Nutrition and Hydration (Letters) (Letter to the Editor‪)‬

To The Editor: Though Repenshek and Slosar ("Medically Assisted Nutrition and Hydration: A Contribution to the Dialogue," Nov-Dec 2004) correctly note the critical importance of circumstances in determining the obligatory nature of treatment, to argue, in agreement with the Ethical and Religious Directives and the papal statement, that there is a presumption in favor of using medically assisted nutrition and hydration (ANH) is to change the nature of the argument from its traditional teleological nature--a judgment on the effects that the proposed intervention will have on the patient--to a more deontological one. This is because the ordinary/extraordinary distinction is being used to classify the technology in the abstract, independent of concrete circumstances, rather than to evaluate whether it is morally ordinary in a specific patient's case. The authors claim that "'in principle ordinary and proportionate' does not mean 'without exception,' but only 'all other things being equal.'" Such an argument sets the circumstances aside. Only when "all things are considered" do circumstances come into play for moral judgment. Thus the authors make a claim that the historical tradition and we would not make, namely, that some medical interventions can be judged morally to be either proportionate or disproportionate before the concrete circumstances of an individual patient are considered. The papal statement says that ANH "always represents a natural means of preserving life, not a medical act." The obligation to provide the "normal care due to the patient in such cases" includes the use of nutrition and hydration. "Death by starvation or dehydration is, in fact, the only possible outcome as a result of their withdrawal. In this sense it ends up becoming, if done knowingly and willingly, true and proper euthanasia by omission." Even though, as the authors note, the term "in principle" occurs in this paragraph, it strikes us as difficult to understand the text as saying anything other than that ANH is morally ordinary and cannot be withdrawn. The phrase "euthanasia by omission" is fairly clear.