The Subject in a Vegetative State: a Personalistic View
Bishop Sgreccia on an End-of-Life Issue
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ROME, APRIL 24, 2004 (Zenit.org).- Here is the text of an address delivered by Bishop Elio Sgreccia, vice president of the Pontifical Academy of Life, at the international congress "Life-Sustaining Treatments and Vegetative State: Scientific Advances and Ethical Dilemmas," held here last month.
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"The Subject in Vegetative State: For a Personalistic View"
Bishop Elio Sgreccia
Vice President of the Pontifical Academy of Life
Emeritus Professor of Bioethics
Catholic University Medical School
Member of the National Bioethics Committee of Italy
The aim of my paper is to outline the condition of the persistent vegetative state beginning with the analysis specific to philosophical anthropology and, more precisely, beginning with the concept of the human person.
The underlying question, and the one to which this paper seeks to give an answer, is the following: Is the human subject who is in a persistent vegetative state a living human person or a corpse?
In simpler terms: Is this subject, who is able to receive nourishment and to breathe but is incapable of having mentally connoted conscious relationships, still a body animated by a spirit? Can an organic, vegetative life exist in the human subject without there being the presence of the spirit as well?
In order to be able to engage in this analysis more effectively it is necessary, in my opinion, to address three assertions:
a) Man is a unitary but at the same time a compound being; his components are the spiritual soul and the material body and as such he is defined as a "person."
In classical, medieval and also modern philosophy, reference is made to the material body and the spiritual soul, but today in the biomedical sciences, and in particular in the neurosciences, the terms "mind" and "brain" are more frequently employed.
These two modalities are not equivalent because whereas the phrase "body-soul" refers to the concreteness of the individual being, to substance, to being, the phrase "mind-body" refers to function and is thus reductive. One can think that the mind does not express its function in the fetus or in the child or in the sleeping person, but this does not mean that these individuals do not have a spiritual soul.
b) The unity of the spiritual soul with the body is of a substantial (and not accidental) character, and is such that whereas the soul is able to live and to operate separately from the body as well, the body receives existence, that is to say life, from the soul. In relation to the spiritual soul the body does not have its own existence. The unity of the person lies in this fact: There is a single existence for these two components.
c) In the living human being there are not different kinds of souls: one vegetative, one sensory, and one rational; instead, the rational soul is responsible for all the functions. Thus the personal being is unitary in the sense that the self invests the whole of the corporeal existence. Even when rationality is impeded this does not mean that the rational soul is not present in a person who is still biologically alive.
In setting out these steps I follow the anthropological approach which, beginning with Albert the Great and Thomas Aquinas,1 and going beyond the Aristotelian vision and especially the vision connected with the Aristotelian philosophy of Arab culture (Averroës), was adopted both in the field of Catholic theological anthropology and in the field of ontologically based personalism.2
Such personalism rejects both the dualism of a Platonic kind and the dualism of a Cartesian kind, and also rejects Marxism, which expresses itself today primarily in materialist approaches.
In contrary fashion, personalism emphasizes the unity of the person as regards the relationship between the spiritual soul and the body by affirming that in the person there is a "dual unity" because the body receives "being," "subsisting," from the spiritual soul.
The body has the poverty of not being able to exist on its own; instead, it exists as a human body because of the existing that is conferred upon it by the spiritual soul. It is precisely this step that is the first step in my analysis.
The human person in his or her living unity
In order to adequately understand the anthropological structure of the human person we need to refer to two kinds of relationships that are defined and used in classical and medieval philosophy: the relationship between matter and form (the ilemorphic approach) and the relationship between essence and existence ("essentia et esse").
Experience offers us the first fact that enables us to know that the individual man has a material body, capable of development and decay like every other living organism, the outcome of different organs and apparatuses and marvelously structured according to what the biological sciences have analyzed with their increasing knowledge.
In this body a spiritual soul shows that it is present and operative; differently from what happens in the organisms of other living species, this spiritual soul is capable of immaterial operations: the intellect, freedom and moral conscience.
From this observation of such operations according to the principle "operari sequitur esse et huic proportionatur" [activity follows from being and is proportioned to it] we may conclude that the spiritual soul is immaterial, although it uses the body, and is thus immortal. The spiritual soul is not only the principle of "animation" of the body but also has an activity that is higher than the body and which transcends the organism and materiality.
The presence in man of the intellect, both as "passive" intellect (understood as a capacity to receive the result of the process of abstraction) and as "active" intellect (understood as a capacity to formulate a concept by abstraction), is a sufficient proof to demonstrate, following Thomas Aquinas, that in the spiritual soul there are activities "cui non communicat corpus" [in which the body does not share] that are higher than the dynamisms of the brain and the senses.
This conclusion, which acts to complete Aristotelian thought,3 leads us to conclude that the spiritual soul is an immaterial and subsistent substance. It is united to the body from the outset as its animating principle, but its capacity does not stop at this task of animation. Indeed, being spiritual, it continues to exist after the death of the body as well.
From this we may derive the following assertion. As the spiritual soul is called to subsist it cannot come from the bodies of the parents because it cannot come from a biological element; instead, it receives its existence ("esse") from God the Creator, because only the Subsistent Being (God) has existence because of his own being.
For this reason, the "esse" of the spiritual soul, since it cannot come from material corporeity (because what is spiritual cannot come from what is material), can only be created by God. At the same time the soul is created to be united to the body and to communicate existence to the body. Just as every form defines the matter, the structure, of a body, so the spiritual soul defines and structures the body and makes it human.
The simultaneousness of the creation of the soul with the conception of the body is a consequence that St. Thomas did not directly affirm -- believing as he did that a certain development of the body was necessary for the infusion of the soul -- but this truth (today recognized by specialists) is more consistent in the context of his thought and his metaphysical principles.4
Above all else it is required by the knowledge of biology and genetics that demonstrate a very specific organizational "form" of the embryo from the first moment of conception. Compared to other forms, the human soul has specific to it the fact of being subsistent in its being and of communicating to the body the being that is specific to the body.5
This "poverty" of the body, which receives existence ("esse") from the spiritual soul, ends up by being wealth because human corporeity is thus realized as an epiphany and language of the spirit. And in every one of its acts it becomes the bearer of a higher meaning, it reveals the dignity that comes to it from a spiritual and immortal soul. Here, medicine has a point that is one of the fundamental cardinal points of its epistemological and ethical status.
The union of the spiritual soul with the body
The spiritual soul has a dual tie with the body: one belonging to the order of essence and one belonging to the order of existence.
In the order of essence, according to classical language the soul is "forma corporis" [the form of the body], that is to say it (the human soul) makes of the body human corporeity, which is a corporeity different from that of any other living thing.
To employ more modern language, one would say that the spiritual soul is a "self" together with the body, which reveals all the richness of spirituality, and such spirituality is expressed in every one of its actions: in movement, in smiling, in pain and in speech.
That this essential value is recognized as a substantial form from the moment of conception is the logical consequence of the fact that the human individual is constituted as an "unum" [unit], indeed as an "unus" [one], from that moment, and during development conserves his organic unity and his unity as an organism throughout the whole of that development. "That self," in "that body," maintains that unity inside, outside, and diachronically in, the same individual from conception to death.6
One single soul for the functions of life and thought
This assertion is an uncontested cardinal point in Thomistic anthropological thought starting from the heritage received from Albert the Great.7
In Question 76 of the "Summa Theologiae," Part I, St. Thomas addresses the question in two separate articles (III and IV) on the uniqueness of the soul in man and the uniqueness of form.
The two questions are not identical. He thought that the uniqueness of the spiritual soul also subsists in the (successive) plurality of forms. Aristotle had stated in relation to the development of the embryo that the human embryo lives first a vegetative life, then a sensory life, and that finally the intellect of divine origin enters (by the door -- "thürathen").
Many contemporaries of St. Thomas even argued in favor of the co-presence of different "forms of animation" in man after the development of the rational soul as well.8
Among the ancient Greek Fathers, there had been, on the other hand, the well-known doctrinal point of St. Gregory of Nyssa according to which the rational soul, with all its perfections is present from the first moment of generation, and with the advance of the formation of the body the various activities of the spirit are gradually manifested.
St. Albert the Great had concluded that in the human being there is a succession of forms and vital principles and that the most perfect spiritual soul, when it arrives, absorbs and takes the place of the inferior forms.
However, St. Thomas,9 who remains receptive to the Aristotelian position and requires the advent of the spiritual soul prior to the formation of the organism, asserts that:
a) the soul is a unique substance that has different (intellectual, sensory and vegetative) powers, and that as a substantial form it constitutes a single entity. If there were more than one soul there would be more than one form and thus more than one entity within the same individual-man;
b) The spiritual soul, as a substantial form, does not absorb the vegetative and sensory soul, but because it is already, as "actus corporis" [the "act" of the body], supplied with the capacity to express vegetative and sensory life, on its arrival, once it is present in the body of the embryo, it transforms its total essence and makes it human.
With this position St. Thomas aims to uphold the unity of the person. One should not think (and this may be said in parentheses) that he thereby admits the lawfulness of abortion, because in destroying the preparatory material moment in the creative design of God, one always commits a grave offense against God.10
Conclusions as regards the persistent vegetative state
Thomistic thought on the unity of the form of the human body, and thus on the unity of soul, which was opposed at the outset, was adopted by Catholic anthropology as regards its strong affirmation of the unity of the person, which excludes any form of dualism.
Such thought shares the same ground as ontological personalism, which is founded, that is to say, on the essence of the human individual and on his or her unitary reality.
The conclusion that is offered by such thought, which has remained characteristic of, and specific to, the philosophical anthropology of Christian personalism, can be formulated in the following way employing the words of S. Vanni Rovighi: "The human soul, which is an intellective soul, is thus the soul that gives to man his being a body -- specifically in this way and made in this way -- which is living, feeling and rational."11
To come to our question and our case, if we adopt this unitary anthropology the body in a persistent vegetative state, which has vitality at the level of an organism, albeit of a merely vegetative nature, is united to the rational soul, the only soul that makes the body living.
There cannot be a vegetative vitality that is separate from the unique vital principle exercised by the only soul that exists in man, the intellectual or spiritual soul, whichever term one chooses.
Only the loss of the vital unity of the organism can be taken as the sign of death.
The conclusion that has been arrived at involves a brief reflection on the concept of the death of the human individual.
Given as known the distinction between ontological death (the separation of the soul from the body), a reality that cannot be observed directly, and clinical death as a set of signs that provide the moral certainty that death has really taken place in an individual, when it come to the signs that allow the ascertaining of death from a clinical point of view three different positions must be recorded:
1) A minority position that in specific terms wants to argue that clinical death coincides with the irreversible cessation of the higher functions of the brain and thus with the loss of relational life, a fact connected neurologically with the compromising of relational life, for which reason it is often designated "cortical death."12
2) On the basis of this position the patient in a persistent vegetative state, whose possible recovery is excluded, should be held to be dead. This is the position that we excluded with the clarifications presented above.
A second position that is diametrically opposed requires for a definition of clinical death so-called biological death, the cessation of every internal biological activity in the body of the individual and in particular the cessation of the circulation of the blood (cardiological death).
In definitive terms, this position is encountered implicitly in those who argue that the so-called death of the whole encephalon, also known wrongly as "brain death,"13 is insufficient.
However, in practical terms this criterion should involve a definitive cessation of the heartbeat. This empirical observation used in cases of deaths in the home, in the street, and outside the context of intensive care, is certainly valid for the ascertaining of death, but it does not allow the transplant of organs.
The possibility and the need to use resuscitation has made possible a third approach which is that known as "brain death," but which should more properly be known as "encephalic death" because it refers to the whole encephalon.
Today, this line is followed not only by the Italian law on transplants (18.8.1993) but by almost all laws and also by the practice followed in relation to transplants.
This criterion is explained not in the sense that one wants to identify the part (the encephalon) with the whole (the body separate from the soul) but in the sense that once the functions of the entire encephalon have been irreversibly lost, including those of the encephalic trunk, which as one knows governs the cardio-respiratory function, the whole living organism loses a unifying principal of life that defines it as a living organism, even though with the help of machines which substitute spontaneous breathing and use the residual vitality of the heart muscle one can maintain artificial circulation for a certain time in order to keep an organ to be transplanted undamaged.
During the address of the Holy Father to those taking part in the congress on organ transplants of 29 August 2000 this criterion was accepted with the following words:
"It is a well-known fact that for some time certain scientific approaches to ascertaining death have shifted the emphasis from the traditional cardio-respiratory signs to the so-called 'neurological' criterion.
"Specifically, this consists in establishing, according to clearly determined parameters commonly held by the international scientific community, the complete and irreversible cessation of all brain activity (in the cerebrum, cerebellum and brain stem). This is then considered the sign that the individual organism has lost its integrative capacity. With regard to the parameters used today for ascertaining death -- whether the 'encephalic' signs or the more traditional cardio-respiratory signs -- the Church does not make technical decisions. She limits herself to the Gospel duty of comparing the data offered by medical science with the Christian understanding of the unity of the person, bringing out the similarities and the possible conflicts capable of endangering respect for human dignity.
"Here it can be said that the criterion adopted in more recent times for ascertaining the fact of death, namely the complete and irreversible cessation of all brain activity, if rigorously applied, does not seem to conflict with the essential elements of a sound anthropology.
"Therefore a health-worker professionally responsible for ascertaining death can use these criteria in each individual case as the basis for arriving at that degree of assurance in ethical judgment which moral teaching describes as 'moral certainty.' This moral certainty is considered the necessary and sufficient basis for an ethically correct course of action. Only where such certainty exists, and where informed consent has already been given by the donor or the donor's legitimate representatives, is it morally right to initiate the technical procedures required for the removal of organs for transplant."14
The Charter for Health Care Workers had for that matter adopted this criterion, which makes the transplant of organs something that can be practiced.15
The persistent vegetative state and the ascertainment of the neurological death of the whole encephalon
It seems to me, however, that the difference that exists between so-called cortical death and encephalic death is clear. In the first case the organism demonstrates the persistence of a unitary organic life, albeit of a vegetative kind -- it is able to breathe autonomously as well, it maintains cardio-circulatory activity, and it is able to be nourished if fed artificially.
In the second case none of these functions is carried out autonomously, respiratory activity is replaced by machines, and as a result cardio-circulatory activity cannot maintain itself except for a short period of time after its autonomous charge of energy has been exhausted.
From the point of view of the personalistic approach, the discriminating criterion between the life and non-life of the human individual is not in itself the function of the encephalon but the unifying principle that vivifies the organism (the soul). This principle of life unity in the adult is ultimately linked to the function of the encephalic trunk and can be controlled with appropriate neurological methods, the control of the evoked potentials or the cerebral flow; whereas in the embryo during the first stages of its development the unity of the organism is activated and maintained by the genome which governs the construction itself of the brain.
For this reason, the ill-founded objection that argues that when one holds the criterion of "encephalic death" to be valid, embryos that do not yet have even a rudimentary form of the cerebral system should be seen as lacking life, has no basis. In the embryo the principle of life (the soul) that defines it as an individualized organism is observable in the unity and the biological function of the genome that governs the progressive development16 of the individual and the formation itself of the central nervous system.
In adults the physiology itself of the nervous system demonstrates that this system has a function of coordination in relation to the other organs and the functions of the whole organism, whereas the respiratory and cardio-circulatory system has the function of transporting the elements needed for nutrition.
All the other systems, such as the endocrinological system, the immunity system, etc., that cooperate and contribute to the vitality and the unity of the organism come anyway in the adult to depend on the central nervous system.
Personally I am convinced that despite the criticisms leveled against the neurological criterion for the ascertaining of death, if observed scrupulously it merits our trust and should not be abandoned in the field of transplants to rely upon the criterion of "cortical death" or to ignore, as some argue, the rigorous observations that it requires because the carrying out of the transplant is said to be a sufficient and proportionate reason for going ahead even in a state of uncertainty.17
Indeed, it should be stressed that in the final analysis the person carrying out the transplant and the specialists of the committees who preside over the ascertaining of death should, when faced with a concrete doubt in an individual concrete case, abstain from declaring the person dead and wait for such certainty to be well founded and morally valid.
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1 Thomas Aquinas, "Summa Theologiae," I, 75-76; "Quaestio De Anima," Art. 1, Art. 2, Art. 6; "Contra Gentes," Chap. 68 and Chap. 69; "De Unitate Intellectus," 83-84.
2 S. Vanni-Rovighi, "Alberto Magno e l'unità della forma sostanziale nell'uomo, in Medioevo e Rinascimento. Studi in onore di Bruno Nardi" (Florence, 1955), pp. 755-778; E. Gilson, "L'ame reaisonable chez Albert Le Grand"; S. Vanni-Rovighi, "Introduzione a S. Tommaso D'Aquino" (Laterza, Bari, 2002); "L'antropologia filosofica di S. Tommaso D'Aquino" (Vita e Pensiero, Milan, 1965); E. Sgreccia, "Manuale di Bioetica," I, 3rd edition, (Vita e Pensiero Milan, 2003), pp. 105-137.
3 In Aristotle the assertion that the "active" intellect was specific to each single individual was not clear. As held by the Aristotelian Arabs, it was believed that there was a single (divine) intellect that impressed abstract concepts in individual subjects (passive intellects). The thesis of Thomas Aquinas is expounded in the "Summa Theologiae," Q. 75, Art. 1 and in "De Anima," Book II, lectio I, nn. 219-221. See also S. Vanni-Rovighi, "L'antropologia filosofica di S. Tommaso D'Aquino," op. cit., pp. 23-34.
4 "Contra Gentes," Chaps. 86-87; "Summa Theologiae," I, p. 118, Art. 2.
5 S. Vanni-Rovighi, "L'Antropologia filosofica," op. cit., p. 34.
6 J. Vial Correa and E. Sgreccia (eds.), "Identità e Statuto dell'embrione umano" (Libreria Editrice Vaticana, Vatican, 1998).
7 S. Vanni-Rovighi, "Introduzione a Tommaso D'Aquino" (Laterza, Rome, 2002) pp. 83-96.
8 S. Vanni-Rovighi, "L'Antropologia filosofica," op. cit., pp. 48-53.
9 Ibid., pp. 53-57.
10 G. Cottier, "Scritti di etica" (Piemme, Casale Monferrato, 1994), pp. 295-8.
11 S. Vanni-Rovighi, "L'Antropologia filosofica," op. cit., p. 57.
12 C.A. De Fanti, "I concetti di morte dell'organismo, morte cerebrale, morte corticale, in A. Ferroni" (ed.), "Atti del II Incontro di aggiornamento in neurologia. attualità in tema di morte cerebrale" (Perugina, Feb. 20, 2003), published in Annali di Neurologia e Psichiatria, 1993, 87, I,II, III, pp. 21-29. It is known that the thought of H.T. Engelhardt, who defines such subjects as "no longer persons," shares the same approach.
13 A. Shewmon, "Brain Death: a Valid Theme with Invalid Variations, Blurred by Semantic Ambiguity," pp. 23-51 in R. Whito, Angstwurm, and Carrasco De Paula (eds.), "Working Group on the Determination of Brain Death and Its Relationship to Human Death" (Vatican City, 1992); J. Seifert, "Is Brain Death Actually Death?," Ibid., pp. 95-143.
14 John Paul II, Address to the 18th International Congress of the Transplantation Society, Aug. 29, 2000, in L'Osservatore Romano, Aug. 30, 2000.
15 Pontifical Council for Health Care Workers, Charter for Health Care Workers, No. 87, 1995.
16 A. Rodriguez Luño, "Rapporti tra il concetto filosofico e il concetto clinico di morte," Acta Philosofica, 1992, 1,I, pp. 58-68; E. Sgreccia, "La persona e la vita," Dolentium Hominum, 1986, 2, pp. 38-41.
17 R.D. Trhog, "Is it Time to Abandon Brain Death?" Hastings Center Report, 1997, 27, pp. 29-37.