I compliment Gilbert Meilaender for his careful and systematic comments concerning Robert D. Orr's position in "Ethics & Life's Ending: An Exchange" (August/September). Some argue that the intention of a physician who withdraws a feeding tube is not to kill but rather to decrease suffering, cease a useless therapy, and allow a disease to progress naturally. My reply has been to quote the succinct statement of Justice Scalia in his dissent in Cruzan: since the withdrawal of food and water is always fatal, and since a patient in a persistent vegetative state (PVS) will not die but for such withdrawal, it is hard to imagine any other intention than "to make Nancy [Cruzan] dead." Every physician has had the experience of discontinuing some form of treatment thought to be lifesaving after he found that it was not. In such cases, the possibly burdensome interventions may become optional. The provision of food and water is simply not one of those interventions.
The Court in Cruzan assumed without proof that feeding and hydration were medical therapy rather than normative care. This assumption has been treated as "black letter law" since Cruzan, and thus is actually the most important aspect of that decision. While I believe this conclusion is a classic example of result-driven jurisprudence, it is not determinative of what is or is not "useless" or "excessively burdensome" therapy. Often discussed under the rubric of "futility," feeding and hydration in a PVS patient are only "futile" if the goal is a return to normal or near-normal cognition. It is never useless in maintaining life.
Pondering Alzheimer's Disease in this context should send up red flags to anyone familiar with current medical practice. The recent conference sponsored by the International Federation of Catholic Medical Associations entitled "Sustaining Treatments and the Vegetative State: Scientific and Ethical Dilemmas" correctly concluded that the diagnosis of PVS is subject to widespread abuse and misunderstanding inside the medical profession. In my experience and that of others, patients in the final stage of Alzheimer's are often said to have PVS in order to invoke the legal protections of various state statutes that permit the withdrawal of food and water for PVS but not for other conditions. This has created a "diagnosis creep," sweeping increasing numbers of vulnerable patients into the nontreatment category.
Furthermore, patients with advanced Alzheimer's do not always...