Some comments and suggestions from Dr Gillian Craig


Ethical dilemmas that come to public attention show how difficult medical practice can be. There are no easy answers to the problems raised. Many people over the years have tried to contribute to the process by which ethical decisions are made in medicine, but in general the end result of all this thought has been of little practical value to a busy doctor. New life support techniques have produced new dilemmas for society and the medical profession to solve. We now have a plethora of guidelines.

It is customary for ethicists to talk in terms of four principles of beneficence, non-maleficence, autonomy and justice1. The emphasis these days tends to be on autonomy-i.e. the wishes of the individual patient. For the doctor the principle ‘First do no harm’ is vital. We also need to remember the basic maxim ‘Thou shalt not kill’.

It is fashionable at present to consider ‘therapeutic decisions’ at the end of life in terms of benefits, burdens and best interests. These B words trip off the tongue in discussion, but do not stand up to careful scrutiny, as theologian Peter Jeffery has demonstrated in a closely argued chapter in his book ‘Going against the stream.’ Jeffery argues that the starting point in any discussion on foregoing treatment must be respect for life. To be of practical value ethical frameworks must be workable, understandable, realistic and universally applicable. This is a tall order, but having ruled out solutions based on substituted judgement, or quality of life assessments Jeffery favours a framework based on the concept of proportionality, which some people may find helpful 2. Decisions based on substituted judgement, i.e. on the view of a proxy decision maker or other third party, as to what an incapacitated person’s wishes might be, are known to be flawed. Decisions made on quality of life judgements by third parties are also inherently flawed, and in America such judgements are not allowed as a legal reason for discontinuing treatment. This means, notes Jeffery ‘that health professionals can only make quality of treatment judgements, and not quality of life judgements, otherwise the acts are a disguised form of euthanasia.’3. The same danger is apparent when the patient’s ‘best interest’ is invoked as a reason for withdrawing life supportive measures.

Jeffery argues that the concept that a treatment can be withdrawn because it is ‘conferring no benefit’ is so broad that it could be applied to anyone incurably ill with a fatal condition 4. There are also objections to the burden argument, for as Jeffery points out ‘what is a burden to one person is quite acceptable to the next.’ Widening the concept to include the burden on the family, insurance company or state is anathema to most physicians whose prime responsibility is to the individual patient. However such considerations cannot be ignored completely. When resources are finite, the needs of other patients on the waiting list may enter the equation. Thus it is easy to see why some elderly incurable patients may be seen as expendable.

It will be readily apparent that every case will be different, and must be considered carefully and with sensitivity, taking into account the clinical situation and the views and wishes of the patient. When the patient is confused, unconscious or mentally incompetent, the views of their nearest and dearest friends and relatives should be sought. It is the doctor’s role to advise and offer appropriate treatment, which a competent patient may accept or refuse. When the patient is mentally incompetent the burden of responsibility is more onerous, and treatment can be given only if it is strictly necessary. Those who look to the law to safeguard the interests of mentally incompetent patients may be sadly disappointed.

When all is said and done, the advice of the House of Lords’ Select Committee on Medical Ethics still has much to recommend it. After careful deliberation at the time of the Bland case, they concluded that it should be unnecessary to consider the withdrawal of hydration or nutrition unless the means of administration was in itself a burden to the patient 5. That eminently sensible conclusion was ignored by the Law Lords in their judgement in the Bland case, for it was their intention to allow Bland, a patient in a permanent vegetative state, to die. I doubt whether their Lordships realised at the time how wide the repercussions of that judgement would be.

Factors that spin on the wheel of fortune to determine the patient’s fate.

Clinical diagnosis
Treatment available
Patient’s physical condition
Patient’s mental state
Benefits and burdens of treatment
Patient’s best interest
Patient’s wishes
Relative’s views
Views of senior clinician and clinical team.
Views of a Court under some circumstances.

A practical approach.

For practical purposes when considering whether artificial hydration or nutrition is appropriate the responsible doctor should consider the following basic points:-

1. Is it necessary?
2. Is it feasible?
3. Can the patient tolerate the procedure?
4. Does the patient wish to undergo the procedure?
5. Is the patient capable of giving informed consent?
6. Beware of making quality of life judgements. Nevertheless consider whether
prolonging life will be a boon to the patient or an intolerable burden. Ask yourself
and others- What would the patient want?
7. Is the patient mentally incapacitated or lacking in self-awareness? If so obtain a
second opinion from an experienced doctor according to BMA guidance if in the
UK6. If the relatives disagree with a proposal to withhold artificial hydration and
nutrition listen carefully to their views, for they could be right. Take into account
and respect deeply held religious views. If dissent remains after careful discussion
legal advice should be sought.
8. Is the condition reversible or permanent? Have all reversible features been treated?
If not, why not?
9. Is the patient in a permanent vegetative state? If so, in the UK, there is a legal
obligation to obtain permission from a Court before withholding artificial hydration
and nutrition.
10. Is the patient terminally ill and death imminent? If so follow the guidance of the
National Council for Hospice and Specialist Palliative Care Services (NCHSPCS),
as issued in July/August 1997 7. Long term nutrition will not be a priority in this
situation but attention should be paid to hydration 8. Subsequent NCHSPCS
guidance for use in the last few days of life plays down the importance of
hydration and is not entirely satisfactory 9. General Medical Council guidance
issued in August 2002 should be taken into consideration by doctors in the UK10.
11. If death is not imminent, and there are no clear indications that artificial hydration
and feeding would be very distressing, or would have no effect, then give fluids
and nutrition by whatever means seem most appropriate, unless there are clear
contraindications. If you do not feel this approach is appropriate obtain a second
opinion and consider the legal position before treatment is withdrawn11.
12. Take heed of guidance issued by respected professional organisations, but do not
allow yourself to be forced into actions that you consider immoral. Be prepared to
justify your conduct and stand firm. Keep in touch with a supportive peer group.
13. Be gentle with relatives and try to ensure that they have appropriate emotional and
spiritual support.
14. There comes a time when everything possible has been done, but the patient
lingers on in a twilight existence that some see as a fate worse than death. Then it
may be appropriate to gently suggest that it might be best to let them go, and hand
them with love to God.12

Acknowledgement. This paper was first published in the Catholic Medical Quarterly in February 2003. Vol. LIV No I (299): p13-15. Minor changes have been made since publication. © Gillian Craig 2005.

References and notes.

1. Beauchamp T, and Childress J.F. Principles of Medical Ethics. First issued in 1978. 4th edition
Oxford University Press 1994.
2 . Jeffery P. Going Against the Stream. Ethical aspects of ageing and care. Chapter 5 Mortal
questions. Gracewing, 2001.
3 . Ibid page 158.
4 . Ibid page 159.
5 . House of Lords’ Select Committee. Report on Medical Ethics. 1994; para 251-7
London,. HSMO.
6. Withholding and withdrawing life-prolonging medical treatment. Guidance for decision
making BMJ Books. 1999.
7. Ethical decision-making in palliative care. Artificial hydration for people who are terminally ill.
National Council for Hospice and Specialist Palliative Care Services. London July/August 1997.
8. Craig G.M. Palliative care from the perspective of a Consultant Geriatrician: the dangers of
withholding hydration. Ethics and Medicine, 1999: 15.1:15-19.
9. Changing Gear- managing the last days of life in adults. NCHSPCS London, December 1997.
10. Withholding and withdrawing life-prolonging treatments: good practice for decision making.
General Medical Council, London. August 2002.
11. The legal situation is complex. See R (Burke) v The General Medical Council, High Court of
Justice, Queen’s Bench Division, London. [CO/4038/2003]. Mr Justice Munby ruled that GMC
guidance contravened the European Convention on Human Rights in certain respects. The case
went to the Court of Appeal in 2005 and judgement is awaited.
Note. There comes a time when a doctor should cease to strive to keep a patient alive, but this
does not mean that measures such as hydration and nutrition should be withheld with intent to
shorten life. Masterly inactivity is not the same as neglect.

This article is reproduced on Compassionate Healthcare Network with the kind permission of the author.

Dr Gillian Craig is a retired Consultant Geriatrician and is the editor of a recently published book “No Water No Life, Hydration in the Dying”.

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