August 13, 2005

Respirators and Feeding Tubes

In this essay, I intend to examine the moral difference between respirators and feeding tubes. This distinction is very difficult to make, and even the Catholic Church, known for taking the conservative side on life issues, did not make any statement on the issue of feeding tubes until 1998. I will discuss the moral relevance of the distinction between ordinary and extraordinary care, and then discuss why a respirator is extraordinary care, and therefore may be withdrawn with a patient's consent, and a feeding tube is ordinary care.

The relevance of ordinary versus extraordinary care is a difficult one, and hard to apply in particular cases. It is worth understanding the reason for this distinction. The question is why starving oneself to death is a form of suicide, but refusing painful chemotherapy is not suicide. The solution has to do with the principle of double effect, which I discuss in this essay. According to the principle of double effect, if someone predicts a negative consequence to an action, but desires it neither as an end or a means, that consequence is not intended but merely foreseen. For instance, in the case of starving oneself to death, one desires to die, and the starvation is the means to that end. In the case of refusing chemotherapy, one desires to avoid the painful chemotherapy, and the death is a foreseen consequence of that refusal. However, one does not desire the death at all, either as an end or a means, so it is unintended and not suicide.

The relevance of this to ordinary and extraordinary care is that most extraordinary care is invasive and often painful. It is something that people would wish to avoid for its own sake. Part of this is the pain, but the invasion is more problematic. It is a violation of our bodily integrity to be cut up and fed chemicals. In the case of extraordinary care, it is reasonable to avoid this violation of our bodies itself, and people should have the right to refuse this care, regardless of whether or not it is life saving. This is because the patient may be intending only to avoid the violating procedure itself, and not intending suicide. However, for ordinary care, a person cannot reasonably claim that he or she is simply avoiding the care while not intending the death. For instance, someone for whom it is not painful cannot reasonably claim that he or she is willing to die to avoid the violation of having to eat. Someone who refused to eat or be washed would not be invoking the principle of double effect, but would be committing suicide.

Let us return then to respirators and feeding tubes. Do they qualify as ordinary or extraordinary care? Neither is obviously one or the other, which is why there has been so much debate. Usually, the criteria for determining extraordinary and ordinary care are commonality and degree of invasiveness. Both are now equally common, though respirators are more expensive. In terms of invasiveness, respirators are more invasive. Both use tubes, though there are different forms of feeding tubes, either oral, nasal, or abdominal. These are relatively small differences. The main reason that respirators are more invasive is that they forcibly expand and contract the lungs every few seconds. This is a constant bodily manipulation the likes of which feeding tubes do not even approach. In fact, because respirators contantly, forcibly manipulate the patient's organs, it is one of the more extraordinary forms of care there is. Feeding tubes do nothing at all like this.

Feeding tubes are less invasive then respirators, then, but do they still meet the test of being considered ordinary care? After all, they could be less invasive than respirators, but still invasive enough to qualify as extraordinary. The difficulty in deciding this is why there is still so much debate. Most arguments focus on the fact that feeding tubes require a fairly non-invasive procedure to insert and are nearly painless once inserted. In the case of abdominal tubes (the most invasive), the tube is inserted in a procedure requiring less than an hour that can be performed under local anaesthetic called a percutaneous endoscopic gastrostomy. It is hard to believe that someone would be so unwilling to undergo this procedure as to be willing to die, unless that person were someone otherwise desiring death, that is, suicidal. Therefore, the principle of double effect does not apply, and the care should be considered ordinary.

Another consideration is that if feeding tubes were considered extraordinary, there would be no form of ordinary care for unconscious patients. No unconscious patient is able to swallow, and there is no other way to feed them except through a feeding tube. This however, is extremely implausible. Keeping people alive who are unconscious for a moderate to extended amount of time should not be considered an act of extraordinary medical intervention. As such, the definition of "ordinary care" must allow for some minimum standard of care for unconscious patients, and any minimum standard of care for unconscious patients would include a feeding tube. Therefore, feeding tubes must be considered a sort of ordinary care.

In conclusion, there is substantial difference between respirators and feeding tubes. Respirators are a form of extraordinary care that patients may refuse for their own sakes without committing suicide. Feeding tubes, on the other hand, are a form of ordinary care that cannot be refused without committing suicide. States that wish to disallow suicide should no more allow patients to refuse feeding tubes than to refuse other forms of nutrition and hydration.


Kyle said...

I am not finding your argument here very convincing. The brief research I've done has actually suggested long-term respirators are relatively painless (maybe you have a source that states the contrary?), and the argument that forcing an organ to do exactly what it would normally do constitutes invasiveness doesn't seem convincing to me.

However, rather than debate those particulars, I would be interested in your response to the following argument.

Based upon your arguments here I believe an iron lung should be considered ordinary care.

Firstly, there are no tubes or other invasive objects placed in the body. Secondly, it does not forcibly operate on an organ in any way that the organ would not usually operate - lungs are supposed to create a negative pressure gradient that allows air to come into the lungs. Iron longs do this. By any measure you have suggested here, respiration by iron lungs are even more ordinary than feeding tubes.

Daniel said...

Thank you for your thoughtful response Kyle.

There are two main comments I'd make:

First, invasiveness is not the only standard of ordinary versus extraordinary care (though traditionally, it, along with accessibility, have been considered the main ones). Another important standard is how much it interferes with normal functioning, that is, the debilitation standard. Ventilators prevent speaking and iron lungs prevent moving around at all. They are both highly debilitating. The debilitation standard exists because we may reasonably suppose that someone avoiding a debilitating treatment is avoiding the treatment itself rather than seeking death for its own sake.

Second, whether or not a device causes an organ to do what it would normally do is irrelevant to invasiveness. In fact, almost all medicine and especially all medical devices cause the body to do what it would normally do (a correctly functioning body is one of the most common definitions of health). Invasiveness is a standard related to the degree of bodily manipulation, not the type of bodily manipulation. As such, that a respirator simulates normal lung function does not make it less invasive.

Kyle said...

Thanks for your response, I will reread and think about it more.

Daniel said...

Thanks for your objection Kyle. It's really good to hear people's comments on arguments like this, since it's such a difficult topic.

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