Editorials

Withdrawing artificial feeding from children with brain damage

Over the past few decades the American legal system has repeatedly confronted the legal dilemmas of stopping treatment for patients in a persistent vegetative state. From 1975 to 1990, 33 cases reached the higher courts. At least half of these concerned the withdrawal of artificial feeding. The British legal system has also had to address the same questions--first in the case of Tony Bland, crushed at Hillsborough football stadium, and now more recently in the case of Thomas Creedon, a 22 month old child who is said to be severely brain damaged and unable to hear, speak, or see.¹ As legal systems are increasingly confronted with these cases, it is important to consider the basic medical, ethical, and legal principles that have unfolded over recent years.

The most critical factor from a medical perspective is when the persistent vegetative state (lasting longer than one month but potentially reversible) becomes permanent (irreversible). Recent American standards developed by the Persistent Vegetative State Taskforce discuss a range of 3-12 months, depending on the aetiology of the condition and the age of the patient.^{2 3} European authorities such as the BMA have generally given one year as the outer limit for recovery and the time at which serious consideration can be given to stopping treatment, which may include removing a feeding tube.⁴ The diagnosis of the permanent vegetative state in children, particularly in infants and young children, is more problematic than in adults. It is also harder to make if a patient has had a traumatic brain injury than if he or she has had a hypoxic or ischaemic insult. In all age groups and for all causes of acute brain injury, however, recovery of consciousness and meaningful function is extraordinarily rare after a year from the original injury.^{5 6}

Artificial nutrition and hydration are medical treatments. It may be much more psychologically difficult to withdraw artificial feeding than other forms of medical treatment, but an overwhelming consensus has developed in recent years that there are no substantial moral or legal distinctions between artificial feeding and other medical treatments. Anyone who believes that eating and drinking in normal children are remotely similar to providing a feeding tube for severely brain damaged children has never been present at the bedside of these patients and has no good sense of the medical reality.

Medical treatment of any type is given to benefit patients by maximising their ability to function, minimising their disability, alleviating their suffering, and preserving their dignity.⁷ Continued treatment in patients who are permanently unconscious cannot accomplish any of these goals. Treatment cannot improve function because meaningful function is non-existent; it cannot minimise disability because disability is maximal (short of death itself); it cannot relieve (or cause) suffering because these patients do not have the neurological capacity to suffer; and it cannot preserve dignity because these patients have no way of experiencing dignity. Treatment is, of course, justified while there is any uncertainty about the prognosis. Later, when the prognosis can be made with a high degree of certainty, treatment is often continued to give families time to accept the hopeless condition of their loved ones and to decide what they would have wanted or what would be in their best interests.⁸

Withdrawing artificial nutrition and hydration results in death in usually 10-14 days. The immediate cause of death is dehydration. In the last few days of life patients may show signs of dehydration such as dryness of the mucous membranes of the mouth and eyes. But the patients do not show any of the terrible signs of starvation described by pro-life supporters.⁹ The withholding or withdrawal of feeding tubes will become more common in the near future as the application of modern medical technology allows more people to stay alive despite severe and irreversible brain damage after acute brain injuries and as the incidence of Alzheimer's disease increases in the aging population. The Persistent Vegetative State Taskforce estimates that there are about 10000-25000 adults and 4000-10000 children in a persistent vegetative state in the United States, and the number in Britain is said to be around 1500.¹⁰

The withholding of medical treatment in irreversibly ill patients--such as the removal of feeding tubes from patients in a permanent vegetative state--is not assisted suicide or euthanasia. Most people believe that medical, moral, and legal distinctions exist between the broad categories of letting a person die by stopping treatment and suicide and euthanasia. There is still, however, substantial disagreement on what these distinctions are and which are most relevant.

Generally, parents, in conjunction with health care providers, are the most appropriate people to make life and death decisions for their children. Decisions by parents to stop treatment are made thousands of times each year without court supervision. Loving, caring families, presumably like that of Thomas Creedon, should not therefore routinely be subjected to undue public and legal scrutiny when they face such an agonising decision as whether to stop treatment on their child. But health care providers must always be on the alert for parents who do not speak in the best interests of their child or have conflicts of interest that may bias their views.

Medical technology has reached a point at which the public, including the courts, must be more involved in these cases and educated on the basic principles, such as the distinctions between stopping treatment and euthanasia. One way is through landmark legal cases. But society needs to debate these issues more publicly and to develop ethical, medical, legal, and social policies on how to deal with them.

Professor of neurology University of Minesota, Department of Neurology, Hennepin County Medical Center, 701 Park Avenue, Minneapolis, MN 55415 1829, USA

Ronald E Cranford 

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