In this first of a four-part series dealing with the removal of food and water from seriously ill patients, Mr. Eckman sheds light on what is happening today in Canadian hospitals.
“Feed the man dying of hunger, because if you have no fed him you have killed him.” – Gratian, quoted in The Church Today, No. 69 (Vatican II)
“I’ve pulled the plug on patients, usually in consultation with other doctors. We’d been dealing with the relatives for some time and you’re aware when families don’t give a damn or don’t want the patient to suffer any more, we take that into consideration. It’s kind of informal ceremony, we just looked at each other and we didn’t know who’d do it, but someone did.
Someone cut down the I.V. to below the minimum, the patient got pneumonia and died.”
Anonymous Canadian Doctor, 1984
In October 1987 at Toronto General Hospital, a doctor tells the daughter of one of his patients that he sees no point in re-inserting the nasogastric feeding tube keeping her father alive. The daughter objects strenuously and the suggestion is immediately withdrawn. Her father dies naturally ten days later.
In September 1988, a woman visiting a patient at the same hospital notices that he is not eating. After discovering that he is in a deep depression and has refused food for several days, she asks his nurse whether the doctor is planning a gastronomy (the painless insertion of a feeding tube through the stomach wall under local anesthetics). The nurse sadly shakes her head.
Isolated incidents? Not at all. In fact, in Canadian hospitals today the withholding of nourishment is a common for of treatment for dying patients—and sometimes even for those who are not dying.
The Criminal Code of Canada clearly defines the responsibilities of health-care workers toward their patients. Sections 198 and 199 state that those who agree to provide medical treatment are obliged to use reasonable knowledge, skill and care. And to continue it “if omitting to do so is or may be dangerous to life.”
Section 205 defined homicide as directly or indirectly causing the death of a human being. Section 209 states that if anyone causes bodily injury resulting in death, he is guilty of homicide even if the effect of this injury is only to hasten death from some other cause.
Technically, these sections (and others which support them) could be applied against doctors who remove any type of life support: respirators, medication, intravenous units, or feeding tubes. In fact, no Canadian doctor has ever been charged with such an offense. There is virtual immunity from prosecution such an action as part of patient “care.”
What in fact are healthcare professionals doing about nutrition and hydration during the last illnesses of their patients? It is not an oversimplification to state that often they are opting to discontinue feeding. The two examples just given do not nearly exhaust the extent of this practice, nor do they indicate how long it has been accepted.
From 1950-1971, Toronto’s Hospital for Sick Children treated 50 Down’s syndrome infants with bowel obstructions. Twenty-three received operations to allow them to process food naturally. The remaining 27, generally at the parent’s request, were starved to death.
In 1968, a 67 year-old woman suffered a stroke and was admitted to Toronto General Hospital, where she lapsed into unconsciousness. Although she was sustained by life support, her doctor told her family that she had virtually no chance of recovering and that even is she did, she would be like a vegetable.” He implied that removing the feeding tube would be a blessing in disguise. The family (all agnostics) refused to consider it.
A short time later, her husband proved that she was responding to simple questions with nearly imperceptible hand and foot movements. After one and a half years of intensive therapy, she returned home to live a normal life until her death three and a half years later from unrelated causes.
In 1982, a professor of pediatrics at the University of Western Ontario said that there is “certainly no question newborns are being allowed to die”—especially those with spina bifida or Down’s syndrome—and that this is generally done by letting “nature take its course.”
In 1983, the director of the Bioethics Institute at Montreal’s Clinical Research Institute told a “Medical Canada” conference that he knew of several cases in which severely deformed babies had been refused nourishment. He further said that instead of the current practice of putting newborns into corners to “starve or scream themselves to death, fatal doses should be administered if that’s what’s required.”
At the same conference a Harvard doctor and open-heart surgery pioneer told the delegates that society can no longer afford medical treatment for “mere conglomerates of metabolizing cells with no individuality.” He suggested letting these “helpless cases” (estimated at about 275 000 in Canada and the U.S.) “slip away” by removing feeding and hydration tubes.
In 1983 an Edmonton nurse with 30 years experience told a radio commentator that when assigned to the neo-natal unit of her hospital, she “discovered there was an unwritten policy that severely handicapped babies were not to be fed.” The medical director of the hospital agreed that “babies do die from benign neglect,” and added that this takes “three or four days.” After admitting that “it’s been going on for years,” he quoted a prominent pediatrician’s prescription formula for babies whom he had decided not to keep alive: one eyedropper of water plus an injection of penicillin every eight hours.
Far from being isolated incidents, public files bulge wit h cases like these. In fact, it is not going to far to say that, in the medical mind, the provision of food and water has moved from the category of ordinary human care to that of medical treatment and that artificially provided nutrition is more frequently being considered to be extraordinary treatment.
The means of withdrawing food and water range from the passive to the aggressively active. At one end is the refusal to:
(a) initiate feeding for a terminally ill patient only a few days from death; or
(b) to perform bowel surgery to allow a deformed or retarded infant to digest food. This moves quickly to the acceptance of a patient’s strongly expressed repugnance to a nasal feeding tube, and to failing to provide him with information about a simple comfortable alternative.
Next is the decision (taken sometimes in consultation with the patient and his family and sometimes by the physician alone) not to initiate feeding at all. Then comes the decision to withdraw feeding already begun; then withdrawal of nutrition, with their families’ consent from comatose patients who are not dying; and finally from competent, permanently disabled patients at their own request.
The practice is justified by its supporters on several counts, some of which we will analyze next month. The principal arguments are:
- Cessation of nutrition and hydration simply allow death to occur, while their provision may prolong dying.
- Patients in the last phases of terminal illness have no sensation of hunger or thirst.
- Food and water can actually cause medical illness complications and distress for persons close to death.
- We have no obligation to preserve the biological existence or “permanent vegetative state” of a comatose person who will in all likelihood never recover.
- We have an obligation to consider the burden to the family of keeping a severely handicapped, debilitated or otherwise “non-functioning” person alive.
In general terms, however, most of these arguments stem from two principles: i. that quality of life is an important — even overriding concern in deciding which care or treatment to initiate continue, or forego and ii. That death with suffering is by all available means to be avoided.
It is important to realize that, like abortion this practice is not a recent phenomenon. Doctors have been removing and IV tubes from patients since they were first used; in fact, I know of now study, which indicates that it is any more common than it was 25 years ago. However, the issue is under heavy scrutiny today, with the positive effect of honest, open and complete discussion, and the negative effect of education by accepted practice. Once the public becomes aware that experienced, respected physicians have been removing nutrition and hydration tubes for decades there will not be too much opposition.
So far, the Canadian Medical Association has issued no official statement on the artificial provision of food and water. But in 1986, the Judicial Council of the American Medical Association ruled that doctors may ethically withhold “all means of life-prolonging medical treatment,” including food and water, from patients in “irreversible” comas; death need not be imminent, it is fair to say that the CMA has no strongly felt objection to this ruling.
Where has the voice of the Catholic Church been in all this? It has been audible, but so far only as the Church debating, not as the Church teaching. Case after public case has seen moral theologian pitted against moral theologian, or against bishops’ conferences, as the Church wrestles with herself over this critical issue. Although the Vatican has not yet issued a statement defining the obligations of feeding the very ill, it’s 1980 Declaration on Euthanasia does say that “it is permitted in conscience to take the decision to refuse forms of treatment that would only secure a precarious and burdensome prolongation of life, so long as the normal care due to the sick person in similar cases is not interrupted.”
This statement has been used to support both sides of the feeding question. The policy of the Canadian Pediatric Association offers hope that our doctors have not completely abandoned their belief in the sanctity of each human life. “The use of painkillers in order to hasten death is forbidden, and the use of sedatives to keep a child asleep so it doesn’t have to eat is also forbidden,” a 1986 policy statement reads.
It adds that every child deserves respect and consideration, and that it is in the best interests of any child to stay alive.
Providing care for the seriously ill raises questions, which cannot always be resolved with simple formulae. Next month consider some of the inescapable moral issues surrounding artificial nutrition and hydration. However, a basic reverence for every human life, irrespective of its “quality” must permeate all our considerations. Otherwise, we will be left at the mercy of those who perceive the end of that life in strictly pragmatic terms—to be achieved or “managed” according to what is least painful, quickest or of least burden to those around it.