Hydration and Nutrition
A Basic Human Need, Not an Option of Medical Care
By Carolyn F. Gerster, M.D.
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.