March 1983 IV/7
TUBE FEEDING--ROUTINE NURSING CARE?
Recently, two physicians in California were charged with felony murder because they withdrew life-support systems from a brain-damaged patient. Because there was no hope of recovery, with permission of the family, the physicians removed the respirator. When the patient continued breathing without assistance, tubes feeding him nourishment and water were also removed. Six days later, the patient died. As any Perry Mason fan knows, in California before a murder trial a preliminary hearing is held to determine whether there is sufficient evidence to proceed with the trial. At the preliminary hearing, the judge determined that the evidence was insufficient and dismissed the criminal case. Civil charges of medical malpractice are still pending.
At present, removing a respirator from a comatose patient who will not recover has been accepted as standard and ethical practice in medicine. But removing artificial methods of providing food and water when the patient is in the same, condition is not so readily accepted. Recently in NEJM (1) a physician recounting this crisis of conscience in caring for elderly people states, "In our nursing home, for example, there is a middle-aged woman who has been comatose for five years as a result of an accident. Although there is no meaningful chance that she will ever improve, she is certainly not "brain dead" and is supported only by routine nursing care that consists of tube feedings, regular turnings, urinary catheters, and good hygiene; she is on no respirator or other machine" (emphasis added). For some medical professionals then, tube feeding patients who are in an irreversible coma is considered standard and proper treatment. But is this an ethical conclusion? Has the practice of using tube feeding, regular antibiotics to avoid infection, and urinary catheters resulted from an ethical analysis of the situation or from a false supposition that physicians must "do everything possible?"
The Principles
Medicine aims at preventing sickness, restoring health, and prolonging life. About this there can be no mistake. But ethical health care professionals realize that they are to prolong life in a manner that is consistent with the value system of the patient and the ethical standards of medicine. In the value system upon which medical care is based, prolonging the life of a person who is irreversibly comatose is not considered a value for the patient nor for the physician. (2) Mere physiological existence is not a value if there is no potential for mental-creative function. True, it is often difficult to determine if the comatose condition is irreversible. When there is a reasonable doubt about the patient's condition and there is some hope that he or she might recover, then prolonging life through life-support systems is indicated. But if the reasonable doubt does not exist, then the ethical decision is to let the patient die. When this decision has been made, then the goal is to keep the patient comfortable, avoiding suffering and pain. For this latter purpose, analgesics may be given even if they have the indirect effect of shortening life. (3)
The Case in Question
When the decision has been made to allow the patient to die, does feeding nourishment and water through tubes constitute a life-support system or is it rather a means of keeping the patient comfortable? Hydration of some type seems necessary to keep a person comfortable. If tube feeding is the only way to accomplish this then it seems to be in order, But is nourishment required? In many cases, the patient is actually dying of a malfunction of the digestive system and this malfunction is obviated by a life-support system, such as tube feeding. It seems then that tube feeding could be withdrawn from a patient, when a decision has been made to let him die, because it is a life-support system rather than a comfort device. If the objection is raised that the patient may suffer hunger or "starve to death," two responses are in order: (1) the pain may be alleviated through analgesics; (2) the patient is not starving to death but is dying of a malfunction of the digestive system and it is time to let nature take its course.
Perhaps the effect of tube feeding will be understood more clearly if we compare it to the use of the respirator. When a decision has been made to allow a patient to die and the respirator is removed, the patient will die due to lack of oxygen (lack of cardiopulmonary function). Ethically, the decision to remove the respirator is justified because there is no longer any responsibility to prolong life. In like manner, nourishment by artificial means may be removed. The patient will die because he cannot assimilate food by natural function just as the person on the respirator cannot assimilate oxygen by natural function, What has been said about the respirator and tube feeding is true of other life-support efforts once a decision has been made to allow the patient to die.
If tube feeding can be withheld from an elderly person after a decision has been made that life need not be prolonged, why not allow the withholding of food from a newborn infant with Down's syndrome and claim that it would die of natural causes? To withhold food from a Down's syndrome child would be unethical because it is the natural process for infants to receive food from others. A Down's syndrome child is not dying due to a pathological digestive system. Moreover, making a decision that a child should be allowed to die merely because it has Down's syndrome is unethical because he/she has potential for mental-creative function. Wouldn't this interpretation of tube feeding for comatose patients cause undue concern if publicized by health care professionals? Yes, I think so. For this reason, it is the responsibility of the ethicists to make known that once the decision has been made to allow a patient to die only comfort therapy is in order. Twenty-five years ago many did not accept withdrawal of a respirator as "standard practice." Now it is accepted as ethical medical practice when the decision has been made to allow the patient to die. Through discussion in the public forum, the same acceptance would develop in regard to tube feeding and other procedures.
Conclusion
In light of the limited resources and some trends in health care, we must make sure that people are not allowed to die merely because they are elderly. But, on the other hand, we must also provide that the lives of elderly people are not extended unduly because the people involved, families and health care professionals, are hesitant to make accurate ethical decisions,
Kevin O'Rourke, OP
Footnotes 1. David Hilfiker, MD, "Allowing the Debilitated to Die;" NEJM, 3/24/83; p.716-719.
2. For more on the ethics of allowing to die, cf. Kevin O'Rourke, OF, "Allowing a Person to Die;" Critical Care State of the Art, Vo1.3, 1983; Section R.
3. Vincent Collins MD,"Managing Pain and Prolonging Life," New Technologies of Birth and Death; St. Louis: Pope John Center, 1980; p.144-149.
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