In November 2009, U.S. Conference of Catholic Bishops issued Ethical and Religious Directives for Catholic Health Care Services, requiring that all patients--including those in so-called persistent vegetative state--be provided with artificial hydration and nutrition if such care could extend life indefinitely. (1) The directives--particularly directive 58--prompted outcry from death-with-dignity movements and confusion within hospital ethics committees. Barbara Coombs Lee, president of Compassion and Choices, was quoted as saying that new directive could potentially create 300,000 Terri Schiavo cases, equal to number of feeding tubes inserted in United States each year. (2) Some hospital ethics committees debated whether their hospitals would be obliged to accept patients who refused such treatment as transfers from local Catholic hospitals. These discussions raise several questions with direct bearing on patient care: Do bishops have authority over Roman Catholic health care institutions? Do bishops' directives represent a departure from--or even a radicalization of--traditional Catholic teaching? How might these directives change clinical practice? The answer to first question is straightforward. U.S. bishops exercise spiritual and structural authority over Catholic institutions in their respective dioceses, but extent to which their authority affects institutions varies by bishop. Depending on influence of other interest groups, some bishops take a proactive role; others allow health care leadership to function autonomously. Next, a brief consideration of evolution of Catholic position on end-of-life care is warranted. In his 1957 Address to an International Congress of Anesthesiologists, Pope Pius XII spoke of obligation to provide ventilator support to unconscious patients without hope for recovery. He emphasized that physicians have a duty to provide ordinary (not extraordinary) treatments as necessary to preserve health and life. In contrast to ordinary care, a stricter obligation (defined as extraordinary) would be too burdensome for majority of patients and would impede what he described as a higher, spiritual good. In 1980, Congregation for Doctrine of Faith (the papal office overseeing Catholic doctrine) adopted a Declaration on Euthanasia that noted that due to technological advancement, delineation between ordinary and extraordinary means of sustaining life had grown muddled. However, declaration permitted physicians (with patient consent) to discontinue treatment if harm would outweigh benefit. The declaration was clear: patients who refused care in such circumstances were not suicidal; rather, they were accepting of human condition. Between 1980 and 2001, various groups within Church--including Pontifical Council on Health Affairs (1981), Pontifical Academy of Sciences (1985), and U.S. Conference of Catholic Bishops (1992)--continued to reflect on these issues, reinforcing notion that minimal care, including feeding, is obligatory. However, as 1992 U.S. Conference of Catholic Bishops stated, the teaching of Church has not resolved question whether medically assisted nutrition and hydration should always be seen as a form of normal care. (3) In 2001, U.S. Conference of Catholic Bishops issued directives for Catholic health care services that would be forerunner for directives of 2009. Directive 58 called for a presumption in favor of providing nutrition and hydration to all patients, including patients who require artificial means, as long as burdens do not outweigh benefits. (4) It was not until a 2004 address by Pope John Paul II on Life-Sustaining Treatments and Vegetative State that Catholic Church specifically addressed issue of medically assisted alimentation for irreversibly ill patients. …