI

The second guardian ad litem, Richard Pearse, Esq., issues his report in which he concludes that Ms. Schiavo is in a persistent vegetative state with no chance of improvement and that Michael Schiavo’s decision-making may be influenced by the potential to inherit the remainder of Ms. Schiavo’s estate.

PVS OFFICIAL

January 24-27,

2000

Trial begins with Pinellas-Pasco County Circuit Court Judge George Greer presiding.

JUDGE

GREER

11-Feb-00

REMOVE PEG

Judge Greer rules that Ms. Schiavo would have chosen to have the PEG tube removed, and therefore he orders it removed, which, according to doctors, will cause her death in approximately 7 to 14 days.

2-Mar-00

SCHINDLERS

The Schindlers file a petition with Judge Greer to allow “swallowing” tests to be performed on Ms. Schiavo to determine if she can consume—or learn to consume—nutrients on her own.

PET SWALLOW

7-Mar-00

Judge Greer denies the Schindlers’ petition to perform “swallowing” tests on Ms. Schiavo.

DENIES SWALLOW

24-Mar-00

Judge Greer grants Michael Schiavo’s petition to limit visitation to Ms. Schiavo as well as to bar pictures. Judge Greer also stays his order until 30 days beyond the final exhaustion of all appeals by the Schindlers.

STAY PEG 30 DYS

Greer Stay and Order Limiting Visitation

24-Jan-01

2001

2DCA

Florida’s Second District Court of Appeal (2nd DCA) upholds Judge Greer’s ruling that permits the removal of Ms. Schiavo’s PEG tube.

22-Feb-01

The Schindler family’s motion for an Appellate Court rehearing is denied.

APPEAL

12-Mar-01

Michael Schiavo petitions Judge Greer to lift his stay, issued March 24, 2000, in order to permit the removal of Ms. Shiavo’s PEG tube.

REMOVE STAY

29-Mar-01

Judge Greer denies Michael Schiavo’s motion to lift stay issued on March 24, 2000; Michael Schiavo can remove Ms. Schiavo’s PEG tube at 1 p.m. on April 20.

REMOVE PEG 1 APR

10-Apr-01

The 2nd DCA denies the Schindlers’ motion to extend Judge Greer’s stay, which is scheduled to expire April 20, 2001.

12-Apr-01

The Schindlers file a motion requesting that Judge Greer recuse himself.

REMOVE GREER

The Schindlers petition the Florida Supreme Court to stay the removal of Ms. Schiavo’s PEG tube.

16-Apr-01

Judge Greer denies the Schindlers’ motion to recuse himself.

REMOVAL DENIED

18-Apr-01

FL SUPREME

The Florida Supreme Court chooses not to review the decision of the 2nd DCA.

REFUSE REVIEW 2DCA

In re Schiavo, 789 So. 2d 248 (Fla. 2001). Case No.: SC01-559

20-Apr-01

FED CT

Federal District Court Judge Richard Lazzara grants the Schindlers a stay until April 23, 2001, to exhaust all their possible appeals.

PEG STAY

4/23/01

23-Apr-01

SUPREME CT KENNEDY

Justice Anthony M. Kennedy of the United States Supreme Court refuses to stay the case for a review by that Court.

REFUSE STAY

24-Apr-01

PEG 1 REMOVED

By order of trial court Judge Greer, and upon issuance of a 2nd DCA mandate, Ms. Schiavo’s PEG tube is removed

26-Apr-01

4/26/01

The Schindlers file an emergency motion with Judge Greer for relief from judgment based upon new evidence, which includes a claim that a former girlfriend of Michael Schiavo will testify that he lied about Ms. Schiavo’s wishes; Judge Greer dismisses the motion as untimely. Also on this date, the Schindlers file a new civil suit that claims that Michael Schiavo perjured himself when he testified that Ms. Schiavo had stated an aversion to remaining on life support. Pending this new civil trial, Circuit Court Judge Frank Quesada orders Ms. Schiavo’s PEG tube to be reinserted.

JD QUESADA

REINSERT PEG 1

4/30/01

30-Apr-01

APPEALS

Michael Schiavo files an emergency motion with the 2nd DCA to allow the removal of Ms. Schiavo’s PEG tube.

9-May-01

The 2nd DCA announces a date for the hearing of oral arguments regarding Michael Schiavo’s motion of April 30, 2001.

11-Jul-01

7/11/01

The 2nd DCA remands the case back to Judge Greer. (1) The 2nd DCA informs the Schindlers that they must address both their desire to have new evidence heard and their perjury claim against Michael Schiavo within the original guardianship proceeding; further, the Schindlers are instructed to file a new motion for relief from judgment in the guardianship proceeding. (2) The 2nd DCA instructs Judge Greer to weigh the Schinders’ new evidence in making a new determination of what Ms. Schiavo would have wanted. (3) The 2nd DCA denies Michael Schiavo’s request to discontinue the PEG tube.

CASE BACK TO GREER

7-Aug-01

After the 2nd DCA remands the case back to Judge Greer, he again finds that Michael Schiavo may remove Ms. Schiavo’s PEG tube on August 28.

10-Aug-01

AUG/10/01

Judge Greer denies the Schindlers’ motion (1) to have their own doctors examine Ms. Schiavo, (2) to remove Michael Schiavo as her guardian, and (3) to disqualify himself from the proceedings.

REMOVE PEG 29 AUG

17-Aug-01

AUG/17/01

Judge Greer delays the removal of Ms. Schiavo’s PEG tube until October 9 in order to allow the Schindlers time to appeal.

PEG STAY OCT/9/01

3-Oct-01

OCT/3/01

The 2nd DCA delays the removal of the PEG tube indefinitely.

PEG STAY INDEF

17-Oct-01

OCT/17/01

The 2nd DCA rules that 5 doctors should examine Ms. Schiavo to determine if she can improve with new medical treatment. The Schindlers and Michael Schiavo are to choose 2 doctors each, and the court is to appoint a doctor. The appeals court also affirms Greer’s denial of the motion to disqualify himself

RULE 5 MD EXAM

1-Nov-01

The 2nd DCA denies Michael Schiavo’s motion to rehear the case.

14-Dec-01

DEC/14/01

Michael Schiavo petitions the Florida Supreme Court to stay the October 17, 2001, ruling of the 2nd DCA. He states that he and the Schindlers will attempt to mediate the dispute in lieu of further litigation.

PET FL SUPREME CT

Michael Schiavo’s Notice of Appeal to the Florida Supreme Court

19-Dec-01

Attorneys meet with a mediator to determine which tests doctors should run on Ms. Schiavo.

10-Jan-02

JAN/10/02

State Supreme Court stays all legal proceedings pending mediation; it orders attorneys to report on the status of mediation in sixty days.

STAY ALL TILL MED

13-Feb-02

FEB/13/02

MED FAILS

Mediation between the Schindlers and Michael Schiavo fails.

14-Mar-02

The Florida Supreme Court denies Michael Schiavo’s petition to review the 2nd DCA’s ruling allowing 5 doctors to examine Ms. Schiavo.

October 12-22, 2002

The trial court holds a new hearing on new potential medical treatments.

15-Nov-02

The Schindlers contend that Michael Schiavo might have abused Ms. Schiavo and this abuse led to her condition. They ask the court for more time to collect evidence, and to remove Michael Schiavo as guardian.

22-Nov-02

Judge Greer rules that Ms. Schiavo’s PEG tube should be removed January 3, 2003.

13-Dec-02

Judge Greer stays his November 22 ruling: Ms. Schiavo should not have her PEG tube removed until an appeals court can rule on the case.

23-Dec-02

The 2nd DCA denies a motion Michael Schiavo filed seeking permission to remove the PEG tube.

6-Jun-03

6-06-03 Court Opinion

9-Jul-03

The 2nd DCA refuses to reconsider its decision.

22-Aug-03

The Florida Supreme Court declines to review the decision.

30-Aug-03

Ms. Schiavo’s parents file a federal lawsuit challenging the removal of Ms. Schiavo’s PEG tube.

17-Sep-03

Judge Greer orders the removal of the PEG tube to take place on October 15, 2003. He also rejects the Schindlers’ request that Ms. Schiavo be given therapy to learn how to eat without the tube.

7-Oct-03

GOV BUSH

Governor Jeb Bush files a federal court brief in support of the Schindlers’ effort to stop the removal of the PEG tube.

10-Oct-03

Federal Court Judge Richard Lazzara rules that he lacks the jurisdiction to hear the federal case.

14-Oct-03

The 2nd DCA refuses to block Judge Greer’s order to remove the PEG tube.

15-Oct-03

OCT/15/03

PEG 2 REMOVED

Ms. Schiavo’s PEG tube is once again removed.

17-Oct-03

The Florida Circuit Court in Pinellas County and the First District Court of Appeal refuse to grant a request by “supporters” of the Schindlers to direct Gov. Bush to intervene in the case.

19-Oct-03

The Advocacy Center for Persons with Disabilities, Inc. files a federal court lawsuit that claims that the removal of Ms. Schiavo’s PEG tube is abuse and neglect.

20-Oct-03

FL HOUSE

The Florida House of Representatives passes a bill, “Terri’s Law,” that allows the governor to issue a “one-time stay in certain cases.”

“TERRI’S LAW”

House Bill 35-E

21-Oct-03

The Florida Senate passes the bill; Governor Bush issues an executive order directing reinsertion of the PEG tube and appointing a guardian ad litem for Ms. Schiavo.

Michael Schiavo files a state-court lawsuit arguing that “Terri’s Law” is unconstitutional and seeking an injunction to stop the reinsertion of the PEG tube; the court requests briefs on the Constitutional arguments about “Terri’s Law.”

The federal court denies the motion for a temporary restraining order filed in the lawsuit of the Advocacy Center for Persons with Disabilities, Inc.

0CT/21/03

PEG REINSERTED

Ms. Schiavo’s PEG tube is reinserted.

22-Oct-03

David Demers, Chief Judge for the Pinellas County Circuit Court, orders both the Schindlers and Michael Schiavo to agree within 5 days on an independent guardian ad litem as required under the Governor’s order. (“Terri’s Law” directs: “Upon issuance of the stay, the chief judge of the circuit court shall appoint a guardian ad litem for the patient to make recommendations to the Governor and the court.”)

28-Oct-03

President George W. Bush praises the way his brother, Governor Jeb Bush, has handled the Schiavo matter.

29-Oct-03

Michael Schiavo files court papers in his state-court lawsuit, arguing that “Terri’s Law” is unconstitutional. The American Civil Liberties Union has joined Michael Schiavo.

31-Oct-03

Judge Demers appoints Dr. Jay Wolfson as Ms. Schiavo’s guardian ad litem. Dr. Wolfson holds both medical and legal degrees; he is also a public health professor at the University of South Florida. He is supposed to represent Ms. Schiavo’s best interest in court, but he has no authority to make decisions for her.

4-Nov-03

Governor Jeb Bush asks Circuit Court Judge W. Douglas Baird to dismiss Michael Schiavo’s suit (filed October 21, 2003) that challenges “Terri’s Law.”

8-Nov-03

Judge Baird denies Governor Bush’s motion to dismiss the state-court suit.

10-Nov-03

Governor Bush appeals Judge Baird’s decision; the filing of the appeal has the effect of staying the removal of Ms. Schiavo’s PEG tube.

14-Nov-03

Judge Baird vacates the stay.

In response to Judge Baird’s lifting the stay, the 2nd DCA issues an indefinite stay.

19-Nov-03

Governor Bush files a petition to remove Judge Baird.

21-Nov-03

Florida Sens. Stephen Wise and Jim Sebesta introduce legislation (S692) that would require persons in persistent vegetative states to be administered medically supplied nutrition and hydration in the absence of a living will, regardless of family beliefs about what those patients would have wanted. The measure is withdrawn from consideration on April 16, 2004.

1-Dec-03

University of South Florida Prof. Jay Wolfson, guardian ad litem, concludes in his report that Ms. Schiavo is in a persistent vegetative state with no chance of improvement.

10-Dec-03

The 2nd DCA refuses to remove Judge Baird, who is the presiding judge in the state-court lawsuit filed October 21, 2003.

5-Jan-04

The Schindler family petitions the Pinellas County Circuit Court to reappoint Jay Wolfson, the guardian ad litem.

8-Jan-04

Judge Demers rejects the request to reappoint the guardian ad litem, citing the pending court decisions over the constitutionality of “Terri’s Law” as reason to wait on any action.

13-Feb-04

The 2nd DCA reverses Judge Baird’s ruling (in the case filed October 21, 2003) that denied the Schindlers permission to intervene in Michael Schiavo’s Constitutional challenge to “Terri’s Law.” The 2nd DCA explains that Judge Baird did not follow proper procedure. The court also gives permission to Governor Bush to question several witnesses who Judge Baird previously had ruled could not offer any relevant testimony.

12-Mar-04

Judge Baird again rejects the Schindlers’ request to intervene in Michael Schiavo’s suit that questions the constitutionality of “Terri’s Law.”

20-Mar-04

POPE JPII

Pope John Paul II addresses World Federation of Catholic Medical Associations and Pontifical Academy for Life Congress on “Life-Sustaining Treatments and Vegetative State: Scientific Advances and Ethical Dilemmas.” His remarks spark widespread interest and controversy.

29-Mar-04

Nursing home workers discover 4 “fresh puncture wounds” on one arm and a fifth wound on the other arm; the workers state that a hypodermic needle appears to have caused the wounds. Attendants discovered the wounds shortly after the Schindlers visited Ms. Schiavo for 45 minutes. Toxicology reports indicate that no substance was injected into Ms. Schiavo. Clearwater police later conclude that the marks might have been made by a device used to move Ms. Schiavo and, in any case, that no evidence of abuse or other wrongdoing could be found.

Judge Greer denies a motion filed by the Schindlers seeking to have Michael Schiavo defend himself in a hearing; they allege that he is violating a 1996 court order that requires him to share a sufficient amount of Ms. Schiavo’s medical information. Michael Schiavo claims that he has shared an adequate amount of information through attorneys.

16-Apr-04

S692 is withdrawn from consideration in the Florida Legislature.

23-Apr-04

The 2nd DCA rules that the Pinellas County trial court has jurisdiction to hear and is the proper venue for the case Michael Schiavo has filed against Governor Bush asserting that “Terri’s Law” is unconstitutional.

5-May-04

Pinellas Circuit Judge W. Douglas Baird rules that “Terri’s Law,” sought and signed by Gov. Bush and approved by the Legislature on October 21, 2003, is unconstitutional. The governor appeals the ruling.

1-Jun-04

The 2nd DCA grants a motion from attorneys for Michael Schiavo to send the case directly to the Florida Supreme Court and bypass a lower-court review. Meanwhile, attorneys for Gov. Bush file a motion asking that all appeals be halted until the issue of whether Michael Schiavo has the authority to fight the governor on his wife’s behalf is resolved.

16-Jun-04

Florida’s Supreme Court, pointing to “a question of great public importance requiring immediate resolution by this Court,” accepts jurisdiction and sets oral arguments for August 31, 2004.

30-Jun-04

2nd DCA affirms Judge Baird’s March 12 ruling denying the Schindlers the ability to intervene in the lawsuit over the constitutionality of “Terri’s Law.”

19-Jul-04

The Schindlers file a motion in the Circuit Court for Pinellas County seeking relief from judgment in Schindler v. Schiavo. Based in part upon the recent statement by Pope John Paul II, they argue that the orders mandating withdrawal of the PEG tube from Ms. Schiavo and authorizing Michael to challenge the constitutionality of “Terri’s Law” violate her “free exercise of her religious beliefs [and] her right to enjoy and defend her own life and, in fact, imperil her immortal soul.”

27-Jul-04

National group of bioethicists files amicus brief “in support of Michael Schiavo as guardian of the person.”

31-Aug-04

The Florida Supreme Court hears oral arguments in the lawsuit over the constitutionality of “Terri’s Law.”

Circuit Judge George Greer, opposed for re-election by an attorney who was known to oppose Greer’s rulings in the Schiavo case, is re-elected by a large margin.

23-Sep-04

Florida’s Supreme Court, unanimously affirming the trial court order, declares “Terri’s Law” unconstitutional.

4-Oct-04

Governor Bush files a motion and then an amended motion for rehearing and clarification of the Florida Supreme Court opinion issued on September 23, 2004

21-Oct-04

Florida Supreme Court denies Governor Bush’s amended motion for rehearing and clarification, as well as a motion seeking permission to file a second amended motion for rehearing and clarification. The Court issues a mandate to transfer jurisdiction back to Judge Greer.

22-Oct-04

In Pinellas County, at the trial-court level, Judge Greer denies the motion filed by the Schindlers on July 19, 2004. He also stays the removal of her PEG tube until December 6, 2004.

25-Oct-04

Governor Bush files a motion with the Florida Supreme Court asking that it recall the mandate it issued on October 22 because he will be filing a petition for certiorari regarding this case with the United States Supreme Court.

27-Oct-04

Florida Supreme Court grants Governor Bush’s motion asking that it recall the mandate issued on October 22. Proceedings in the trial and all appellate courts in the case of Bush v. Schiavo are stayed until November 29, 2004.

22-Nov-04

In the guardianship proceeding in Pinellas County, the Schindlers appeal from Judge Greer’s October 22 order denying their motion for relief from judgment.

1-Dec-04

Governor Bush files a petition for certiorari, seeking review of the Florida Supreme Court’s decision regarding “Terri’s Law,” with the U.S. Supreme Court.

29-Dec-04

2nd DCA, without opinion, denies the Schindlers’ November 22 appeal from Judge Greer’s order refusing to reopen the guardianship proceeding.

10-Jan-05

The Schindlers again ask Judge Greer to remove Michael Schiavo from his judicial appointed post of Ms. Schiavo’s guardian.

13-Jan-05

The Schindlers file two motions – one in the 2d DCA, asking it to reconsider its decision of December 29, 2004, and a second in the trial court guardianship proceeding, asking Judge Greer once again to prevent withdrawal of nutrition and hydration until the 2d DCA does so.

24-Jan-05

JAN/24/05

US SUPREME

The United States Supreme Court refused to grant review of the case in which the Florida Supreme Court struck down “Terri’s Law” as unconstitutional.

REFUSES HEARING

7-Feb-05

Florida’s Department of Agriculture and Consumer Services cites the Terri Schindler-Schiavo Foundation for failing to register with the state to solicit donations.

11-Feb-05

In Pinellas County, Judge Greer denies the Schindlers’ motions, filed January 10 and 13, 2005. The order authorizing withdrawal of the PEG tube remains in effect, although implementation is stayed pending the outcome of currently pending appeals.

15-Feb-05

The Schindlers ask the 2nd DCA to stay the mandate issued when it refused to hear their most recent appeal.

16-Feb-05

Randall Terry, founder of the pro-life activist organization Operation Rescue, appears with the Schindlers at a news conference, vowing protest vigils against removal of the PEG tube.

18-Feb-05

The Schindlers again petition Judge Greer in Pinellas County for reconsideration of the order of February 11, 2005, in which the court upheld its judgment, made in the year 2000, that the PEG tube should be removed.

Florida Representatives Baxley Brown; Cannon; Davis, D.; Flores; Goldstein; Lopez-Cantera; Murzin; Quinones; Traviesa introduced H 701 in the Florida Legislature. H 701, mirroring S. 692 (introduced in October 2003 and withdrawn in April 2004), would require maintenance of medically supplied nutrition and hydration in incapacitated persons in most instances.

21-Feb-05

The 2d DCA denies the Schindlers’ motion of February 15, 2005, clearing the way for removal of the PEG tube when the current stay expires on February 22, 2005. Judge Greer schedules a hearing on the Schindlers’ motion of February 18, 2005, for February 23, 2005.

22-Feb-05

Judge Greer stays removal of the PEG tube until 5 p.m. on February 23, 2005 (after he hears argument on the motion filed by the Schindlers on February 18, 2005).

23-Feb-05

After a hearing, Judge Greer extends the stay preventing removal of the PEG tube until 5 p.m. on February 25, 2005, to permit time to issue an order detailing his decisions regarding matters discussed at the hearing. Officials from Florida’s Department of Children and Families (DCF) move to intervene in the case, but Judge Greer denies the motion to intervene at the hearing.

25-Feb-05

Judge Greer denies the motion before him and orders that, “absent a stay from the appellate courts, the guardian, Michael Schiavo, shall cause the removal of nutrition and hydration from the ward, Theresa Schiavo, at 1 p.m. on Friday, March 18, 2005.”

26-Feb-05

The St. Petersburg Times reports that a Vatican cardinal spoke on Vatican Radio opposing removal of the PEG tube.

28-Feb-05

The Schindlers file a number of motions with Judge Greer, addressing a range of issues. They also indicate that they will appeal the judge’s decision of February 25, 2005. Judge Greer denies some of the motions but agreed to set a hearing date to consider others.

7-Mar-05

The Schindlers appeal Judge Greer’s February 25, 2005 order to the 2nd DCA.

Bioethicists from six Florida universities submit an analysis of H701.

8-Mar-05

U.S. Rep. David Weldon (R.-Fla.) introduces in the United States House of Representatives H.R. 1151, titled the Incapactitated Persons’ Legal Protection Act. The bill would permit a federal court to review the Schiavo matter through a habeas corpus lawsuit.

9-Mar-05

The Florida House Health Care Regulation Committee considers H.701, voting to approve a Council/Committee Substitute 701 instead of the original version.

10-Mar-05

Judge Greer issues order denying Florida’s Department of Children and Families the right to intervene in the guardianship case.

14-Mar-05

The Judiciary Committee in the Florida House considers H.701, voting to approve another Committee substitute for the original bill. The South Florida Sun-Sentinel reports that the House and the Senate have agreed that this bill will come to a vote.

15-Mar-05

The Florida House Health & Families Council considers and approves the second committee substitute H.701.

The Florida Senate Judiciary Committee passes S.804, providing that medically supplied nutrition and hydration cannot be “suspended from” a person in a PVS if: (1) the purpose of the suspension is “solely to end the life of” a person in a PVS; (2) a conflict exists on the issue of suspension of medically supplied nutrition and hydration among the persons who could be proxy decisionmakers for that person under Florida law; and (3) the person in the PVS had not executed a written advance directive or deignated a health care surrogate.

16-Mar-05

The 2d DCA affirms Judge Greer’s orders and refuses to stay the scheduled March 18 withdrawal of the PEG tube.

The U.S. House of Representatives, by voice vote, passes H.R. 1332, the Protection of Incapacitated Persons Act of 2005. This bill would amend federal law to provide for removal of certain cases to federal court from state court, rather than authorizing use of the federal habeas corpus remedy to obtain federal court review, as H.R. 1151 would have.

17-Mar-05

The Florida House of Representatives approves H.701, after some amendments.

The Florida Senate votes down S.804.

FL DCF

Florida’s Department of Children and Families (DCF) petitions the Florida Supreme Court for relief, and the Florida Supreme Court denies the petition.

US SENATE

The U.S. Senate passes a “private bill” applying to the Schiavo case but differing from H.R. 1332. The U.S. Senate website, at http://www.senate.gov, explains a “private bill” as follows: “A private bill provides benefits to specified individuals (including corporate bodies). Individuals sometimes request relief through private legislation when administrative or legal remedies are exhausted. Many private bills deal with immigration–granting citizenship or permanent residency. Private bills may also be introduced for individuals who have claims again the government, veterans benefits claims, claims for military decorations, or taxation problems. The title of a private bill usually begins with the phrase, “For the relief of. . . .” If a private bill is passed in identical form by both houses of Congress and is signed by the President, it becomes a private law.”

The Schindlers ask the U.S. Supreme Court to hear the case, but the U.S. Supreme Court denies their petition.

Republican senators circulate a memo on the political advantages of supporting legislation to reinsert Ms. Schiavo’s nutrition tube. On April 7, The Washington Post reported that “The legal counsel to Sen. Mel Martinez (R-Fla.) admitted [on April 6] that he was the author of a memo citing the political advantage to Republicans of intervening in the case … Brian H. Darling, 39, a former lobbyist for the Alexander Strategy Group on gun rights and other issues, offered his resignation and it was immediately accepted, Martinez said.”

18-Mar-05

The U.S. House of Representatives Committee on Government Reform issues five subpoenas: one commanding Michael Schiavo to appear before it and bring with him the “hydration and nutrition equipment” in working order; three commanding physicians and other personnel at the hospice to do the same; and one commanding Ms. Schiavo to appear before it. The subpoenas would require that the PEG tube remain in working order until at least the date of testimony, March 25, 2005. The subpoenas are included as appendices to the U.S. House All Writs Petition (see just below).

The Committee on Government Reform also moves to intervene in the guardianship litigation before Judge Greer and asks Judge Greer to stay his order requiring removal of the PEG tube. Judge Greer denies the motions.

The Committee on Government Reform files an emergency all-writs petition with the Florida Supreme Court, effectively seeking reversal of Judge Greer’s denial of its motions. The Florida Supreme Court denies this petition.

The House Committee on Government Reform asks the U.S. Supreme Court to review the Florida Supreme Court’s denial of its petition. Justice Kennedy, acting for the Court, denies the application for relief.

MAR/18/05

PEG 3 REMOVED

The PEG tube is removed in mid-afternoon. This is the third time the tube has been removed in accordance with court orders.

The Schindlers, as “next friends” of their daughter, file a petition for writ of habeas corpus in federal district court in the Middle District of Florida. That court dismisses the case for lack of jurisdiction and refuses to issue a temporary restraining order because “there is not a substantial likelihood that [the Schindlers] will prevail on their federal constitutional claims.”

March 19-20, 2005

The U.S. Senate delays its Easter recess and works on Saturday to reach a compromise with the House on a bill, S.686, closely resembling the special bill it passed on March 17. On Palm Sunday (which holiday is frequently noted in debate), it then passes S.686 and the U.S. House of Representatives returns from Easter recess for a special session to debate S.686.

20-Mar-05

House Democrats and Republicans hold news conferences.

21-Mar-05

Shortly past 12:30 a.m., the U.S. House of Representatives votes 203-58 to suspend its rules and pass S.686.

CONGRESS DEBATE

Congressional Debate on S.686

President Bush signs S.686 at 1:11 a.m.

Federal District Court Judge James D. Whittemore, Middle District of Florida (in Tampa), hears arguments on the Schindlers’ motion that he order re-insertion of the PEG tube while the lawsuit they will assert pursuant to S.686 is litigated.

22-Mar-05

Federal District Court Judge Whittemore refuses to order re-insertion of the PEG tube.

The Schindlers appeal Judge Whittemore’s decision to the U.S. Court of Appeals for the Eleventh Circuit.

The Schindlers file an amended complaint in the federal district court, adding a number of new claims.

NPR “Morning Edition” broadcast

23-Mar-05

The U.S. Eleventh Circuit Court of Appeals, in a 2-1 vote, denies the Schindlers’ appeal.

United States Eleventh Circuit Court of Appeals, acting en banc (as a whole), refuses to rehear the Schindlers’ appeal, leaving intact the court’s ruling earlier in the day.

The Florida Senate, by a vote of 21-18, again refuses to pass S.804. This bill was approved by the Senate Judiciary Committee on March 15, 2005.

Florida Governor Jeb Bush reports that a neurologist, Dr. William Cheshire, claims that Ms. Schiavo is not in a persistent vegetative state. The governor asks the Florida Department of Children and Families (DCF) to obtain custody of Ms. Schiavo in light of allegations of abuse. Judge Greer holds a hearing on the matter.

The Schindlers file a petition for writ of certiorari with the U.S. Supreme Court.

Judge Greer issues a restraining order prohibiting DCF from removing Ms.Schiavo from the hospice or otherwise re-inserting the PEG tube.

The Schindlers ask again for a restraining order in federal court.

Five members of the U.S. House of Representatives ask the U.S. Supreme Court to file a “friend of the court” brief.

24-Mar-05

The U.S. Supreme Court refuses to hear the Schindlers’ case.

The Schindlers file a Second Amended Complaint, adding several claims, in the federal court case. Count X, titled “Right to Life,” alleges a violation of the Fourteenth Amendment’s right to life because removing the PEG tube is “contrary to [Ms. Schiavo’s] wish to live.”

The trial court (Judge Whittemore) schedules a hearing for 6 p.m. and orders supplemental briefs on Count X.

Judge Greer denies DCF’s motion to intervene. DCF appeals Judge Greer’s order. Judge Greer vacates the automatic stay upon appeal. The 2d District Court of Appeal refuses to reinstate the stay. The Florida Supreme Court dismisses a motion on this matter because it “fails to invoke” the court’s jurisdiction.

25-Mar-05

Judge Whittemore denies the Schindlers’ second motion for an order re-inserting the PEG tube.

The Schindlers appeal Judge Whittemore’s order to the U.S. Court of Appeals for the Eleventh Circuit. The Eleventh Circuit affirms. The Schindlers announce that they will pursue no more federal appeals.

The Schindlers file an emergency motion attempting to convince Judge Greer to reinsert the PEG, at least temporarily until the Eleventh Circuit decides their appeal. The motion contends her family heard her try to verbalize “I want to live,” according to news reports. (This motion and accompanying affidavits comprise Appendix 7 of the Schindlers’ Petition linked under March 26, just below.)

DCF appeals Judge Greer’s March 23 denial of its first motion to intervene to the 2d DCA.

26-Mar-05

Judge Greer denies the Schindlers’ motion of March 25, 2005.

The Schindlers appeal to the Florida Supreme Court to reverse Judge Greer’s refusal to reinsert the PEG tube, but the Florida Supreme Court refuses to do so, citing a lack of jurisdiction.

News agencies report the arrest on March 25 of Richard Alan Meywes of Fairview, N.C., for offering $250,000 for the killing of Michael Schiavo and another $50,000 for the death of Judge Greer.

The Schindlers advise supporters demonstrating around the hospice to return home to spend the Easter holiday with their families. The protesters remain.

27-Mar-05

In an interview on CNN, Governor Bush says: “I cannot violate a court order. I don’t have power from the U.S. Constitution, or the Florida Constitution for that matter, that would allow me to intervene after a decision has been made.”

29-Mar-05

The Rev. Jesse Jackson leads a prayer service outside the hospice and speaks out against removal of the PEG tube.

The 2d DCA upholds Judge Greer’s ruling refusing to let the DCF intervene.

Despite earlier indications that they would pursue no further federal appeals, the Schindlers petition the entire Eleventh Circuit Court of Appeals for permission to file a motion for rehearing en banc although the time to do so has expired. A grant of that petition would enable the Schindlers to ask for review of the Eleventh Circuit decision of March 24.

30-Mar-05

The Eleventh Circuit permits the Schindlers’ filing and then, acting both through a panel and as a whole, denies the motion for rehearing.

The U.S. Supreme Court refuses to review the Eleventh Circuit ruling.

31-Mar-05

MAR/31/05

TERRI DIES

Ms. Schiavo dies at 9:05 a.m. Her body is transported to the Pinellas Country Coroners’ Office for an autopsy.

Hospice of the Florida Suncoast issues a statement.

President Bush discusses Schiavo (video includes remarks on, WMD Commission Report)

Florida Gov. Bush issues a statement.

Judge Greer authorizes Michael Schiavo to administer Ms. Schiavo’s estate.

On this date in 1976, the New Jersey Supreme Court ruled that PVS patient Karen Ann Quinlan could be disconnected from her respirator. She remained in a persistent vegetative state and died in 1985.

12-Apr-05

The Wall Street Journal Online / Harris Interactive Health Care Poll finds that “most people disapprove of how President Bush, Governor Bush, and the Congress handled the issue.” Harris Poll

15-Apr-05

In response to a motion from the media, Judge Greer orders DCF to release redacted copies of abuse reports regarding Ms. Schiavo. Newspapers report that DCF found no evidence of abuse after investigating the 89 reports filed before February 18, 2005. Thirty allegations are outstanding and still being investigated, but Judge Greer earlier had ruled that those allegations duplicated those previously filed.

17-May-05

More than six weeks after Ms. Schiavo’s death, Lisa Wilson is the last of the hundreds of protesters outside Ms. Schiavo’s hospice.

15-Jun-05

Dr. Jon Thogmartin, Florida’s District Six Medical Examiner, releases the results of Ms. Schiavo’s autopsy. He reports that the autopsy showed Ms. Schiavo’s condition was “consistent” with a person in a persistent vegetative state. “This damage was irreversible,” he said. “No amount of therapy or treatment would have regenerated the massive loss of neurons.” No evidence of abuse was found, he said.

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*****Please watch these videos and answer questions. Also see the other attachments. Answers must come from attachments and videos. ***********

Nutrition & Hydration/Persistent Vegetative State (PVS)

1. Cure / care: compare and contrast.

2. Basic care: Nutrition, hydration, shelter, human interaction.

· Are we morally obliged to this? Why? Example

3. Swallow test, describe; when is it indicated?

4. When is medically assisted N/H indicated?

· Briefly describe Enteral Nutrition (EN), including:

· NJ tube

· NG tube

· PEG

· Briefly describe Parenteral Nutrition (PN), including:

· a. Total parenteral nutrition

· b. Partial parenteral nutrition

5. Bioethical analysis of N/H; state the basic principle and briefly describe the two exceptions.

6. Case Study: Terry Schiavo (EXCEL FILE ATTACH). Provide a bioethical analysis of her case; should we continue with the PEG or not? Why yes or why not?

7. Read and summarize ERD paragraphs #:

32, 33, 34, 56, 57, 58.

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