Nutrition and coexisting disease

Ethics of artificial nutrition

Application of these principles provides a systematic and relatively objective means of approaching ethical dilemmas. Advocates stress that they should be seen, not as precise guides to
inform doctors in every circumstance, but as a framework of
values that are relevant to ethical debate.

John MacFie

Clinical guidelines
The decision-making process in the provision or withdrawal
of artificial nutrition can be difficult. A clear understanding of
the clinical aims of therapy and an appreciation of the ethical
issues facilitates resolution of dilemmas. These have recently
been given extensive media coverage with high profile cases
such as the need to feed or otherwise the late Pope John Paul
II and the tragic case of Terri Schiavo in the US.1 Application of
the principles of autonomy, beneficence, non-maleficence and
justice is one approach and is recommended; Figure 1 illustrates
how this may be used to assist clinicians in the decision whether
to feed.
The patient should be encouraged to state his preferences
throughout the process; if this is not possible, the views of relatives, friends and medical or legal representatives should be
sought to determine his likely wishes. Members of the healthcare
team or relatives may disagree about the patients best interests. This may reflect conflicts in religious, ethnic or other value
systems, and these must be discussed openly before instigation
or withdrawal of therapy. Although the views of relatives are
important in building a picture of the patient for the clinician,
relatives have no right to overrule the decisions of a doctor. The
doctor has the final say as to what is deemed futile and what is
in the patients best interests.
Clinicians must be seen to be transparently honest in their
discussions with all concerned. They must not arbitrarily
impose their own value systems or preferred biases in feeding modality in the absence of evidence, and they should not
make recommendations for treatment or its withdrawal on the
basis of resource considerations. When doubt about the validity of treatment persists, the patients preferences when fully
informed, or his presumed preferences based on discussions
with others, take precedence over healthcare systems or individual doctors opinions, providing this serves the patients best
interests.
Is the patient eating normally? If the answer is yes, he must be
encouraged to maintain an adequate intake; ideally, this should
be monitored by the healthcare team. Formal assessment of intake is appropriate in cases of uncertainty. In these situations,
there are no ethical dilemmas.
If the patient is not eating adequately, the next step is to involve him. Is he competent (Table 1)? If yes, the pros and cons
of feeding must be discussed, with a clear explanation of possible
outcomes and morbidity. Patients have a right to refuse therapy,
and respect for their wishes is paramount. Appropriate palliative
care must be offered, with offers of oral hydration or nutrients.
The patient should be able to change his mind at any point. If
treatment is futile, the doctor has a responsibility to outline this.
Basic care (i.e. food and water), adequate hydration and nursing
care should never be withdrawn.
If the patient is deemed incompetent, it should be established whether he has made an advance directive (living will)

Abstract
Recent decades have seen dramatic improvements in our ability as a
profession to care for patients with critical illness and chronic disease.
One consequence of this is that patients now more often survive to a
point where nutrition becomes a limiting factor in their care. In addition,
we now have the skills and technology to maintain a patients nutritional
status indefinitely. Taken together, these factors have significantly raised
the professions awareness of the ethical dilemmas involved in the provision of artificial nutrition. This short article suggests one approach to
these vexed questions.

Keywords artificial nutrition; ethics; nutrition; terminal illness

In normal adults, total starvation leads to death from malnutrition within 6070 days. However, functional metabolic deficits
become evident after only 10 days of semi-starvation in previously healthy individuals (less in those already compromised by
disease), and psychological and mood disturbances may emerge
after as little as 1 day without food. Nutritional support should
be considered in all patients in whom oral intake is anticipated to
be inadequate for 710 days or more. Modern technology enables
such support to be given for indefinite periods in almost all clinical situations, but this has resource and ethical consequences.
Most doctors face the dilemmas to treat or not to treat and to
withdraw or continue on a daily basis, but the ethical concerns
are greatest when the treatment is provision of food.
Ethical codes of caring professions include not only minimum
standards of behaviour but also ideals, and have been described
as the collective conscience of the profession. Contemporary
medical ethics can be considered as based on four important
principlesautonomy, non-maleficence, beneficence and justice.
Autonomy is the principle of self-determination and involves
recognition of patient rights; in most democratic states, it is now
the pre-eminent theme in law.
Non-maleficence is deliberate avoidance of harm.
Beneficence is the concept that the patient is provided with
some form of benefit.
Justice is the fair and equitable provision of available medical
resources to all.

John MacFie MD FRCS is a Consultant Surgeon at Scarborough Hospital,

Scarborough, UK. Competing interests: none declared.

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Nutrition and coexisting disease

Decision-making in artificial nutritional support

Yes

Monitor

Uncertain

Involve dietitian/nutrition team

Is the patient eating normally?

No
No
Is patient competent?

No
Is there an advance directive?

Is there uncertainty over futility of treatment?

Yes

Yes

Yes

No

No
Discuss benefits and
burdens of treatment

Patient defers

No treatment

Is life-prolonging
therapy indicated?

Patient agrees

Time-limited trial

No treatment

Yes

Artificial nutritional support a possibility

Figure 1

indicating his preference for treatment or non-treatment should

he ever become incompetent to make that decision. This does
not have to be a formal, witnessed, written document; contemporaneous records in, for example, his general practitioners
notes may suffice. If an advance directive specifically refers
to prolonging therapy, the patients wishes must be observed.
Not to do so renders the attending doctor liable to a charge of
assault.
In the absence of an advance directive, the decision must be
made by a surrogate; in the UK and most of continental Europe,
this is usually the patients medical attendant. The doctor must
decide whether treatment is futile or confers benefit, and this
requires a clear view of the aims of therapy. Does the patient
fulfil any of the conditions for non-treatment (Table2)? Would
treatment not be in his best interests? Doctors are not obliged to
instigate therapies that they believe will do no good.
Genuine uncertainty about the futility of treatment necessitates discussion with other members of the health-care team,
possible second opinions and involvement of the relatives. Every

e ndeavour must be made to establish what the patient might have

wanted, were he able to express a view. The overriding factor
must be to do what is in his best interests. This entails providing
care that provides a positive advantage to him, preferably agreed
by him and not simply with the aim of achieving physiological
goals. It is technically possible to maintain life in patients in a
persistent vegetative state, but this may not be in the best interests of the individual. Continuing uncertainty is a good reason for
commencement of a time-limited trial of therapy. The aims and
duration of such trials must be clearly recorded, and frank and
open discussion with relatives and other carers is essential.
It is well established in law and ethics that competent adults
have the right to refuse any medical treatment, even if that
refusal will result in their death. In the UK, most of continental Europe and the USA, there is no acceptance of the principle
of retro-active consent, whereby a patient gives consent after

Conditions for non-treatment of incompetent patients

Irreversible closeness to death
Extensive neurological damage leading to permanent
destruction of both self-awareness and intentional action
Little self-awareness accompanied by such severe motor
disability that sustained independent and intentional action
is impossible
Destruction of both long-term and short-term memory to
such a degree that the individual no longer exists and no
other individual can evolve in his or her place
Patient has severely limited understanding of distressing and
marginally effective life-saving treatment that will lead to a
demonstrably awful life

Competence
Competent patients should be able to
Understand a simple explanation of their condition, its
prognosis and proposed treatment or non-treatment
Reason consistently about specific aims linked to their
personal beliefs
Choose to act on the basis of such reasoning
Communicate the substance of and their reasons for that
choice
Understand the practical consequences of their choice
Table 1

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Table 2

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being given a treatment that was initially refused. In Israel, however, patients rights law permits treatment of competent patients
against their will, on the basis that there is reason to believe that
they would change their mind after treatment. The rationale is
that, at the time the patient refuses treatment, he is not of sound
mind as a consequence of starvation or other factors; following
treatment, however, he becomes rational and can provide retroactive consent. In most countries, force-feeding of a competent
individual would constitute assault.
There is an ethical dilemma in the management of confused,
semiconscious or demented patients who remove or dislodge
feeding tubes or lines. Use of restraint may be considered a violation of patient freedom, and thereby their autonomy. Clinicians
must exercise judgement, compassion and common sense in such
situations. In the UK, the Mental Health Act permits compulsory
detention of patients with recognized mental disorders, including eating disorders such as anorexia nervosa. Under certain circumstances, the law permits use of artificial nutritional support
against the will of these patients, on the basis that feeding is an
integral part of their treatment. This might apply to other patients
who are deemed incompetent.

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Reference
1 Casarett D, Kapo J, Caplan A. Appropriate use of artificial nutrition
and hydrationfundamental principles and recommendations. N Eng
J Med 2005; 353: 260712.
Further reading
Lennard-Jones L E. Ethical and Legal Aspects of Clinical Hydration
and Nutritional Support. A Report for the British Association of
Parenteral and Enteral Nutrition. Maidenhead: BAPEN, 1999.
MacFie J. Ethical and Legal Considerations in the Provision of
Nutritional Support to the Perioperative Patient. Curr Opin Clin Nutr
Metab Care 2000; 3: 239.
Rosenthal E T. Artificial butrition and hydration: how to make decisions
in a complicated and emotive area. Oncology Times 2006; March:
45.
MacFie J. Ethics and Nutrition. In: Gibney M, Elia M, Ljungqvist O,
Dowsett J, eds. Clinical nutrition (Nutrition Society Textbook series).
Oxford: Blackwell Science, 2005.
(These publications provide a full discussion and explanation
of the terms best interests, basic care, futility, autonomy,
beneficence, maleficence, justice, and time-limited trial.)

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2006 Published by Elsevier Ltd.