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Abstract

Technologies for feeding permanently incapacitated patients enterally or parenterally through various forms of artiﬁcial nutrition and hydration (ANH) have generated moral questions and controversies. Particularly for patients in a persistent vegetative state or in advanced Alzheimer disease but also for terminally ill newborns, there are questions about whether ANH should be withheld or withdrawn. Is ANH extraordinary or even futile care? Do its burdens outweigh its beneﬁts? For patients provided with terminal sedation at the end of life, there are questions about the accompaniment of sedation with withdrawal of ANH. Is that removal a form of euthanasia? Or is it a justiﬁed part of the palliative care being provided at the end of life. Two further kinds of cases raise different sets of issues. First, is the forced feeding, by means of ANH, of hunger-striking prisoners, as, for example, the detainees at Guantanamo Bay, morally permissible, or is it a violation of bodily integrity and perhaps a form of torture? And second, is the failure to provide more adequate nutrition and hydration, including ANH, for Ebola patients in the developing world a matter of global injustice? This entry looks at each of these issues in turn.

Introduction

Nutrition and hydration are necessary components of any attempt to maintain human life, including any individual human being’s attempt to maintain his or her own life. At certain points in the human life span, however, individuals may be not yet capable of providing nutrition and hydration for themselves, or they may be temporarily or permanently incapacitated and thus no longer capable of so providing. In some cases, the difﬁculty may be rectiﬁed with assistance that is in no way medical: mothers nurse their children at the breast, and children spoon-feed their aging parents. In other circumstances, feeding and hydrating must be performed using some form of medical intervention: a nasogastric tube, for example, or a percutaneous endoscopic gastrostomy (PEG) tube. Only these latter interventions should be considered part of the domain of artiﬁcial nutrition and hydration (ANH), sometimes also called medically assisted nutrition and hydration (MANH), though there are questions about the similarity between ANH so considered and other assisted forms of nutrition and hydration that require no medical intervention.

In many cases, the provision of ANH raises no signiﬁcant moral questions. Where a patient is temporarily incapacitated, and is expected to recover fully, nutrition and hydration will be provided medically as necessary to sustain life. At the end of life, however, and in certain other cases, the decision to provide, withdraw, or refuse ANH raises moral issues on which there is no consensus. Four distinct kinds of end of life cases raise pressing dilemmas. First are cases involving care of patients in a persistent vegetative state (PVS), many of whom have no advance directives; must they be provided ANH, or is it permissible or even obligatory to remove ANH? Second are those cases involving care of patients suffering from advanced Alzheimer disease (AD) who are no longer willing or able to take food orally; again, the issue is raised whether they should be provided ANH or not. Third are cases of infants suffering from terminal or otherwise devastating conditions but who could live for some period of time, possibly extended, with the provision of ANH. Fourth are cases of dying patients who have been put into deep or terminal sedation; is it permissible to accompany the practice of terminal sedation with a withdrawal of ANH?

Two further kinds of cases raise additional questions. The ﬁrst concerns reports that hunger-striking prisoners at Guantanamo Bay have been coercively provided with ANH in order to sustain their lives. Some have asked whether this is a violation of core bioethical principles and even whether it might amount to torture. A second issue has arisen concerning the recent Ebola epidemic. There is a considerable discrepancy in care for Ebola patients between developed and developing nations, including in the speciﬁc domain of ANH, with patients in Western hospitals experiencing higher recovery rates due, among other things, to better maintenance of hydration in the face of persistent diarrhea and vomiting. This discrepancy raises questions about the worldwide distribution of resources and global justice.

All these issues may be considered properly “global” in the following ways. First, the conditions that lead to questions about ANH are found globally: PVS, Alzheimer disease, and life-threatening impairments among infants are not culturally speciﬁc difﬁculties; worldwide, medical professionals, families, and societies must address the moral problems raised by these conditions. Similarly, Ebola now should be considered a global health issue as well. And even the question of force-feeding of hunger strikers has global reach: hunger strikes are a favored form of protest of the disenfranchised worldwide.

Second, across a variety of different cultural contexts, there are important differences and commonalities to the concerns raised by ANH. Different ethnic, religious, and medical communities take different approaches to the provision of ANH; some are aggressive in providing, while others aggressive in refusing ANH. In some parts of the globe, the focus is primarily on the individual: it is asked whether ANH is in his or her best interests, or in line with his or her autonomous choices. In other areas, the approach may be more familial: what does the family wish for the patient and how may those wishes be best respected. Different conceptions of the human person likewise create differences of emphasis and approach.

At the same time, there is a core cluster of moral issues and concerns that remain relatively constant across global contexts. Those issues involve questions about our positive obligations to maintain life and prevent suffering, and our negative obligations not to kill, and the perceived tensions between these norms in particular cases. Moreover, even when the issue of the provision of ANH has not yet become exigent due to a lack of resources in parts of the developing world, this state of affairs is unlikely to continue in perpetuity. ANH is a relatively easy and inexpensive technology to provide. With globalization, it is unlikely that any area of the world will fail to be faced with the moral issues raised by ANH.

Finally, the moral discussion of ANH is permeated across the globe by religious values and language. Most of the major world religions, for example, issue guidance in the treatment of the dying and offer ofﬁcial teaching on the permissibility or impermissibility of taking life. Some offer additional guidance speciﬁcally on the matter of providing food and hydration by artiﬁcial means. Thus, to the extent that the religious inﬂuences on the discussion of ANH are global, to that extent are the issues themselves global.

History

Reﬂective discussion of the ethics of refusing or withdrawing nutrition and hydration from sick or dying persons has a substantial history. A sustained theological discussion takes place in the work of Catholic moralists between the sixteenth and twentieth centuries in terms relevantly similar to contemporary discussion: if a person requires food that would be costly, or difﬁcult to obtain, or to which he/she is strongly averse in order to preserve life, does he/she have an obligation to procure it? Francisco de Vittoria (1492–1546) answered in the negative, and subsequent discussion over the next four centuries tended to concur with his opinion (Cronin 2011).

The discussion inevitably needed to take account of the development of techniques by which nutrition and hydration could be provided to the incapacitated. The relevant techniques may be divided into two categories, enteral feeding technologies and parenteral feeding technologies (American College of Gastroenterology 2011). The former deliver nutrition and hydration to the gastrointestinal tract, whether by a nasogastric tube or by insertion of a tube through the skin near the abdomen. Nutrition and hydration are then delivered either to the stomach, duodenum, or jejunum. The most common of these techniques is the percutaneous endoscopic gastrostomy tube (PEG tube). Parenteral ANH, by contrast, is provided intravenously.

Reﬂecting on the previous 400 years of discussion of nutrition and hydration, but in light of the opportunities afforded by nasogastric feeding, the moral theological Daniel Cronin suggested in 1958 that tube feeding could be “extraordinary” treatment on occasion, that is, that it would fail to provide proportionate beneﬁt to burden and thus not be obligatory to provide a patient (Cronin 2011). The language of “ordinary and extraordinary” and “proportionate and disproportionate” continues to be used often in the discussion of these issues, although it is rejected by others in favor of either principlist analysis, which emphasizes autonomy, benevolence, non-maleﬁcence, and justice, or consequentialism, which emphasizes the pursuit of the greatest good for the greatest number.

Norms concerning the removal of ANH have also emerged through prominent legal cases. In the United States, the Supreme Court ruled in 1990 in Cruzan v. Director, Missouri Department of Health, that ANH was a form of medical treatment that could be refused by a patient. Thus, given “clear and convincing” evidence that an unresponsive patient would not have desired it, ANH should be withdrawn. In the United Kingdom, Anthony Bland had been in a persistent vegetative state for 4 years when the House of Lords ruled in Airedale N.H.S. Trust v. Bland (1993) that ANH should be withdrawn on grounds of medical futility. Again in the United States, the question of withdrawing ANH returned to prominence in 2005, in the case in Theresa (Terri) Schiavo. Schiavo had suffered cardiac arrest in 1990 and was in a persistent vegetative state, kept alive with a feeding tube for 15 years. After years of legal challenge by her parents, who wished to continue caring for her, her husband was eventually allowed by the courts to remove her feeding tube and he/she died.

These three cases, and especially the Bland and Schiavo cases, have generated both controversy and analysis. The analysis and the moral considerations arising from it have been exported to additional areas of controversy over ANH, specifically to questions concerning the care of patients with Alzheimer disease, terminally ill infants, and patients undergoing terminal sedation. Thus, the case of ANH for patients in a PVS is in many respects foundational for the ethics of artiﬁcial nutrition and hydration.

ANH And The Persistent Vegetative State

Patients in a so-called persistent vegetative state (PVS) are in an awake but nonresponsive condition, whether as a result of some sort of physical trauma or because of a prolonged period of anoxia. While there are cases of misdiagnosis, patients in the latter kind of PVS are generally considered to be in an irreversible state. The damage to the cerebral cortex is irreparable; there is no cure, nor will the brain heal itself. Because this part of the brain is responsible for consciousness and other higher brain functions, patients in a PVS are thus reasonably expected never to recover consciousness again.

Under such circumstances, many judge that aggressive medical interventions are to be judged “extraordinary” – that is, not morally obligatory (“ordinary”) – or “disproportionate” in the ratio of burdens to beneﬁts. A relatively noncontroversial example concerns the use of a ventilator for those whose ability to breath is severely compromised. In 1976, before the Supreme Court of New Jersey, Karen Ann Quinlan’s parents argued that her ventilator should be removed because it constituted extraordinary means. Removal of such means should not, they argued, be considered euthanasia, since death would be a side effect of the removal and not intended. The Court agreed; however, Quinlan was able to breathe on her own and survived, with ANH, for 9 more years.

Her parents did not argue that ANH constituted extraordinary or disproportionate means, but in subsequent medical practice ANH has increasingly been understood as extraordinary for patients in a PVS, and the assertion that its withdrawal is not euthanasia has been challenged.

The most prominent challenge was made by Pope John Paul II in an allocution to an International Congress on Life-Sustaining Treatments and Vegetative States in 2004 (John Paul 2004). In that address, the Pope identiﬁed the provision of nutrition and hydration, even if medically assisted, as itself always:

…a natural means of preserving life, not a medical act. Its use, furthermore, should be considered, in principle, ordinary and proportionate, and as such morally obligatory, insofar as and until it is seen to have attained its proper ﬁnality, which in the present case consists in providing nourishment to the patient and alleviation of his suffering.

The Pope then warned that

Death by starvation or dehydration is, in fact, the only possible outcome as a result of their withdrawal. In this sense it ends up becoming, if done knowingly and willingly, true and proper euthanasia by omission.

Many commentators argued that this stance of the Pope’s revealed a move away from traditional Catholic teaching of the refusal of medical interventions when they are judged no longer to provide proportionate beneﬁt (Shannon 2006). Others defended the Pope’s teaching, which was reiterated in a document subsequently released by the Congregation for the Doctrine of the Faith (see the essays in Tollefsen 2008). The Pope’s views have remained controversial and do not mirror larger trends; withdrawal of ANH for patients in a PVS seems to be widely practiced, and the view articulated by the Pope is a minority position.

Nevertheless, the Pope’s view has been defended on natural law grounds and is not obviously a matter of revelation or faith only. Moreover, the issues raised by the allocution are important and are related to those raised by the foundational cases of Quinlan, Cruzan, Bland, and Schiavo. One concerns the nature of tube feeding and its end. Is such an act a medical procedure whose purpose is the cure of the sick

or the alleviation of the symptoms of an illness? The provision of nutrition and hydration to a patient in a PVS does not provide a cure and so might be judged by some to be medically futile. Or, is the provision of ANH, like the provision of nutrition and hydration by other means, such as a spoon or a straw, to those incapable of self-feeding better understood as a form of nursing care, part of the basic package of beneﬁts including maintenance of life that we typically provide to those who are incapable of caring for themselves?

Pope John Paul II’s remarks indicate his acceptance of the second construal. So understood, both his point and its contrast with competing views may be better comprehended. First, while attempts to cure and to care may be both refused and withdrawn if they no longer provide proportionate beneﬁt to burden and are therefore judged to be “extraordinary,” the judgment that the intervention is extraordinary must ﬁrst be guided by accurate assessment of what the relevant beneﬁt is. If ANH is primarily provided in order to maintain a patient’s life, then it cannot be considered to be futile so long as it successfully does that.

A second concern may be raised at this point: is the maintenance of human life itself good, independently of the other goods that a conscious agent is typically able to pursue? Here again, there are disagreements between those, such as the Pope, who hold life to be a basic and fundamental human good, intrinsic to the nature of the human person, and those who believe it is an instrumental good only, whose worth is curtailed when other, higher or intrinsic goods, may no longer be pursued. On this second view, even if the “ﬁnality” appropriate to ANH as such is the preservation of life, successful achievement of that end could only be judged morally by looking to the further ends that sustaining life helped the patient to realize.

However, if the Pope is correct that the primary purpose of ANH is the form of care associated with maintaining life and that life is indeed a basic good, then his claim that ANH is in principle “proportionate” where patients in a PVS are concerned becomes intelligible. Where providing a good constitutes a form of basic care, then the burdens necessary to render that care disproportionate must be signiﬁcant; but the burdens of providing ANH just as such are not very signiﬁcant. The cost, for example, is only a fraction of the cost of keeping a patient on a respirator; and patients in a PVS (unlike other cases to be considered below) do not suffer, if they are truly incapable of consciousness. Thus, just as the costs of bathing the patient, of providing clean bedclothes, and of turning the patient to prevent bedsores – all forms of nursing care and not medical acts as such – are not reasonably judged disproportionate or extraordinary, so ANH should also not be judged disproportionate or extraordinary for patients in a PVS, barring some other set of circumstances.

What of the Pope’s claim that withdrawing ANH for such patients would constitute euthanasia by omission? Here again, there are a number of interrelated questions. The ﬁrst concerns the relationship between euthanasia and intention. Euthanasia is understood by many as intentional taking of life in order to end suffering. It is thus distinguished from the refusal of various forms of life-sustaining interventions in order to avoid the burdens consequent upon those interventions: ﬁnancial costs, negative impacts on health, emotional distress, and others. When death results as a consequence of the refusal of such interventions, it is a side effect, and the act is not one of euthanasia.

Some reject the distinction between intention and side effect on which this difference is supposed to rest. If the distinction makes no difference, then each case of withdrawing, refusing, or omitting a life-sustaining intervention must be judged on its independent moral merits to assess its rightness or wrongness. No advanced judgment that acts intended to bring about death are always wrongful is possible on this view.

Even for those who do accept the importance of the intend-foresee distinction, the Pope’s claim that withdrawal of ANH is euthanasia by omission can be challenged: why is refusal of ANH different from refusal of, say, a ventilator? Even if unreasonable, must the intention be the patient’s death? One possible way to understand the Pope’s suggestion is this: the costs and burdens that are avoided in withdrawing ANH just as such are, as noted above, somewhat minor. ANH is relatively inexpensive, for example. However, the burdens sustained by those caring for the patient overall are much more extensive, including the cost of hospital care and the emotional burdens experienced by families. But those burdens are avoided not by rejecting ANH but by the subsequent death of the patient. If so, then the death is a means to the end of avoiding the substantive burdens, and the intention is thus indeed lethal (Brugger 2009).

John Paul’s allocution and subsequent discussion have thus set the template for much discussion of ANH worldwide, particularly among Catholics. The starting points of that discussion are widely rejected, however. For many, the framework for thinking about the merits of withdrawing ANH for patients in a PVS concerns questions of quality of life and patient autonomy. Where the patient has given any prior indication that he/she would not desire extraordinary measures, or to be on “life support,” this is sometimes judged sufﬁcient to withdraw ANH under the patient’s authority; and where the patient is judged to no longer have a life worth living, or a reasonably high level of quality of life, this is sometimes judged sufﬁcient to withdraw independent of expressed patient wishes, often by appeal to the patient’s best interest. A further question may be raised using the language of “personhood.” To those who associate personhood exclusively with beings who are currently capable of consciousness or self-consciousness, patients in a PVS may no longer appear to be persons, and thus the debate about whether to feed them will seem misconstrued; what point can there be in keeping a nonperson alive, even if to do so would not be in any real sense contrary to their interests?

Alzheimer Disease

Alzheimer disease is a progressively debilitating and dementing disease, whose cause is still unknown. As Alzheimer disease progresses, it affects different parts of the brain, thus determining a typical pattern of symptoms over time. Alzheimer patients in early stages suffer memory loss; as the disease progresses, patients experience difﬁculties with language, perceptual problems (leading to “getting lost” or disoriented), motor control deﬁciencies, personality changes and social deﬁcits, and poor judgment. In the ﬁnal stages of the disease, patients are increasingly immobile and unresponsive (Brumback 2004).

In this ﬁnal stage of the disease, patients suffer a variety of impediments as regards eating and drinking, including loss of appetite, dysphagia, and resistance to attempts to feed them by hand. Malnutrition and severe weight loss are typical consequences of these difﬁculties, raising the question of whether these difﬁculties should be addressed by ANH. Alzheimer patients are also at risk for aspirational pneumonia; the question has been raised whether a PEG tube might be a beneﬁcial response to this risk.

In addition to these medical concerns, there are symbolic and social dimensions to the question of feeding. Families of Alzheimer patients are in an especially vulnerable and helpless state, unable to reverse their loved ones’ decline. In advanced stages, when it becomes increasingly difﬁcult even to feed by hand, and the consequences of inadequate nutritional intake become obvious, provision of ANH appears to be one of the few things that could be done that will actually make a difference, both in terms of the patient’s quality of life (for nutrition and hydration are thought to be both strengthening and palliating) and in terms of quantity of life (for nutrition and hydration are thought to be life prolonging).

These claims about the effectiveness of ANH for patients suffering from Alzheimer disease have been challenged, as regards both their medical and their palliative effect.

In a widely cited review in The New England Journal of Medicine, for example, Martha Gillick has disputed claims that ANH provides nutritional beneﬁt: “Because of problems with diarrhea, clogging of the tubes, and the tendency of patients with dementia to pull out the tubes, nutritional status often does not improve with the use of feeding tubes” (Gillick et al. 2000, p. 206). He/she additionally questions whether ANH prolongs life in patients with Alzheimer disease, citing a well-known study by Finucane which suggests the opposite (Finucane et al. 1996). Finally, Gillick and others have argued that ANH does not reduce the risk of either aspirational pneumonia or bedsores.

Additionally, ANH for patients with advanced Alzheimer brings with it further burdens. Some of these burdens are common to other uses of ANH, including those with patients in a PVS, such as an increased risk of infection. But others are more prominent with Alzheimer and other dementia patients including, most importantly, distress and confusion at the presence of the tubes, leading to efforts by the patient to pull the tubes out. Gillick cites one study in which 71 % of Alzheimer patients with feeding tubes had to be restrained in order to prevent them from pulling the tubes out. Restraints themselves will in turn often be experienced negatively by Alzheimer patients, causing an additional burden.

The palliative qualities of ANH for patients with advanced Alzheimer disease have also been questioned. Family members often desire that ANH be provided in order to prevent the suffering associated with dehydration and starvation. Some question whether these ends are better pursued, even in advanced stage dementia and Alzheimer patients, by hand-feeding; ice chips, for example, can prevent the experience of dehydration. And some question whether Alzheimer patients have a diminished capacity for experiencing hunger and thirst and subsequently suffer little or not at all in the ﬁnal stages of dying.

In the face of these claims, physicians, nurses, and palliative specialists appear to be broadly suspicious of the use of ANH for advanced Alzheimer patients, although some studies suggest that this is less the case in the United States than elsewhere (Buiting et al. 2011). In consequence, the state of the question currently seems to pit medical professionals against the desires of family members, who, as noted above, are more supportive of ANH.

Some additional questions must be raised, however. First, many commentators agree that while the evidence for the inutility of ANH for Alzheimer patients is strong, it is not deﬁnitive. Further investigation is necessary to determine what is genuinely best for patients in these cases. Second, important questions about the proper palliative approach to these patients remain, questions that are increasing in urgency as the number of Alzheimer patients increases worldwide. Third, some who would agree that ANH constitutes extraordinary or disproportionate care for advanced Alzheimer patients might nevertheless disagree with an additional criticism sometimes leveled at the practice, namely, that provision of ANH extends the dying process. If this is true, it calls into question the claims that ANH does not increase survival time; moreover, it suggests a concern to hasten the dying process. But those who adopt the framework of ordinary/ extraordinary or proportionate/disproportionate typically hold as well that the death should never be hastened, even if it should not always be prevented. Here, as elsewhere (as will be seen again below), some see a risk that refusal or withdrawal of ANH might be used as a form of euthanasia, bringing death in order to relieve suffering.

Critically Ill Infants

A third category of patient for whom questions of ANH arise is infants suffering from terminal illnesses. In some cases, such infants are not expected to live longer than a few hours or days, and ANH will not even be considered. But in other cases, newborns suffering from life-ending illnesses could nevertheless be expected to live for weeks, months, or even years with ANH, although their premature death would be expected at some point.

Many of the same sorts of considerations raised by the previous cases of patients in a PVS and patients with advanced Alzheimer disease will be relevant here. Those who believe that intentional killing or hastening of life is always wrong will ask whether the beneﬁts of ANH are proportionate to the burdens. Among the burdens to be considered here is whether ANH itself interferes with other palliative measures that should be provided to critically ill newborns (Uhl 2011). Others will ask whether the life of the infant is worth living and whether the provision of ANH merely postpones an inevitable death at the cost of a longer period of suffering.

Terminal Sedation

The ﬁnal issue concerning the provision of ANH to the dying or apparently dying concerns patients at the end of life whose suffering is so extensive that they are palliated with sedatives to a state of permanent unconsciousness. This practice has itself raised some moral questions: to some, it seems the only reasonable response to pain or suffering for which there is no other relief. Others have argued that terminal sedation constitutes a form of “slow euthanasia” and that the current state of palliative care and pain relief makes terminal sedation unnecessary. To this, it is replied that death is not intended in terminal sedation; rather, a relief of suffering is sought. Nor is the suppression of consciousness intrinsically bad or wrong; anesthesia and sleep serve as persuasive counterexamples (see the essays in Taboada 2014).

The question of terminal sedation intersects with the ethics of ANH, however, insofar as an occasional part of that practice includes the simultaneous discontinuation of ANH. Once again, a central question is whether the withdrawal of ANH constitutes a form of intentional killing. Some argue that while terminal sedation need not involve any such intention, it is accompanied by the withdrawal of ANH primarily in order to hasten death. Thus they draw a distinction between terminal sedation with and terminal sedation without ANH, arguing that the latter is akin to euthanasia (Holm 2013). On the other hand, where permanent unconsciousness is expected, and there is no possibility of recovery, others argue that the provision of ANH is futile or that it constitutes an unreasonable prolongation of life. Thus, once again, key arguments from the debate over PVS are replicated.

Across the four areas discussed so far, then, common themes emerge. Is the withdrawal or refusal of ANH in some particular case, with a patient in some particular condition, a form of euthanasia? Or is the provision of ANH to such a patient futile, or non-beneﬁcent, increasing rather than decreasing suffering, whether directly, or by prolonging a life not worth living? To these questions we may add a further question: when questions about ANH should be addressed for incompetent patients, whose decisions should be given authority? In the case of Terri Schiavo, this question was central to the dispute between her husband and her parents. In other cases, there are conﬂicts between doctors and families or between doctors and nurses or other medical professionals. And in yet other cases, there are conﬂicts between the wishes of family members or physicians and courts. In England, for example, a court judgment is required in order to remove ANH from a PVS patient; this typically is a somewhat pro forma matter. However, in 2011, requests by family members to remove ANH from a patient in a minimally conscious state were denied by a judge in the case of W v M on grounds of both sanctity of life and best interests. The case indicates that questions concerning the locus of authority in medical decision making remain troubled.

ANH And Hunger Strikers

The next case to be discussed raises rather different issues than the ﬁrst four. As part of the continuing response to the attacks of September 11, 2001, so-called unlawful enemy combatants have been kept, in many cases without trial, at a United States prison in Guantanamo Bay, Cuba. Since 2002, there have been several hunger strikes, by individuals or groups, to protest various aspects of captivity, ranging from the initial denial of permission to wear turbans to continued detention without trial or expatriation.

In response, the United States has forcefully restrained prisoners in order to feed them enterally through a nasograstric tube. Since 2005, a “restraining chair” has been used to subdue prisoners during the procedure. In one of the most recent cases, a federal judge permitted the forced feeding of a Syrian detainee, Abu Wa’el Dhiab, to prevent his death, while criticizing the Pentagon’s unwillingness to compromise with the detainee.

The case of forced feeding of hunger strikers in a prison raises difﬁcult issues for which the ordinary framework of bioethics may not be well suited. Under the vast majority of circumstances, to forcefully impose medical treatment upon another against their stated wishes would be considered an unacceptable violation of patient autonomy and bodily integrity. Moreover, genuinely forced feeding of the sort undertaken at Guantanamo is not only contrary to the autonomy of the prisoners but also appears to be painful and to threaten physical and psychological harms while also, of course, sustaining life. Accordingly, a number of medical organizations have condemned force-feeding of prisoners, and some have argued that the practice is not only impermissible but is also a form of torture and in violation of the Geneva Convention.

The situation of ordinary prisoners is not straightforwardly analogous to that of other medical patients, however. Prisoners’ autonomy is already curtailed justly as part of their sentence, and it is arguable that they should not be permitted by the state to willfully end their lives by starvation, thus ending their just punishment. So the state might reasonably force-feed under such circumstances. But these considerations surely make most sense in the context of punishment imposed through legal sentence, precisely what is lacking for many of the Guantanamo detainees. And in the case of Abu Wa’el Dhiab, he/she was slated for transfer from the base to Syria until circumstances in Syria rendered that impossible. So it is unclear what the legal relationship is between him and the United States and whether morally that relationship entitles the United States to overrule his lack of consent and engage in forced feeding. An additional issue, raised by the judge in the case, is that Dhiab had indicated that he/she would be willing to be fed enterally in the Guantanamo hospital; yet the United States declined to do so, opting instead to feed him in the restraining chair. And a ﬁnal difﬁculty, the case is further complicated by the actions of a nurse at Guantanamo who has refused to comply with military orders to participate in the feeding of the detainees. His case highlights the possibility of conﬂict between norms of the medical profession and norms of the military profession, with the conﬂict here centering around the provision of ANH (Olson and Gallagher 2014). The issues raised by this and similar cases are still in need of adequate resolution, and they threaten to recur, given the prominence of hunger strikes as a form of political protest, especially in prison.

Ebola, ANH, And Global Justice

Ebola virus disease is a hemorrhagic disease characterized by intense ﬂu-like symptoms including high fever, vomiting, and diarrhea. Found primarily over the past 40 years in Central Africa, it appeared in late 2013 in Guinea, West Africa, was diagnosed in March of 2014, and spread to Sierra Leone and Liberia. Cases have also appeared in Mali, Nigeria, Senegal, Scotland, Spain, and the United States. Additionally, medical personnel have been ﬂown from West Africa to a number of Western countries for treatment.

Containment of the disease in West Africa was initially hindered by a slow international response, poor African medical infrastructure, and local suspicion at Western medical teams. Moreover, treatment options in West Africa are poor: lack of resources and staff initially resulted in an inability to provide quarantine and care for all patients, and some areas resorted to home treatment and quarantine. By September of 2014, several Western nations had pledged a signiﬁcant increase in aid; by December, the epidemic seems to have peaked, although there are warnings that it might remain endemic in countries such as Sierra Leone that have not managed to fully control its spread.

There is an obvious discrepancy between survival rates of Ebola patients who have been treated in Western hospitals and those in West Africa. In the United States, for example, ten Ebola patients have been treated and of those only two have died. There are a number of causes for the discrepancy, but one of relevance in this context concerns the role of nutrition and hydration in care for Ebola patients. According to a recent report in the New England Journal of Medicine:

The predominant clinical syndrome of EVD involves substantial volume loss due to vomiting and diarrhea. This requires aggressive oral and intravenous volume repletion and close follow-up to avoid further complications and hypoperfusion-associated organ dysfunction. (Fowler et al. 2014, p. 6)

The ability of patients to be quickly rehydrated and to be provided electrolyte replacement is crucial for the patient’s body to be able to stave off Ebola long enough to be able to defeat the disease. Inadequately hydrated patients grow weaker and suffer other deﬁciencies, leading to higher mortality.

In the United States and other developed nations, provision of parenteral ANH to Ebola patients was a given. But in West Africa, most patients have not been afforded this level of care. While it is impossible to say what difference in overall mortality rate improvements just in this sphere would make, it appears to be an area in which the proportion of beneﬁt to expense would be considerable (Roberts and Perner 2014). Food aid in general constitutes a large part of what is necessary to treat Ebola patients, but it is apparently often overlooked and underappreciated.

The gap between developed and developing countries on this matter raises questions about global justice in the distribution of healthcare resources. No doubt it is too much to expect Western-style medical infrastructure to appear in West Africa in the near future. But a starting point for equitable distribution could be meaningful improvement in the resources available to provide ANH to patients who are critically but reversibly ill – not just Ebola patients but, for example, malaria patients as well.

Conclusion

The moral issues raised by the possibility of artiﬁcial provision of nutrition and hydration overlap considerably with the range of issues addressed in “traditional” end of life ethics: suicide, euthanasia, ordinary and extraordinary care, and the like. But because ANH involves questions of feeding and eating, acts central to the human life, not death, this area of controversy takes on additional symbolic and emotional weight. On the one hand, withdrawal of ANH can feel like an abandonment of solidarity with a patient, while on the other, continued provision of ANH to a dying demented patient can feel like “forced feeding.” Navigating these competing emotionally charged intuitions within the framework established by end of life ethics is a crucial but fraught task for medical ethics.

At the same time, questions about feeding hunger strikers or hydrating Ebola patients indicate that the questions surrounding ANH can diverge from those of end of life ethics in additional ways. Hunger strikers are not terminally ill; and while Ebola patients are sick, it appears that artiﬁcially hydrating them is part of a treatment for their disease; in this, they are unlike, say, PVS patients. Moreover, these issues raise questions of military ethics and global justice, respectively, that are unusual in ordinary end of life contexts. ANH is thus a complex and continuing moral issue in medical ethics.

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