In this column, I thought that I would address a dilemma, which many of us, who have loved ones with a terminal disease or irreversible condition, face: “When is it ethical to withhold or withdraw nutrition and hydration?”

The problem actually becomes less complicated if we make a distinction between medical treatment and palliative care. Medical treatment would include artifi cial substitutes for irreversibly

broken-down body functions, such as kidney dialysis, a respirator, the installation of a mechanical heart, a feeding tube when used as a substitute for a malfunctioning alimentary system. Such “treatments” can be renounced “when death is imminent and cannot be prevented.” Why? Because they can “only yield a precarious and painful prolongation of life.” (Enchirdion Vaticanum, vol. VII, Documenti Uffi cialia Della

Santa Sede, Declaration on Euthanasia, p. 348, nn. 370-371).

Palliative Nursing Care would include pain relief, hygiene, medication, as well as hydration and nutrition. These cannot be renounced except to the extent that administering these is deemed useless, or brings excessive pain or burden to the patient. In other words, they have become ethically “extraordinary means.” This, then, is an application of the principle “Above all, cause no harm,” which has special application to a patient who is in the end stages of a terminal condition or in an irreversible condition and suffering from systemic failure of their organs.It is noteworthy that the Declaration of Euthanasia, written more than 30 years ago, uses the word “curationibus” which means “healing” but is underscoring what we now call “palliative care” when speaking of the “medical interventions,” which a patient may renounce in good conscience, such as a D.N.R. (a “do not to resuscitate” order) for a patient in hospice. The same document uses the word “ordinariis curis” meaning “carefulness, solicitude, attention,” when speaking of the “ordinary care” due to the sick in such cases where medical treatment may not be interrupted, for example, the use of oxygen in the case of the person with C.O.P.D. Father Gerald Kelly, a Jesuit ethicist who wrote two articles for Theological Studies on the subject of the duty to preserve life, holds that receiving basic nutrition and hydration is an ethically “ordinary means” of preserving life which, as a general rule, cannot be denied to the sick. Why? The denial of such basic support would be “a direct killing of a person through thedeliberate omission of

an act which is obligatory, namely, to feed the person.” No human has complete dominion over his body to the point where he or she could say “let me starve to death.” What does this imply? If the feeding tube is to facilitate a mal-functioning digestive system, this is a medical treatment and therefore it may not be denied. The use of the feeding tube, in this case, would be considered “ordinary means.” When the normal process of ingesting and digesting food is facilitated by means of tube feeding, the digestive system as a system is considered impaired but still in working order.

Tube feeding can be regarded as palliative care when administrating nutrition through a gastrostomy or by nasogastric tube especially has become impossible or has become ineffective for a patient. This is often what eventually occurs to patients in hospice. Their body organs begin to shut down, one by one. Systemic failure, including the digestive system, is no longer able to tolerate the ingestion of food, regardless of how it is administered. In this case, recourse to intravenous feeding could be rejected by a competent patient who is in a terminal condition, or by the one who has been designated health care proxy for a patient who is incompetent or is in a permanent irreversible condition.

To summarize, the feeding tube is only required for those who are not at the end stages of a terminal illness or irreversible condition, but who simply have an impaired digestive system which relies on assistance for nutrition. For those who are dying, the feeding tube is not required, especially if it would be ineffective, cause the patient unnecessary pain or burden or prevent his/her natural journey toward death, which we should not fear as the end but as a passageway to a new and better existence.

Whenever it is ethical to withhold or withdraw nutrition and hydration, we must always remember to treat all patients with dignity, for all life is sacred and, all people are children of God, made in the image and likeness of the God who became one of us so that we might become more like him.