Withholding Nutrition as a Form of Euthanasia – Medical Ethics Example

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"Withholding Nutrition as a Form of Euthanasia" is a perfect example of a paper on medical ethics. Modern advances in medicine constantly bring about new challenges and adjustments to the traditional standards of ethics. Recent decades witnessed the superb technology that can prolong life through artificial ventilation and more efficient resuscitation especially for the terminally- ill or patients in the persistent vegetable state (PVS). Technically, the current situation demonstrates that only the duration of life is extended in most cases, not the quality itself. In very complicated situations, the concept of euthanasia (or mercy- killing) appears as a painful option for the patient, family, physician, and other people involved.

Now the question lingers, is withholding nutrition also considered a form of euthanasia? The degree to which euthanasia is applied varies in every case. The choice of medical interventions such as nutrition, ventilation, and cardiovascular support to be withheld and the manner of how it is done determine whether the act is morally acceptable to the purpose of allowing a dignified death. Several cases exist when patients who are still capable of making decisions voluntarily request euthanasia. With this regard, cases of euthanasia may be categorized into either self-administered or other- administered (Center for Health Ethics 2011).

Actually, these categories arise only from the viewpoint of those who, in the first place, already accepted the idea of euthanasia. By contrast, these categories appear to have no value for people who are against it no matter what form it takes on. In both categories, the case is further classified whether there is an act of commission or an act of omission. An act of commission constitutes active euthanasia, in which a certain method is committed to ending the patient’ s life.

These methods may include lethal injection or administering high-dose drugs that instantly cause a painless death. Active euthanasia violates the rigid standards of ethics that most ethicists condemn. Medical professionals are prohibited from providing this option to their patients and family for many reasons. It is very likely that physicians will get used to the idea of euthanasia that the value of life is lost (Center for Health Ethics 2011). On the other hand, passive euthanasia takes place when there is an act of omission such as allowing death without taking any medicine or refusing medical treatment (Center for Health Ethics 2011).

Although it can be inferred that withholding nutrition is a form of passive euthanasia because basic medical care is omitted, the dilemma remains whether conservative schools of thought accept the concept to a certain degree to allow adjustments from the rigid ethics. A position paper from the Scottish Council on Human Bioethics (2010) explicitly explains that withholding nutrition and hydration can be considered when ‘ death is imminent and inevitable’ for as long as the purpose of doing so is to ‘ relieve the suffering rather than to hasten death’ .  Sometimes, it is practically assumed that it is in the best interest of terminally- ill patients to die and be saved from the lengthened suffering.

But in cases of the uncertainty of survival and prognosis, the decision should always be on the side of prolonging life (Craig 1996, pp. 147- 153). After all, the time of actual death is easily identified in retrospect than in prospect (Gillon 1994, pp.

131- 132). Meanwhile, care must be made to assess whether the patient's condition presents that death is imminent. If the probability of impending death remains uncertain, then withholding nutrition should not take place because the fundamental right to life declared in the European Convention on Human Rights might be dishonored. Clear criteria have been laid down in such cases to view nutrition not as an intervention, but as part of routine care. Thus, withholding nutrition should not take any form of euthanasia, as this is still not allowed (Scottish Council on Human Bioethics 2010).   However, the provision of artificial nutrition may at times become part of a special medical intervention rather than a basic routine of care.

Since most PVS patients’ cases warrant the use of artificial nutrition and artificial hydration, the ethics of providing or withholding nutrition becomes thwarted. Even in the present practices, the benefits and burden of providing artificial nutrition in the last weeks of life of terminally- ill cancer patients remain unclear (Raijmakers et al. 2011, pp. 1478- 1486). In one meta-analysis that compiled the actual clinical practices in the provision of artificial nutrition and artificial hydration, five studies reported on the effects of artificial hydration.

Positive effects included a significant reduction in the incidence of nausea and physical dehydration signs. On the other hand, the negative effects of artificial hydration accounted for the increased incidence of fluid volume overload especially in the peritoneal and gastrointestinal regions. In these comparisons, no available data has yet been seen for the positive and negative effects of artificial nutrition (Raijmakers et al. 2011, pp. 1478- 1486).   Again, physicians involved may become reluctant to prescribe such therapy in the context of whether it still adheres to the best interest of the patient. The most difficult issue to be decided rests on balancing the best interests of the patient.

The fear of doing more harm to the patient in cases of hypersensitivity, multiple organ failure, development of ascites, and nutrient- rejection reduces the physician’ s motivation to prescribe artificial nutrition. The altered functionality of multiple internal organs increases the risk of underestimating or overestimating the physiological effects of artificial nutrition. Individual patients can vary widely with their responses. Since the actual consequences of providing artificial nutrition remain uncertain unless tried, the grey areas of ethics are apparently illustrated.

Physicians are both legally and morally bound to uphold the best interest of the patient at all times by having a sound decision in determining which treatments are not beneficial (Gillon, 1994, pp. 131- 132). When the physician and the patient’ s family are obligated to decide for the patient’ s welfare, it should be made sure that the provision and withholding of all medical interventions should have a purpose of offering relief from suffering rather than speeding up death (Gillon 1994, pp.

131- 132). For instance, terminally- ill patients are heavily sedated to prevent them from suffering severe pain and discomfort. In this case, withholding nutrition does not essentially provide relief from suffering but instead equate to something that might hasten death.   Medical personnel knows that adequate hydration is necessary even in patients under sedation. Again, withholding nutrition, in this case, takes the form of passive euthanasia. As to the question of whether withholding nutrition is a form of euthanasia or not, the fundamental definition says it is.

Adjustments are just formulated depending on the situation to make it morally acceptable not as to hasten death, but as a way of relieving the agony and maintaining the dignity of death. Having dignity in death underscores the freedom from pain and suffering in the dying process. It is, in other words, to die in a peaceful manner. Indeed, the truth of the matter relies on the moral consequences of euthanasia. Ethicists fear that when withholding nutrition becomes acceptable medical practice, eventually the administration of lethal injection would be preferred since it provides an instant death rather than death by starvation, which sounds totally inhumane (Scottish Council on Human Bioethics 2010).   The debate is still on.

In fact, the decision of withholding nutrition is not spelled by a single aspect. In the actual setting, it is not decided solely on the basis of the patient’ s welfare. Family and other significant people need to pursue a thorny decision especially when the patients themselves are not capable of deciding for themselves and no advance directives have been established. Cultural consideration and religious affiliation come at play to complicate matters about the legality, morality, and ethics of the thin line that distinguishes killing and letting the patient die.  

References

Center for Health Ethics 2011, Euthanasia, viewed 23 April 2012, http://ethics.missouri.edu/Euthanasia.aspx

Craig, GM 1996, 'On withholding artificial hydration and nutrition from terminally ill sedated patients. The debate continues', Journal of Medical Ethics, vol. 22, pp. 147- 153.

Gillon, R 1994, 'Palliative care ethics: non-provision of artificial nutrition and hydration to terminally ill sedated patients', Journal of Medical Ethics, vol. 20, pp. 131- 132, 187.

Raijmakers, NJH., van Zuylen, L., Constantini, M. et al. 2011, 'Artificial nutrition and hydration in the last week of life in cancer patients. A systematic literature review of practices and effects', Annals of Oncology, vol. 22, pp. 1478–1486.

Scottish Council on Human Bioethics 2010, Position statement on euthanasia, by Eric Liddell Centre, Edinburgh.

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