Starving to death in medical care: Ethics, food, emotions and dying in Britain and America, 1970s\u20131990s

Ian Miller

doi:10.1057/s41292-016-0034-z

Abstract

Recent controversies about prisoner force-feeding have renewed debates on the ethical appropriateness of feeding individuals against their will. Critics condemn force-feeding as it seems to clash with prevailing bioethical principles of patient autonomy which grant patients the right to refuse medical treatment (or food) if they wish. This article uses contemporary history to highlight the complex development of policies on supported feeding in recent decades. It maintains that since the late-1970s, doctors and medical personnel have grappled with the problems posed by feeding numerous types of patients (not just hunger strikers) without express permission including the comatose, infants, anorexics and the elderly demented. Between the 1970s and 1990s, inconsistent approaches developed, which regularly negated the principles of patient autonomy. Many doctors and family members struggled emotionally with the prospect of letting an individual starve. Decisions made about whether or not to feed were informed by factors such as age, gender and perceptions of vulnerability. If patient autonomy is to guide decisions made to use, withdraw or withhold nutritional support, it would benefit from being consistently applied. Emotional detachment is essential to achieve this, although emotions, at the same time, present barriers to the implementation of ethical standards in clinical practice.

Highlights

Starvation occupies a prominent place in the cultural memory of the 1980s: a decade that saw international concern about the 1980–1981 Maze Prison hunger strikes in Northern Ireland, charity initiatives such as Live Aid and a heightened visibility of images of starving children in impoverished areas of Africa
Since the 1970s, complex and contradictory policies have emerged relating to the rights of patients to be allowed to die naturally from the effects of withdrawing or withholding nutritional support
Discussion on the matter arose in the context of broader debates on the technologisation of death, patient and prisoner rights, euthanasia and patient autonomy

Summary

The Technologisation of Feeding

In the late twentieth century, new life-support technologies emerged that could prolong life indefinitely, keeping alive severely debilitated patients ( the comatose) who would otherwise have naturally died. The idea of a doctor letting a patient starve raised a markedly different set of emotional responses than switching off a life-support machine. Initially developed for children, PEG was quickly adopted by gastroenterologists and surgeons (Gauderer, 1999, 2001) The impact of these new technologies on hospital practice was profound. In response to a number of controversies, bioethics emerged from the 1970s; an interdisciplinary project that sponsored greater regulation on medical practice, often with the participation of individuals in diverse fields such as philosophy and theology (Rothman, 1991; Wilson, 2014). Patients sought to regain control of their own bodies from medical professionals (Filene, 1998)

Patient Autonomy and the Comatose

Enforced Feeding in Clinical Practice

Denying the Right to Starve in Prisons

Conclusion