Prudential decisions in the face of terminal illness. The case of artificial hydration and feeding.

Enrique H. Prat.
workshop Bioethics Conference.
Pamplona, 23 May 2009.

Let me start with a clinical case to bring topic conceptually into focus by bringing it closer to real life.

A 78-year-old man was admitted to department for internal medicine on suspicion of cerebral circulation disorders. Relatives report having observed altered behaviour in recent weeks: the patient, for example, could not find his home after shopping and sometimes talked nonsensically about various things.

On admission, the patient is temporally and spatially disoriented and speaks in a confused and nonsensical manner. Clinical examination revealed some dehydration and a subfebrile temperature. A chest X-ray revealed a small infiltrate in the left lung. Medication with antibiotics, infusions and circulation-enhancing substances was started.

While the pneumonia can be controlled within a few days, there is a rapid worsening of the cerebral status . The patient no longer recognises family members, has to be fed, urinates at the bedside, becomes increasingly aggressive and no longer reacts to tranquillisers.

As the predominant dementia could not be controlled, it was decided to transfer the patient to a psychiatric hospital. In the following days, the confusion Degree continued to worsen and meningitis was suspected and the patient was transferred to a neurological department .

On admission, the patient was still drowsy, reacting with uncontrolled movements to painful stimuli. A complete neurological examination is carried out with lumbar puncture, EEG (electroencephalogram), several CT scans, etc.

Finally, he is diagnosed with vascular dementia, and after a stay of two weeks the patient returns to the psychiatric hospital. On re-admission the patient was still drowsy, barely able to get out of bed and requiring 24-hour care staff . He can hardly swallow, so after a few days he is transferred to department for internal medicine to solve the feeding problem ("artificial feeding").

On arrival, the patient opens his eyes from time to time, but does not respond to questions and hardly reacts to painful stimuli. Treatment with intravenous solutions is started, as well as treatment of a decubitus ulcer.

The family is reassured that "everything possible is being done".

At visit the head of department asks what sense it makes to treat a dying patient with infusions and recommends to withdraw them and let the patient die peacefully, because here we are only prolonging the dying process unnecessarily!

This intervention triggers a very passionate discussion between the doctors and staff . The doctors, who are treating the patient, are totally against it, although they recognise that this treatment subject makes no sense, as there is no hope of improvement, but they justify their position with two arguments: firstly, the relatives are reassured, and secondly, we do not know whether the patient is thirsty or not. The chief objects that the latter is highly improbable, and that in this sense it would also be necessary to quench a possible hunger and therefore to feed him anyway. The staff (nurses) also take a dual position: some are in favour of stopping the liquid treatment; others absolutely refuse, as they do not feel emotionally capable of continuing to care for a sick person for whom the doctors are no longer doing anything. The doctors, for the most part, join in this stance, and the patient continues to receive infusions, without the boss knowing about it.

During the weekend, which follows this visit, the patient develops a fever. The doctor on duty (who normally attends other wards at department) assumes pneumonia due to the patient's poor general condition and orders the intravenous administration of antibiotics. The patient overcomes the crisis and the fever disappears. Over the next few days, status stabilises and the patient reacts incoherently when spoken to. The infusion schedule is followed, although the calories administered are below what is necessary.

A week later there is a new visit with the head doctor. On this occasion it is agreed that the infusion plan will be discontinued and the patient will be given as much to drink as he can tolerate. The patient is moved to a separate room ("Sterbezimmer"), which allows visit and the company of his relatives around the clock. They are informed that the prognosis is grim. A few days later, the patient died.

One of the most cumbersome problems on the medical internship is undoubtedly the withdrawal of treatment that is presumed to be useless when the end of life is near. This withdrawal does not naturally affect palliative measures, such as analgesic therapies - on the contrary, these are the only ones that are maintained - but only those which by their nature are aimed at prolonging life, but which in some cases may only prolong the suffering and the lethal process.

To cure, to soothe and to comfort are the three classic objectives of the medical art. The active choice for death is not and never will be a medical decision, and morally it is not lawful either for oneself or for others. Therefore, the decision to limit therapeutic effort must never have the intention to kill. It cannot be a decision to end a human life. To make use of the medical art for that purpose would be an abuse of science, which, as I have said, is only conceived for that threefold purpose: to cure, to relieve and to console.

But how is this to be reconciled with the principle of autonomy, which is nowadays regarded as a priority principle, especially by American bioethics? Does the right to self-determination include the right to free disposal of one's own life? Today, some experts say yes, but what sense can such an assertion make, when the existence of man is the basis of all rights, including the right to self-determination? To include within the right of self-determination the right to suppress one's own existence would mean relativising the validity of all other rights, which would become arbitrary. If I can legitimately suppress them at a stroke, I make them arbitrary and their demand has little binding force. It would be comfortable and legitimate to ask the person who demands a right that is uncomfortable for others: why do you demand this right and not withdraw from existence and leave me alone?

No one can claim to have the right to fix the end of his existence, the date of his death, let alone that of his neighbour, just as no one could influence the decision that brought about his existence, his birth. However, the foundation of these principles of the medical ethos is not our concern here topic.

It is a fact that when faced with a terminally ill patient, the doctor is more inclined to be active than inactive. A failure to act is interpreted as a confession of impotence, while an action manifests a hope that has not yet faded. In these cases the action does not need any special justification, as long as it is within the spectrum of possible therapies foreseen in the medical internship , i.e. it is lege artis; an omission, on the other hand, always requires a justification: "Doctor, why don't you do anything, couldn't we try again? This explains why the doctor delays, sometimes indefinitely, the decision to withdraw or reduce futile treatment, especially when the patient, his family and even the doctor himself have not accepted the incontrovertible fact of a death that is already very close and inevitable. However, the hesitation of the physician who hesitates between withholding or prolonging treatment should not be interpreted lightly as a superficial hesitation. It could also be a prudent consideration and manager of the fatal circumstances that raise many questions for the patient, his relatives and also for the physician.

The decisions discussed here are medically so difficult because medicine is not an exact science that can predict whether a therapy that has been effective up to a certain stage of the disease will continue to be effective at a later stage, or that a therapy that has been effective in some patients will also be effective in others, nor can one be sure that what has been tried repeatedly in vain will perhaps be effective after a few more attempts. The parameters available to determine the "point of no return", the passage from life to death, are very imprecise. Medical science builds its theories by the inductive method. It is therefore a conjectural knowledge, as Popper said. Its hypotheses are always statistically corroborated by empirical programs of study provisional , as long as the data falsifying the hypothesis does not appear.

But the difficulty in making a decision to limit therapy for presumed terminally ill patients may well be due to the fact that the issue is poorly framed. In the literature on the limitation of therapeutic effort one often finds descriptions of medical interventions that either amount to saying that the physician decides about life and death, e.g. that he delays or accelerates the dying process, or even imply an intention to cause death directly. Such descriptions of medical action are usually not ethically correct. Although it cannot be ruled out that a doctor may unfortunately also have the intention to kill, it is wrong to speak of an intention to kill the patient when a terminally ill patient is treated with Withdrawal , which is usually applied to prolong life, because there is no longer any reasonable hope of such an effect. It is simply a renunciation to continue the hitherto futile attempts and to interrupt the process that leads to death. When the doctor comes to the conviction that the treatment is useless, no longer produces the desired medical effects, not only is Withdrawal permitted, but morally it is necessary to proceed with it, and to avoid at all costs what has come to be called therapeutic overkill. In the patient's agony, activism is no longer justifiable.

Of course, the decision to limit therapeutic effort can be emotionally difficult, sometimes traumatic, for doctors and nurses, especially when it is perceived as a direct or indirect cause of the patient's death. The problem is that doctors and nurses often do not have a good command of the ethical terminology and have a poor ethical perception of their own actions. There is a categorical difference between the morality of the action of attempting to kill a person, and the action that does not exclude eventual death as a possible collateral effect, when the main effect of agreement with the rules of double effect action is morally justified. Causing the death of an innocent person directly and deliberately will never be morally justified. On the other hand, the withdrawal of therapy can fall within this second subject of actions (e.g. if a morphine derivative to alleviate enormous pain of the terminally ill patient has the possible consequence of death that is not explicitly intended). In the terminally ill patient, however, death is in many cases no longer a direct effect of the doctor's action or omission, but an event that coincides chronologically with this action or omission, which by its very futility has no or only a morally irrelevant influence on the lethal process.

Between what should be done and what is already too much, or between what morally should be done and what morally should be omitted, there is no clear and precise dividing line, but rather a fuzzy area in which it is difficult to move. There is no exact formula or clear rule that relieves us of the responsibility of weighing a myriad of circumstances and making a decision with relative certainty.

The ethical justification for the reduction is based on three judgements, which are the sole responsibility of the physician:

1. The disease process is advanced.

2. There is no longer any therapeutic measure that has any hope of success.

3. A new attempt could have harmful side effects or reduce the patient's quality of life.

It is the physician who, from his or her professional deontological perspective as an advocate for life in all its phases, will weigh these three opinions and make his or her judgement. This will be a very serious judgement in which his medical skill will come into play. But as I said before, medical knowledge is conjectural. It is based on statistical programs of study carried out with different, sometimes not very homogeneous, groups; whether or not the specific theory is applicable to the particular case that the doctor has in front of him in the clinic is something uncertain, which he must assess and which is not given to him by any theory. The doctor needs to appeal to his knowledge of the patient, to his medical experience and to general ethical principles, and to medical ethics principles in particular. In other words, also to his conscience.

Nothing less than the life or death of the patient may depend on this judgement. The physician is therefore called upon to make a prudential judgement. Prudential because it is the virtue of prudence that perfects reason internship in its decision-making role. However, prudential judgements do not allow for superficiality or rashness; they do not allow themselves to be carried away by unbridled emotions or unchecked intuition. They are considered judgements that mature in the conscience.

With the certainty and firmness of all his work St. Thomas Aquinas sample that prudential decision is carried out in three acts (STh II-II, q. 47 a. 8). It is a simple outline which is already intuitively convincing: consilium, iudicium et imperium.

The first act is deliberation, including appropriate and competent advice.

The second act is the judgement: the decision on what to do.

The third act is the mandate: let's get on with it.

A prudential decision therefore requires careful consideration and a evaluation of the various circumstances in the light of scientific knowledge and one's own experience. It also and above all requires competent advice, as one cannot be an expert on all aspects of the issue at hand. Even if the goal is clear, it is necessary to have as accurate a picture of reality as possible before taking action. The purpose of deliberation (consilium) is to achieve moral certainty about what to do and what means to use.

Prudence is not a virtue that works by magic wand, but has a discursive-practical pathway that none other than St. Thomas Aquinas himself has already outlined perfectly in his Summa Theologica (II-II, q 49 a. 1-8). These are the eight integral virtues of prudence. That is to say, those that compose it. Some are intellectual virtues and others are moral virtues. And this is so because prudence, as is well known, is the only cardinal virtue that belongs to both genres.

First quotation the report (lat. report), which in this case means to keep in mind the data of concrete experience and put it at the service of the current evaluation ; but we will also have to put into action the intellectual virtue of understanding or science (intellectus) which will provide us with the knowledge of general subject applicable to the concrete case, from the first principles to the data of scientific evidence; docility (docilitas) will lead us to seek, listen and follow the good committee, always necessary especially in complex questions; and sagacity (solercia) which is the virtue of knowing how to find quickly what is right; and of course the intellectual virtue of reasoning well, which is what the Saint refers to when he includes ratio in the list; and then foresight (providentia) for as the saying goes "prevention is better than cure"; circumspection (circumspectio) to consider well the circumstances relevant to the question at stake and finally caution to which in vulgar language the virtue of prudence is often reduced: to be prudent is to be cautious.

These eight integral parts of prudence lead to the judgement of reason internship and also to decision making.

Of course, commandments, rules and maxims, i.e. verbal normative formulas, can be a financial aid for making these decisions. Indeed, by making explicit the principles to be applied, the prudential weighing of all factors and circumstances can be facilitated, but this weighing will never end up in a mathematical formula with an exact result . A prudential decision, i.e. a decision on the good moral behaviour in a concrete real status , can never be taken without a weighing of the specific circumstances of the status, which because they are infinite cannot be encompassed in their totality.

The prudential decision is precisely prudential because it is not the necessary, unambiguous and unique result of a logical deduction without any indeterminacy. Neither medicine is an exact natural science nor ethics provides us with an unequivocal rule for action. In the end, a decision has to be made in which not all the unknowns have been cleared up, but it must be ensured that the most important ones have been cleared up and that the remaining ones cannot influence the result. The certainty of medical science is - as I said before - a mostly statistical certainty and statistical certainties have only a relative moral coercive force when applied to the particular case. Am I obliged to undergo a therapy that has only produced an effect in 5% of the cases, or in 20% or in 30% or in 40%? There are many factors in addition to the knowledge that medicine provides me to take into account in prudential decisions.

The medical profession has always been ethically sensitive. No other profession since antiquity has devoted so much effort to defining its moral identity. For physicians, the cultivation of medical science and evaluation of their own experience have always gone hand in hand with what might be called the cultivation of conscience. The cultivation of conscience consists in acquiring and maintaining the ethical sensitivity that is necessary to deal with many problems, more so today than centuries ago. For this there is no other recipe than to cultivate the virtues, especially the virtue of prudence. But bioethics is in itself an ethics that reflects in the third person, that is, in which the judge is always a spectator who stands outside the action, and in order to become an eminently reflective internship it always needs the complement of virtue ethics. This is the weak point of the Anglo-Saxon and German approaches to bioethics. In the United States, the exception is Edmund Pelegrino.

The special case of withdrawal of food and hydration

topic A much debated issue in medical ethics is the extent of the obligation to provide nutrition and hydration to some terminally ill patients, especially when there is reason to presume that such actions prolong suffering without benefiting the patient's health. Within this discussion it is also questioned whether there is a distinction between natural and artificial nutrition and hydration.

In 2004 John Paul II took a clear position on this question in a speech to the participants of a congress of neurological specialists. His statement has given rise to much discussion, surprise and incomprehension, especially within the medical profession:

"In particular, I would like to emphasise that the administration of food and water, even if carried out by artificial means, always represents a natural means of preserving life, not a medical act. Its use must therefore be considered, in principle, ordinary and proportionate, and as such morally obligatory, to the extent and until it proves to achieve its proper purpose, which in this case consists in providing nourishment to the patient and relief from his suffering".

Both Catholic and non-Catholic doctors find it difficult to understand that artificial feeding is not a medical act. Although the Pope was referring especially to patients in a persistent vegetative state, if the Pope's words could be interpreted as a resounding no to the possibility of withdrawing or renouncing artificial nutrition and hydration, then it would also mean that for Catholic doctrine the express Withdrawal of a patient - orally or in an advance declaration of will - to this feeding subject would be suicide. Is this interpretation really correct?

To realise the importance of the issue, it is necessary to go deeper.

Let us take the first part of the declaration: "In particular, I would like to emphasise that the administration of food and water, even if carried out by artificial means, always represents a natural means of preserving life, not a medical act. It is therefore not a treatment but normal care to which everyone, healthy or sick, is entitled.

What many representatives of the medical profession were very much against was the grade of artificial feeding as a non-medical act. Who but only doctors are the ones who implant the nasogastric tubes or perform the enterotomy to insert the corresponding stomach tube or the transfistula tube for enteral feeding? Who but only doctors are the ones who insert the intravenous catheters for parenteral nutrition? And who but only doctors are responsible for the substances to be administered and their dosage?

How can this refusal be explained in the pontifical speech ?

On the other hand, the text raises some questions such as: is there not a certain contradiction in terminology when the same things are referred to once as "artificial ways" and then as "natural means"? Is there not some confusion that "artificial ways of administering water and food" are "natural means of preserving life"? Can something be both natural and "artificial" at the same time? This is only an apparent contradiction.

First of all, it is necessary to distinguish between two meanings of natural that are used in the text quoted. On the one hand, natural as opposed to technical. This is the use of the concept in the natural sciences. In this sense, the term "artificial ways" is being used. On the other hand, reference letter is used for "natural" in the sense of the moral Philosophy , i.e. derived from nature, as a principle of operations, which we perceive by reason. In this sense, nutrition and hydration, whether natural or not in the biological sense, are always natural, i.e. a moral obligation.

Moreover, making the distinction between the "what" and the "how" of the action of feeding and hydrating, i.e. between the object (what we do) and the mode (how we do it) of the action easily resolves the apparent contradiction.

With regard to the "what", i.e. the object of the action of nourishment and hydration: It is connatural for man to feed himself and therefore to seek food and to take it. Because of his natural inclination towards self-preservation and well-being, man seeks liquid and food as if by instinct. Hunger and thirst are pre-rational sensations that signal an existential need for food and liquid. Nourishment is not only a natural activity and existential function in itself, but also a prerequisite for man's development as a human being. In other words, nourishment also corresponds to man's nature as a rational being, because without the functions of nourishment and hydration he cannot maintain and develop his rational Schools . Therefore, there is a moral obligation to feed and hydrate oneself, to allow oneself to be fed and hydrated, as well as to feed and hydrate a third party who is unable to feed and hydrate himself (e.g. a nursing infant, a coma patient). In a word, the action of feeding and hydration is always a natural means because man has a reasonable natural appetite for food and drink. It is in the nature of man to feed and drink.

In terms of the "how", i.e. the execution of feeding: The action of feeding happens in three stages: preparation, ingestion and utilisation of food. The table sample shows different ways of organising the three stages. Feeding is carried out by natural means when 1.1., 2.1.1. or 2.1.2. and 3.1. occurs, artificially when 1.2. or 2.1.3. or 2.2.1. or 2.2.2. or 3.2. occurs. financial aid In medicine we speak of artificial feeding only from 2.2.1, 2.2.2. and 3.2. but not in 2.1.3. and 1.2. There is also a form of artificial feeding (e.g. the ingestion of prepared food), even if it is medically assisted (2.1.3) and is, however, basically distinguishable from artificial feeding in the sense used in medicine.

Table: Artificial and natural feeding and hydration

When food and liquid are taken naturally, there is no problem in distinguishing between object and mode. A biological function, proper to man's nature, is performed by clearly natural means.

When feeding and drinking require a technical financial aid , the action of feeding also basically involves two additional operations of a medical nature. The first is the fixation of the feeding instrument, nasogastric tube or parenteral catheter etc. and the second is the observation and regular or periodic monitoring of the patient, to adapt the dosage of calories and quantity of liquid to the patient's condition. But the actual administration of food and drink can be carried out by a nurse or nurse practitioner, i.e. by a non-medical person, or even in many cases by a family member or an easily trained assistant. The medical operations - fixing the apparatus and dosage - are therefore an integral part, among other components, of the action of feeding. From the distinction between the object and the modality and the list of modalities we deduce that a feeding with medical financial aid cannot be reduced to an action exclusively of a medical nature, and that the artificiality of the ingestion does not cancel out the natural character - in a moral sense - of the nourishing function. The nourishing function is based on a need that can be supported technically, like the senses of hearing or sight, which are also natural functions that can be supported by medical technology with hearing aids or spectacles. Neither of these functions ceases to be natural because of the use of supporting devices.

Turning now to John Paul II's statement, we can say that he wants to emphasise that nutrition is in principle a natural activity, i.e. independent of any medical support. The argumentation developed here sample that this statement is not contradictory, but quite logical, and wants to make it clear that the artificiality of the way of feeding has no ethical relevance.

The second part of the statement marks the limits of the moral obligation to administer liquid or food:

"Therefore, its use is to be considered, in principle, ordinary and proportionate, and as such morally obligatory, to the extent and until it proves to achieve its proper purpose, which in this case is to provide nourishment to the patient and relief from his suffering".

It should be noted that reference letter applies to all feeding or hydration actions and not only to those carried out by artificial means. They are always an obligation in principle. They must therefore always be offered. The question is: is refusing feeding and hydration then always suicide, and is withholding food from those who cannot feed themselves (e.g. a breastfed child) always homicide? The message of the document is that when food and liquid no longer contribute to the nourishment and relief of the patient's suffering, there is no moral obligation to accept or offer them. So the question of whether it is artificial feeding in the medical sense or not is irrelevant.

Medical theory and practice know situations at the end of life in which feeding and fluid supply have lost their meaning. Thus, the supply of food is no longer reasonable if the process of biodegradation or catabolism is already much stronger than that of recovery (anabolism). Due to resorption dysfunction and/or lack of protein synthesis, an intensification of nutrition and hydration would not produce the desired effect. This is the case e.g. in cancerous cachexias, cardiorespiratory cachexias, etc., or in other diseases that consume the organism due to multi-organ dysfunctions and/or polyneuropathies.

In trying to understand the tragic situations the physician is confronted with on his daily work , the question arises to what extent he is obliged to interfere in the natural dying process. In the natural process of dying already far advanced, the dying often refuse nourishment and hydration. The slow desiccation of cells acts as a natural narcotic as life slips away in agony.

The process progresses slowly and the lack of liquid clouds perception and acts as a natural anaesthetic. In some indigenous societies unjustly called primitive, e.g. the Aymara (Bolivia), the dying ask financial aid to be allowed to die in the company of their loved ones without receiving any more food and liquid. And so, little by little, he says goodbye to his loved ones and enters into death through drowsiness. The dying person and his family accept death and share the moments of agony together in an intense and very human way. This tradition of primitive societies contrasts in the so-called advanced societies with the more and more frequent dying alone with hardly contact with family and friends, in a sterile conference room of a state-of-the-art hospital full of devices and monitors.

When the patient consciously accepts his death and in its proximity refuses to eat and drink because this food intake no longer achieves its own goal , is he acting wrongly? I think not. What is difficult is when the decision has to be made by others. Then it is time for the prudential decision. And it is part of prudence to take the risk of deciding without absolute certainty. But moral certainty is enough.