January 1985 VI/5
THE CLAIRE CONROY CASE: WITHHOLDING TUBE FEEDING
Claire Conroy was an 84-year-old patient in a nursing home. She suffered from severe organic brain syndrome, necrotic decumbitus ulcers, urinary tract infection, arteriosclerotic heart disease, hypertension, and diabetes mellitus. She was unable to speak or move, though from her fetal position she sometimes followed people with her eyes. Nurses were not able to feed her by hand, so a nasogastric tube was inserted and several times a day a nutrient formula, vitamins, and medicine were poured through the tube. Her only surviving relative, her nephew and legal guardian, requested the Superior Court of Essex County, New Jersey, to allow the nasogastric tube to be removed and thus allow Claire Conroy to die. The Superior Court granted the request, but the Appellate Division of New Jersey decided to review the decision of the Appellate Court even though Claire Conroy had died because of the relevance for other people in nursing homes and hospitals who are in somewhat the same condition. On January 17, 1985 the decision of the Superior Court of New Jersey became public and because this decision (like the Karen Ann Quinlan decision from the same court) will have ethical and legal ramification for the whole country, we shall consider the pertinent statements and assumptions of the decision in this essay. (All quotes from the New Jersey Supreme Court decision.)
The Principles
1. The Court decided that "life-sustaining treatment may be withheld from incompetent patients when it can be determined that the patient would have refused the treatment under the circumstances involved." The proof that a person would have refused life-prolonging treatment in such circumstances "may have been expressed orally, or in writing, or it might be deduced from a person's religious belief or prior decisions about medical care." (l)
2. The same decision may be made for incompetent patients whose desires in regard to treatment cannot be determined "if it is manifest that such action would further the patient's best interest." In these latter cases, how does the surrogate determine "the best interests of the patient"? The Court answers the question by stating that a limited objective or a pure objective test should be used, depending upon knowledge of the patient's desires. "Under the limited objective test....there is some trustworthy evidence (but not a clear expression) that the patient would have refused the treatment and the decision maker is satisfied that the burdens of the patient's continued life with the treatment outweighs the benefits of life for him." In the pure objective test there is no evidence of the patient's desire, but the life-support treatment may be removed, "the net burdens of the patient's life with the treatment should clearly and markedly outweigh the benefits that the patient derives from life."
3. How does the Court define an incompetent patient? "A patient is incompetent if medical evidence establishes that the patient is an elderly incompetent nursing home resident with severe and permanent mental and physical impairments and a life expectancy of approximately one year or less." A few comments in regard to this description are in order. Why must the patient be elderly? Ethically speaking, the same standards should be used for older and younger patients. The statement in regard to the time the patient will live seems superfluous. Even if life expectancy with tube feeding would be more than a year, the ethical standards for removing tube feeding could still be present (cf. n.4).
Discussion
4. The Court explained its standards by stating "we expressly decline to authorize decision making based on assessments of personal worth, or social utility of another's life of the value of that life to others. We do not believe that it should be appropriate for a court...to determine that someone else's life is not worth living simply because the patient's 'quality of life' or value to society seems negligible. The mere fact that a patient's functioning is limited or his prognosis dim does not mean that he is not enjoying the remains of his life or that it is in his best interest to die," The Court explains the burden-benefit ratio by declaring, "By this we mean that the patient is suffering, and will continue to suffer, unavoidable pain and that the net burdens of prolonged life markedly outweigh any physical pleasure, emotional enjoyment or intellectual satisfaction that the patient may be able to derive from life." Summarizing these statements we can delineate three conditions which must be present in order to withhold or withdraw tube feeding from an incompetent patient: (1) there must be a terminal pathology which is prevented from having its effect by means of tube feeding; (2) the patient's overall condition is such that he or she cannot strive for the social or spiritual (creative) values of life even with the tube feeding; and (3) the condition is judged medically to be irreversible. By reason of this decision, tube feeding may be considered the same as a respirator or any other mechanical device that prevents a physical pathology from causing death (cf. Ethical Issues in Health Care, Mar.'83).
5. Care should be taken to ensure that the patient does not suffer pain because tube feeding is not utilized. Thus hydration or analgesics might be utilized to keep a patient comfortable as death approaches. The Court's decision does not countenance withholding food and water from patients who are able to eat, even if such nourishment must be prepared and given to them by others.
6. The Court allows tube feeding and other treatment to be continued for persons in the condition of Claire Conroy, no matter how great the burden, "if the patient expressed the desire to be kept alive in spite of any pain that he might experience." This seems to be an unreasonable statement because it approves the effort to maintain life after the point at which a person can no longer strive for values and purpose of life. Mere physical existence is not a human value and the wishes of a person should not be allowed to circumvent the reasonable practice of medicine. Medical care is unethical if it is useless care.
Conclusion
With a few reservations then, the basis for the Claire Conroy decision seems to be ethically sound. One would hope that they dispose physicians and families to realize that the goal in care for the dying is to help the patient die well, not to extend mere physical existence.
Kevin O'Rourke, OP
Footnote 1. The Living Will and other documents of the same nature (e.g., Christian Affirmation of Life) will be used more extensively because they provide a clear expression of desired treatment.
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