Palliative care ethics: non-provision of artificial nutrition and hydration to terminally ill sedated patients.

Abstract

In this issue of the journal Dr Gillian Craig (1) and her commentator Dr Eric Wilkes (2) raise a variety of important questions about ethical aspects of palliative care medicine that deserve careful reflection. Perhaps the most difficult and contentious of the issues raised by Dr Craig are (a) the question of withholding or withdrawing of artificial nutrition and hydration from terminally ill patients who, because of pain or severe suffering, have been sedated; and (b) the question of how to deal with disagreement between the patient's health care workers and the patient's family members, if this arises when the patient cannot be consulted directly. So far as the first question is concerned, Dr Craig is clear that except at the time of actual dying (easier to identify in retrospect than in prospect), 'I do not think it is morally acceptable to leave a sedated patient for long without hydration' by which, the context makes quite clear, she means that if the patient is too sedated to take sufficient fluids by mouth then a drip should be put up so as to attain the normal medical standards of adequate hydration. As she also writes, 'Others would dissent from this view using words such as meddlesome and unethical if intravenous fluids are suggested under such circumstances'. However, so far as she is concerned, 'To take a decision to sedate a person, without hydration, until he/she dies is a very dangerous policy, medically, ethically and legally.' For Dr Craig 'The only way to ensure that a life will not be shortened is to maintain hydration during sedation in all cases where inability to eat and drink is a direct consequence of sedation, unless the relatives request no further intervention, or if the patient has made his/her wishes known to this effect ... the responsible medical staff must face the fact that prolonged sedation without hydration or nutrition will end in death, whatever the underlying pathology' and she points out that 'even a fit Bedu tribesman riding in the desert in cool weather can only survive for seven days without food or water'. The issues of killing and letting die have been addressed before in these columns (3-4). In summary, while it has been very thoroughly demonstrated by example and philosophical argument that there is no necessary moral distinction to be drawn between killing and letting die, they are not necessarily morally equivalent. Moral distinctions between killing and letting die may arise: as a result of religious commitments; as a result of legal obligations; as a result of differences in the overall benefits and harms resulting from policies that forbid all intentional killings (of non-aggressors) versus those that would result from policies that would also forbid all intentional allowings to die; as a result of differences in the motives and intentions of the agent, and as a result of differences in the duties of care owed by agents to the persons who are killed or allowed to die. In practical ethical terms, doctors are both morally and legally justified in withholding or withdrawing any treatments that are not beneficial to their patients, and are morally and legally required to withhold or withdraw any treatments that are harmful. The fact that withholding or withdrawing non beneficial or positively harmful medical inter ventions would or might result in the patient's death earlier than would otherwise have been the case if the medical intervention had been instituted or maintained does not, it is widely agreed, demonstrate that such withholding or withdrawing is either wrong or illegal (5-10). On the contrary, as the lawyer Professor Skegg put it, 'Doctors are sometimes free sometimes indeed required to allow a patient to die' (11). Thus, pace Dr Craig, concern about 'the only way to ensure that a life will not be shortened' is widely held to be less important than the traditional medico-moral objective of benefiting the patient with minimal harm, and the legal translation of this into the doctor's obligation to fulfil his or her duty of care. Artificial hydration and nutrition may or may not be ways of fulfilling those moral and legal obligations. While in normal circumstances it is in principle possible to ask the patient about his or her preferences concerning such treatment and different patients in similar predicaments may well