April 1986 VII/8
THE AMA STATEMENT ON TUBE FEEDING: ETHICAL ANALYSIS
Recently the Council on Ethical and Judicial Affaire of the American Medical Association (AMA) issued a statement declaring that life-prolonging medical treatment, such as technologically supplied respiration, nutrition, and hydration, may be withheld from patients in irreversible coma even if death is not imminent. (1) While we agree with the statement, several tight-to-life groups and some court decisions follow a different rationale. In the Brophy case in Massachusetts, for example, Justice Kopelman focused inappropriate to cause and water which can be provided him in a manner which causes no pain and suffering." (2) In the Jobes case in New Jersey, tube feeding was continued because "death was not imminent." Our purpose in this essay is to explain some distinctions which help develop consensus in regard to tube feeding and explain the AMA statement more exactly.
The principles
One of the basic ethical assumptions upon which medicine and all efforts to nurse and feed people is based is that there is an obligation to prolong life because living enables us to pursue the purpose of life. Does this obligation ever cease? Clearly, it would cease if prolonging life no longer enables one to strive for the purpose of life. If efforts to prolong life are useless insofar as pursuing the purpose of life is concerned, or if prolonging life results in a severe burden for the patient insofar as pursuing the purpose of life is concerned; then the ethical obligation to prolong life is no longer present. Thus, the significant ethical question is not: Is death imminent or are the means required to prolong life painful?; but, rather, is there an obligation to seek to remove or circumvent a fatal pathology in order to prolong life?
To pursue the purpose of life, one needs some degree of cognitive-affective function. Hence, if efforts to restore or develop cognitive-affective function can be judged useless and a fatal pathology is present, the person may be allowed to die because prolonging life would not enable the individual to strive for the purpose of life. This is the precise ethical justification for discontinuing artificial hydration and nutrition for people in irreversible coma, not the fact "that benefits of treatment outweigh its burdens," as the AMA statement seems to indicate. Pain, or lack of it, associated with the life-prolonging therapy is not in itself a determining ethical factor when considering whether the therapy is useful or useless. For this reason Justice Kopelman's decision is inadequate because life-prolonging therapy should be withdrawn, whether it is painful or not, as soon se it is obvious that it is useless in regard to restoring cognitive-affective function.
Whether prolonging life will result in a grave burden for the patient, insofar as striving for the purpose of life is concerned, is more difficult to determine. But difficulty does not warrant supplanting the ethical decision with a law which eliminates consideration of meaningful circumstances. If the person with a fatal pathology is competent, then he or she should be allowed to make the decision whether or not to prolong life, the decision taking into account personal, familial; and social circumstances because one has responsibility to self, family, and society insofar as fulfilling the purpose of life is concerned. For example, a father whose life is threatened because of cancer may decide that his purpose in life would be better fulfilled if he rejected chemotherapy and surgery in order to devote time to his family during his remaining days, and to devote his savings toward the education of his children. Realizing that he must die sometime, he determines that it is spiritually more beneficial for him to die in the immediate future, rather than to prolong his life and as a result sacrifice other important values, such as meaningful time with loved ones or the education of his children. When making the ethical decision concerning grave burden, we seek to assess the burden associated with pursuing the purpose of life, not the burden that the therapy used to prolong life would involve. This distinction seems to be misunderstood by many ethicists and judges. Hence, when faced with the decision of whether or not to prolong the life of another, some ask: "Will the therapy be painful?" Severe pain, or great expenses causing the loss of other more important goods, may result in a decision that one would have a very difficult time striving for the purpose of life. But, on the other hand, it may happen that the means to prolong life do not involve great pain or expense but prolonging life would result in a grave burden insofar as pursing the purpose of life is concerned. For example, a competent. person with cancer, who has contracted a severe case of pneumonia, may determine that it is better for him to die presently from the pneumonia rather than wait and inter die a painful death from cancer. Thus he may decide to forego the comparatively painless therapy which might overcome the pneumonia.
Discussion
More difficult decisions are required when a decision based upon grave burden must be made for another person. For example, if the life of an infant with a fatal pathology could be prolonged with some hope that the infant would develop cognitive-affective function, but if prolonging life would involve grave burden in regard to striving for the purpose of life, is attempting to remove the fatal pathology or arrest its effects always an ethical obligation? The Federal Regulations concerning care of debilitated infants indicate that legally this is required. (3) But, ethically speaking, if a fatal pathology is present, need a family consent to life-prolonging therapy for an infant who has severe genetic disease such as Leech-Wyhan Syndrome or who will require nursing care 24 hours 8 day for the rest of his life? Should every child born with severe deficiencies in the immunological system be enclosed in a plastic bubble as was Baby David in Houston? Again, we are called upon to assess the burden associated with striving for the purpose of life; not the burden intrinsic in the means to prolong life. Rearing a child in a plastic bubble is comparatively painless, but is it humane? When making decisions for infants, the proxy must realize that simply because an infant is debilitated does not imply that he or she may be allowed to die; moreover, a fatal pathology should never be induced in debilitated infants. But, on the other hand, the notion that there is an ethical obligation to prolong the life of every infant with a fetal pathology simply because prolonging life is possible is not ethically justifiable.
The ethical obligation to keep dying patients comfortable leads some to demand artificial hydration and nutrition for all patients even those who are in irreversible coma. Is there medical evidence that persons in this condition feel hunger pains? Does the description of "starvation or dehydration" given in regard to healthy persons, as in the Brophy case (p.28), apply to patients in irreversible coma? In hospices and in infirmaries of religious sisters, the latter institutions being the embodiment of compassionate care for the dying, artificial hydration and nutrition are not utilized when a dying patient lapses into coma. In sum, evidence is lacking that removing or withholding tube feeding for the reasons mentioned above induces a new cause of death.
Conclusion
In regard to preserving one's own life or the life of another, the significant ethical question is: Is there an ethical obligation to prolong life? not, Are we able to prolong life? While inducing the pathology that causes death in an innocent person is never ethical, allowing a fatal pathology to take its normal course, not seeking to remove it or circumvent its effects, in some circumstances may be the better way to enable oneself or another person to achieve the purpose of life.
Kevin O'Rourke, OP
Footnotes 1. Mar. 15, 1986.2 The Probate and Family Court, Norfolk Division, p. 42.
3. Federal Register, 12/10/84, Vol. 49, n.238.
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