Executive Director - Euthanasia Prevention Coalition
The Canadian Paediatric Society - bioethics committee, released a statement today concerning the Withholding and Withdrawing of artificial nutrition and hydration.
The statement of the Canadian Paediatric Society is similar to the statement from the American Academy of Pediatrics. Both statements approve the withholding or withdrawing of nutrition and hydration (fluids and food) from infants, who may not be dying.
The statement on the Withholding and Withdrawing of artificial nutrition and hydration allows euthanasia by dehydration (slow euthanasia) of infants with cognitive or other disabilities based on a "quality of life" assessment and with the consent.
I refer to this as euthanasia by dehydration because there is a clear difference between withholding or withdrawing fluids and food from a person who is actually dying and nearing death and a person who is not otherwise dying.
When a person is actually dying and nearing death, the death occurs from the medical condition. But when a person has cognitive or other serious disabilities or conditions, but is not otherwise dying, when fluids and food are intentionally withheld or withdrawn, the cause of death is intentional dehydration.
Many leading bioethicists would like you to believe that there is no difference between killing and letting die, but in fact there is a big difference. When we allow the killing of a person, we are allowing an intentional action or omission to directly cause death. Letting someone die means that we are actually allowing natural death to occur.
Some bioethicists will refer to the "artificial" nature of providing fluids and food as the issue. This argument is false. We always receive fluids and food by some means, whether it be by a spoon, straw, bottle or mothers milk, etc.
In a media release, the Canadian Paediatric Society stated:
ANH refers to nutrition or hydration that is delivered by artificial means, such as via a feeding tube or intravenously. Legal and ethics experts say there is no difference between withholding or withdrawing ANH versus other therapies that sustain or prolong life. The CPS makes clear that any decision should be based solely on the benefit to the child, while considering the child's overall plan of care.A recent article that was written by Kate Johnson and published in Medscape Medical News on October 7, 2010; reported on a presentation at the 18th International Congress on Palliative Care in Montreal last year. The article was titled: Prolonged Survival Frequent After Withdrawal of Neonatal Nutrition and Hydration.
"Food and drink evoke deep emotional and psychological responses, and are associated with nurturing," said Dr. Tsai. "But artificial nutrition and hydration is not about providing food and fluids through normal means of eating and drinking. It should be viewed the same as any other medical intervention, such as ventilatory support."
The article stated:
Neonatal survival after withdrawal of artificial hydration and nutrition can last up to 26 days, according to a case series presented here at the 18th International Congress on Palliative Care.Clearly, a child that lived 26 days after having fluids and food withdrawn was not otherwise dying. This child, and others who lived for a long time before dying by intentional dehydration, were not dying of their medical condition, but rather died of dehydration.
Although physical distress is not apparent in the infants, the psychological distress of parents and clinicians builds with the length of survival, said Hal Siden, MD, from Canuck Place Children's Hospice in Vancouver, British Columbia.
"These babies live much, much longer than anybody expects. I think that neonatologists and nurses and palliative care clinicians need to be alerted to this," he said.
"The time between withdrawal of feeding and end of life is something that is not predictable, and you need to be cautioned very strongly about that if you are going to do this work."
He presented a series of 5 cases that clinicians at his hospice had overseen over a 5-year period. Two infants had severe neurologic impairment, 2 had severe hypoxic ischemia, and 1 had severe bowel atresia.
The infants were transferred to the hospice from neonatal intensive care after their families had received an average of 3 consultations with the hospice team, reported Kerry Keats, MSW, who is Dr. Siden's colleague at the hospice, and a coinvestigator and copresenter.
After feeds and hydration were discontinued, the mean duration of survival was 13.2 days (range, 3 to 26 days), she said. Infants' ages at death ranged from 18 to 67 days.
The article went on to state:
"Parents really wanted to know that medications were being used because they didn't want their child to have the sensation of hunger in any way, shape, or form," she said.It is interesting to note that the physicians have yet to force the coroners to change the language concerning the act. Soon enough there will a policy statement that states that death by dehydration is natural death.
"Families were absolutely clear about that each time," added Dr. Siden. "They wanted to see absolutely no signs of discomfort. Babies cry, that's normal, but this was not acceptable, so we were using sedatives to really dampen that out."
Despite this, there is one factor that medication cannot alleviate, and that is the visual signs of emaciation, said Ms. Keats.
"The longer a child lives, the more emaciated he or she becomes. This is something that we as clinicians need to anticipate. You can alleviate some of the physical symptoms, but this is one symptom, or result of our action, that we can't relieve. A critical factor for counseling is to anticipate the kind of suffering that comes with witnessing the emaciation. It isn't something people can prepare themselves for."
Autopsies are often encouraged in such neonatal palliative care cases to help both parents and medical staff gain a better understanding of the reasons for the death, said Dr. Siden. Parents should be warned that the report will document the technical cause of death as "starvation" — a loaded word for all concerned. It is important that parents separate this word from any notion of suffering, he said.
The article concluded by stating:
An informal poll of the room by Dr. Siden revealed that most of the attendees had direct experience with this type of case. ...When reading the report from the Ontario Chief Coroner titled: Paediatric Death Review Committee - June 2009, the report states:
"Not everybody is comfortable or aware that it's morally and ethically permissible to make decisions to discontinue these types of interventions. This study highlighted those key things more systematically — that it's acceptable and it doesn't invoke suffering — while acknowledging that there is a physical change that we need to be prepared for, and that we need to help the family prepare for and proceed through."
Once notified, the coroner determines whether or not to accept the death for investigation. The underlying principles are related to certain natural deaths, and “non-natural” deaths. Natural deaths with children usually occur in hospitals or specialized facilities, which care for medically fragile or significantly disabled children. These deaths are largely expected due to medical illness. These natural deaths may not necessarily be accepted for investigation. At times, allegations are promulgated regarding negligence and malpractice by health care providers, or under circumstances which may require investigation, and the coroner will then investigate. These natural deaths are accepted for investigation by the coroner.The statement from the Paediatric Death Review Committee is extremely concerning when it is compared to the Ontario Coroner's definitions of natural death as including:
"refusal, discontinuation or withdrawal of treatment, food or fluids, on the direction of the patient or an appropriate substitute decision maker."In other words, the Ontario Coroner defines these deaths as "natural deaths."
Sadly, there was another time in history when euthanasia by dehydration of newborns was accepted. Those deaths became the T4 euthanasia program that progressed to euthanasia by injection and then euthanasia by gassing.
No not everyone is willing to turn a blind-eye to intentionally dehydrating infants to death. These infants are vulnerable people because they have been born with disabilities. Many medical professionals view their lives as "life unworthy of life" and their parents are afraid and have been told that these children will live lives that are "wretched to the extreme."