The Critical Calling: Reflections on Moral Dilemmas Since Vatican II

21. Nutrition-Hydration: The New Euthanasia?

Chapter 21 Nutrition-Hydration: The New Euthanasia? Crista Nursing Center is a 271-bed nursing home in Seattle with a 35bed nursing wing.In 1984-85 two families,after learning from the attending physician and two consulting doctors that death was imminent for their elderly dear ones, requested the removal of the nasal-gastric feeding tube. The patients had been diagnosed as being in a persistent vegetative state. Six of the twelve nurses in the nursing wing refused to act on the request. Nancy Farnam, one of the resisting nurses, stated: "They are trying to make us the executioners. And I don't like it."1 "Executioner" is a very loaded word. It conjures up the electric chair, the lethal dose, the guillotine. It obviously reflects Nurse Farnam'sanalysis of and feelings about what she was asked to do. Whether it reflects an accurate moral assessment of the withholding or withdrawingof artificial nutrition and hydration in some instances is another question. That question may seem to be trivial, at the far-flung fringes of ethical and theological concern in a world dallying with the temptation ofnuclear self-destruction, one where thousands are wiped out by malnutrition, AIDS, illegal drugs and alcohol abuse, where millions never see the light ofday due to abortion. Actually, I believe the question is a crucial one, not perhaps in itself as a bit of isolated casuistry, but for what it may symbolize and presage. For if the withdrawal of artificial nutrition-hydration is what some people (judges and theologians included) say it is—killing—then clearly we have lowered the barriers against extrauterine killing in a very ominous way. I say "ominous" because we will have accepted a principle whose constraints may be swayed by influences beyond our eventual control. It is this that Daniel Callahan has in mind when he locates the importance of this matter in the waywe are in the future to understandthe roleofthe physician.Is the 370 / Richard A. McCormick, S.J. tradition of always caring, even if nothing more can be done, to give way to one of neglect, or worse?2 During March 1986, the Council on Ethical and Judicial Affairs of the American Medical Association issued guidelines for the situation. The statement reads in part as follows: Even if death is not imminent but a patient's coma is beyond doubt irreversible and there are adequate safeguardsto confirm the accuracy of the diagnosis and with the concurrence of those who have responsibility for the care of the patient, it is not unethical to discontinue all means of lifeprolonging medical treatment. Life-prolonging medical treatment includes medication and artificially or technologically supplied respiration, nutrition or hydration. In treating a terminally ill or irreversibly comatose patient, the physician should determine whether the benefits of treatment outweigh its burdens . At all times, the dignity of the patient should be maintained.3 Under analysis, the AMA position is structured around three assertions : (1) The criterion for morally appropriate treatment is the burdensbenefits calculus. (2) It is at times ethical to withdraw alllife-prolonging medical treatment from the irreversibly comatose. (3) Artificial nutrition and hydration are a form of such medical treatment. Implied in these statements is the judgmentthat for the permanently comatose the benefits of nutrition-hydration do not outweigh the burdens. The AMA statement leaves unstated or unclear whether it considers artificial nutrition-hydration as being of no benefit for such a patient, or of some benefit but a benefit outweighed by the burdens. As we shall see, this is a key analytic point. The AMA statement was not the first of its kind to emanate from physicians. On July 17, 1985, at the height of the Paul Brophy case (see below), the Massachusetts Medical Society endorsed by voice vote the following resolution: The Massachusetts Medical Society recognizes the autonomy rights of terminally ill and/or vegetative individuals who have previously expressed their wishes to refuse treatment, including the use of intravenous fluids and gastrointestinal feeding by tube, and that implementation of these wishes by a physician does not in itself constitute unethical medical behavior provided that appropriate medical and family consultation is obtained.4 The reaction to the AMA ruling was predictable in light of the controversy that preceded it. Archbishop Philip M. Hannan (New Orleans) denounced it in his archdiocesan newspaper, The Clarion Herald. "The Church strongly condemns this position."5 Hannan insisted that food and Nutrition...