Is a decision to forgo tube feeding for another a decision to kill?

• Author: Brodeur, Dennis

Important moral discussions can degenerate into sloganeering, emotional hype, and name calling. But important moral discussions require patience, careful reasoning, and insight into a particular case where principles, norms, and virtues are brought to bear. At times, important moral discussions are confused with the crafting of public policy, forming a nation's conscience, or yielding to the political art of compromise--all of which are important to law, but not always helpful in ethical analysis.

This article is an attempt to contribute to moral reasoning about the withdrawing or withholding of tube feeding from patients. Public policy should follow from such a discussion but is beyond the scope of this article. First, I will examine assumptions made in the arguments about withholding or withdrawing artificial nutrition and hydration and then attempt to frame the moral question within the context of health care. Next I will examine the moral basis of feeding and the moral arguments about when it is appropriate to discontinue feeding. Finally, I will offer some reflections about ethical decisions involving persons in persistent vegetative states (PVS).

The Moral Question

The tiel given to this article suggests that moral significance lies with three issues--forgoing treatment, forgoing food as treatment, and reaching a possible conclusion that this decision might be killing. The assumptions of the title require analysis.

First, there is no moral difference between withdrawing or withholding treatment. (1) The moral significance of withholding or withdrawing treatment depends upon the relationship between the particular goal of a given therapeutic modality, the obligations of the caregiver or health care institution, and the moral obligation of the person to pursue the purpose, goal, or mission of life. For example, when a treatment does not promote a cure, rehabilitation, or a palliative goal, it can be withheld or withdrawn. When a treatment decision violates the caregivers' personal values, as in abortion or assisted suicide, or violates the clearly articulated values of an institution, then they can refuse to offer it. However, a patient cannot be abandoned becuase of this. When a treatment is futile or too burdensome to the patient, then ti can be withheld or withdrawn. In an ethical analysis there is a relationship between these various factors. The moral issue is not withholding or withdrawing per se.

Second, some commentators distinguish between medical treatments and nursing treatments or basic care issues for patients. (2) The thrust of this distinction implies that the benefit/burden calculus is acceptable for medical treatments but not for nursing or basic care treatments. Thus some commentators claim that nutrition and hydration in any form is basic nursing care and therefore cannot be withheld or withdrawn unless death is imminent. This is frequently the argument for providing nutrition to patients in a PVS.

The difficulty with this argument is that it fails to relate the patient's goals and values of life with his or her obligation to continue to pursue life and accept or reject health care treatments. The argument does not address what the goals of therapeutic interventions are and how these goals relate to the patient. Rather, the argument relies on the classification of a treatment modality--medical or nursing--as morally significant and then equates the treatment modality with a moral imperative.

In the President's Commission Report, Foregoing Life Sustaining Treatment, (3) and in the Roman Catholic moral tradition, (4) the moral argument for withholding or withdrawing treatment is based on the benefit/burden, proportionate/disproportionate analysis of the given treatment, and the moral obligation of the person to pursue life's goals through the acceptance of treatment. Unfortunately, treatment categories do not acknowledge the central place of the human person in ethical decisionmaking and relegate the person to a secondary consideration in favor of whether a treatment is medical or nursing care. Moral arguments that rest on the assumption that nutrition and hydration are basic nursing care and therefore always, or almost always, morally obligatory confuse the moral argument.

Another note about these types of arguments is the moral obfuscation that results by using words like "starvation," "killing," and "murder" when framing the ethical question. "Starvation" and "murder" are morally charged words that conjure up deliberate and, by definition, immoral actions. These words do not suggest moral dialogue. Rather, they present moral conclusions. When discussing respirators, for example, the moral question is not asked: "Can we turn off a ventilator and suffocate a person to death?" Certain physiological characteristics may be similar if one suffocates someone and when one removes a ventilator. But the moral judgment does not rest on similarity of physiological response. Intentions, moral obligations, the ability to pursue life's goals and the goals of medical treatment are factored into the moral discussion. In moral discussions about nutrition and hydration the same care for the use of language is required.

Third, the question of killing demands special attention. A morally normative statement about killing could be: "It is immoral to act in such a manner that one is the cause of the wrongful death of another, and it is immoral to refuse to act when one has a positive obligation to prevent the wrongful death of another." This statement implies that one cannot be the initiator or cause of another person's death, with certain exceptions, such as self defense or just war activities, where the death of another is the only proportionate means to protect oneself. Similarly, one must act to try to save another when there is a recognized obligation, such as that of a lifeguard at a pool or an emergency room physician in a hospital--all other factors being equal. To say that one person killed another in these contexts is to say that a person has acted immorally.

One can also use the verb "to kill" in other situations without the same moral jugment, such as wehn a person, driving at appropriate speed, kills a child who ran between two parked cars. The difference in moral judgments between the two sets of examples depends on an analysis of motives, intentions, and other relevant factors. The moral judgment does not depend on the fact that the outcome is the same--death to another...