Should Nutrition and Hydration Be Provided to Permanently Unconscious and Other Mentally Disabled Persons?
O'Rourke, Kevin, Issues in Law & Medicine
In this article, issues will be considered concerning the providing or withholding of nutrition and hydration to people who are permanently unconscious, that is, in irreversible coma or in a persistent vegetative state, using the statements composed by various medical societies. Second, the norms derived from the statements of the medical societies in regard to providing or withholding life support to people who are permanently unconscious will be compared with the teaching of the Roman Catholic Church. Third, the opinions of some Catholic theologians and other scholars will be considered who do not agree with the author's application of the official teaching of the Church to the question of utilizing nutrition and hydration.
The question of providing artificial nutrition and hydration from the legal perspective will not be considered. While the decisions of legislatures and courts should be founded upon ethical norms, present legal opinions are founded more upon the so-called right to privacy than upon the ethical evaluation of what is beneficial for the person and for the community. Moreover, it is difficult to discern with any certainty the proper legal perspective in regard to withholding life support from permanently unconscious people as illustrated in the decisions of Brophy v. New England Sinai Hospital(1) and Cruzan v. Harmon.(2)
Second, the provision or withholding of nutrition and hydration from persons who are less severely mentally disabled will not be considered. From a medical point of view, there is a significant difference between permanently unconscious persons (that is, people who are designated by medical terminology as being in a persistent vegetative state or p.v.s.) and people who are less severely mentally disabled. People who are permanently unconscious and those with mental disabilities both suffer from impairment of their mental faculties. But people who are permanently unconscious are considered to have no potential for meaningful mental activity, whereas people with mental disabilities have some degree of active mental function.
More significantly, the diagnosis or description of a permanently unconscious state (or p.v.s.) carries with it the implication that one is suffering from a fatal pathology, a fatal pathology being understood as an illness, disease, or lesion which will cause death unless it is removed or circumvented. The fatal pathology affecting the homeostasis of a p.v.s. patient is the inability to chew and swallow, purposeful human activities which are no longer possible if the cerebral cortex is unable to function. The diagnosis or description as mentally disabled does not imply the presence of a fatal pathology. The presence of a fatal pathology is the reason which justifies asking: Should nutrition and hydration be withheld? If a fatal pathology is not present, whether in the person who is mentally competent or in the person who is mentally disabled, then nutrition and hydration should be provided by others if one cannot provide these goods of life for oneself. To put it another way, we have a positive responsibility to prolong our own lives and the lives of others who are dependent upon us as long as our efforts to help another person are beneficial. Only when one's own life or the life of a loved one in our care is threatened by a fatal pathology do we have a moral right to ask the questions: Will attempts to remove or circumvent this pathology be effective or ineffective? Will attempts to circumvent or remove this pathology result in greater burden than benefit for the patient?
The Norms of Medicine Concerning Artificial Nutrition and Hydration
In the last few years, several medical societies have presented norms concerning the care of people in an irreversible coma or persistent vegetative state. Thus, the Council on Ethical and Judicial Affairs of the American Medical Association (AMA),(3) the American Nurses Association (ANA),(4) the American Dietetic Association (ADA),(5) and the American Academy of Neurology (AAN)(6) have all issued statements in regard to care for permanently unconscious patients. …