CARE OF THE
TERMINALLY ILL: DEFINITIONS
And Application to
Tubal Hydration and Feeding
1. Dying: active deterioration of the
self-therapeutic faculties (nutrition, elimination, respiration, circulation,
immune system) of an individual which, absent external intervention, terminates
in death.
2. Danger of Dying: The set of any internal and/or
external circumstances of an individual which have a constituted and/or active
potential to begin or continue the process of dying in that individual.
Note that
from 1 and 2 above, everyone who is dying is in danger of death, but not
everyone in danger of death is dying.
3. To kill the dying: To deliberately introduce a new
cause of death by action or omission.
Alternatives:
To deliberately set in motion a new cause of death by action or omission.
To deliberately cause an
attack on the remaining
natural life sustaining faculties of an individual so that the
person dies of that attack and not of the original cause(s) of dying.
4. Hastening Death: Any act or omission which either causes or allows death to
occur at an earlier time than the body or its circumstances would have
otherwise determined.
5. Delaying death: Any act which causes death to
occur at a later time.
Notes on #3-5: Neither #4 of itself implies killing nor is #5 mandated by the
prohibition on suicide or killing. .
Note that #4 includes many unethical and ethical, many killing and
non-killing, many suicidal and non suicidal, many free and obligatory acts.
Examples: a convict choosing an earlier date of execution is hastening death
without being suicidal. A pilot in a falling plane who directs it into a
close-by uninhabited hillside to avoid a more distant crash on inhabited homes
and playgrounds is obligated to hasten his own death. He is not killing the
passengers or himself. Obeying a DNR order given by the dying patient, or
removing a non-therapeutic death prolonging ( more
accurate, but clumsy, would be "dying-prolonging") device is neither
killing nor assisting in a suicide due to definition # 3.
Performing an exhausting act which may drain the strength
of the dying and hasten dying can be morally good and even obligatory --e.g. to
tell heirs where their future property
is, to tell creditors where their due payments may be recovered, even to pay
one's library fines. And, of course, to
use a pain medication to make dying more comfortable, as long as introducing a
new cause of death is not the intended goal, may foresee ably hasten death,
since it may burden the remaining faculties of the body. As a decision to use
one's remaining strength in a good cause it could be plain compassion for one's
self, or it could be to facilitate final communication with loved ones. Doing
something for a good purpose which has a side-effect of shortening life is no
more suicidal or immoral in any way when death is near than at any other time
of life. A touch-stone of this kind of "shortening
of life" is that no hostility to life is operating here.
6: Prolonging Dying: To delay the death of a dying
person without introducing a new curative procedure.
7: Shortening life: Not morally or logically
distinguishable from #4. This name is sometimes chosen to make an act or
omission seem suicidal. In medical uses it is sometimes confusing because it
seems to allow the medical profession to assign how long a life was "supposed to be". The profession has the sole obligations to
cure or, failing that, keep comfortable the dying. It clearly does not have the
duty to make the dying process last as long as possible. Hence when some
non-curative technology is either refused or removed from the dying person the decision is
not suicidal or killing. By itself to
shorten life does not imply killing. Almost all exertion in a person of fragile
condition might be seen as shortening life, but we have no obligation to live
as long as possible, but only to use our strength for good purposes. Both the
dying and the non-dying can shorten their lives without being accused of
suicide. To refuse to allow a physician to prolong their dying, the patient
does not introduce a new cause of death.
8. Fabricated Life: A condition in which the
man-made interventions replace major functions or organs in a dying person which can successfully
arrest the dying process but not cure the patient, i.e. return the person to
his/her self-therapeutic capacities. As a human creation, a fabricated life
must be judged on the basis of its impact on the patient. As a kind of
"gift" to the patient, the patient is entitled to judge its
goodness, i.e. the patient is entitled to consider the "quality" of the fabrication.
APPLICATION TO TUBAL
HYDRATION AND NUTRITION
The purpose of the following remarks is
to provide a guide for medical staff, patients and their guardians in making
clinical and ethically defensible decisions with respect to end of life care.
Mere reading of the definitions above should reveal that the precisions and
distinctions made were aimed at maximizing the freedom of all, especially the
dying, to act in the pursuit of all sorts of good goals, including pain relief
and shortening the dying process without incurring any reasonable charge of
suicidal intent. The clinical importance
of these definitions is based on the responsibility of medical staff to protect
patients' peace of mind and conscience wherever possible and consistent with
the goals of medicine. Any kind of avoidable torment, emotional, psychological or moral, of a
patient is unprofessional. Hence clinical staff need to choose language and
make distinctions both in mind and in practice which will enable the patient to
use their help or decline it
without feeling they have violated their religious principles.
For those
patients who have no scruples about suicide, there is less need for this
clinical delicacy, but public-policy, legal and "conflict of
interest" concerns may remain.[1]
Many diseases and forms of trauma can kill by a process
in which inability to eat or take fluids, or benefit by them if taken
naturally, will be the immediate cause of the damage to the remaining vital
organs and death. Modern medical ability to avoid this cause of death does not
of itself create a moral obligation to employ or continue the use of tubal
hydration and nutrition. A first consideration is whether the patient is dying
or merely in danger of dying. (See definitions #1 & 2 above.) Medical obligation is clear when the patient
is merely in danger of dying. It is a
less straight-forward decision if the inability to eat and
drink normally are part of a dying process. Traditional medical ethics
allows a person or their guardian to follow any reasonably probable opinion about the
technical state of affairs provided no "third parties" are put at
risk by the opinion. For example a relatively slow moving but irreversible
cancer might attack the digestive system or the esophagus first. It cannot be
claimed that there is an obligation to introduce or retain tubal feeding
in this case because such a claim would imply that medical ethics is required,
and the patient obliged, to fight death to last defensible set of organs, and
indeed to accept every resuscitation effort even if it produced only 10 minutes
more life. No argument about how natural and necessary food and water are can
overcome the right of the dying to accept the earlier time of death simply
because someone, doctor or not, has found a way to delay the dying. No new
cause of death is being set in place. The ability of modern medicine to
discover that the dehydration is the earliest cause of death in this kind of
cancer does not give it the obligation, let alone the right, to circumvent this
immediate event and impose a later and perhaps much more distressing one on the
patient. Its obligation is to cure or keep comfortable. Naturally if the added
time would allow medicine to employ a cure for the cancer, the matter would
change, for then the lack of food and water would become a danger of dying
alone.
If a case is a mere danger of death and one
introduces a new cause of death by refusing to avert the danger this becomes
passive killing. The cases of Michael Martin and Robert Wendland, as described
by Smith[2]
will seem clearly to be killing if the courts allow the removal of tubal
intervention. Both of these patient's were, and have been recovering physically
and mentally and while dependent on the tubes, no other evidence of a dying
process is in place. To remove the tubes will cause a death by dehydration and
no other cause. At the moment they are not even in danger of dying from
anything biological. Their danger is purely legal. Their failure to recover
totally and their remaining in a diminished quality of life, where that quality
is due to the initial trauma, is the reason for the threat (by wives, in both
cases). These women wish to attack that life due to its low quality. The new
cause of death they introduce by removing the tubes is dehydration, a
particularly cruel means to use. Another sign of their desertion of traditional
medical responsibility is that they must abandon their husbands to cruel
suffering because they cannot find another way to kill them in the present
state of the law. They abandon "keeping comfortable" in order to
kill.
In the cases of Edna M. F. and Nancy Cruzan[3]
as well as the cases of Brophy v.
This discussion has the advantage of
reducing the ethical task of the medical staff to determining if the patient is
dying or merely in danger of dying and if the reason for removing the medical interventions is because
of their failure or because we wish to end a life of a recovering person by
introducing a new cause of death due to
a dislike for the diminished state in which they may live afterwards. Only the
latter is killing or suicide. This seems to be the motive in the cases of Martin and
Wendland. And motives matter.
I do not oppose those who wish to prohibit
removal of feeding and hydration tubes
from comatose patients because of the risk that decisions as to whether the
patient is dying of an underlying disease or not may be influenced by bad
motives. There is a real potential for abuse and "slippery slope"
extensions. The author of this paper was fed by tubes for three months where
clever arguments could have been made that I was dying. I now run 5K's
regularly. My intent is that such a blanket prohibition needs to be based
explicitly on the prudent policy of preventing abuse and not on the claim that
every tubal removal is killing or suicide.
[1] See the comments of
[2] Ibid., pp.58-61
[3] Ibid.
[4] 497
North Eastern Reporter, 2nd Series, 626 (