Step One: Gather relevant information
Artificial Hydration and Nutrition (AHN) are applied to patients who cannot obtain proper nutrition by natural means due to various reasons. These reasons include the state of deep unconsciousness. In terms of ethical decision-making, three conditions are “particularly challenging: terminal illness, advanced dementia, and a persistent vegetative state” (Geppert, Andrews, and Druyan 79). In such cases, although patients need AHN for life support, the issues of initiating, maintaining, and withdrawing such nutrition have proved to pose a serious ethical dilemma.
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One of the main aspects of the debate over AHN is the patient’s will. If any preferences concerning AHN had been previously expressed by the patient before he or she lapsed into permanent vegetative state (PVS) or minimally conscious state (MCS), such preferences should be taken into consideration when making a decision on initiating, maintaining, or withdrawing life support.
Quality of life
The ethical dilemma of whether AHN should be applied occurs in cases where a patient’s quality of life is seen as very poor, sometimes to the point where a debate rises on whether it can even be called “life” (e.g. PVS and MCS).
Organizational factors (policies, procedures, structure)
Organizational factors include the policies of a hospital, nursing home, or another medical facility where the patient is placed.
Professional factors (expectations, requirements)
Professional factors include the considerations of medical ethics principles. Four main principles are autonomy, beneficence, non-maleficence, and justice.
Financial and other resource factors
One of the considerations in the ethical dilemma of maintaining or withdrawing life support of a patient in MCS/PVS is the amount of resources that a medical facility spends on AHN. Some people argue that these recourses could be used to help non-hopeless patients instead (Del Rio at al. 920)
Legal factors and precedents
Many cases of legal struggles over end-of-life care are known, including the Terri Schiavo case. A scholarly discussion has been going on for decades on the “ethical adequacy of the judge’s decision not to authorise withdrawal [of AHN from a minimally conscious patient]” (Kitzinger and Kitzinger 157).
Social factors (society, family, culture, etc.)
Social factors include cultural and religious considerations of the community, to which a patient belongs.
Step Two: Identify the practical problem
In case a patient has a disorder of consciousness and his or her state is deemed hopeless, should health care providers decide to withdraw AHN?
Step Three: Identify the ethical issues and questions
Formulate the ethical question you wish to answer.
Should patients in MCS/PVS whose state is deemed hopeless receive AHN?
Formulate the additional ethical questions you wish to answer.
Do health care practitioners have the right to cease AHN in hopeless cases of MCS/PVS, which will lead to a patient’s death of starvation and dehydration? Should health care practitioners cease AHN based on the wish of the patient to do so? Based on his or her family’s wish?
Step Four: Select the ethical principles and/or frameworks to be considered.
The principles to be considered in such dilemmas are autonomy, non-maleficence, and beneficence. Autonomy is about the patient’s right to decide whether he of she wants to receive AHN in hopeless cases of disorders of consciousness. Non-maleficence means that a health care practitioner cannot make a treatment-related decision that will harm the patient. In this case, the decision to cease life support leads to death of starvation and dehydration. Beneficence is about making only those decisions that benefit the patient. Since there are documented cases of recovery from MCS/PVS (Kitzinger and Kitzinger 158), life support is necessary because it is beneficial to the patient.
Step Five: Conduct an analysis and prepare a justification
Patients in MCS/PVS whose state is deemed hopeless should receive AHN. Their right to be kept alive is based on the principles of non-maleficence and beneficence.
Health care practitioners have the right to cease AHN in hopeless cases of MCS/PVS, even though it will lead to a patient’s death of starvation and dehydration, based on the decision of the patient (that had been made before the patient lapsed into MCS/PVS) or his or her family. The right is based on the principle of autonomy, which declares respect for the patient’s wishes concerning his or her health. Particularly, the right to refuse treatment is recognized by the principle of autonomy.
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Step Six: Consider one or more counterarguments
The counterargument is that hopeless patients should not be kept alive because they can never recover. Their brain functions are decreased, they are not aware of themselves or their environment, therefore, although their bodies function, their states cannot be described as “living.” Maintaining life support gives the patient’s close ones an illusion that the patient is living, which is cruel and will make accepting the patient’s death more painful. Also, a lot of resources are spent on life support of hopeless patients. Instead, these resources could be used for providing health care to other patients. All these arguments should be rebutted because they suggest violation of two fundamental principles of medical ethics: non-maleficence and beneficence.
Step Seven: Explore the options for action
The action to be taken is providing AHN to the MCS/PVS patient. In case the action is not taken, the patient will die of starvation and dehydration. However, if the case is deemed hopeless and the patient’s family requests to cease AHN, health care practitioners should do so. The decision to cease life support against the family’s will (or the will of the patient) violates autonomy, beneficence, non-maleficence, and should be qualified as murder.
Step Eight: Select, complete and evaluate the action
The proposed action to maintain AHN in hopeless cases is ethical because it complies with fundamental ethical principles. The proposed decision to allow ceasing AHN based on the desire of the family or the patient is justified by the principle of autonomy. However, when there are additional complications, like disagreement among the patient’s family members, the dilemma is not so easily solved. In order to find the most ethical solution, each particular case should be thoroughly examined.
Geppert, Cynthia M.A., Maria R. Andrews, and Mary Ellen Druyan. “Ethical Issues in Artificial Nutrition and Hydration: A Review.” Journal of Parenteral and Enteral Nutrition 34.1 (2010): 79-88. Print.
Kitzinger, Celia, and Jenny Kitzinger. “Withdrawing Artificial Nutrition and Hydration from Minimally Conscious and Vegetative Patients: Family Perspectives.” Journal of Medical Ethics 41.2 (2015): 157-160. Print.
Del Rio, MI., B. Shand, P. Bonati, A. Palma, A. Maldonado, P. Taboada, and F. Nervi. “Hydration and Nutrition at the End of Life: A Systematic Review of Emotional Impact, Perceptions, and Decision-Making among Patients, Family, and Health Care Staff.” Psycho-Oncology 21.9 (2012): 913-921. Print.