This article appears in the February 1999 edition of the Catholic Medical Quarterly
LETTERS TO THE EDITOR
Dept. of Anaesthesia and Intensive Care
Yan Chai Hospital
I read with interest Dr D Kingsley's criticism of the arguments by Drs. Treloar and Howard regarding assisted feeding in mentally incapacitated patients. Whilst I agree wholeheartedly with the assertion that food and fluid constitute ordinary care, I utterly reject the notion that nutrition and hydration can be considered as nothing other than ordinary means, regardless of how such basic daily needs are administered. Surely spoon feeding a disabled patient is very far removed from total parenteral nutrition (TPN) in a renal failure patient prone to fluid overload; yet both constitute no more than the provision of the basic needs of nutrition and hydration. They are just different parts of the same spectrum.
The story of this unfortunate baby I had once anaesthetised might put this problem area of assisted feeding into sharper perspective. This neonate underwent a laparotomy at 7 hours of age to diagnose and treat the cause of intestinal obstruction believed to be aganglionosis of the gut. As the surgeons biopsied various parts of his gut for the next 7 hours, the nerve cells vital to intestinal motility could finally be located in the jejunal area, leaving him insufficient gut to survive. The decision was made to feed the neonate parenterally Given that TPN can result in fatal liver failure in the neonate and the infant, one is faced with the prospect of starving the baby to death to avoid feeding the baby to death, or vice versa. Personally I don't think I would choose to feed the baby until he died of liver failure induced by TPN. I wonder what Drs. Kingsley, Treloar or Howard would choose?
In the article on feeding tubes, the authors argued that the placement of a tube is not an ordinary means, when the medium risks are considered unacceptable. Dr. Kingsley seemed to reject this in his letter, asserting that we have an obligation to feed and hydrate our patients by whatever means are necessary, implying that the provision of nutrition is of such central importance in the care of a patient that no risk can ever be too high. Reductio ad absurdurn, we have a duty to provide TPN to all, if other means of providing nutrition fails, regardless of the risks and burdens that such "care" may impose.
The Declaration on Euthanasia issued by the Sacred Congregation for the Doctrine of the Faith in 1980 changed from the language of "ordinary" and "extra-ordinary means" of the 1957 address by Pius XII to that of talking about due proportion in the use of remedies. It clearly elucidated the arguments behind the various course of action open to the faithful, should they find themselves in the unfortunate position of having to decide on complicated treatments which are risky and uncertain of benefit. Neither in this nor the earlier document does the Church imply that human life must be preserved at all costs, whatever the costs may be.
Amidst the current clamour for living wills, advanced directives, enduring powers of attorney, even voluntary active euthanasia, I can personally discern a fear of hopelessly ill patients being kept alive with the most modern technologies science can offer. They fear doctors may ignore their pleas to be left to die without the loss of dignity and the distress such modern technologies may impose. They resent the loss of control, especially the loss of control over their own departure from this world. Some people may support euthanasia for these reasons.
I am absolutely against euthanasia. Let us not score an own goal by suggesting that we are obliged to keep the patient alive at all costs. We do no one a service if we insist on this, least of all our Church, which will be portrayed as remote and insensitive to the changes brought about by the advancement of science.
Dr Peter Au-Yeung Staff Specialist