Christian Worldview Concepts

Feeding Tubes and End-of-Life Decision Making

Is Tube Feeding Artificial Life Support?

Much of the Terri Schiavo media coverage was filled with misinformed sound bites; claims that she was "being kept alive by artificial life support," that her feeding tube was "heroic medical treatment." Do these ambiguous claims stand up to serious ethical and medical scrutiny?

Such statements reflect the fears that people have about the kinds of catastrophic things that can happen to them and their ideas of what life would be like should such unfortunate circumstances occur. It is common for people to say things like "I would never want to live like that," meaning remain alive in a less than desirable condition. Who would? I do not know of anyone who says, "I want to live in a permanent state of dependence upon others without any engagement with the world around me."

The most common response to such circumstances is for people to say, "If I am ever in that condition (i.e., permanent severe brain damage, medically dependent on life support, no quality of life), I do not want to be kept alive by artificial life support." Most people have in mind not being tethered to machines that sustain vital organ function, e.g., ventilators. They usually do not mean "starve me to death with dignity."

The idea of death by starvation and dehydration is repugnant, and deliberately withholding or withdrawing food and fluids from people in order to hasten their deaths is undoubtedly active euthanasia, not comfort care. Withdrawing or withholding food and fluids seems to fly in the face of what we consider normative in caring for individuals who cannot care for themselves.

It is no trivial matter to begin tampering with basic methods of care like providing food and fluids. As bioethicist Daniel Callahan observes, "[These traditions] were cultivated to provide as solid a fortress as morality can offer against a human propensity — seen time and again with the elderly — to neglect, abuse, or kill the powerless, the burdensome and the inconvenient . . . . It is one thing to make an occasional exception to a general rule to provide food and water as part of minimal nursing care, and still another to make it a routine way to help death along." ¹

Tube feeding does nothing more than provide nutrition (food) and hydration (fluids) in order to retain and sustain the integrated organ systems of the body. A feeding tube is no more "artificial" than a flexible straw in a milkshake from McDonalds. A feeding tube is not a spectacular medical intervention; it is merely a delivery system for food and fluids. If it has any features akin to medical treatment it is its insertion (i.e., it requires a medical procedure) and its location (i.e., a stoma or opening in the person's abdomen). Although the stoma requires nursing care in order to prevent infection from developing, what comes through the feeding tube into the person's body is NOT medical. Food and fluids are not medical; they are basic care required for anyone. Some argue that tube feeding is medical treatment because it is provided by medical personnel. Does anyone really think that a hamburger becomes a medical treatment if it cooked by a doctor and served by a nurse? Just because something is administered by medical personnel within a medical facility does not make it medical.

Furthermore, food and fluids are not "artificial life support" or "heroic medical treatment." Food, fluids and oxygen are basic to human survival, whether one is healthy or deathly ill. The healthiest person among us will rapidly become the least healthy if we withhold these life essentials. Generally, individuals are capable of receiving these life essentials by both voluntary (eating and drinking voluntary choices) and involuntary (breathing is an involuntary bodily function) means. When there is a disruption of a person's ability to breathe, eat or drink, we rightly assume that restoring either the ability to eat, drink and breathe is desired, or that the person would want those essentials provided until they can resume such basic functions on their own.

What, then, makes the provision of food, fluids or air "artificial" and, therefore, undesirable? Do food, fluids and air suddenly become artificial when a person cannot raise a spoon or fork to his mouth, sip and swallow a beverage or take in a breath on his own? Should we regard these as the criteria for determining that a person should be allowed to die? Does the temporary or permanent loss of the ability to feed oneself or breathe spontaneously mean that we are to step back and allow nature to takes it course?

Typically, we do not just surrender to nature. Over time, we have come up with ways to provide the essentials of food, fluids and air. When conditions warrant, we are able to provide life-sustaining food, fluids and air through things like feeding tubes and ventilators. Generally speaking, people do not think of these as "heroic," but as ordinary care.

Feeding tubes are routinely used is many post-surgical patients who temporarily cannot take food by mouth. Ventilators provide oxygen to patients following a wide array of surgeries. No one really considers these technologies "heroic" under these circumstances, which is precisely the point. There are no heroic medical treatments; there are only ordinary ones.

¹ Daniel Callahan, Setting Limits: Medical Goals in an Aging Society (New York: Simon and Schuster, 1987), p.188