By Peter Gould
BBC News, Rome
To what extent should medical science be used to prolong the life of John
The delicate question has been raised by the fragile condition of the
He is now thought to be close to death, despite efforts by doctors in recent
days to halt his decline.
A tracheotomy was performed to help him breathe, but it left him almost
without the power of speech.
Then, after concern over his loss of weight, doctors inserted a nasal
feeding tube to allow him to receive nutrition.
But over the past 48 hours, there has been a dramatic worsening of his
The Pope has apparently refused the option of being taken back to hospital,
and appears to be serenely waiting for death.
The measures used to treat the Pope have given a new focus to discussions
within the Catholic Church about the care of the dying.
Euthanasia by omission
It was the Pope himself who re-opened the debate a year ago with remarks to
a medical conference in Rome.
Speaking about the treatment of patients in a persistent vegetative state,
he said that artificial feeding was "morally obligatory".
Providing food and water by tube was a natural means of preserving life, he
argued, and not a medical act.
Furthermore, he warned doctors, the removal of feeding tubes would be
"euthanasia by omission".
The Pope's words caused a stir in the medical world, particularly in the 600 Catholic-run hospitals in the United States.
Many doctors had assumed that it was permissible to withdraw such treatment
where there was no hope of recovery.
The Pope's words also created doubts about the ability of Catholic doctors
to comply with the terms of a "living will" in which the patient asks not to
be resuscitated in the event of them slipping into a coma.
But while John Paul II defends the sanctity of human life, he has made it
clear he is opposed to extreme measures being used to keep patients alive
"at all costs".
"It is necessary to approach the ill with that healthy realism which avoids
generating in those who suffer the illusion of medicine's omnipotence," he
said in 2002.
In the United States, Catholic doctors who care for the terminally ill have
been given guidelines by the US Conference of Catholic Bishops.
They have been told that the duty to preserve life is not absolute, and the
patient may reject any procedure that is "insufficiently beneficial or
But the bishops go on to warn that suicide and euthanasia are never morally
"Physicians and their patients must evaluate the use of the technology at
their disposal," they say.
"The use of life-sustaining technology is judged in light of the Christian
meaning of life, suffering, and death.
"Only in this way are two extremes 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."
One unresolved issue is what would happen if the Pope becomes incapacitated
but remains alive. Who will then decide what to do?
"The same moral rules apply to the Pope as to anyone else," says Father
Thomas Reese, editor of the religious journal America.
"His situation is problematic because he does not have a living relative and
Church law does not say who would make medical decisions for him if he is
"Whether he has a living will or not is unknown, but his statement of a year
ago on these issues would have to be respected as an indication of his will.
"In the past, most moralists would have considered feeding tubes a medical
intervention like a respirator.
"If a person is going to get better, obviously you do not disconnect them.
If they are dying, you do not have to keep them connected. The disputed
issue is a person in a persistent vegetative state.
"The Pope now says they should continue to receive liquids and nourishment."
It is widely believed that John Paul II has written a letter authorising the
Church to hold an election if he becomes incapacitated.
But has he left instructions over the medical options open to his doctors?
We simply do not know, and the Church remains in a state of uncertainty over
the health of its ailing Pope.