Should nutrition and hydration be provided to permanently unconscious and other mentally disabled persons?

• Author: O'Rourke, Kevin

In this article, issues will be considered concerning the providing or withholding of nutrition and hydration to people who are permanently unconscious, that is, in irreversible coma or in a persistent vegetative state, using the statements composed by various medical societies. Second, the norms derived from the statements of the medical societies in regard to providing or withholding life support to people who are permanently unconscious will be compared with the teaching of the Roman Catholic Church. Third, the opinions of some Catholic theologians and other scholars will be considered who do not agree with the author's application of the official teaching of the Church to the question of utilizing nutrition and hydration.

The question of providing artificial nutrition and hydration from the legal perspective will not be considered. While the decisions of legislatures and courts should be founded upon ethical norms, present legal opinions are founded more upon the so-called right to privacy than upon the ethical evaluation of what is beneficial for the person and for the community. Moreover, it is difficult to discern with any certainty the proper legal perspective in regard to withholding life support from permanently unconscious people as illustrated in the decisions of Brophy v. New England Sinai Hospital(1) and Cruzan v. Harmon.(2)

Second, the provision or withholding of nutrition and hydration from persons who are less severely mentally disabled will not be considered. From a medical point of view, there is a significant difference between permanently unconscious persons (that is, people who are designated by medical terminology as being in a persistent vegetative state or p.v.s.) and people who are less severely mentally disabled. People who are permanently unconscious and those with mental disabilities both suffer from impairment of their mental faculties. But people who are permanently unconscious are considered to have no potential for meaningful mental activity, whereas people with mental disabilities have some degree of active mental function.

More significantly, the diagnosis or description of a permanently unconscious state (or p.v.s.) carries with it the implication that one is suffering from a fatal pathology, a fatal pathology being understood as an illness, disease, or lesion which will cause death unless it is removed or circumvented. The fatal pathology affecting the homeostasis of a p.v.s. patient is the inability to chew and swallow, purposeful human activities which are no longer possible if the cerebral cortex is unable to function. The diagnosis or description as mentally disabled does not imply the presence of a fatal pathology. The presence of a fatal pathology is the reason which justifies asking: Should nutrition and hydration be withheld? If a fatal pathology is not present, whether in the person who is mentally competent or in the person who is mentally disabled, then nutrition and hydration should be provided by others if one cannot provide these goods of life for oneself. To put it another way, we have a positive responsibility to prolong our own lives and the lives of others who are dependent upon us as long as our efforts to help another person are beneficial. Only when one's own life or the life of a loved one in our care is threatened by a fatal pathology do we have a moral right to ask the questions: Will attempts to remove or circumvent this pathology be effective or ineffective? Will attempts to circumvent or remove this pathology result in greater burden than benefit for the patient?

The Norms of Medicine Concerning Artificial Nutrition and Hydration

In the last few years, several medical societies have presented norms concerning the care of people in an irreversible coma or persistent vegetative state. Thus, the Council on Ethical and Judicial Affairs of the American Medical Association (AMA),(3) the American Nurses Association (ANA),(4) the American Dietetic Association (ADA),(5) and the American Academy of Neurology (AAN)(6) have all issued statements in regard to care for permanently unconscious patients. While these statements are in general agreement, they differ in detail. The statement of the ADA, for example, is more concerned with legal than ethical norms. In presenting a summary of medical statements in regard to care for the patient who is permanently unconscious, the author relies upon the statement of the American Academy of Neurology because it is the most complete and the most authoritative. The following quotation is from the AAN statement:

The Medical Condition of the Patient

The persistent vegetative state is a form of . . . permanent

unconsciousness in which the patient has . . . sleep/wake cycles, but at

no time is . . . aware of him- or herself or the environment.

Neurologically, being awake but unaware is the result of a functioning

brainstem and the total loss of cerebral cortical functioning. . . .

Primitive reflexes and vegetative functions that may be present

are either controlled by the brainstem or are so elemental that

they require no brain regulation at all. Although the [p.v.s.]

patient is generally able to breathe spontaneously, . . . the capacity

to chew and swallow in a normal manner is lost because these

functions are voluntary, requiring intact cerebral hemispheres.

. . . The diagnosis of permanent unconsciousness can usually be

made with a high degree of medical certainty . . . after . . . 1 to 3

months.

Patients in a persistent vegetative state may . . . survive for a

prolonged period of time . . . as long as the artificial provision of

nutrition and fluids is continued. [Because life support has

already been utilized to circumvent the fatal pathology of being

unable to chew and swallow, those patients in p.v.s. are not

|terminally ill.']

Persistent vegetative state patients do not have the capacity

to experience pain or suffering. Pain and suffering are attributes

of consciousness requiring cerebral cortical functioning, and

patients who are permanently and completely unconscious cannot

experience these symptoms.

There are several independent bases for the neurological

conclusion that persistent vegetative state patients do not

experience pain or suffering.

First, direct clinical experience with these patients

demonstrates that there is no behavioral indication of any awareness of

pain or suffering.

Second, in all persistent vegetative state patients studied to

date, postmortem examination reveals overwhelming bilateral

damage to the cerebral hemispheres to a degree incompatible

with consciousness or the capacity to experience pain or

suffering.

Third, recent data utilizing positron emission tomography

indicates that the metabolic rate for glucose in the cerebral cortex

is greatly reduced in persistent vegetative state patients, to a

degree incompatible with consciousness.

[The Nature of the Procedure]

The artificial provision of nutrition and hydration is a . . .

medical treatment . . . rather than a nursing procedure . . .

[Though] the placement of nutrients into the tube is itself a

relatively simple process, and [though artificial] feeding [may] not

require sophisticated mechanical equipment, [this] does not

mean that the provision of fluids and nutrition in this manner is a

nursing rather than a medical procedure. Indeed, many forms of

medical treatment, including, for example, chemotherapy or

insulin treatments, involve a simple self-administration of

prescription drugs by the patient. Yet such treatments are clearly

medical and their initiation and monitoring require careful

medical attention. . . .

[The Ethical Norms for the Use of Artificial Hydration and Nutrition]

[The social commitment of the physician is to sustain life

and relieve suffering. However he should not intentionally cause

death (AMA).] In caring for hopelessly ill and dying patients,

physicians must often assess the level of medical treatment

appropriate to the specific circumstances of each case.

The recognition of a patient's right to self-determination is

central to the medical, ethical, and legal principles relevant to

medical treatment decisions.

In conjunction with respecting a patient's right to self-determination,

a physician must also attempt to promote the

patient's well-being, either by relieving suffering or addressing or

reversing a pathological process. Where medical treatment fails

to promote a patient's well-being, there is no longer an ethical

obligation to provide it. Treatments that provide no benefit to the

patient or the family may be discontinued. Medical treatment

that offers some hope for recovery should be distinguished from

treatment that merely prolongs or suspends the dying process

without providing any possible cure. Medical treatment,

including the medical provision of artificial nutrition and hydration,

provides no benefit to patients in a persistent vegetative state,

once the diagnosis has been established to a high degree of

medical certainty.

[The decision to...