Development in clinical medicine has made it possible for medical practitioners and care givers to supply nutrition and hydration to patients whose medical conditions do not allow normal eating processes.1 In most cases, these life-supporting substances are given through a host of methods, including but not limited to intravenous tubes, nasogastric tubes, hyperalimentation and surgical gastrostomy tubes.
This procedural provision of food to patients has, however, been viewed by others as a form of treatment, being compared to a respirator, used to allow breathing in patients. On the other hand, this form of feeding is perceived as a form of basic care, which should not be denied patients in need of it.2
Numerous cases have been decided, involving this matter with no consensus being reached, regarding the implication of tube-feeding in the health of a patient. 3
This essay discusses the question of whether nutrition and hydration should be withheld or withdrawn from patients or not. Even though the discussion is two-sided, this analysis supports the fact that nutrition and hydration should be withheld or withdrawn under medical and ethical circumstances. In particular, the arguments presented in this essay will focus on laws and ethical issues in Australia.
Reluctance to withhold food
In cases where a person cannot eat because of his or her medical condition, a decision is usually made about providing food through the available feeding methods for such patients. However, emphasis for this decision is based on medical needs of the patient, challenges and benefits of carrying out the process.4
While physicians find no difficulty in initiating this mode of feeding, it is evident that the main challenge arises when they are supposed to withhold or withdraw nutrition and hydration towards the end of life. Although most physicians are qualified in making other medical-ethical decisions of terminating treatment or life, forgoing feeding is still a problematic issue.
Whilst most decisions concerning medical issues are supposed to be weighed thoroughly, there is a notion that decisions to withdraw or withheld nutrition and hydration in patients are never based on advantages and disadvantages of the process. In some cases, physicians are usually reluctant to terminate feeding even when the demerits of the process evidently outweigh the benefits.5
Additionally, it has been observed that some medical practitioners become biased on the kind of treatment to be forgone when a patient is in a critical situation and is not willing to withdraw or withhold feeding. It is essential to note that this reluctance persists although medical organizations do recognize withdrawing or withholding nutrition and hydration from patients under proper ethical and medical conditions.
By considering this kind of feeding as a form of life-prolonging treatment, similar principles of terminating treatment have to be observed within the confines of ethical and medical implications.6 In fact, there are several professional organizations around the world, which have gone ahead to list nutrition and hydration under life-sustaining treatment, while others do criminalize the withdrawing or withholding of feeding.
Moreover, medically provided food and water is viewed a basic human need, which patients in all situations are entitled to. As a result, physicians may develop the fear of subjecting patients to unfair pain or denying them their right to feed and live.7
While addressing this issue, it is extremely important to appreciate the fact that it can be viewed from a legal, ethical and religious point of view. This further implies that different countries or societies may hold varying views concerning the issue, due to the diverse nature of human ideologies.8
The following segment narrows down to Australia and how it ethically and legally views the issue of withdrawing or withholding nutrition and hydration from patients.
Nutrition and Hydration in Australia
The question of withdrawing or withholding feeding in certain circumstances has drawn international attention, from the United Kingdom, U.S., Canada and Australia among other countries around the world.
For instance, Australia has witnessed court rulings revolving around the issue of terminating feeding in incompetent patients and its implications. The most mentioned case is Gardner; re BWV in which the Victorian Supreme Court issued a landmark verdict that was to influence the society’s perception towards assisted-feeding in hospitals.9
Legal provisions in Australia
Currently, any life-supporting systems in Australia are partly covered under the country’s common law and statutes from various territories. For example, the first law was the Natural Death Act of 1983, in South Australia, Natural Death Act (NT) 1989, Natural Death Regulations (NT) 1989 and the Medical Treatment Act (Vic) 1988.
Unlike these territorial acts, it is worth noting that the common law addresses the issue of withdrawing or withholding treatment in all states, including the Australian Capital Territory.
Australian Statutory Provisions
The Natural Death Act was enacted by the Australian authorities in 1983. This act gives incompetent patients the freedom to withdraw life-supporting systems under certain circumstances. Notably, it applies to patients suffering from terminal health complications; the illness is incurable, irreversible and any support system would simply prolong the patient’s dying process.10
In essence, NDA gives power to terminal patients who possess soundness of the mind to direct physicians not to expose them to extraordinary measures, which could be aimed at prolonging life. In this context, extraordinary measures are intended to prolong a patient’s life by supporting certain body operations that cannot operate independently.
It is worth noting that patients exposed to this act have to be sound in mind when the direction is being made but incompetent when it is being executed. Additionally, this act does not recognize the withdrawal of extraordinary measures as a cause of death, especially when there is a direction to be acted upon.
The implication of this is that physicians who comply with the direction issued by patients are not held responsible for causing the death, by acting accordingly, even when the patient lacked soundness of the mind during the execution time. The Northern Territory of Australia also has similar provisions as those recognized by the South Australian Natural Death Act of 1983.
On the other hand, the Victorian statute holds a different stance, regarding the issue of withdrawing or withholding medical treatment from patients. The Medical Treatment Act was enacted in the year 1988 and has undergone a series of amendments to address the changing dynamics of ethical and professional issues in medicine, which present dilemmas for physicians.
Unlike NDA which applies only to terminally-ill patients who are incompetent, the MTA applies to terminally-ill patients together with all adult Australians under medical care.11
Additionally, the decision by a competent patient to be denied treatment is applicable depending on the status of the patient at the time of such a refusal. This means that the decision to withdraw or withhold life-supporting systems cannot be based on the patient’s anticipation of incompetency, but the current medical status.
Under the MTA, it is essential to note that a patient is allowed to have medical agents during treatment to ensure that he or she has control over medical decisions made by physicians.
These agents are legally permitted to request for termination of extraordinary measures as directed by the patient, while she, or he was competent, based on the health status.
As stated under common law, a person is allowed to appoint a medical agent while he or she is in a sound mode, even though the attorney’s powers are withdrawn once the donor is legally out of mind.12 Of great significance is the fact that the statutory does not give the agent or a competent patient the power to refuse palliative care.
The MTA defines palliative care as any form of treatment given by physicians for the well-being of the patient through relieve of pain without curing the illness.
Provision of reasonable food and water is also included under this act, and it encompasses life-supporting measures like induced nutrition and hydration. In essence, MTA does not allow patients and their agents to direct physicians to withdraw or withhold artificial feeding like tube-feeding and intravenous feeding.
From an analytical point of view, it can be argued that the Medical Treatment Act protects physicians who may consider discontinuing support-treatment from being guilty of causing death of incompetent patients.
However, the same immunity is not applied to medical practitioners who may choose to withdraw or withhold “reasonable provision of food and water.” Withdrawal of life-supporting systems from incompetent patients can be supported on the basis that the result would be unreasonably disturbing and that such procedures were not meant to save life but to sustain or prolong the dying process.13
Despite the course taken by this debate, it is essential to note that the issue of withdrawing or withholding nutrition and hydration is a weighty matter that deserves serious attention and caution in debating it. Importantly, the MTA is not an exception across the globe.
In twenty American states, the law favours living wills of patients and further detaches termination of one’s life from denial of reasonable supply of food and water.
In summary, the South Australian and Northern Territory laws allow patients to direct the termination of extraordinary measures, which are usually aimed at supporting the biological functioning of the body.14 On the other hand, the Victorian law gives adult patients the right to appoint a medical agent, to give consent to the withdrawal of life-support measures from a patient who is out of his or her sound mind.
In analyzing the concept of forgoing life-support, it is paramount to consider the implication of certain words and phrases, which are commonly used by medical practitioners. For instance, ordinary and extraordinary measures are used to prolong the life of a person regardless of their status.15
However, the difference arises in their application and perceived impact in the society. Generally, ordinary measures must be applied by physicians to ensure that a healthy status of the patient is restored. On the other hand, extraordinary measures are commonly applied when handling patients with terminal-illnesses.
As a result, extraordinary measures can be withdrawn based on the fact that their continued application would only increase the treatment burden and prolong the dying process of the patient. Based on this argument, there is confusion in deciding whether assisted nutrition and hydration is ordinary or extraordinary.
Moreover, some procedures, which are recommended by physicians, may be a composition of medical support and comfort. For instance, Pope John Paul II is historically remembered for having considered assisted nutrition as a normal care, contrary to the view that the practice is a medical act.16
Although this can be argued from various view points, it suffices to mention that assisted nutrition and hydration procedures involve a lot of medical and professional skills, including surgery. This is commonly used by those who argue against assisted-feeding being considered as a normal act.
Nevertheless, the material or food which, is usually given to the patients is natural, thus coupling with idea that the process is a normal act that promotes life. In fact, it would be better to argue that assisted nutrition and hydration encompass natural and medical aspects of supporting life.
When one talks about withdrawing or withholding nutrition and hydration, the emotional impact is what dominates the mind of most people. This is highly anticipated since one is expected to die shortly after these life-support measures are withdrawn.
The main purpose of maintaining or withdrawing nutrition and hydration depends on the benefits are likely to be witnessed against the burden of prolonging the life of such a patient.17 In general, the goal of medical care is to restore or preserve one’s health by minimizing the pain.
In other words, medical procedures like assisted-feeding are supposed to promote the optimum functioning of the body, so that a meaningful state of health is achieved. Therefore, medical processes do not necessarily cure infections or prolong life.
Unlike other medical approaches applied in prolonging life, nutrition and hydration are principally aimed at promoting physiological and psychological aspects of life. In other words, it is capable of offering spiritual and social nourishment to the body.
This kind of care is essential in ensuring that a sick person enjoys his or her life to the fullest. They also help a person in ordering his relationship with the maker and are often bestowed in the mind of the patient, through the evaluation of living a better life.
Should burdens be considered when deciding whether to withdraw or withhold nutrition and hydration? This is a question, which has drawn a host of controversies in the society. According to religious approaches, medical burdens have the potential of affecting that which is supposed to be enjoyed in life by both the sick and those who are healthy. As such, nobody would prefer being exposed to any form of burdens in life.
However, for one to forgo life based on medical and other forms of burdens, it is essential for several factors to be considered.18 The commonest is the degree and impact of the burden. How excess is the burden?
There is no doubt that the determination of the excessive nature of a burden is the greatest challenge encountered in justifying burdens as a reason to withdraw or withhold nutrition and hydration from patients. Needless to say that any form of medical care is a burden and has the potential of making it difficult for one to enjoy life.
Theologians, therefore, support the need for one to acquire fortitude, which is a virtue in handling some of the burdens experienced in life. When discussing medical burdens, it is equally important to note that burdens can occur during medication and even in the future.
For instance, maintaining a person’s health on assisted nutrition and hydration may be seen as a future problem, on the ability of family members and other caregivers to enjoy their lives normally. Under this, a decision may be considered to withdraw or withhold a life-supporting program like assisted-feeding as a way of averting future burdens.
Another aspect of human life that is essential in determining whether or not assisted feeding should be terminated is the quality of life. Even though “quality of life” is medically viewed as a measure of human functioning, it is imperative to note that human life is sacred.
In this case, the right to live or die is commonly seen to be beyond human power but rather within the powers of the Supreme Being.19 It is on this basis that Pope John Paul II argued that assisted-feeding ought not to be terminated.
Based on the arguments presented in this discussion, it suffices to mention that withdrawing or withholding of nutrition and hydration remains a controversial issue. Nevertheless, the decision to discontinue assisted–feeding should be based on medical and ethical issues surrounding the patient.
With regard to medical factors, physicians are better placed to make this decision even though all parties involved like family members and other caregivers have to be consulted.20 Generally, medical decisions can also be guided by professional provisions. Legal statues defined by countries’ constitutions equally play a major role in helping family members and physicians to achieve a credible consensus.
The issue of withdrawing or withholding nutrition and hydration remains contentious around the world. Nevertheless, a concise decision can only be achieved if ethical and medical aspects of the situation are considered. This is important to ensure that all parties involved are treated fairly with dignity while handling incompetent patients.
Ashby, Michael, and Danuta Mendelson, “Gardner; re BWV: Victorian Supreme Court makes landmark Australian ruling on tube feeding.” Medical Journal of Australia 181, no. 8 (2004): 442-445. Web.
Buckley, Tom, et al. “Ethics roundtable debate: Withdrawal of tube feeding in a patient with persistent vegetative state where the patient’s wishes are unclear and there is family dissension.” Critical Care 8, no. 2 (2004): 79–84. Web.
Fisher, Anthony. Catholic Bioethics for a New Millennium. Cambridge: Cambridge University Press, 2011.
Hamel, Ronald, and James Walter. Artificial Nutrition and Hydration and the Permanently Unconscious Patient: The Catholic Debate. Washington, D.C: Georgetown University Press, 2007.
Mendelson, Danuta. “Legal and Ethical Ramifications of Withdrawal of Life Support Systems from Incompetent Patients.” School of Law Deakin University Victoria. 1993. Web.
O’ Rourke, Kevin. “The Catholic Tradition on Forgoing Life Support.” The National Catholic Bioethics Quarterly 5, no. 3 (2005): 537-553. Web.
Slomka, Jacquelyn. “Withholding nutrition at the end of life: Clinical and ethical issues.” Cleveland Clinic Journal of Medicine 70, no. 6 (2003): 548-552.
Staunton, Patricia, and Mary Chiarella. Nursing and the Law. Sydney: Elsevier Australia, 2007.
Stewart, Cameron, Ian Kerridge, and Malcolm Parker. The Australian Medico-legal Handbook with Pda Software. Sydney: Elsevier Australia, 2007.
Tollefsen, Christopher. Artificial Nutrition and Hydration: The New Catholic Debate. London: Springer, 2007.
1 Patricia Staunton and Mary Chiarella, Nursing and the Law (Sydney: Elsevier Australia, 2007) 130.
3 Anthony Fisher, Catholic Bioethics for a New Millennium (Cambridge: Cambridge University Press, 2011) 229.
4 Jacquelyn Slomka, “Withholding nutrition at the end of life: Clinical and ethical issues,” Cleveland Clinic Journal of Medicine 70, no. 6 (2003): 548.
5 Ibid., p. 549.
6 Tom Buckley et al., “Ethics roundtable debate: Withdrawal of tube feeding in a patient with persistent vegetative state where the patient’s wishes are unclear and there is family dissension,” Critical Care 8, no. 2 (2004): 79.
8 Cameron Stewart, Ian Kerridge, and Malcolm Parker, The Australian Medico-legal Handbook with Pda Software, (Sydney: Elsevier Australia, 2007) 159.
9 Michael Ashby and Danuta Mendelson, “Gardner; re BWV: Victorian Supreme Court makes landmark Australian ruling on tube feeding,” Medical Journal of Australia 181, no. 8 (2004): 442-445.
11 Danuta Mendelson, “Legal and Ethical Ramifications of Withdrawal of Life Support Systems from Incompetent Patients,” School of Law Deakin University Victoria, 1993.
15 Kevin O’ Rourke, “The Catholic Tradition on Forgoing Life Support,” The National Catholic Bioethics Quarterly 5, no. 3 (2005): 537.
17 Christopher Tollefsen, Artificial Nutrition and Hydration: The New Catholic Debate (London: Springer, 2007) 180.
18 Ibid., p. 181.
19 Ronald Hamel and James Walter, Artificial Nutrition and Hydration and the Permanently Unconscious Patient: The Catholic Debate (Washington, D.C: Georgetown University Press, 2007) 119.