Case XXXI: The Administration of the Viaticum in Cases of Cancer of the Esophagus (Gullet)

In a certain hospital the last Sacraments have to be administered to two patients suffering from a malignant or cancerous growth in the esophagus. In the case of one the growth is situated at the opening of the esophagus into the stomach, so that, in the physician’s opinion, the passage is completely closed, and the patient has to be fed artificially and cannot live more than a very short time. The question arises whether, under such circumstances, he is still able to receive the holy Eucharist sacramentally.

From the very nature of this most holy Sacrament it follows that, in order to produce the sacramental effect in the recipient, it must be received after the fashion of bodily food. In his Moral Theology, de Eucharistia, n. 226, on the mode of this reception, St. Alphonsus quotes Busenbaum’s short text without entering into any discussion of the subject, and refers the reader to Bonacina. Busenbaum writes as follows: (1) “Grace is given in the first eating even of the first part, since the whole Sacrament is present; eating, however, is said to be passage from the mouth toward the stomach, although others say that grace is given only when some part has been received into the stomach,”

(2) “The species are not to be retained in the mouth until they entirely disappear, because then Christ would not be eaten, nor would the grace of the Sacrament be conferred, just as it would not be if you died while the host was still in the mouth.”

(The passage in Bonacina to which St. Alphonsus refers is in Disp.

IV. Quaest. IV. P. II. n. 1: “The Eucharist produces its effects when some part of the host and blood has been swallowed and reaches the stomach. The reason is, first, that for the Eucharist to produce its effect it is required that it be applied to the recipient; and it is said to be applied to the recipient when some part of the host has been swallowed and transmitted to the stomach, according to John 6: ‘He who eats Me, he also shall live because of Me.’ Second, this Sacrament confers grace in the manner of nourishment; but food nourishes when it is transmitted to the stomach; therefore the Sacrament of the Eucharist confers grace when it is transmitted to the stomach, namely, at that instant in which it is true to say: now it has been swallowed or drunk. Thus Soto and others, and the others commonly.” This is Bonacina’s opinion, and Capellmann adopts the same view, for he says in his Pastoral-Medicin, pp. 144, 145: “ Circumstances may arise which render the absorption of food into the body difficult or even impossible. No matter what may be the obstacle, the administration of Holy Communion is possible as long as the sick person can swallow. If, however, he is unable to swallow, there can be no manducatio, and in such cases Communion cannot be administered even in articulo mortis.” Capellmann mentions (pp. 140, 141) an opinion expressed by von Olfers in his Pastoral-Medicin, and says: “Von Olfers argues logically that swallowing is essential to the conception of manducare, but he thinks it is enough to receive the Holy Eucharist into one’s mouth, with the intention of assimilating it. I personally adhere to the old opinion, and believe that desecration of the Sacrament might easily result from the adoption of von Olfers’ views.” On p. 145 Capellmann again refers to the same subject, and says: “If von Olfers were right in his interpretation of manducatio, in cases where the sick person cannot swallow, it would be permissible to introduce a small particle into his mouth, and allow it to be gradually absorbed or eliminated subsequently with the saliva. I think, however, that, quite apart from the incompleteness of the assimilation, the reverence due to the Sacrament would be wanting."

Where it is a question of assuring the sacramental effects of the Holy Eucharist, we prefer the stricter view, extra casum necessitatis, and we regard it as important to take care that the particles for consecration are neither too small nor excessively thin, and that the sacred Host should not be kept too long in the mouth; yet in casu necessitatis for the benefit of a dying person we gladly accept the broader interpretation of manducare, if it is possible to claim on its behalf at least sufficient probability, in accordance with the general rules de administratione Sacramentorum in casu necessitatis.

In order to assure ourselves of this probability, let us bear the following points in mind:

(1) A patient, suffering from this disease, either vomits all the food that passes into the esophagus, and does so, as a rule, immediately after swallowing it, or he can retain a very minute quantity, such as a little water with a particle of a host. It is well therefore to experiment with an unconsecrated particle and water, or sugared water; if vomiting follows, it is of course impossible to administer the Viaticum.

(2) If vomiting does not follow, according to the testimony of experienced physicians the food may have come in contact with parts of the esophagus that are already dead, and decomposes mechanically without supplying any nourishment to the organism; or—and this seems more probable—it meets with parts of the esophagus that are still active, and undergoes a kind of assimilation, which can be regarded as to some extent equivalent to digestion and nutrition. If the tendency to vomit did not make it impossible to introduce sufficient nourishment into the esophagus, the patient might be kept alive for some time in this way, as is not infrequently done in cases where the patient is fed through the rectum, although the food does not then reach the stomach.

(3) From what has been said we may draw the following conclusions:

(a) The sick man is able to receive Holy Communion in a way in which it very probably serves as nourishment, and thus the chief condition essential to its sacramental reception is fulfilled. "This Sacrament confers grace in the manner of nourishment," Bonac. I. c. (b) The manner in which this divine food is assimilated by the patient does not appear to be opposed to the requirements of theologians: Busenbaum ap. St. Alph., "grace is given in the first eating, while eating is said to be passage from the mouth toward the stomach." (c) According to Olfers' opinion, to which reference has been made above, and which from the physiological point of view is very probably correct, the reception of the food into the oral cavity, and the change that it there undergoes, satisfy the conception of " manducare." With still greater probability therefore may we regard the swallowing of the sacramental species, and the change that it undergoes in the lower part of the esophagus to be a " manducatio " sufficient to produce the sacramental effect, (d) Finally it may be pointed out that there is no other possible way of giving the sick man Holy Communion except by administering to him the species panis. It is absolutely forbidden to give him Communion sub specie vini, which might perhaps still reach the stomach. St. Alphonsus writes on this subject: "A priest sins if he gives the species of wine to a dying person who, because of dryness of the tongue, cannot swallow the host, as they very commonly say, because the precept of Viaticum does not bind when it cannot be received in the due manner and according to the rite of the Church," lib. VI. n. 245. Any artificial incorporation of the sacred Host is equally inadmissible, and Capellmann is right in saying: " If it is impossible for the sick person to swallow, no manducatio can take place. It would be irreverent to introduce a particle of the sacred Host into the stomach through an esophageal sound or even through a gastric fistula."

To conclude therefore: It is still possible for the sick man in question to receive Holy Communion in a way which formally satisfies the requirements of the Church, and which very probably suffices to produce its sacramental effect: as he is in danger of death, it is his privilege and duty to receive Holy Viaticum, and the priest may give it to him, if he is otherwise in good disposition and there is no apparent danger of irreverence.

The second patient has a malignant tumor in the oral cavity, at the entrance to the esophagus, and the growth has become so large that any examination of it confirms the doctor's opinion that special manual dexterity is required, in order to insert some fluid nourishment into the esophagus in such a way that he can swallow it. As the chaplain of the hospital does not believe himself to possess this dexterity, he takes, when administering the Viaticum, a spoonful of water, places in it a particle of the sacred species, and hands it to the Sister, who is nursing the patient. She gives it to him so skil fully that he is able to swallow it down and it reaches his stomach.

The question here is: Did the priest act rightly in administering the Viaticum to this patient by means of a spoon, and through the agency of the Sister of Charity?

( I ) As to using a spoon in administering Holy Communion, St. Alphonsus says that it may be done in two cases, viz., with patients suffering from plague, to protect the priest from infection, and when a sick man is unable, owing to the dryness of his mouth, to swallow the sacred Host without wine or water, and he says that although this opinion is contrary to that of several theologians, it is probably correct. Cf. Theol. mor., lib. VI. n. 244, 6, and especially Hom. Apost. Tract, XV. n. 12. We need not hesitate to extend this permission to the case under discussion, and therefore the chaplain cannot be blamed for using a spoon, as otherwise it would not have been possible to administer Holy Communion to this patient.

(2) We have next to consider whether he did right in handing the sacred Host to the Sister, for her to give it to the patient. Two prohibitions issued by the Church seem opposed to this course; laymen and clerics, who are not priests or deacons, are forbidden to touch the most holy Sacrament, and must not administer it to themselves or others. With reference to the first prohibition Marc, Institutiones morales, n. 1632, says: "If a sacred vessel actually contains the Most Holy Sacrament, outside a case of necessity or danger of profanation, no one may touch it, even indirectly, without grave fault, except a priest or deacon. Thus commonly. But, on the other hand, in justification of the chaplain's action, we may argue that, besides periculum profanationis, theologians admit of other casus necessitatis as exceptional cases when this prohibition must be disregarded. Such, for instance, is the necessitas honestatis: "if the host should fall upon a woman’s breast, the priest himself must not remove it, but the woman herself should take it away with her hand and replace it in the ciborium." S. Alph., lib. VI. n. 250. Schuch says, in his Past.-Theol., § 280: " If a consecrated Host falls into a woman's clothing, or into any place where the priest cannot pick it up with decency, the woman herself must place it in her mouth, and afterwards wash her hands."

It seems, therefore, that the necessitas viatici is as weighty a reason, as this and other exceptional cases, for disregarding the prohibition and justifying the chaplain's action.

There is, however, another special instruction forbidding priests to entrust the administration of the Holy Eucharist to the laity (cf. c. Pervenit 29. de consecr. dist. 2), and some great theologians consider that it applies also to the necessitas viatici. But against this there are two arguments which may be adduced in support of the chaplain's opinion. In the first place the help given by the nun in this particular case can scarcely be regarded as an administration of Holy Communion. We have seen that a woman into whose clothes a consecrated Host has fallen is allowed to place it in her own mouth, instead of handing it to the priest and then receiving it from him. This proceeding is sanctioned by Schuch, and by Pope Benedict XIV, whom the author follows on this subject, but they cannot be said to have thus permitted a woman to administer Holy Communion. Even if, in the present case, the action of the nun is regarded as a real administration of the Viaticum, the priest, who commissioned her to act as she did, can appeal to the doctrine of St. Alphonsus, who asks (lib. VI. n. 237, III): "whether it is lawful for a layman in a case of necessity to administer Viaticum to a dying person?" and answers the question affirmatively, refuting the contrary opinion; although of course it is permissible only where it is impossible for a priest or deacon to administer it, and a layman can do so without giving scandal.

As in the present case the priest could either not have given the man the Viaticum at all, or could not have done so without great risk of irreverence, by causing him to vomit, the assistance of the nun was abundantly justified, although it would certainly have been grievously sinful under other circumstances; and the priest deserves nothing but praise for having made it possible for the sick man to receive the last Sacraments, and so to do his duty.— P. Johann Schwienbacher, C.SS.R.