- Email: [email protected]
Drs. MClave et al respond
Volume 22 䡲 Number 12 䡲 December 䡲 2011
Editor: In the August issue of JVIR, guidelines for gastrointestinal access for enteral nutrition and decompression are well presented (1). However, a major flaw of the article concerns the section on ethical issues. In this section, there are fundamental errors, misleading statements, and an emotive tone conveying an unbalanced appraisal of an important clinical matter, which is probably best not to appear in an official statement of practice guidelines. First, the comment that providing unwanted medical care diminishes patient dignity is not accurate. Certainly unwanted medical interventions may be performed in a way that is inappropriate, not respectful of the patient, or downright unethical. However, human dignity is of constant value, and is not diminished by another’s actions, despite actions that may be undignified. Second, nutrition is essential, and basic to life, and is different from medical therapies, some of which are clearly not essential. To understand the distinction, it may be helpful to consider an essential intervention as something, independent of anything else, without which a person will die. The absence of nutrition and hydration alone are sufficient for leading to death. The absence of antibiotics or chemotherapy are not—alone, or independent of something else—sufficient to lead to death. Third, there are innumerable ethicists who see the provision of nutrition and hydration as very different from various medical therapies. Making the generalization that “providing nutrition and hydration is indistinguishable in the eyes of ethicists” from antibiotics and other medical therapies is misleading. Finally, the authors’ assertion that the distinction between ordinary and extraordinary therapy is meaningless is simply false. One needs only to know that ethical thought and analysis over centuries, which has shaped current understandings in medical ethics, hinges in large part on the distinction between ordinary and extraordinary interventions. In light of these errors, coupled with an emotive undercurrent suggesting only one side of an important and ongoing debate in medical ethics, it may have been best for the guidelines to have omitted this section or to have conveyed a more balanced discussion.
REFERENCE 1. Itkin M, DeLegge MH, Fang JC, et al. Multidisciplinary practical guidelines for gastrointestinal access for enteral nutrition and decompression from the Society of Interventional Radiology and American Gastroenterological Association (AGA) Institute, with endorsement by Canadian Interventional Radiological Association (CIRA) and Cardiovascular and Interventional Radiological Society of Europe (CIRSE). J Vasc Interv Radiol 2011; 22:1089 –1106.
1781
Drs. McClave et al respond: Despite extensive literature and the ruling by state appellate courts and the Untied States Supreme Court, we are still arguing about the ethics of delivery of enteral nutrition and hydration 35 years after the precedent-setting case involving Karen Quinlan (1). As the letter from Dr. Travaline indicates, providing nutrition and hydration at the end of life is still an emotional and controversial issue (2). This writer demonstrates the paternalist view, which prevailed in the early 1970s. According to this view, the provision of nutrition and hydration is a basic obligation of health care providers regardless of patient wishes (3). He is not alone in his beliefs, as a similar view was evident in the 2004 Papal Allocution for Roman Catholics and was operative in the intervention by Florida politicians in the Terri Schiavo case in 2005 (4). Although the author refers to “innumerable ethicists” who might follow his line of thinking, the courts are, fortunately, very clear in their direction, and most of what resulted from 35 years of litigation would be in disagreement with this viewpoint (5). Dignity can be defined as “the quality or state of being worthy of esteem or respect, inherent nobility, and worth” (6). Although the writer is using a rather technical argument to imply that dignity is a constant value that cannot be altered by another’s actions, he is nonetheless avoiding a very common traditional paternalist argument for providing nutritional support at end of life because “maintenance of nutrition support respects and preserves the dignity of the patient, or enhances the trust and confidence that are essential to the physician-patient relationship” (5). Providing unwanted medical care violates the basic tenet of autonomy. How can we hold a patient in esteem if we show disrespect for his autonomy? How can we preserve dignity if we ignore the patient’s wishes? The right to consent to medical therapy is meaningless if the patient does not have the right to refuse. Providing nutrition support is not without risk and discomfort. How could a complication arising from unwanted medical care be justified? One could argue that such an act could actually be perceived as battery (“an intentional unpermitted act causing harmful or offensive contact with the person of another” [6]). In a review of 41 cases of judicial decisions regarding foregoing artificial nutrition and hydration (5), a majority of the cases (24 of 41) specified that there was a constitutionally protected right to have feeding tubes removed based solely on the patient’s wishes. Of these, four specified that, if a facility was not able to meet the patient’s wishes, the patient had to be transferred to an institution that would honor their wishes to have the tube removed. An additional six of the 41 studies denied removal of the tubes simply because the patient’s wishes were not known ahead of time (5). Although the exact definition of human dignity can be a lengthy discussion in
The author has not identified a conflict of interest.
None of the authors have identified a conflict of interest.
DOI: 10.1016/j.jvir.2011.10.006
DOI: 10.1016/j.jvir.2011.10.007
1782 䡲 Letters to the Editor
itself, one cannot use this argument to justify providing unwanted medical therapy. Second, Dr. Travaline argues that nutrition is essential and basic to life and is clearly different from other medical therapies. Here, the courts could not be any clearer. Of the 41 cases described in the review by Mayo (5), all 41 indicate that the courts make no distinction between the provision of nutrition and hydration and other forms of medical treatment. If the provision of basic nutrition support requires a surgical incision and placement of a percutaneous gastrostomy tube, even the lines of distinction between invasive and noninvasive become blurred. The writer goes on to state that “the absence of nutrition and hydration alone are sufficient for leading to death” that distinguishes it from other medical therapy. This line of thinking is based on a faulty legal concept called “but for causation,” implying that “but for” the cessation of a certain level of care, the patient would still be alive (7). “But for causation” is flawed because it does not provide a complete account of the cause of a patient’s death and is deficient in determining whether such an act is morally praiseworthy or blameworthy (5,7). Although the provision of nutrition and hydration may delay the inevitable, it is the patient’s underlying disease illness or disease process that causes the patient’s death. Finally, the writer argues that there is an important distinction between ordinary and extraordinary therapy. This argument violates a basic premise of technology, that the extraordinary care of today is the ordinary care of tomorrow. As Mayo asserts (5), it is pointless to compare oxygen therapy (via mechanical ventilation) on the one hand, and nutrition and hydration on the other, to determine which one is more “basic.” Ethicists and the courts have moved away from this “now-discredited distinction between extraordinary and ordinary care” (5). With an emphasis on patient autonomy, patients can simply choose which end-of-life therapy they want. The form from the Physician Orders for Life-Sustaining Treatment Paradigm Program (8) provides a checklist of end-of-life treatment options for participating states to honor patient wishes. Although Dr. Travaline demonstrates a recurrent paternalistic view, we hope he does not imply that his
McClave et al 䡲 JVIR
beliefs should supersede those of the courts. The balanced discussions have been done, and the courts have decided that this paternalistic view is not in the best interests of the patient. One would hope that the study of ethics would provide an objective approach to navigate difficult end-of-life decisions, but it is clear from this response to our publication (9) that such ethical wrangling is still an emotional issue. Stephen A. McClave, MD Andrew Taber, MD Division of Gastroenterology/Hepatology University of Louisville School of Medicine Louisville, Kentucky Matthew Bozeman, MD Department of Surgery University of Louisville School of Medicine Louisville, Kentucky Arvin Gee, MD, PhD Robert G. Martindale, MD, PhD Department of Surgery Oregon Health Sciences University Portland, Oregon
REFERENCES 1. In re Quinlan, 70 N.J. 10, 355 A.2d 647, cert. Denied, 429 U.S. 922 (1976). 2. Travaline JM. Letter to the editor regarding ”multidisciplinary practical guidelines for gastrointestinal access for enteral nutrition and decompression. J Vasc Interv Radiol 2011; 22:1780 –1781. 3. Meyers DW. Legal aspects of withdrawing nourishment from an incurably ill patient. Arch Intern Med 1985; 145:125–128. 4. Sulmassy DP. Terri Schiavo and the Roman Catholic tradition of forgoing extraordinary means of care. J Law Med Ethics 2005; 33:359 –362. 5. Mayo TW. Forgoing artificial nutrition and hydration: legal and ethical considerations. Nutr Clin Pract 1996; 11:254 –264. 6. The American Heritage Dictionary of the English Language, Fourth Edition. New York: Houghton Mifflin, 2009. 7. Brock DW. Deciding for others. London: Cambridge University Press, 1993. 8. Physicians for Life-Sustaining Treatment Paradigm. POLST Paradigm Forms. Available at: www.ohsu.edu/polst/programs/sample-forms. htm. Accessed October 11, 2011. 9. Itkin M, DeLegge MH, Fang JC, et al. Multidisciplinary practical guidelines for gastrointestinal access for enteral nutrition and decompression from the Society of Interventional Radiology and American Gastroenterological Association (AGA) Institute, with endorsement by Canadian Interventional Radiological Association (CIRA) and Cardiovascular and Interventional Radiological Society of Europe (CIRSE). J Vasc Interv Radiol 2011; 22:1089 –1106.
Editor: In the August issue of JVIR, guidelines for gastrointestinal access for enteral nutrition and decompression are well presented (1). However, a major flaw of the article concerns the section on ethical issues. In this section, there are fundamental errors, misleading statements, and an emotive tone conveying an unbalanced appraisal of an important clinical matter, which is probably best not to appear in an official statement of practice guidelines. First, the comment that providing unwanted medical care diminishes patient dignity is not accurate. Certainly unwanted medical interventions may be performed in a way that is inappropriate, not respectful of the patient, or downright unethical. However, human dignity is of constant value, and is not diminished by another’s actions, despite actions that may be undignified. Second, nutrition is essential, and basic to life, and is different from medical therapies, some of which are clearly not essential. To understand the distinction, it may be helpful to consider an essential intervention as something, independent of anything else, without which a person will die. The absence of nutrition and hydration alone are sufficient for leading to death. The absence of antibiotics or chemotherapy are not—alone, or independent of something else—sufficient to lead to death. Third, there are innumerable ethicists who see the provision of nutrition and hydration as very different from various medical therapies. Making the generalization that “providing nutrition and hydration is indistinguishable in the eyes of ethicists” from antibiotics and other medical therapies is misleading. Finally, the authors’ assertion that the distinction between ordinary and extraordinary therapy is meaningless is simply false. One needs only to know that ethical thought and analysis over centuries, which has shaped current understandings in medical ethics, hinges in large part on the distinction between ordinary and extraordinary interventions. In light of these errors, coupled with an emotive undercurrent suggesting only one side of an important and ongoing debate in medical ethics, it may have been best for the guidelines to have omitted this section or to have conveyed a more balanced discussion.
REFERENCE 1. Itkin M, DeLegge MH, Fang JC, et al. Multidisciplinary practical guidelines for gastrointestinal access for enteral nutrition and decompression from the Society of Interventional Radiology and American Gastroenterological Association (AGA) Institute, with endorsement by Canadian Interventional Radiological Association (CIRA) and Cardiovascular and Interventional Radiological Society of Europe (CIRSE). J Vasc Interv Radiol 2011; 22:1089 –1106.
1781
Drs. McClave et al respond: Despite extensive literature and the ruling by state appellate courts and the Untied States Supreme Court, we are still arguing about the ethics of delivery of enteral nutrition and hydration 35 years after the precedent-setting case involving Karen Quinlan (1). As the letter from Dr. Travaline indicates, providing nutrition and hydration at the end of life is still an emotional and controversial issue (2). This writer demonstrates the paternalist view, which prevailed in the early 1970s. According to this view, the provision of nutrition and hydration is a basic obligation of health care providers regardless of patient wishes (3). He is not alone in his beliefs, as a similar view was evident in the 2004 Papal Allocution for Roman Catholics and was operative in the intervention by Florida politicians in the Terri Schiavo case in 2005 (4). Although the author refers to “innumerable ethicists” who might follow his line of thinking, the courts are, fortunately, very clear in their direction, and most of what resulted from 35 years of litigation would be in disagreement with this viewpoint (5). Dignity can be defined as “the quality or state of being worthy of esteem or respect, inherent nobility, and worth” (6). Although the writer is using a rather technical argument to imply that dignity is a constant value that cannot be altered by another’s actions, he is nonetheless avoiding a very common traditional paternalist argument for providing nutritional support at end of life because “maintenance of nutrition support respects and preserves the dignity of the patient, or enhances the trust and confidence that are essential to the physician-patient relationship” (5). Providing unwanted medical care violates the basic tenet of autonomy. How can we hold a patient in esteem if we show disrespect for his autonomy? How can we preserve dignity if we ignore the patient’s wishes? The right to consent to medical therapy is meaningless if the patient does not have the right to refuse. Providing nutrition support is not without risk and discomfort. How could a complication arising from unwanted medical care be justified? One could argue that such an act could actually be perceived as battery (“an intentional unpermitted act causing harmful or offensive contact with the person of another” [6]). In a review of 41 cases of judicial decisions regarding foregoing artificial nutrition and hydration (5), a majority of the cases (24 of 41) specified that there was a constitutionally protected right to have feeding tubes removed based solely on the patient’s wishes. Of these, four specified that, if a facility was not able to meet the patient’s wishes, the patient had to be transferred to an institution that would honor their wishes to have the tube removed. An additional six of the 41 studies denied removal of the tubes simply because the patient’s wishes were not known ahead of time (5). Although the exact definition of human dignity can be a lengthy discussion in
The author has not identified a conflict of interest.
None of the authors have identified a conflict of interest.
DOI: 10.1016/j.jvir.2011.10.006
DOI: 10.1016/j.jvir.2011.10.007
1782 䡲 Letters to the Editor
itself, one cannot use this argument to justify providing unwanted medical therapy. Second, Dr. Travaline argues that nutrition is essential and basic to life and is clearly different from other medical therapies. Here, the courts could not be any clearer. Of the 41 cases described in the review by Mayo (5), all 41 indicate that the courts make no distinction between the provision of nutrition and hydration and other forms of medical treatment. If the provision of basic nutrition support requires a surgical incision and placement of a percutaneous gastrostomy tube, even the lines of distinction between invasive and noninvasive become blurred. The writer goes on to state that “the absence of nutrition and hydration alone are sufficient for leading to death” that distinguishes it from other medical therapy. This line of thinking is based on a faulty legal concept called “but for causation,” implying that “but for” the cessation of a certain level of care, the patient would still be alive (7). “But for causation” is flawed because it does not provide a complete account of the cause of a patient’s death and is deficient in determining whether such an act is morally praiseworthy or blameworthy (5,7). Although the provision of nutrition and hydration may delay the inevitable, it is the patient’s underlying disease illness or disease process that causes the patient’s death. Finally, the writer argues that there is an important distinction between ordinary and extraordinary therapy. This argument violates a basic premise of technology, that the extraordinary care of today is the ordinary care of tomorrow. As Mayo asserts (5), it is pointless to compare oxygen therapy (via mechanical ventilation) on the one hand, and nutrition and hydration on the other, to determine which one is more “basic.” Ethicists and the courts have moved away from this “now-discredited distinction between extraordinary and ordinary care” (5). With an emphasis on patient autonomy, patients can simply choose which end-of-life therapy they want. The form from the Physician Orders for Life-Sustaining Treatment Paradigm Program (8) provides a checklist of end-of-life treatment options for participating states to honor patient wishes. Although Dr. Travaline demonstrates a recurrent paternalistic view, we hope he does not imply that his
McClave et al 䡲 JVIR
beliefs should supersede those of the courts. The balanced discussions have been done, and the courts have decided that this paternalistic view is not in the best interests of the patient. One would hope that the study of ethics would provide an objective approach to navigate difficult end-of-life decisions, but it is clear from this response to our publication (9) that such ethical wrangling is still an emotional issue. Stephen A. McClave, MD Andrew Taber, MD Division of Gastroenterology/Hepatology University of Louisville School of Medicine Louisville, Kentucky Matthew Bozeman, MD Department of Surgery University of Louisville School of Medicine Louisville, Kentucky Arvin Gee, MD, PhD Robert G. Martindale, MD, PhD Department of Surgery Oregon Health Sciences University Portland, Oregon
REFERENCES 1. In re Quinlan, 70 N.J. 10, 355 A.2d 647, cert. Denied, 429 U.S. 922 (1976). 2. Travaline JM. Letter to the editor regarding ”multidisciplinary practical guidelines for gastrointestinal access for enteral nutrition and decompression. J Vasc Interv Radiol 2011; 22:1780 –1781. 3. Meyers DW. Legal aspects of withdrawing nourishment from an incurably ill patient. Arch Intern Med 1985; 145:125–128. 4. Sulmassy DP. Terri Schiavo and the Roman Catholic tradition of forgoing extraordinary means of care. J Law Med Ethics 2005; 33:359 –362. 5. Mayo TW. Forgoing artificial nutrition and hydration: legal and ethical considerations. Nutr Clin Pract 1996; 11:254 –264. 6. The American Heritage Dictionary of the English Language, Fourth Edition. New York: Houghton Mifflin, 2009. 7. Brock DW. Deciding for others. London: Cambridge University Press, 1993. 8. Physicians for Life-Sustaining Treatment Paradigm. POLST Paradigm Forms. Available at: www.ohsu.edu/polst/programs/sample-forms. htm. Accessed October 11, 2011. 9. Itkin M, DeLegge MH, Fang JC, et al. Multidisciplinary practical guidelines for gastrointestinal access for enteral nutrition and decompression from the Society of Interventional Radiology and American Gastroenterological Association (AGA) Institute, with endorsement by Canadian Interventional Radiological Association (CIRA) and Cardiovascular and Interventional Radiological Society of Europe (CIRSE). J Vasc Interv Radiol 2011; 22:1089 –1106.