Yimin Chen
by A.S.P.E.N. Guest Blogger Yimin Chen
As many of your are aware, the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) recently released a statement responding to recent articles and videos relating to the topic of forced tube feedings of hunger strikers in Guantanamo Bay. The statement includes a list of facts relating to tube feeding, and I think one of the main bullet points that closely addresses the issue in my mind is:
- Before beginning tube feeding, clinicians should consider ethical, religious and cultural beliefs of the patient and family. The risks and benefits of tube feeding, as well as how it will affect that particular patient, should be discussed with the patient and family.
Photo by Marco Bellucci via Flickr Creative Commons.
Until a couple of months ago, I had really not given much thought to the issue of forced feedings taking place in Guantanamo Bay until I came across a letter, published in The Lancet, written by some physicians to the President against tube feeding the prisoners on hunger strike. The American Medical Association also voiced opinions against this practice at the end of April. I am typically not the most politically charged person, but I wanted to open up the issue for discussion with my colleagues. I was pleasantly surprised when I contacted my colleagues at A.S.P.E.N. and was informed that this very issue was already being evaluated.
I’ve been a nutrition support dietitian for about ten years, and when I first came across the Lancet letter and felt confronted by the issue, my immediate knee jerk reflex was, “Well, of course, we should tube feed the hunger strikers! They cannot make the right decisions because they are fueled with anger and have irrational thoughts, we must save them from themselves, just like we save eating disordered patients!” However, during the 48 hours following this immediate reaction, I had more time to obsessively evaluate the various aspects of the situation. Everything I’ve ever learned from ethics classes during my training, multiple discussions with ethicists and chaplains over the course of my career thus far, as well as the Hippocratic Oath I took when I graduated from grad school all came rushing back to me. And I realized that this is an issue that is much beyond the simple face value of what we typically see in a clinical setting. This is really an issue of ethical, religious, and cultural beliefs, and therefore it needs to be examined through a completely different set of lenses.
I would like to invite all to please share your thoughts on this very difficult but important topic. I think a lively discussion is much needed and deserved!
This is such a difficult issue and leads to very interesting discussion! My views have gone back and forth on this issue. Here is a question – is this starvation-assisted suicide? If so, we would certainly not allow them other items to assist in suicide (rope, knife, etc), so why would we allow this method (starvation)?
This is a very complex political issue, but pretty clearly violates the ethical principle held most dear in medical decision-making; that of patient autonomy. Many people are very upset about the forced feeding. Unfortunately, their passion about the issue has led to what I believe is, in itself, unethical behavior. By carelessly and with great emotionality describing enteral feeding as a “painful procedure” and “torture”, credible journalists and socially conscious activists may have potentially caused great harm by making it likely, through their portrayals, that our patients will be more resistant to tube feeding. The ends do not justify the means.
This issue was very well addressed by the statement issued by ASPEN’s Board, and will be discussed at a special session at Nutrition Week, in the early evening on January 20th, 2014..
For examples of the kinds of reporting that caused me to have this concern, please see:
http://www.nytimes.com/2013/04/30/opinion/nocera-the-detainees-dilemma.html?_r=0
http://www.youtube.com/watch?v=z6ACE-BBPRs (Note this is a very graphic and upsetting depiction of forced insertion of a nasal tube. While I have had patients react similarly, this is not usual when inserting a tube for feeding. Further, tubes used in Guantanamo were smaller caliber than that used in this video, with lubrication and the option of topical anesthetic offered.)
David Seres, MD, ScM, PNS
Associate Professor of Medicine
Director Medical Nutrition
Columbia University Medical Center
Yimin Chen’s Blog on Thoughts on Forced Tube Feeding Images in the News addressed the complexity related to forced feeding of hunger strikers with the statement, “…this is an issue that is much beyond the simple face value of what we typically see in the clinical setting.” For this very reason, the International Clinical Ethics Section (ICES) of A.S.P.E.N. steering committee reviewed their mission statement (below), before developing a draft proposal to submit to the Board of Directors of A.S.P.E.N., who then created the final Press Release August 2, 2013 on A.S.P.E.N. Response to Forced Tube Feeding Images in the Media
International Clinical Ethics Section
Steering Committee
Albert Barrocas, MD, FACS, FASPEN; Georgia, U.S.A.
Gustavo Kliger, MD; Argentina
Alfredo Matos, MD; Panama
Alessandro Pontes-Arruda, MD, MSc, PhD, FCCM; Brazil
Denise Schwartz, MS, RD, FADA, CNSC; California, U.S.A
John Wesley, MD, FACS, FAAP, FASPEN; Illinois, U.S.A.
International Clinical Ethics Section
Mission Statement
As an interprofessional section of A.S.P.E.N., we will strive to achieve a patient-centered focus in the management of nutrition support (artificial nutrition and hydration), including options not to provide the therapy, for the patients we serve. This will be accomplished by an international and synergistic collaborative focus on the education and empowerment of health care professionals, and the integration of key concepts including preventive ethics, shared decision-making, health literacy, and the use of the teach-back method in nutrition support practice. Our ultimate aim is to advance the field of nutrition support practice with measurable goals and shared best practice.
Additionally, there were two current resources developed by A.S.P.E.N. related to ethics, that the International Clinical Ethics Section steering committee used in their discernment process.
1. Barrocas A, Geppert G, Durfee SM, O’Sullivan Maillet J, Monturo C, Mueller C, Stratton K, Valentine C, A.S.P.E.N. Board of Directors. A.S.P.E.N. Ethics Position Paper. Nutr Clinc Prac. 2010;25:672-679.
Excerpt
It is the position of A.S.P.E.N. that:
(1). To the extent possible, decisions regarding artificial nutrition, hydration (ANH) should be based on evidence-based medicine (EBM), best practices, and clinical experience and judgment in the discussion with the patient, family, or significant others.
(9). The religious, cultural and ethnic background of patients and families need to be respected to the extent is consistent with other ethical principles and duties.
(10). Consent, respect, and preservation of dignity should be paramount during ethical and legal deliberation regarding ANH.
2. Geppert CMA, Barrocas A, Schwartz DB. Ethics and Law. In: Mueller C,McClave S, Schwartz DB, Kovacevich D, Miller S, eds. The A.S.P.E.N. Adult Nutrition Support Core Curriculum 2nd ed. Springfield, MD:American Society for Parenteral and Enteral Nutrition. 2012, pp. 656-676.
Excerpt
The Application of Core Ethical Principle to Nutrition Support Therapy
Principle: Autonomy
Autonomy Definition: The individual’s right to self-determination as expressed in healthcare decision making. It is the predominant value in American bioethics and law.
Autonomy Application to ANH: A patient with intact decisional capacity may
refuse ANH even if medically recommended.
David Seres, MD, who also participated in the draft proposal, in his blog comment brought clarity to the clinical problem that has occurred with the images portrayed in the media of enteral feeding. A.S.P.E.N.’s media response focused on the impact that these negative images can have, which could be detrimental to patient care.
For further information on joining the International Clinical Ethics Section (ICES) of A.S.P.E.N. contact: Colleen Harper, CAE, Director of Membership A.S.P.E.N. [email protected]
Denise Baird Schwartz, MS, RD, FADA, CNSC
Chair International Clinical Ethics Section (ICES) of A.S.P.E.N.
Indeed, this is a difficult issue. The issue of patient autonomy is applicable, but somewhat misleading.. These hunger strikers are not patients. They are, in fact, prisoners who we have confined. That means they still have basic human rights, among which is a limited degree of autonomy.
But… does that autonomy extend to suicide? We (collectively) are their custodians. We are responsible for feeding and housing them, and for safeguarding their well-being. That includes providing health care, as necessary. And that also includes preventing them from harming each other or themselves. It specifically includes preventing them from committing suicide.
As Jessica has noted above, if we allow a prisoner to starve to death voluntarily,should we not also provide knives or ropes to other prisoners?
The ethical question then comes down to this. If we are opposed to forced feeding, do we then allow hunger strikers to die? And if we allow them to die, have we not breached our duty as their custodians?
Think about it.
Clinicians may feel that “Forced Feeding of Hunger Strikers” does not pertain to patient care. However, Dr. Van Way and Jessica brought forth an important point, “Is this an attempt at suicide?”, in regards to the hunger strikers. For hunger strikers the focus appears to bring awareness to a grievance, with an undefined in end point in the hunger strike. The aspect of forced tube feedings, has added to the issue.
Declining a feeding tube is different for patients in the hospital, who have indicated their wishes in an advance directive, Physician Orders for Life-Sustaining Treatment (POLST), and/or verbally to family members/surrogate decision-makers or healthcare providers. For informed individuals in the hospital or other health care facilities the risk/burdens to them of administration of a feeding solution through an external tube into their body may be repugnant to them or even result in harm. Yet for other patients this is an acceptable method of nutrient delivery for either a short or long period of time.
As Dr. Seres indicated, ”ethical principle held most dear in medical decision-making; that of patient autonomy.”
Denise Baird Schwartz, MS, RD, FADA, CNSC
Chair International Clinical Ethics Section (ICES) of A.S.P.E.N.
A provocative issue indeed. The ethical principle of autonomy is clear in the case of patients. That of prisoners may not be as clear and Dr. Van Way has challenged us to approach them from a different perspective. I have no clear answer to the question, but have additional questions. Does our role as ‘custodians” include surrogate decision makers for health related issues? Legally, that does not appear the case since prisoners requiring surgical procedures provide their consent and not that of a surrogate.
Is the particular hunger strike harmful to a larger group e.g., violating the ethic tenets of the state? If the answer is affirmative, does it provide justification for ignoring the individual’s autonomy?
This issue, like many others, represents a Challenging/Troubling Trichotomy of Technology, Ethics and Law-what Can, Should and Must be done. Should “custodians” of prisoners be required to obtain court orders in order to provide interventions such as force feedings against the desires of the individual as is the case of non-prisoners or do prisoners give up their legal health-care/harm prevention decision making capacity?
Hunger Strike articles continue to make the news, with varying viewpoints. Please continue to add your perspective as healthcare professionals. This topic will be discussed by a multidisciplinary panel at Clinical Nutrition Week 2014, Savannah, Georgia.
ICES of A.S.P.E.N. Section Meeting
Monday, January 20, 2014 6:30 to 7:45 PM
Ethical Considerations Surrounding Patient Feeding Issues: Comfort Feeding to Forced Feeding
Panel Discussion:
John Wesley, MD, FACS, FAAP, FASPEN Moderator
Panel Members
Albert Barrocas, MD, FACS, FASPEN
Alessandro Pontes-Arruda, MD, MSc, PhD, FCCM
David Seres, MD, PNS, ScM
Carol Ireton-Jones, PhD, RDN, CNSC, FACN, FASPEN
Deborah Andris MSN APNP
Yimin Chen, MS, RD, CNSC
New York Times
Tuesday, November 26, 2013
Hunger Strikes
News about Hunger Strikes, including commentary and archival articles published in The New York Times.
Hunger Strikes Chronology
http://topics.nytimes.com/top/reference/timestopics/subjects/h/hunger_strikes/index.html
New York Times Magazine
The Ethicist
Is It O.K. to Force-Feed Prisoners?
By CHUCK KLOSTERMAN
November 22, 2013
http://www.nytimes.com/2013/11/24/magazine/is-it-ok-to-force-feed-prisoners.html?ref=theethicist