Tuesday, December 13, 2005

"Artificial" vs "natural" nutrition and hydration...and Terri Schiavo

The current Archives of Internal Medicine has two articles of note.
First is a commentary questioning the distinction between 'natural' and 'artificial' nutrition and hydration .  This is their proposition:

[W]e propose that under certain circumstances surrogates may choose that all forms of hydration and nutrition be forgone, regardless of whether they are administered artificially (by tube) or naturally (by hand-feeding). More specifically, we argue that the justification for withdrawal of feedings does not hinge on whether feeding is administered artificially or naturally; rather, it is based on the fundamental rights to self-determination and bodily integrity that permit patients to refuse any unwanted intervention.
Their argument seems to go like this: 
If a competent patient can refuse any intervention and can choose to stop taking food/fluid--or could competently refuse being orally fed food/fluid--then why can't a surrogate make this decision?  What I'm having trouble with is imagining a situation when this would occur and be an "issue." The authors relate this to the Schiavo case, but--her parents' claims notwithstanding--she couldn't take orals (she received aggressive speech therapy early after her arrest to no avail).  My sense is they are proposing a scenerio like the following.  Someone becomes neurologically devastated but retains some swallow reflex and is technically capable of being nutritionally sustained with conscientious hand-feeding.  Their surrogate says they'd never want to be kept alive like this and asks for the hand-feeding to be stopped totally.  Is this ethical?  If it's permissible, let's say, for a competent quadriplegic to refuse needed tube feeds, then why not an incompetent neurologically devastated person refusing hand feeding via a surrogate? 
Technically, I think this is true, although an extremely unlikely/uncommon/unnecessary event.  Issues of potential discomfort due to stopping feeding aside, the major problem I have with this is via thinking about a situation I see commonly.  Particularly, I'm thinking of the situation where an elderly person undergoes a large stroke from which they are unlikely to recover much/any cognitive & motor function (although they may very well live a long time if they were 'artificially' fed); their family/surrogate says they wouldn't want to live in this condition; everyone agrees; the patient is kept comfortable with meticulous symptomatic care; and they usually die in a week or two.  During this, if the patient shows any interest--or at the initiation of the family--they are offered food/drink as a comfort measure (although this is not enough to change/delay their outcome).  During this, there's no sense of obligation towards giving the patient as much oral sustenance as they could possibly take.  And this is what seems to be missing from the article; the authors' take on the ethical injunction to not withhold oral sustenance is interpreted as an injunction to force 'nutritionally adequate' oral sustenance onto anyone who could conceivably 'take it.'  Regarding patients who are dying, most people, I would guess, interpret this ethical standard as meaning we should offer oral food/drink to them to offer comfort etc. but not out of some injunction to give 'adequate' nutrition.  If you take away the idea that it's necessary to 'force feed' people 'adequate nutrition' (I have no clue what adequate nutrition is for a dying person) then the 'need' to deny someone a little food or drink goes away. 

That was a long paragraph that I'll probably decide doesn't make sense in the morning...

Second, there's a brief analysis on public opinion about the Terri Schiavo case.  It looks at polling data on public opinion about whether people thought it was justified to remove her feeding tube, as well as how they thought the courts and politicians 'performed' during the saga.  Not too many shocks--public opinion was divided but on the whole most people thought that it was OK to remove the tube.  Most people would not want to be kept alive in a similar condition, and most thought that politicians had performed pretty poorly during the whole thing.  Not surprisingly, evangelicals and "highly religious" Catholics were more inclined to think that removing the feeding tube was a mistake.  Overall, it is heartening to know that those threatening violence against Ms. Schiavo's hospice, her husband, and Judge Greer (& even Governor Jeb Bush for not sending state troopers in to kidnap and, presumably, forcibly reinsert her feeding tube) represent a minority--albeit, however, a substantial one.  This not-too-welcome news concludes the article:
Efforts are already under way to pass legislation placing limits on who can make choices when a patient is in a vegetative or comatose state for a long period and has left no written directive, as well as regarding what level of proof should be required before such choices can be implemented. This includes a proposal for a partial moratorium on the removal of food and water from people diagnosed as being in a PVS or "minimally conscious state" in the absence of new diagnostic processes or a written directive or power of attorney by the person.  In addition, we predict that these issues are likely to spill over into the selection process for judges at various levels of government as organizations representing these individuals try to get judges appointed who share their views.

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