1. Referring to information about a Polish citizen who is under medical care in United Kingdom and controversy related to the discontinuation of nutrition and hydration in this case (RS/P case), Polish Association for Spiritual Care comprising of Polish physicians, nurses, psychologists, other healthcare professionals, ethicists and chaplains, reminds about the basic ethical principles related to the medical care of people in vegetative state (VS) or minimally conscious state (MCS), particularly related to RS/P case. From the available information it appears that the patient suffered brain damage after a heart attack seven weeks ago and hospital petitioned a court for permission to discontinue tube feeding nutrition and other life-sustaining treatment. The patient’s mother and sisters do not accept this decision and emphasize RS’s religiosity and pro-life Catholic beliefs. We do not know the patient’s wishes. Therefore, it seems important to recall the principles of medical ethics adopted in Poland and the official teaching of the denomination to which the patient belongs.
2. Withdrawing hydration and feeding in a person living in VS or MCS is ethically controversial,,,. It can be found in medical publications that tube feeding in VS/MCS should be provided and monitored,. Discontinuation of tube feeding is ethically doubtful in many medical and religious groups around the world. Discrepancies in ethical and legal standards between United Kingdom and other European countries have already appeared in the context of discontinuing life-sustaining treatment and care.
3. In Republic of Poland standards of medical ethics are based on the Polish Code of Medical Ethics. It directly states that a physician cannot euthanize or assist a patient in suicide (article 31). In end-of-life situation a physician is not obliged to undertake resuscitation or other extraordinary measures perceived as persistent therapy (article 32). However, tube feeding or hydration in VS, MCS or other neurological disorders cannot be treated as extraordinary measures or persistent therapy. Broad consensus reached by the Polish Working Group on End-of-Life Ethical Problems regarding a definition of “persistent or overzealous therapy” underlines that this concept cannot be strictly extended to basic care procedures such as pain relief or feeding and hydration, as long as they are for the patient's good: „Overzealous therapy is the application of medical procedures with the goal of supporting vital functions in a terminally ill person that results in prolonged dying, and is associated with excessive suffering and/or with violation of the patient's dignity. Overzealous therapy does not include basic nursing, control of pain and of other symptoms or feeding and fluid administration, as long as these actions are beneficial to the dying person”.7
4. This means that these forms of care (hydration and nutrition) cannot be considered as persistent therapy in VS, MCS or other neurological disorders and cannot be discontinued. Hydration and nutrition withholding should be limited to agony or other terminal stages, e.g. in cancer patients. This interpretation was confirmed in medical ethics articles published in leading Polish medical journals. Guidelines for doctors published by Polish Pediatrics Society regarding withholding and withdrawing persistent therapy in children also state that in neurological diseases patients should receive feeding by tube or by gastrostomy – the lack of nutrition in these cases leads to death by starvation and cannot be accepted from ethical point of view.
Medical community in Poland is very sensitive to distortions of the goals of medicine and subordinating medical practice to ideologies. For several years, we have been analyzing the causes of the transition of doctors attitudes “from healing to killing” in totalitarian regimes, such in Nazi-German Auschwitz death camp practice. Therefore, protecting dignity, respecting for autonomy, religious and conscience freedom, nondiscrimination, are very important values in Polish ethical and legal standards regarding health care.
5. Cultural-sensitive and whole-person care should also consider beliefs and spirituality of every patient, especially who is at the end of his/her life,. It built a prestige and trust in healthcare workers. Since the discussed case regards a person with Christian beliefs and a member of the Catholic Church, the official teaching of the Catholic Church should also be recalled. Congregation for the Doctrine of the Faith of Catholic Church in the Letter “SAMARITANUS BONUS on the care of persons in the critical and terminal phases of life” mentions about the moral obligation to exclude aggressive medical treatment (point 2). However, at the same time emphasizes that nutrition and hydration (also artificial) is a basic care, not therapy and causing death by deprivation of hydration and nutrition is not allowed: “In particular, required basic care for each person includes the administration of the nourishment and fluids needed to maintain bodily homeostasis, insofar as and until this demonstrably attains the purpose of providing hydration and nutrition for the patient. When the provision of nutrition and hydration no longer benefits the patient, because the patient’s organism either cannot absorb them or cannot metabolize them, their administration should be suspended. In this way, one does not unlawfully hasten death through the deprivation of the hydration and nutrition vital for bodily function, but nonetheless respects the natural course of the critical or terminal illness (...) Obligatory nutrition and hydration can at times be administered artificially, provided that it does not cause harm or intolerable suffering to the patient (point 3). The same opinion was expressed in official response to United States Conference of Catholic Bishops regarding nutrition in VS (“The administration of food and water even by artificial means is, in principle, an ordinary and proportionate means of preserving life”; “A patient in a “permanent vegetative state” is a person with fundamental human dignity and must, therefore, receive ordinary and proportionate care which includes, in principle, the administration of water and food even by artificial means.”) and in New Charter for Health Care Workers of Pontifical Council for Pastoral Assistance to Health Care Workers (point 152), where nutrition and hydration, even if administered artificially, are classified as basic care.
6. In the assessment and appraisal of the RS/P case the differences in ethical and legal medical standards between Poland and United Kingdom and the Catholic beliefs of patients should be recognized. All actions must be taken with respect to the patient’s dignity, autonomy and fundamental rights such as freedom of religion and conscience, and in accordance with the patient’s beliefs, if they are not opposed to British law. If such actions were not possible, the patient’s transport to Poland should be allowed. We hope that any doubts in this matter will be resolved according to the principle: "in dubio pro vita humana".
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