Biomedical Ethics: Assignment Week 3

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Chapter 10

Ethical Issues in the Use of Fluids and Nutrition: When Can They Be

Withdrawn

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Withholding Artificial Nutrition

• Recent cases have highlighted the contentious nature of these decisions.

• When patients have a chance for recovery, these substances are a great assist.

• When patients have no hope of recovery, they can be inappropriate.

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Ethical Decisions are Complex

• Withdrawing treatments when they are no longer effective is viewed as acceptable practice.

• Fluids and nutrition are not viewed in the same way.

• They are the clinical scaffold. • From the family view, they constitute hope.

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Definitions are Needed to:

• Determine how to define fluids and nutrition. • Determine when providing them serves no

medical purpose for the patient.

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Definitions are Needed to:

• Define artificial hydration and nutrition. • Decide if artificial nutrition and hydration are

not needed to sustain life.

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Ethics and Artificial Hydration/Nutrition must:

• Differentiate between hunger and thirst and artificial hydration/nutrition.

• Consider care versus therapeutic goals. • Respect the patient’s integrity and autonomy. • Consider the medical condition.

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Ethics and Artificial Hydration/Nutrition

• Ethical analysis must consider the patient’s claim to integrity.

• The strength of claim of integrity and informed consent must be considered.

• One must consider the function of rights in making clinical decisions.

• Some rights require collective responsibility.

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Ethics and Artificial Hydration/Nutrition

• The manner of death can become a moral enterprise.

• The decision to withhold artificial hydration/nutrition can be a patient’s most important moral need.

• This right can conflict with society’s right to preserve life.

• The patient’s claim must not be a threat to society’s claim.

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Ethics and Artificial Hydration/Nutrition

• The Quinlan Case provided a formula for addressing conflicting claims.

• The futile nature of the medical treatment must be considered.

• What if withholding these elements leads to death? What is the patient’s right?

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Benefits and Burdens

• There is a need to balance the benefit of providing the intervention against the burdens.

• When the benefit does not exceed the burden, a decision not to have the treatment is ethical.

• The right to bodily integrity is the core issue.

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Benefits and Burdens

• The physician can decide that the burden is not worth the benefit independent of the patient.

• This would not be ethically acceptable without considering the patient’s right to integrity.

• Patient consent or refusal is essential.

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Tensions

• There is a tension between the rights of the patient and the rights of the treating physician.

• What is the patient-physician relationship with respect to this decision?

• How can the physician withdraw artificial nutrition/hydration and still do no harm?

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What Happens at End of Life?

• Dehydration eases the discomfort of terminal illness.

• Artificial hydration can add to the discomfort in the long run.

• Tube feeding adds to the discomfort of the dying.

• Food and fluids are often decreased in end stages without thirst or hunger.

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Research Shows…

• That there is no clinical benefit to nutritional support at the end of life for cancer patients.

• Inserting feeding tubes does not improve survival.

• In one study, nursing home residents with feeding tubes died sooner than those without.

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During the Dying Process

• Adaptation to starvation prevents discomfort due to the lack of food.

• Dehydration usually occurs before starvation and its changes produces a sedative effect on the brain.

• Terminally ill patients experience dehydration differently so giving fluids may prove futile.

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Can the Preservation of Life be Unethical?

• Can favoring life actually be unethical? • Should life be prolonged when there is no

hope of recovery? • Is continuing treatment an impossible burden

on the patient? • If this is true, then it is no longer ethical to

prolong life.

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Does the Argument Fit?

• This argument alone is not enough. • Consider the consequences of the action. • Quality of life must be a consideration. • The patient’s preferences must be considered

in the decision. • We cannot hold the patient hostage.

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In Summary…

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