Food & water: an ethical burden:
Walter, James J.
THE WITHDRAWAL OF ARTIFICIAL NUTRITION Food & water: an ethical...
...A closer look at the Paul Brophy case might family...
...Brophy later requested that the G-tube be heads...
...The AMA opinion applies to cases in which a meaning of food/water...
...This medical intervention morally obligatory...
...once inserted surgically, was not invasive and that denying a Commonweal: 616 patient food and water would inevitably in each and every two authorities who are searching for a policy concerning the instance guarantee and cause the death of a patient...
...How one distinguishes between "ordi- In the Brophy case, as in the Conroy and Herbert cases, nary" and "extraordinary," however, has not always been so theologians, medical specialists (e.g., Joanne Lynn, M.D...
...As such, these ethicists, like the President's Academy of Sciences, and the original trial judge in the Commission and the AMA, would consider the withdrawal of Brophy case, on the means (food/water) themselves, apart nutrients as permissible, though not morally required...
...Dennis Brodeur (director of health care between the withdrawal of food/water and the withdrawal ethics for the Sisters of St...
...tionality of benefits and burdens to the patient which makes Thus according to the distinction, one is morally obliged to use any medical treatment, including the provision of food/water, ordinary means to preserve life but would not be obliged to use obligatory or optional...
...nature of means used, and since the provision of nutrition and What is at stake, then, is precisely the "quality" of a person's hydration is not burdensome treatment, it must be considered life as it affects his or her ability to pursue and attain values "ordinary" and thus morally mandatory...
...have I would argue that how one defines these two terms has much argued that a patient-centered approach which focuses on the to do with where one focuses attention in the clinical environ- disproportionality of benefits or burdens to Paul Brophy would ment...
...Brophy for are defenseless and in need of the basic nutritional elements for more than a year...
...Thus, by focusing attention on the G-tube itself or moral meaning of providing food/water in isolation from after it was in place, the judge seemed to deny any assessment the patient, then one can reasonably ask how the preserving of of a quality of life judgment for Mr...
...The split, then, is maybe not so much between our hearts and heads as between the two focal points of our attention in the clinical environment...
...Brophy's condition...
...sires not to be treated in such a condition...
...He had proposed that since nutrition and creation of the stoma (surgical opening) for placement of the hydration conferred benefits on Mr...
...First, the denial of food and fluids is patient in an irreversible coma has expressed beforehand a biologically "final" in a way that the denial of medical or wish not to be kept alive through artificial feeding, or when the surgical therapy is not...
...to refuse treatment (patient autonomy...
...on the television or read about the court cases in our To imply that this intensely debated issue can be reduced to morning newspapers...
...Connery has been a frequent spokesperson against the for someone in Mr...
...Though the issues at stake in such cases The Brophy family appealed the judge's ruling to a higher as the Brophy legal case and the disagreement between the two court...
...explaining the relationship between a patient's biological conFor him, the assessment of burden must be confined to the dition and his or her ability to pursue life's goals and purposes...
...and surgical therapies are not...
...He argues that the More specifically, we are inquiring about the legitimacy of question of benefit seems limited largely to terminal cases, "quality of life" judgments...
...Brophy because they kept G-tube was in fact "an intrusive and invasive surgical procehim alive, albeit without conscious life, the provision of this dure" (and thus burdensome), once it was in place the tube care was "ordinary" and thus morally mandatory...
...182...
...This report, Brophy case, also has focused on the meaning of food and backed by twenty doctors and scientists, is at some variance water in distinguishing these from other medical technologies...
...with the opinion authored by a seven-member American Med- Though he offered several reasons to support his distinction in ical Association Council on Ethical and Judicial Affairs in the Brophy case, two of them in particular focus directly on the March 1986...
...assessment deals with different issues...
...Following the criterhonored distinction goes back at least as far as the seventeenth ion outlined in the Sacred Congregation for the Doctrine of century, and it has been used by theologians and recent popes Faith's Declaration on Euthanasia (1980), these Catholic to determine the moral duty to preserve life...
...The celebrated court cases of fer of her husband to an acute care hospital where a gastrosincompetent patients in a persistent vegetative state (PVS) like tomy tube was inserted so that Mr...
...They argue that an assessment of the heal, but also of our limits to control the time of a person's burden of the life preserved was always part of what the death...
...confront the likelihood of per- to death would be to destroy, or at least seriously to erode, one manent disability which will accrue to the patient (paralysis, of the most basic "moral emotions" appropriate to human inability to see or speak, etc...
...He did regain consciousness and then waited sevbers turn to one another and debate whether providing nutrition eral weeks before undergoing a craniotomy...
...assessment of benefits of giving food/water to count in the The trial judge in the Brophy case argued that, though the decision-making...
...If we allow "quality of that "quality of life" judgments are based on some arbitrary life" judgments, how and where do we draw the line to prevent standard that the patient must meet...
...Per- questions exist...
...Also, I agree that quality of life judgments are not only permissible but necessary in the assessment of benefits and burdens to the patient...
...However, he maintains food/water and that of medical or surgical therapies focus their that medical and surgical therapies are not universally needed, attention in the medical setting on the patient...
...He was situation...
...We hear about it available to support the desired conclusion...
...According to accepted setting while establishing the criteria upon which to form and medical standards, PVS patients are not dead, nor are they evaluate moral judgments...
...from the patient who is the recipient of the nutrients...
...Even if the physician's prognosis is the "necessary social instinct" to feed others when they need inaccurate and a patient who has been maintained on some it...
...Many believe that we have gone far beyond bers look to the physician for any glimmer of hope for the the Quinlan-type cases where the withdrawal of a respirator loved one and then ask what can be done...
...one brief argument can serve to summarize my position...
...means a plea for moral relativism in public policy, but rather it is a realization that moral argument is controlled in part by one's decision to focus on and interpret one set of factors as central...
...Connery is aware that the distinction between ordinary and T His brings us to the second issue, namely, whether the extraordinary means was originally based on the assessment of burdensomeness of the life preserved by the offering of benefits and burdens to the patient, but he maintains such an food/water can be part of the overall assessment of burden...
...other medical treatments (e.g., a respirator...
...The court here applied the standard of "substituted judg- patients any different morally from the refusal/withdrawal of ment" to the case, agreeing that if he were able to speak, Mr...
...Den argues that no human being What should one make of the disagreement between these can survive without nutrition and water, and death is the 21 November 1986: 617 universal consequence of their denial...
...It is possible to interpret the criterion as a way of his distinction between ordinary and extraordinary measures...
...Perhaps...
...In other words, these patients illustrate some points of disagreement between Catholic ethican remain in their medical state for years or even decades...
...The trial judge refused to accept this "substituted judgment" and ordered the G-tube to remain in place...
...As such, we might reasonably conclude that family presented that on several occasions Mr...
...extraordinary means...
...the Study of Ethical Problems in Medicine and Biomedical and Many who hold that there is a real moral distinction between Behavioral Research (1983) indicated that if a prognosis of the refusal/withdrawal of food and fluids and the refusals of permanent unconsciousness is correct, then all pain and suffer- medical technologies focus their attention on either the syming are absent, as are joy, satisfaction, and pleasure...
...Finally, she asked a court to authorize the physical existence...
...Brophy's ures...
...beings...
...The state- founded all the expert medical opinion by surviving the withment does not recommend withdrawal of feeding tubes in these drawal of artificial respiratory support, but she surely would cases, but it states that it is not unethical when the patient or have died had food/water been withdrawn...
...sibilities of the physician, along with the legal implications, In March 1983, Paul Brophy, a forty-eight-year-old Easton, seem to warrant providing food and water to the patient artifi- Massachusetts, firefighter and emergency medical technician, cially through a gastrostomy tube in order to sustain physical suffered a massive brain damage as a result of a ruptured life...
...Connery would con- beyond biological existence...
...After the surgical insertion of the and Paul Brophy in Massachusetts well illustrate the complex G-tube, Mr...
...Here I think Connery also focuses can in fact be linked to, rather than opposed to, the "sanctity of primarily on the nature of the means needed to preserve life in life" issue...
...Here Callahan casts his vote to follow our moral sentiments, which are symbolized in actions toward others in I N OCTOBER 1985, the Pontifical Academy of Sciences in need, rather than to follow what "a more straitened rationality Rome issued a report stating that "If the patient is in a would call for...
...Other questions are at limbs can be used in deciding whether the surgery is obliga- stake in the discussion: how much moral weight do we give the tory...
...Brophy's quality of and begins to assess the burdensomeness of a life devoid of life in a persistent vegetative state would go far beyond what pursuing life's temporal goals, one recognizes that medicine the Catholic distinction between ordinary and extraordinary has reached its limit in bringing this patient to any level of means would allow...
...University of ANOTHER way to state the case for a moral difference Notre Dame) and Rev...
...health and wholeness...
...Without going into all the problems with this distinction, and health-law experts (e.g., George J. Annas, J.D...
...Does jusstates that a person's life is not worth anything unless that life tice require us to limit the allocation of resources to these is able to function at an arbitrary1evel, the usefulness of the patients, etc...
...For exam- I HAVE looked at only two of the issues involved in establishple, the burden that would follow the amputation of all four ing a public policy on PVS patients...
...tradition meant by the distinction, and thus they deny that "benefit" and "burden" apply to different cases...
...to the symbolic and moral meanings of artificially giving food Estimates are that on any given day in the U.S...
...In October, Paul preserved by the treatment also count in the judgment to Brophy was transferred to a different hospital where, eight refuse/withdraw...
...And second, is Brophy would have rejected the tube-feedings, and that in his the evaluation of burdensomeness that might justify the stead his family had the right to enact his wishes...
...Brophy's stated demodern medicine...
...Brophy...
...Because life is not ethicists have argued that it is the proportionality or disproporthe highest good, it need not be preserved under all conditions...
...not require health-care givers to provide nutrition and hydraRev...
...legitimacy of "quality of life" judgments...
...There is the gathering around the a split between our hearts and heads is, of course, too simple, bedside of a patient in a modern hospital by the physician and albeit enticing...
...Second, food and family has expressed such a wish and there are no local laws fluids are universal biological needs, whereas modern medical against withdrawal...
...By becoming since "almost every human being can and does survive quite patient-centered, theologians like Rev...
...To avoid "quality of life" judgments environment - on the artificial means of providing nutrition, on PVS patients' lives, though, Connery permits only the or on the patient and his/her ability to realize life's values...
...Callahan reasons that since feeding the hungry is the most form of artificial feeding for a long period of time regains fundamental of all human relationships, then to starve a person consciousness, one must still...
...permanent, irreversible coma, as far as can be foreseen, treat- Patrick Derr, an associate professor of philosophy at Clark ment is not required, but all care should be lavished on him [or University who was called to give expert testimony in the her], including feeding" (emphasis added...
...By using the Brophy case, I will necessarily in the dying phase...
...Paris, S.J., nicely without renal dialysis, artificial respiratory support, another expert who testified in the Brophy case, have argued antibiotic medicines, or any of the other armamentaria of that the original trial judge violated Mr...
...On the other hand, our heads inquire discontinuation of all medical treatments, including nutrition whether the provision of such nutrition and water is not in the and hydration through the G-tube...
...Additionally, theologians like Rev...
...In his case alone, the monthly cost to search for the proper place to focus our attention in the clinical Blue Cross was in excess of $13,400...
...In other words, such means were useless everyone is morally obligated to preserve life with such meas- ("extraordinary") with respect to ameliorating Mr...
...The basis of his (mere physical existence) that would have accrued to him as a argument is that food/water are "ordinary" means, and result of the nutrition...
...21 November 1986: 619...
...transferred to the New England Sinai Hospital in Stoughton, Though this scenario is fabricated, it all too often reflects the Massachusetts, but in October 1983 his wife authorized transheart-wrenching facts of real life...
...cists on the two questions, and then I will briefly offer my own Expert testimony given before the President's Commission for evaluation...
...Mary) have argued that it is not the of medical therapies is to turn to the traditional Catholic category of disease or the kind of therapy that makes a certain distinction between ordinary and extraordinary means...
...what is in all probability only physical life could be a benefit Fr...
...But that is precisely what has been central to the two issues to begin with, namely, where do we focus our analysis and on whom...
...Both questions require us to to that of a Mr...
...Connery arrives at this conclusion...
...In September 1986, the Massachusetts Supreme Judi- medical authorities are broader than I can treat here, I would cial Court ruled that Mr...
...The case was refusal/withdrawal of a treatment limited only to the burden of immediately appealed to the United States Supreme Court, but the treatment itself or can the burdensomeness of the life the Supreme Court refused to consider it...
...Disabil- bolic or moral meaning of giving nutrition/hydration in itself...
...But if one could be considered "neither uncomfortable nor painful" (not focuses on the condition of the patient, and not on the symbolic burdensome...
...Far from being arbitrary, these judgFr...
...His most recent book, co-authored with have something as sophisticated as a respirator removed, he Stephen Happel, is Conversion and Discipleship: A Christian Foun- believed that a technology as simple as a gastrostomy tube, dation for Ethics and Doctrine (Fortress...
...Mistaken prognoses argued that the providing of nutrients is "the perfect symbol of are possible, but normally physicians arrive at these conclu- the fact that human life is inescapably social and communal...
...Brophy had indicated members can justifiably refuse or can withdraw nutrition and while competent that he would have desired the artificial hydration from their loved ones...
...care of PVS patients...
...McCormick and other Catholic ethicists disagree with ments, made with a great deal of fear and trembling, are Connery's interpretation of the distinction between ordinary objective assessments of not only the limits of our abilities to and extraordinary means...
...Because a Paul Brophy would not have regained conprovided expert testimony in the Brophy case, has argued for sciousness, in all probability, the "benefits" of providing several years that health-care providers have a moral obliga- nutrition would have been disproportionate to the kind of life tion to provide food/water to PVS patients...
...Furthermore, these ethicists disagree to withdraw nutrition and hydration...
...end useless or even burdensome for the patient in this condi- At the original trial in May 1985, substantial evidence was tion...
...When one focuses on the patient clude, then, that any assessment of Mr...
...Brophy never and hydration is what the loved one would have wanted in this regained consciousness subsequent to the operation...
...They concede that if ourselves from slipping down the slope into the euthanasia of "quality of life" stands for a certain norm or criterion which severely handicapped patients who are conscious...
...Brophy's G-tube was indeed a medi- like to isolate two major nodal points in the discussion: First, is cal treatment and that as such, the patient had the right to refuse the refusal/withdrawal of nutrition and hydration from these it...
...In fact, then, "benefits" and "burdens" can coincide in sensitivities of the family and/or health-care givers who refuse some clinical situations...
...An answer to the second turns on the issue of approximately 10,000 patients who are in a similar condition "quality of life" judgments...
...Because of the condition of Paul Brophy, and thus because of the probable lack of his ability to experience hunger or thirst, I do not see how the symbol of "offering food to the hungry" could have mediated anything to Brophy, though I surely do not deny that such actions might convey important meanings to those who stand_ at the bedside of PVS patients and care for them...
...Brophy...
...Richard A. McCormick, S.J...
...Derr's conclusion, then, was that Mr...
...I think, because general medical condition, much less with restoring him to a he focuses, like Callahan, Derr, the scientists of the Pontifical state of health...
...Brophy could be provided Claire Conroy in New Jersey, Clarence Herbert in California, nutrition and hydration...
...Though the prog- was at issue, and we stand now at the edge of the slippery slope nosis for recovery to consciousness is dim or maybe even toward euthanasia by allowing "quality of life" judgments on non-existent, the medical training, conviction, and moral sen- patients' lives...
...Brophy was transferred back to Sinai Hospital...
...JAMES J. WALTER is associate professor of theology at Loyola Though the judge indicated he might have granted a request to University of Chicago...
...The latter assumption is by no or accomplish...
...The conflict can become so feedings stopped...
...Uneasy with even asking the question, the family mem- aneurysm...
...Though I admit some validity to Callahan's implication that certain actions not only aim at goals but express values (symbols of care and compassion), I remain unconvinced that offering nutrition to PVS patients can in fact convey or mediate the bonds of communal sharing and concern to them...
...Here Paris and others Brophy had to continue to be provided the nutrients through would give moral weight to a once-competent patient's wishes the gastrostomy tube...
...We cannot assume that easy answers to these criterion in moral decision-making is indeed improper...
...issues that frequently drive a wedge between our hearts and But when Mrs...
...On the two issues under discussion at least, I side with those who see no necessary moral distinction between the refusal or withdrawal of nutrients and the refusal/withdrawal of various medical technologies (e.g., a respirator...
...John Connery, S.J., a moral theologian who also tion...
...there are and water...
...THE WITHDRAWAL OF ARTIFICIAL NUTRITION Food & water: an ethical burden JAMES J. WALTER intense that fair-minded people will line up on one side of the issue or the other and marshal the evidence and argument THE SCENE is not all that unusual today...
...clear...
...sions only after patients have received vigorous medical atten- He believes that a well-ordered moral life requires proper tion, careful observation, and complete diagnostic studies over feelings and sentiments, and one of these sentiments is surely a long period of time...
...The family mem- stake in the debate...
...If the person Commonweal: 618 does not meet the standard, then the life is not considered "Quality of life" as a criterion in moral decision-making worth living or preserving...
...ity is total and no return to an even minimal level of social or For example, Daniel Callahan of the Hastings Center has human functioning is possible" (p...
...However, we can assume that thoughtful sons do not derive worth or meaning merely from what they do people will continue to disagree...
...Again, this issue is controlled, at whereas the question of burden can be an issue even in cases least in part, by where one focuses attention in the clinical which are not terminal...
...For example, Karen Quinlan confamily of such a patient decides to withdraw care...
...On the one hand, our moral sensibilities seem mini- removed from her husband, the physicians, nurses, and hospimally to require of us that we offer food and water to those who tal administrators refused the requests of Mrs...
...The dreaded diagnosis is uttered in a hushed voice by prove helpful in sorting out two of the many issues that are at the physician: "persistent vegetative state...
...days after feeding had been discontinued, he died of The answer to the first question will require some attention pneumonia...
...John...
...In his view, the An increasing number of Catholic ethicists who tend not to principle underlying these judgments is that the duty to presee any moral difference between the refusal/withdrawal of serve life is based on some arbitrary standard...
Vol. 113 • November 1986 • No. 20
