Care of the Terminally Ill: Definitions

 And Application to Tubal Hydration and Feeding

There is a ot of confusion in the whole field of care for the dying so we have to set out some clarifying definitions and divisions (i.e. distinctions), a work that makes philosophers unpopular.  So get some coffee and a highlighter:

    1. Dying: active deterioration of the patient’s self-therapeutic faculties  such as nutrition, elimination, respiration, circulation,  and immune system which, without intervention, terminates in death.
    2. Danger of Dying: The set of any internal and/or external circumstances of an individual which have an 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. Alternative: To deliberately 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..

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 foreseeably 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. Recent literature by ethicists refer to a right to refuse a fabricated life as being a decision against unduly burdensome technologies.

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. As a first principle let us state: Any kind of avoidable torment, emotional, psychological or moral, of a patient is unprofessional 

          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.

         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. With death approaching, the desire to be faithful to those God-given principles may be especially intense.

       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]

        Fairly simple tubal artificial  nutrition and hydration (ANH) is a welcome innovation. 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  by ANH 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 had been recovering physically and mentally and while dependent on the tubes, no other evidence of a dying process was in place. To remove the tubes will cause a death by dehydration and no other cause. At that moment they were not even in danger of dying from anything biological. Their danger was 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. New England Sinai Hospital, [4] it is less easy to decide because the patients were or became comatose. Prior to the designing of successful tubal feeding and hydration all permanently comatose patients would die by dehydration as simply the way the respective traumas or disease killed. The devising of tubal hydration, together with heavy doses of anti-coagulants, antibiotics and even respirators makes it possible to circumvent the various organ failures such diseases would kill by. They do not cure the patient. They at most construct a “fabricated life” whose quality is now our responsibility because we fabricated it. It is not God’s gift, not nature’s, but medicine’s and imposed on the patient. There was little reason, based on the prohibition of suicide, to oppose the removal of tubes on the grounds that it would introduce a new cause of death. The entire set of interventions can be seen as simply delaying death. This seems true for Edna M.F., whose death was attributed to dehydration which occurred when her Alzheimer’s put her into a coma and her tubes were removed. But pain relief is essential because we have no secure way of knowing whether the comatose patient is able to feel the pain of thirst. The underlying cause was the advancing ravages of Alzheimer’s. The tubes merely fooled the disease’s usual way of killing and put in its place a possibly more distressing one. That one can identify the organs which were first in line to fail lethally is irrelevant. She was both in danger of death and, by the time she slipped into a coma, actually dying from Alzheimer’s. It matters little what the death-certificate says. (Hers said “dehydration.”). The problem, of course, is intention. If the fundamental moral prohibition is to not act in direct and lethal hostility to life, even life of the dying, then one’s intention can be directed in hostility to an intervention which is doing no good, not curing, and doing much harm, making dying more prolonged and distressful. In addition to the critical difference of intention, these cases differ from the earlier cases because these are dying and the others were recovering. For them it was the very success of the tubal feeding in allowing a partial recovery which made it a target for removal, whereas here the tubes are not assisting in any recovery, but merely slowing the dying.

         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 support those who wish to prohibit removal of feeding and hydration tubes  or a respirator 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 on a respirator and fed by tubes for three months where clever arguments could have been made that I was dying. I recovered to run 5K’s regularly.  My intent is that any 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. It is killing/suicide when a new cause of death is introduced.

NEW DEVELOPMENTS

        A 2018 case in Britain’s National Health Service (NHS) involving a darling but moribund boy, Alfie Evans, has brought to light a ghastly practice of the NHS to use the removal of ANH from thousands of comatose  and usually elderly dying patients. Reported by Matthew Cullinan in Life Site News (5/17/2018) we read:

       How could Britain’s prime minister get away with denying that a health care system that allows hundreds of people to be dehydrated or starved to death every year is in a “humanitarian crisis”? Perhaps it’s because the British public has become desensitized to the problem. As incredible as it may seem, starvation and dehydration deaths in the hundreds each year have been reported on a regular basis since at least the year 2000, when 862 patients were killed principally or in part by starvation or dehydration in NHS hospitals and care centers. By 2010, the horrific figure had climbed even higher, to 1,316 patients annually.

While I make no judgment on the Alfie Evans case, this ghastly practice at Britain’s NHS shows all the dangers which motivated this article. Routinely the NHS doctors would offer the vaguest claim that chosen patients were dying. But the tubal withdrawal is the proximate cause of death and not the result of the disease, often Alzheimers. And there was no routine provision of pain-killers. The slippery slope is savaging the morale of the staff as well as the last days of the patients.

[1] See the comments of California Superior Court Judge Bob NcNatt in the Robert Wendland case and Wesley Smith’ comments in his “The Dehumanization of Robert Wendland.” in Human Life Review, 26,4, (Fall 2000) p. 59.  A prudent policy-maker cannot ignore the clear danger of the steep “slippery-slope’ which has occured many countries and even in California where permission to commit suicide become compulsion to accept it.

[2] Ibid., pp.58-61.

[3] Ibid.

[4] 497 North Eastern Reporter, 2nd Series, 626 (Mass. 1986)

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