Refusal of hydration and nutrition: irrelevance of the "artificial" vs "natural" distinction.

T HE RECENT CASE OF Terri Schiavo has reignited a public dispute about certain aspects of the care of patients who are severely cognitively impaired, including those inapersistent vegetative state. Schiavo’s parents repeatedly pointed out that her abilitytoswallowwasnevertestedand believed that it was possible for her to be safely hand-fed. They also unsuccessfully petitioned the courts to bepermittedtoattempthand-feeding ifandwhenhergastrostomytubewas removed. In the United States there is an ethical and legal consensus that a competent adult or surrogate may refuse any unwanted medical intervention. Since hand-feeding is not a medical intervention, this request by Schiavo’sparentsmayhaveappeared legitimate.Inthisarticle,wearguethat aconvincingresponsetotheirrequest cannotbemadewithintheframework of thecurrent consensus. Instead,we propose that under certain circumstances surrogates may choose that all forms of hydration and nutrition beforgone,regardlessofwhetherthey areadministeredartificially (by tube) ornaturally (byhand-feeding).More specifically, we argue that the justification for withdrawal of feedings does not hinge on whether feeding is administered artificially or naturally; rather, it is based on the fundamental rights to self-determination and bodily integrity that permit patients to refuse any unwanted intervention. Thecurrentconsensusaboutrefusal ofhydrationandnutritionhasevolved through a series of legal cases, beginningwith the landmarkcaseofKaren Ann Quinlan in 1976. That case initiatedthedevelopmentofasetofprinciplesthathavecometoguidedecision making in end-of-life care. Perhaps foremostamongtheseprinciplesisthat a competent patient may refuse any medical intervention,evenwhensuch treatmentmaybelife-saving.Whenpatientsarenotcompetenttomakethese decisionsforthemselves,surrogatesare legally empowered to make these decisions on the patients’ behalf. ThecaseofNancyCruzan in1989 testedthe limitsof theseprinciples,by questioningwhethernutritionandhydration administered through a feedingtubeshouldbeclassifiedasa“medical intervention” that may be refused byapatientorsurrogate. Inthatcase, the US Supreme Court affirmed that tube feedings are medical interventions, just likemechanicalventilation ordialysis.The justicesdidnot,however, inquire whether Nancy Cruzan couldsafelytakeoralnourishmentand did not address the question of what todowhenpatientsforwhomthewithdrawal of tube feedings is being consideredarecapableofbeinghand-fed and of being sustained by oral hydration and nutrition. To set the stage for considering this question, a review of some of the arguments on each side of the debate about withdrawal of tube feedings is helpful. Those who oppose the refusal of tube feedings on behalf of patients like Terri Schiavo argue that the kinds of medical interventions that may be refused should be limited to those that typically occur in medical settings and that require special medical expertise, such as mechanical ventilation or dialysis. Once a patient has had a feeding tube surgically placed in the stomach, they claim, then feeding the patient requires no special technology or expertise and therefore should not be seen as a medical intervention. As such, they claim that providing food and water to a patient through a feeding tube is not an act that can be refused by surrogates, but rather is an obligatory part of simple humane care. On the other hand, those who support the rights of surrogates to withdraw tube feedings from these types of patients insist that tube feedings are indeed a medical intervention. Just as mechanical ventilation artificially supports life by breathing for patients who are unable to breathe on their own, feeding tubes artificially support life by providing nutrition and hydration to patients who are unable to eat and drink on their own. On this view, just as patients and surrogates are empowered to refuse mechanical ventilation when the burdens of this treatment are judged to exceed its benefits, so should they be permitted to refuse tube feeding.