By No Extraordinary Means: The Choice to Forgoe Life-Sustaining Food and Water. Lynn J, (ed). Bloomington, IN. Indiana University Press, 1986, 266 pages, hardcover, $25.
Over the last several years, the question of whether artificial methods of providing nutrition and hydration can or should be witheld or withdrawn have surfaced. Cases involving Baby Doe, Claire Conroy, and Karen Quinlan have raised awareness of the complexities of treatment issues. The symbolic importance of feeding vs "starving" makes this a particularly difficult dilemma.
By No Extraordinary Means is a collection of writings dealing with the question of whether food and water must be given by artificial means to sustain life. The collection is edited by Joanne Lynn, MD, who served as Assistant Director of the President's Commission for the Study of Ethical Problems in Medicine.
Anyone interested in exploring the ethical, moral, and legal implications of the artificial feeding question should read this book. While the references to legal cases without fully describing the cases can lead to some confusion in the early chapters , the reader eventually becomes familiar with all the landmark decisions in this area. The Claire Conroy case is covered in depth in the concluding chapters.
The strength of this book is in the broad coverage, given the issue. Authors range from those who are quite liberal in their interpretation of when nutrition and hydration can be witheld or withdrawn to those who view such witholding or withdrawal as an option for very few cases. Disciplines represented include ethics, law, theology, medicine, nursing, and public policy. Authors refer to the views of writers of other chapters in their analysis of issues, making it easy for the reader to compare and contrast views.
Issues discussed include: What treatments can be witheld or withdrawn? Is hydration and nutrition medical treatment? Who decides to forgo treatment and based on what criteria? Are there different criteria for withdrawing than witholding nutrition and hydration? What are the public policy implications of these decisions? What impact does the symbolic nature of providing food and fluid have on feeding decisions?
Terminology regarding types of treatment is discussed by several authors. "Ordinary" versus "extraordinary" does not seem to be useful in treatment decisions. Alternatives include proportionate versus disproportionate, obligatory versus optional, natural versus artificial, and non-invasive versus invasive. Definition becomes problematic for most of these alternatives.
The "benefit versus burden" argument is utilized by most of the authors in their analysis of the issue. The authors generally argue that there is no ethical difference between witholding and withdrawal of treatment.
Most also caution against viewing the forgoeing of food and fluids as commonplace. If the decision becomes too easy, less careful thought may go into it. There is also a fear expressed that the "slippery slope" phenomenon will occur, changing the decision from a "nay" to a "must." Economic and justice issues then arise - will the vulnerable, non-productive members of society be denied treatment of this nature? One author mentions another financial issue - if care facilities get higher reimbursement for persons on artificial feeding, will they have any incentive to withdraw treatment even if indicated? Several authors offer guidelines for decision-making in individual cases.
By No Extraordinary Means should be a useful resource for all professionals who must deal with treatment/nontreatment situations. Ethics committees should find it an educational tool. A comprehensive index makes the book a valuable reference.