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May 8, 2005

Hydration and Nutrition: A Basic Human Need, Not an Option of Medical Care

Topics: Commentary

Here is an excellent piece(via Wired Catholic) on why nutrition and hydration should not and are not reasonable options of medical care. As we move forward in this post-Terri Schiavo world, lets not lose sight of the tragic causes of her death - the emergance of a euthanasia-accepting secular society, a loss of respect for life fostered by legal abortion, and an activist anti-life and anti-faith secular and liberal judiciary. While others may disagree with me as to just what caused Terri's murder to be an acceptable societal execution, most will find these at the least to be contributing factors. However, as Dr. Gerster points out in her article, what was in the past an almost universal consensus concerning a patient's right to receive nutrition and hydration even when surgical or highly technological medical intervention was discontinued as ineffective, we now find such humane concerns to be on their way out the window. But should food and water ever be considered as an option of medical care?

By Carolyn F. Gerster, M.D, from the NRLC.

There has been a recent striking reversal of the previous almost universal consensus concerning a patient's right to receive nutrition and hydration even when surgical or highly technological medical intervention was discontinued as ineffective, after consultation with the patient or family.

The reasons that food and water should not be considered an option of medical care are summarized as follows:

1. All patients, no matter how severe or hopeless their illness, have the basic right to nursing care, emotional support, food, and water.

2. Hydration and nutrition are biological necessities. Food and water are not medications. We go into the kitchen, not to the pharmacy, for dinner.

3. Unlike all other modalities of care (e.g., antibiotics, cardiac drugs, etc.), the withdrawal of hydration and nutrition is universally fatal. Death will occur within a predictable time, usually within 10 to 14 days. There are no survivors. This means the doctor, not the disease, kills the patient. Withdrawal of water is essentially a homicidal act. A hospital is an inappropriate place to kill a patient. The lethal impact of the order to withdraw fluids is well understood by nurses, hospice staff, and hospital personnel. It is neither fair nor appropriate to involve health care professionals in hastening the death of a patient.

4. Unlike respirators, dialysis, and other technology, "artificially administered" nutrition and hydration are not burdensome or painful. If long-term support is contemplated, a percutaneous gastrostomy (done by a gastroenterologist, not a surgeon) offers the alleviation of hunger and thirst without discomfort. There is no substance to the argument that fluid may represent a risk to some patients. In instances of renal or cardiac failure or cerebral edema (swelling of the brain), hydration may be temporarily decreased but is not discontinued.

5. The cost of a gastronomy feeding, itself, is minimal. In some cases, the formula may be simply prepared in a blender. Family or nursing home personnel may administer the feeding. The patient may resume oral feedings if he or she improves.

6. Death by dehydration is protracted and painful for the patient (if conscious) and for the family and hospital staff in all cases. One need only recall photos from the Ethiopian famine to realize the enormity of the act. Since the only purpose of stopping hydration and nutrition is to hasten death, it is only rational that euthanasia proponents will promote "death by injection" as a humane alternative. Such has been the argument of Derek Humphry, the past executive director of the Hemlock Society, in promoting "assisted suicide." It is illegal in Arizona to starve a horse or dog to death. Surely human beings deserve the same protection.

7. Continuing hydration allows a "time buffer" in the event that an error has been made in diagnosis. Doctors are not omnipotent. Most physicians have had the personal experience of patient survival or improvement despite their initial diagnosis of terminal illness or irreversible coma. Once the patient is put to death by dehydration, it is too late for the doctor to rectify the error.

8. The potential for abuse in allowing death by dehydration is undeniable, given the interest in reducing the cost of health care and concern of some family members that their inheritance not be devoured by hospital costs. Those most vulnerable are the elderly, the physically and mentally impaired, and the poor. We already had a 1987 example in Tucson, Arizona, of a surrogate appointed by the county to make a life or death decision regarding withdrawal of fluids, even though the surrogate had never known the incompetent patient.

9. There is no evidence that most patients desire their lives to be shortened. There is, in fact, very strong evidence that patients, once actually confronted with a terminal illness or serious illness, want intervention to delay death. An American Journal of Psychiatry article (143:2, February 1986) cited an interview of 44 terminally ill patients. The majority (34) never wished death to come early. All the remaining 10 were found to be suffering from clinical depressive disease. (Three had been suicidal before their illnesses.)

A 1998 study in the Journal of the American Medical Association involved 160 patients age 55 or older who underwent treatment in the intensive care unit (ICU) at the University of North Carolina, Chapel Hill, during a one-year period. Of these patients, 74% would be completely willing to undergo intensive care again, even if it meant their lives would be prolonged for as little as one month. Twenty-two percent expressed a desire for ICU treatment dependent upon the duration of survival. Only 4% were unwilling to repeat heroic life-sustaining treatment.

As a physician treating a large percentage of elderly and seriously ill patients over the past 35 years, I have had only five persons ask that no life-prolonging treatment be given as death approached. I have had no patient ask that nutrition be discontinued.

Carolyn Gerster, M.D., is vice chairman of the National Right to Life Medical Ethics Committee and chairman of the board for Arizona Right to Life. For more information about NRLC's "Will to Live," go to www.nrlc.org.

Cross posted at Hyscience

Posted by richard at May 8, 2005 10:13 AM


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Comments

There is an old saying that the road to hell is paved with good intentions. That certainly is true of the road to a premature grave where, if truth be told, the halfway--to be generous--measures implicit in the above article are apt to lead you.

Your life deserves the truth. Indeed, in a Culture of Death, it depends on it!

Posted by: Earl Appleby at May 8, 2005 11:45 AM

Actually, I appreciate this article a good deal. If we could get everyone to agree to what Dr. Gerster is saying, we'd be a long way toward reversing some very bad things that are happening.

Moreover, she nowhere says that any forms of treatment she names (such as dialysis) _should_ be discontinued or denied in any particular circumstance; she merely distinguishes basic care in the form of food and water from things that actually are treatment. In fact, her eagerness to report the study at the end about ICU treatment indicates a positive attitude even toward the relatively invasive forms of treatment that may be undertaken in the ICU.

From a _doctor_, the statements here are _very_ strong and _very_ rare. Even ostensibly pro-life doctors tend to hem and haw when it comes to an absolute prohibition on dehydration. They usually throw in some sort of qualifying statements or phrases that could be taken to mean that it might be okay to withhold food and water. Medical training nowadays appears to mess up students on this issue. Dr. Gerster, in contrast, even takes on some of the qualifying things you hear people say when, in #3, she says outright that fluids don't present a risk to patients. That's a biggie. You hear this whole thing about how you _have_ to withhold fluids in the case of kidney failure. She is giving important information when she says that in that case you only need to decrease fluids.

So I'm glad she wrote this. Even before the article appeared on here, I had clipped it from NRL News and marked some of the passages. And I usually hate keeping paper copies of things, but this one's a keeper.

Posted by: Lydia at May 10, 2005 7:00 PM

Lydia raises some legitimate points. In concentrating on the fundamental weaknesses implicit in Dr. Gerster's article, I overlooked the explicit merits Lydia rightly notes. I appreciate her bringing them to our attention.

Part of the problem is the Hobbes' choice I often face. To comment or not to comment, when there is not sufficient time to compose a comprehensive response.

By way of example of the fundamental weaknesses implied by the article, consider point 5, which reflects a popular concession to advocates of checkbook euthanasia, viz., we can do it cheaper.

I know this one firsthand, because it made me wince every time I heard some "pro-lifer" raise it during the decade my father lived a life against the odds in coma, during which he was fed through a g-tube.

Perhaps, that's why I liked to refer to Dad as our "million dollar man." Believe me, he was worth every penny and far, far more, as is every innocent life. Preserving human life need not be justified in terms of "minimal cost" and frankly it imperils the lives of those who need costly care just to survive to do so. Good intentions can kill just as much as bad ones.

Earl

PS--I served on the Board of Directors of NRLC when Dr. Gerster was its President. To her credit, she introduced a harsh critic of hospice at an NRLC conference, at a time when many "pro-lifers" were touting this Trojan horse of the Culture of Death--alas, they still do so.

Posted by: Earl Appleby at May 10, 2005 9:08 PM

I know what you are saying about cost, Earl. Here's the thing--very often "philosophical" people who discuss these issues pretend that the reality is different from what it really is and end up discussing nonsense situations without acknowledging that this is irrelevant to the real world.

This is especially true about G-tubes. Say _anything_ to a pro-death person about keeping a G-tube in, and this person will start talking (babbling) like you're advocating having the entire world beggar themselves, starving other people from poverty, and so forth, to "save" one person in some wildly expensive way. This is, of course, quite silly, and it is a red herring that takes the discussion off course. It means that they don't have to admit that they really just think certain people should die. Cost _isn't_ really what's driving it in some cases, but they _pretend_ that it is. Consider Terri's case--her parents were willing to take on the entire cost of her care. Cost wasn't the issue, it was the idea that she ought to die, plain and simple.

By pointing out that a G-tube is actually not only not expensive but also fairly simple, Dr. Gerster takes the wind out of the sails of that particular red herring (I believe I'm mixing metaphors dreadfully!).

Posted by: Lydia at May 11, 2005 10:42 AM