Artificial Nutrition and Hydration (ANH) is given to a person who, for some reason, cannot eat or drink. Artificial nutrition and hydration are a balanced mix of nutrients and fluids provided by placing a tube directly into the stomach, intestine, or 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 them 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 is often 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) 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 is also 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 differently. For example, the NYS Proxy Law does not automatically grant permission to a relative or caregiver of an incapacitated patient to forgo ANH. However, it does grant permission if the relative or caregiver is reasonably familiar with the patient’s view of ANH. Courts in New Jersey and Massachusetts sometimes allow the withdrawal of ANH from patients in a permanent vegetative state at the request of family members. In Missouri, state courts rejected family testimony as evidence sufficient to prove the wishes of the incapacitated person (O’Rourke, 1990).
If one believes that ANH is medical treatment, then any decision about its use is made by weighing the burdens and benefits of the treatment. This means that 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 the patient’s 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 to 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 from giving life-saving measures like putting a person on an artificial respirator. The simple way of distinguishing active and passive forms 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 was initially accepted in history. Greece and Romans permitted it in certain circumstances (Beauchamp, 2005). However, with the arrival of religions like Judaism, Christianity, and Islam, the practice of euthanasia was morally and ethically rejected. Life was regarded as the gift of God and under no circumstances permitted its annihilation. Laws of modern societies also followed the general principles of religions. It was only in the 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 the 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. The 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 today, most countries in the world, including the United States, retain restrictions on some forms of euthanasia. However, the debate continues unabated. The issue is intricate and thought-provoking. If taking a person’s life under unbearable pain is unethical, then keeping the same person alive is inhumane. Both sides have strong arguments. This essay will scrutinize the arguments of both sides while focusing on the negative effects of legalizing active euthanasia. Various aspects related to the issue, encompassing the viewpoints of both 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 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 a persistent vegetative state is not in a terminal condition since nutrition and hydration, and ordinary care will allow them to live for years. It is only when that care is taken away that the patient will die. Therefore, it is the removal of nutrition and hydration that brings about 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. Treatment will allow the 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. This is also called a NasoGastric or NG tube. It can also be administered through the wall of the abdomen into the stomach, which is called gastrostomy, G tube, or PEG. Another way is through a procedure called jejunostomy, where it is inserted into the intestine.
TPN requires the surgical insertion of a special port, usually into a vein below the collarbone. Fluid with limited amounts of nutrients can be supplied directly into a vein in the arm through an intravenous (IV) line.
Nutrition and hydration can be supplied through artificial means temporarily or indefinitely, depending on the patient’s 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 cannot 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 helps dehydration and may lessen their confusion and discomfort. Giving fluids and nutrition helps the patient as they are 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 based on the argument that ANH is necessary to preserve patient dignity. Nutrition and hydration are ordinary humane treatments that should be provided to every patient. The 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 have also observed that symptoms such as nausea, vomiting, abdominal pain, congestion, and shortness of breath decrease when artificial nutrition and hydration are 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 are stopped. Reports from conscious dying patients indicate that they increasingly experience a lack of appetite and thirst. Dry mouth is the only commonly reported symptom, and this can be managed without resorting 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’s 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 is 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 and 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 such as 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 via NG or G-tube have brain disease and are unable to report feeling full or unwell. As a result, they may experience abdominal bloating, cramps, or diarrhea.
With careful attention by healthcare providers, many side effects can be avoided or managed fairly well. However, confused patients can also become anxious over a tube’s presence and try to pull it out. This often leads to the use of restraints or sedation, which can have a serious effect on patients’ mental state and their ability to interact or 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 bypasses 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 a much-debated topic. The passive form of euthanasia has been accepted by societies, but the issue of the legality of active euthanasia remains contradictory. People who favor the proposal generally advocate for the right of self-determination and the principle of mercy as the major driving forces towards deciding on euthanasia. On the other hand, the other school of thought rejects the idea of autonomy. According to them, a person undergoing serious physical and mental stress is not competent enough to decide about their 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. The majority of the reasons were more psychological in nature. Besides religious and ethical rationale, it is perceived that allowing active euthanasia will result in shattering people’s confidence in society and trust amongst each other. It will widen inter and intra-generational gulf. The sanctity of human relationships will disappear. Permitting active euthanasia will eventually open doors to its misuse and abuse on an unimaginable scale.
Some people regard the removal of artificial nutrition and hydration as a means to ease the suffering of the terminally and permanently ill, while others consider it a religious obligation for all humans to preserve and protect life. Additionally, prolonging life with excessive pain and suffering is not only a religious duty but an ethical one as well. Giving ANH is not an option if it can preserve and protect life but increase the suffering of the patient. Miracles have happened in the past when terminally ill patients have recovered by sheer force of will and fate. Therefore, it is better to preserve life in the hope of such unexplainable occurrences as long as it does not become a burden for the suffering individual.
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