Artificial Nutrition and Hydration
Artificial Nutrition and Hydration (ANH) is given to a person who for some reason cannot eat or drink. Artificial nutrition and hydration is a balanced mix of nutrients and fluids, provided by placing a tube directly into the stomach, the intestine or a vein. It is a medical treatment that allows doctors to overcome whatever may be preventing a person from eating or drinking. During the course of an illness, a patient often loses the ability to receive nutrition or hydration by natural means. When a patient can no longer receive food and fluids normally, artificial nutrition or hydration can benefit the patient by helping the patient to maintain proper nutrition and fluid balance. Since inadequate nutrition and hydration can result in death, artificial nutrition and hydration can also benefit the patient by supporting life.
Short-term artificial nutrition and hydration often is given to patients recovering from surgery, greatly improving the healing process. It may also be given to people with increased nutritional requirements or to someone who cannot swallow because of an obstructing tumor.
A highly sophisticated form of artificial nutrition and hydration called Total Parenteral Nutrition (TPN) which can be given indefinitely. TPN can be administered to patients with serious intestinal disorders that impair their ability to digest food, enabling them to live fairly normal lives. However, long-term artificial nutrition and hydration also is commonly given to people with irreversible neurological disorders.
In this paper an effort has been made to explain this treatment in some detail along with different views and its advantages and disadvantages.
Medical and Ethical Views Regarding ANH
The most common legal view of ANH is that it is a medical treatment. But some people view it otherwise. For example, the NYS Proxy Law does not automatically grant permission to a relative or caregiver of an incapacitated patient to forgo ANH, but it does if the relative or caregiver is reasonably familiar with the patient’s view of ANH. Courts in New Jersey and Massachusetts at times allow the withdrawal of ANH from patients in permanent vegetable state at the request of family members. In Missouri the state courts rejected the family testimony as evidence sufficient to prove the wishes of the incapacitated person. (O’Rourke 1990)
If one believes ANH is medical treatment, then any decision about its use is made by weighing the burdens and benefits of the treatment. That means it is treated as a part of the medical treatment plan, which is aimed at achieving defined goals of medical care determined from the patient’s perspective. The patient’s values and attitudes dictate legitimate goals of treatment.
On the other hand, if ANH is not considered a medical treatment, then decisions about its use are much simpler. If the patient is not eating and drinking, ANH is mandatory in all cases, irrespective of patient wishes, goals of treatment, likelihood of improvement, or burden of its administration.
Religious Point of View
The religion indicates that all humans are created in the image of God and they have a god given duty of life preservation. This duty falls on the shoulders of even the terminally ill patients and all conceivable means should be employed to preserve and save life even if it involves the use of artificial nutrition and hydration.
Euthanasia is the practice of ending a person’s life for the sole purpose of relieving the person’s body from excruciating pain and suffering due to an incurable disease. The term euthanasia is often referred as mercy killing or the ‘good death’ as derived from the Greek. Euthanasia can be classified into four categories. In active euthanasia, a person’s life is terminated by a doctor through a lethal dose of medication. Passive euthanasia implies non provision of life-sustaining treatment to a patient based on logical reasoning or in other words doing nothing to save a person’s life by abstaining to give life saving measures like putting a person on artificial respirator. Simple way of distinguishing active and passive form of euthanasia is a mere difference of act and omission. The other forms include voluntary and non-voluntary euthanasia. In voluntary euthanasia, a patient’s consent is obtained for either active or passive euthanasia. Whereas non-voluntary euthanasia refers to ending a patient’s life without his/her consent (Rachels, 1975).
Euthanasia had been initially accepted in the history. Greece and Romans permitted it in certain circumstances (Beauchamp, 2005). However, with the arrival of religions like Judaism, Christianity and Islam, practice of euthanasia was morally and ethically rejected. Life was regarded as the gift of God and under no situation permitted its annihilation. Laws of modern societies also followed the general principles of religions. It was only in last century that active debates on euthanasia commenced to authenticate its legality and ethical righteousness. Proponents of the issue started advocating the option of life and death as sole right of a human being. Alexander Capron, a renowned American lawyer propagates the concept by stating that I never want to wonder whether the physician coming into my hospital room is wearing the white coat of the healer or the black hood of the executioner. Opponents however strongly reject the idea highlighting its serious ramifications. Majority of people opposing the issue are overshadowed by religious ethos. In 1995, Pope John Paul II strongly opposed the idea by saying “Euthanasia is a grave violation of the law of God, since it is the deliberate and morally unacceptable killing of a human person”. In 1999, Pope John Paul II again spoke out against death by the hands of doctors (Sabelko, 1999).
Till to-date, most countries of the world including United States retain restrictions on some of the forms of euthanasia. Debate however continues unabated. The issue is intricate and thought-provoking. If taking a person’s life under suffering from unbearable pain is unethical then keeping the same person alive is inhumane. Both the sides have strong arguments. This essay will scrutinize arguments of both the sides while focusing on negative effects of legalizing active euthanasia. Various aspects related to the issue encompassing viewpoint of both the sides are covered in subsequent paragraphs.
Mitigation of suffering through the purposeful destruction of the life of the sufferer is clearly contrary to the religious concept of the respect for life. It is said that in the Netherlands as many as one sixth of all deaths are attributable to euthanasia. In 1986 the Council of Ethical and Judicial Affairs of the American Medical Association stated that “it is not unethical to discontinue all means of life-prolonging medical treatment” for patients in irreversible comas.
A patient in the persistent vegetative state is not in a terminal condition, since nutrition and hydration and ordinary care will allow him to live for years. It is only if that care is taken away that the patient will die. So it is the removal of the nutrition and hydration that brings about the death. This is euthanasia by omission rather than by positive lethal action. It is morally wrong to take these extreme cases and make them the norm for all cases of persistent vegetative state patients, when treatment will allow that patient to continue to live without a burden of excessive pain or suffering. In such cases their removal is equivalent to passive euthanasia i.e. killing by omission.
Artificial nutrition and hydration can be administered in several ways. Usually it is provided through a flexible tube inserted through the nasal passage into the stomach, it is also called NasoGastric or NG tube, through the wall of the abdomen into the stomach, this procedure is called gastrostomy, G tube or PEG, or into the intestine through a procedure called jejunostomy.
TPN requires the surgical insertion of a special port, usually into a vein below the collar bone. Fluid with limited amounts of nutrients can be supplied directly into a vein in the arm through an Intra Venous (IV) line.
Nutrition and hydration through artificial means can be supplied temporarily or indefinitely depending on the patients condition. If artificial nutrition is likely to be given for a long time, a surgically implanted tube is considered more comfortable for the patient and has fewer side effects. (Questions and Answers 2006)
Advantages and Disadvantages
A person with a temporary illness who can’t swallow may be hungry and thirsty. A feeding tube may help. Sometimes a person may become confused because of dehydration. Giving a patient fluids through a tube help dehydration and may lessen his or her confusion and discomfort. Giving fluids and nutrition helps the patient as he or she is recovering. For a patient with an advanced life-threatening illness who is dying, artificial hydration and nutrition may make the patient live a little longer, but not always. (American Family Physician 2000)
The opposition to the withdrawal of ANH is done on the grounds that ANH is necessary to preserve patient dignity. Nutrition and hydration is an ordinary humane treatment and should be provided to every patient. Withdrawal of ANH amounts to starving the patient to death. Food and water symbolize basic human care for the dying. If we begin withholding such care from the dying, we are denying their humanity. (Cranston 2001)
People who have had a great deal of experience caring for the dying have noticed that patients who are not tube fed seem more comfortable than those who are. Caregivers also have observed that symptoms such as nausea, vomiting, abdominal pain, congestion and shortness of breath decreased when artificial nutrition and hydration was discontinued. For example, patients with pneumonia will not suffer as much from coughing or shortness of breath if they are not receiving fluids. Medical observation has found no indications that patients who have suffered massive brain damage causing permanent unconsciousness experience any pain when artificial nutrition and hydration is stopped. Reports from conscious dying patients indicate that they increasingly experience a lack of appetite and thirst. Dry mouth is the only common reported symptoms, and this can be managed without resort to tubes.
Animal studies indicate that the body responds to lack of food by increasing the production of natural pain relievers. However, if food is supplied, the body stops producing endorphins and the benefit of this natural pain relief is lost. Historically, coma was nature’ way of relieving the suffering of dying. However, the provision of artificial nutrition and hydration may prevent the development of this natural anesthesia in some cases. (Partnership for Caring 2006)
There’s also a risk when someone is fed through a tube of liquid entering the lungs. This can cause coughing and pneumonia. Feeding tubes may feel uncomfortable. They can become plugged up, causing pain, nausea and vomiting.
Also the tubes can damage and erode the lining of the nasal passage, esophagus, stomach, or intestine. If tube placement requires surgery, complications like infection or bleeding may arise. Intravenous lines can become uncomfortable if the insertion site becomes infected. If fluid leaks into the skin it may cause inflammation or infection.
Many patients receiving artificial nutrition and hydration by NG or G-tube have brain disease and are unable to report that they feel full or unwell, so abdominal bloating, cramps, or diarrhea may occur.
With careful attention by healthcare providers, many side effects can be avoided or managed fairly well. However, confused patients also can become anxious over a tube’s presence and try to pull it out. This often leads to the use of restraints or to sedation, which can have a serious effect on patients’ mental state and their ability to interact or to perform any small activities they might be capable of such as changing position in bed.
The normal intake of food and fluids can also provide the patient with many psychological benefits, such as pleasure, satisfaction, comfort, and a sense of dignity and control. However, since artificial nutrition and hydration bypass the normal method of receiving food and fluids, it does not provide the patient with any of these psychological benefits. In fact ANH can sometimes threaten the patient’s sense of dignity and control. (Medical Ethics Committee 2006)
Euthanasia remains much debated. Passive form of euthanasia though has been accepted by the societies but issue about legality of active euthanasia remains contradictory. People favoring the proposal generally advocate right of self determination and the principle of mercy as the major driving forces towards deciding on euthanasia. Whereas the other school of thought rejects the idea of autonomy since according to them a person undergoing serious physical and mental stress is not competent enough to decide about his/her life or death. Moreover, different surveys reveal that less than one third of the people favoring euthanasia actually reasoned their support as ending the pain or incurable disease. Majority of the reasons were more of psychological in nature. Besides religious and ethical rationale, it is perceived that allowing active euthanasia will result in shattering people’s confidence on the society and trust amongst each other. It will widen inter and intra-generational gulf. Sanctity of human relationships will disappear. Permitting active euthanasia will eventually open doors to its misuse and abuse to an unimaginable scale.
Some people regard removal of artificial nutrition and hydration a mean to ease the suffering of terminally and permanently ill, while some people consider it a religious obligation of all human to preserve and protect life, along with the fact that the prolonging of life with excessive pain and suffering is not only religious but ethical duty. Giving ANH is not an option if it can preserve and protect life with increasing the suffering of the patient as miracles have happened in the past when terminally ill have recovered by the sheer force of will and fate. Hence it is better to preserve life in the hope of such unexplainable occurrence as long as it does not become a burden for the suffering individual.
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