Explained | What would the Church say about end-of-life decisions for a Pope?

Vatican City: A respiratory crisis suffered by Pope Francis on Friday during his two-week hospitalisation for pneumonia has added urgency to a delicate, and uncomfortable, question worrying many in the church: What would happen if the pope remains in critical condition for an extended period, with his health worsening, his faculties fading, his quality of life deteriorating?

And what would his approach be to extended medical interventions, as well as, ultimately, his end-of-life plans?

Francis, 88, has talked about a resignation letter he put on file with the Vatican soon after his election in the event that he became incapacitated, but its contents are unknown. It is also unknown if he has a living will, or whom, if anyone, he has entrusted to make decisions about his health if he no longer can do so himself.

Asked about the pope's desires, the Vatican responded that "it's too early" to talk about end-of-life details. And while his prognosis remains guarded, Saturday evening's health bulletin had encouraging news about the pope's health.

"The clinical condition of the Holy Father remains stable," said the Vatican statement, which added that the pope had no fever or signs of new infection.

It said that he spent extended time off the noninvasive mechanical ventilation he initially needed during Friday's respiratory crisis, was vigilant and prayed for about 20 minutes in a private chapel connected to his hospital room.

On Sunday morning, they added that he had slept peacefully through the night and continued to rest.

Some supporters of the pope say questions about his end-of-life preferences are premature, even intrusive. But church experts say the lack of a public protocol on how to make end-of-life decisions for the leader of the Roman Catholic Church is troubling. And with setbacks like Friday's respiratory crisis, the question is no longer theoretical.

"It's a problem we have to face when we come to it," said Archbishop Paul Gallagher, the Vatican's foreign minister, who stressed that he had no knowledge about the pope's health, other than the public statements by the Vatican.

Catholic doctrine teaches that life begins at conception and ends at natural death, and should be defended from start to finish. But there is ambiguity and debate within the church on the bioethics of when the surrendering of life is legitimate.

Church teaching allows for the cessation of "extraordinary means" to keep a person alive, but there is vast interpretation and debate about the definition of extraordinary means.

Critics of the ambiguity say the church is woefully behind the times given the breakthroughs in modern medicine and its ability to keep people alive through life-sustaining treatments such as artificial nutrition and hydration, resuscitation, antibiotics, respirators and dialysis.

"I'm being told that there was some document prepared by Benedict on this issue," Gallagher said, referring to Francis' predecessor, Pope Benedict XVI. He added that he had no personal information about its contents or whether Francis had "indicated that he's in agreement with the document."

Asked about the existence of such a letter, the Vatican press office said it had no awareness of it.

But the notion that there are secret letters spelling out the end-of-life wishes of popes did not comfort those who advocate transparency.

"Secret documents are really dumb," said the Rev. Thomas J. Reese, a longtime Vatican analyst, who has urged the Vatican to provide clear protocols for the pope.

He said the concealment of the documents made them vulnerable to conspiracy theorists in a gossipy city-state where people still have their doubts about the death of John Paul I, who served as pope in 1978 for only 33 days.

"In a family, if there's no document," Reese said, relatives often wrestle with excruciating decisions about when to let go. "Imagine if this is the Vatican and the church is debating on whether or not we unplug the pope. It will be chaos."

He envisioned fights over critical health decisions between cardinals who want the pope to remain alive and those who want someone else, perhaps themselves, in his place. "These are the kinds of things that cause schisms," he said, referring to the formal, and epochal, splits in the church.

Francis has weighed in publicly on the ethics of end-of-life issues before, just not for himself. His remarks, people who know him say, reflect his acceptance of humanity-defining limits as key to his theology and worldview.

"Surgery and other medical interventions have become ever more effective, but they are not always beneficial," Francis wrote to a European meeting of medical professionals to discuss end-of-life issues in 2017. He added that it was morally legitimate to forgo or discontinue some interventions if they only delayed an inevitable end. "Such a decision," he said, "responsibly acknowledges the limitations of our mortality once it becomes clear that opposition to it is futile."

Popes going back to at least the 1950s have weighed in on the ethical considerations surrounding the end of life. Pius XII told a meeting of anesthesiologists that in some cases it was appropriate to refrain from therapies.

In 2020, the Vatican's office on church doctrine issued a document that promoted the use of hospice centers and palliative care, and argued that "extraordinary" care can be suspended to avoid prolonged suffering at the end of life because it "expresses acceptance of the human condition in the face of death."

It was important, the document said, that such cessation not be conflated with euthanasia or assisted suicide, which it considered "intrinsically evil," because the goal was death.

Sedating patients to the point where they lose consciousness is morally legitimate, the Vatican wrote, "to ensure that the end of life arrives with the greatest possible peace." The Vatican declared that it was also acceptable to cease ineffective care to people in a vegetative state if it saddled patients with "an excessive burden with negative results that exceed any benefits."

In 2024, the church's Pontifical Academy for Life issued a booklet on end-of-life terminology. Archbishop Vincenzo Paglia, the president of the Pontifical Academy for Life, and a close aide of the pope, wrote in the introduction that the booklet was intended to foster "heartfelt and in-depth dialogue" about painful decisions, and not "prepackaged and partisan ideologies."

The booklet included a template of a living will to be prepared with the help of a priest and explained that at the end of life, mitigating pain could allow patients the space to concentrate on their human relationships.

"The communication between a doctor and patient -- and with family members," the booklet said, "is an element of decisive importance in the development of ethical choices concerning the changes in treatment."

Gallagher said that while he hoped Francis would be back at work soon, it was entirely possible the pope was having those conversations now.

"Francis," he said, "may be saying things to his doctors in these days, you know, about how he feels about these things and what he wants."