December 12/26, 2005

Refusal of Hydration and NutritionIrrelevance of the “Artificial” vs “Natural” Distinction

Author Affiliations

Copyright 2005 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.2005

Arch Intern Med. 2005;165(22):2574-2576. doi:10.1001/archinte.165.22.2574

The recent case of Terri Schiavo has reignited a public dispute about certain aspects of the care of patients who are severely cognitively impaired, including those in a persistent vegetative state. Schiavo’s parents repeatedly pointed out that her ability to swallow was never tested and believed that it was possible for her to be safely hand-fed. They also unsuccessfully petitioned the courts to be permitted to attempt hand-feeding if and when her gastrostomy tube was removed.1 In the United States there is an ethical and legal consensus that a competent adult or surrogate may refuse any unwanted medical intervention. Since hand-feeding is not a medical intervention, this request by Schiavo’s parents may have appeared legitimate. In this article, we argue that a convincing response to their request cannot be made within the framework of the current consensus. Instead, we propose that under certain circumstances surrogates may choose that all forms of hydration and nutrition be forgone, regardless of whether they are administered artificially (by tube) or naturally (by hand-feeding). More specifically, we argue that the justification for withdrawal of feedings does not hinge on whether feeding is administered artificially or naturally; rather, it is based on the fundamental rights to self-determination and bodily integrity that permit patients to refuse any unwanted intervention.

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