The UK’s highest court has ruled that legal permission will no longer be required to end care for patients in a permanent vegetative state.
Bishop John Wilson responds to the Supreme Court ruling to back agreed end of life decisions:
“On 30 July 2018 the United Kingdom Supreme Court ruled it is no longer necessary to seek legal permission from the Court of Protection to remove artificial feeding and hydration from patients in a persistent vegetative state. This means that clinicians and families can decide among themselves to bring about a patient’s death by discontinuing the provision of food and water by artificial means.
A person in a persistent vegetative state exists in an altered state of consciousness following some kind of trauma. The person breathes without assistance and follows patterns of sleeping and waking, although without any detectable external response. They are not dying as such, but remain dependent on medical and nursing care.
The Catholic Bishops’ Conference of England and Wales addressed the question of artificial feeding and hydration in cases of patients in a persistent vegetative state in their 2004 teaching document Cherishing Life. In considering the ethics of suicide and euthanasia, the Bishops stated: ‘There is a basic level of nursing care that is demanded by human solidarity. We all recognise that leaving a patient cold, unclean, in pain or without human contact for significant periods of time would fall below a decent standard of care. Within the health service, great efforts are made to maintain high standards in this area, despite the pressure of resources and limited staff. In general, providing food and fluids should also be considered basic care.’ (185)
The Bishops continued: ‘when patients are in the final phase of dying they should not be troubled by intrusive treatment and efforts to place or replace a feeding tube may well be excessive or burdensome.’ However, they clarified: ‘What is not morally acceptable is to withdraw tube-feeding, or other life sustaining treatment, precisely in order to end a patient’s life. This would cross the line from reasonable withdrawal of inappropriate treatment into the realm of passive euthanasia.’ (185)
No one should underestimate the challenges placed on families and carers when a loved one enters a persistent vegetative state. Sustained pastoral support for them is essential. Artificial nutrition and hydration, however, are not treatment. They do not cure anything. In whatever way they are delivered, food and water for a person in a persistent vegetative state fulfil the same purpose as for any other person. They keep them alive as part of their basic care. They prevent death by malnutrition and dehydration.
Patients in persistent vegetative states are some of the most vulnerable in our society. It is not an act of compassion to remove their food and drink in order to cause their death. Equally, it cannot be in patients’ best interests, whatever their level of consciousness, to have their life intentionally ended. Our care for those in such situations is the test of our common humanity and our solidarity with some of the most fragile of our brothers and sisters.”
The Anscombe Bioethics Centre response:
Protecting the lives of the most vulnerable
The recent Supreme Court judgement, An NHS Trust and others v Y, in effect makes it much easier for doctors to deprive patients with prolonged disorders of consciousness of the food and water they need to live.
The English law has been misshapen since 1993 when judges in the Bland case allowed doctors to withdraw clinically assisted nutrition and hydration from a profoundly brain-damaged patient who was in a stable condition but was unable to feed himself. However, until now there was a requirement for each case to go to court for nutrition and hydration to be removed, and this has provided the opportunity for a diagnosis to be challenged, along with the claim that the patient could not benefit from being provided with sustenance. The cost and burden of a court case has seemingly deterred many doctors and families from taking this route. Hence, although offering this court option was still fundamentally unjust in that it was intended to enable an unethical end in some cases, it had the effect of protecting many lives. The Supreme Court judgement now removes the requirement to go to court in cases where the diagnosis is not disputed and where relatives, carers and doctors are in agreement. This change further endangers the lives of many hundreds of the most vulnerable patients.
In opposition to this change it should be reiterated that people have a right to adequate nutrition and hydration. This is an aspect of the basic care, respect and solidarity that is every person’s due. No one should starve to death or die of dehydration where their carers have the means easily to supply their need. This includes supplying nutrition and hydration via feeding tube when the person cannot eat or drink in the usual way.
Hence, Pope John Paul II was very clear that the provision of nutrition and hydration is, in principle, obligatory, even when this is clinically assisted. While clinically assisted nutrition and hydration remain effective and where the means do not impose a great burden on the patient (which they do not for an unconscious patient, in particular), then it is unethical to remove them. The English law is in this respect defective because it treats clinically assisted nutrition and hydration as though these were purely medical acts and ignores the human significance of providing food and water.
The Supreme Court judgement recommends that cases are brought to court when there is disagreement among or between relatives, carers or healthcare professionals, or where the facts are in doubt. This judgement therefore places a greater duty on conscientious relatives, carers and healthcare professionals not to stand by while patients are deprived of necessary sustenance but to be willing to disagree. In this way, the prospect of court action can still be invoked and may still dissuade doctors from removing sustenance. Those defending the patient should in any case stress that no medical decision should be motivated by the aim of ending life.