In regard to information about a Polish citizen who is under medical care in the United Kingdom and the controversy related to the discontinuation of nutrition and hydration in this case (RS/P case),1,2 the Polish Association for Spiritual Care that includes Polish physicians, nurses, and other healthcare professionals as well as psychologists, ethicists and chaplains, reminds the basic ethical principles related to the medical care of people in vegetative state (VS) or minimally conscious state (MCS), particularly related to RS/P case. From the available information, it appears that the patient suffered brain damage after heart attack on November 7, 2020, and the hospital petitioned the court for permission to discontinue nutrition using tube feeding and other life-sustaining treatment. Patient’s mother and sisters do not accept this decision and emphasize RS’s Catholic beliefs and prolife convictions. We are not aware of the patient’s wishes. Therefore, it seems important to recall the principles of medical ethics adopted in Poland and the official teaching of the denomination to which the patient belongs.

Withdrawal of hydration and feeding in a person living in VS or MCS is ethically controversial.3-6 It can be found in medical publications that tube feeding in VS or MCS should be provided and monitored.7,8 Discontinuation of tube feeding is ethically doubtful in many medical and religious groups around the world, which view nutrition and hydration as part of basic care rather than a treatment that could be withdrawn.9-12 Discrepancies in ethical and legal standards between the United Kingdom and other European countries have been already noticed in the context of discontinuing life-sustaining treatment and care.13

In the Republic of Poland, standards of medical ethics are based on the Polish Code of Medical Ethics.14 It directly states that a physician cannot euthanize or assist a patient in suicide (article 31). In end-of-life situation, a physician is not obliged to undertake resuscitation or other extraordinary measures perceived as persistent therapy (article 32). However, tube feeding or hydration in VS, MCS, or other neurological disorders cannot be treated as extraordinary measures or persistent therapy. Broad consensus reached by the Polish Working Group on End-of-Life Ethical Problems regarding a definition of “persistent or overzealous therapy” underlines that this concept cannot be strictly extended to basic care procedures such as pain relief or feeding and hydration, as long as they are for the patient’s good: “Overzealous therapy is the application of medical procedures with the goal of supporting vital functions in a terminally ill person that results in prolonged dying, and is associated with excessive suffering and / or with violation of the patient’s dignity. Overzealous therapy does not include basic nursing, control of pain and of other symptoms or feeding and fluid administration, as long as these actions are beneficial to the dying person.”15 The Polish law does not provide for exceptions to the legal protection of human life by withdrawal from nutrition and hydration in VS and MCS, and the Polish Penal Code explicitly prohibits euthanasia (article 150).

From the above point of view, analyzed forms of care (hydration and nutrition) cannot be considered as persistent therapy in VS, MCS, or other neurological disorders and cannot be discontinued. Guidelines for physicians published by the Polish Pediatrics Society regarding withholding and withdrawing persistent therapy in children also state that in neurological diseases, patients should receive feeding by tube or by gastrostomy. Lack of nutrition in these cases leads to death by starvation and cannot be accepted from the ethical point of view (p. 117).16

Medical community in Poland is very sensitive to distortions of the goals of medicine and subordinating medical practice to ideologies. For several years, we have been analyzing the causes of the transition of doctors’ attitudes “from healing to killing” in totalitarian regimes, such as in Nazi-German Auschwitz death camp practice.17 Therefore, protecting dignity, respecting autonomy, religious and conscience freedom, nondiscrimination, are important values in Polish ethical and legal standards regarding healthcare.

Cultural-sensitive and whole-person care should also consider beliefs and spirituality of all patients, especially those at the end of their life.18,19 It built the prestige and trust in healthcare workers.20 Since the discussed case regards a person with Christian beliefs and a member of the Catholic Church, the official teaching of the Catholic Church should also be recalled. Congregation for the Doctrine of the Faith of Catholic Church in the Letter “Samaritanus Bonus. On the care of persons in the critical and terminal phases of life,” mentions the moral obligation to exclude aggressive medical treatment (point V.2). However, at the same time, it emphasizes that nutrition and hydration (also artificial) are a basic care, not therapy, and causing death by deprivation of hydration and nutrition is not allowed: “In particular, required basic care for each person includes the administration of the nourishment and fluids needed to maintain bodily homeostasis, insofar as and until this demonstrably attains the purpose of providing hydration and nutrition for the patient. When the patient no longer benefits from the provision of nutrition and hydration, because the patient’s organism either cannot absorb them or cannot metabolize them, their administration should be suspended. In this way, one does not unlawfully hasten death through the deprivation of the hydration and nutrition vital for bodily function, but nonetheless respects the natural course of the critical or terminal illness (…) Obligatory nutrition and hydration can at times be administered artificially, provided that it does not cause harm or intolerable suffering to the patient” (point V.3).21 The same opinion was expressed in the official response to the United States Conference of Catholic Bishops regarding nutrition in VS (“The administration of food and water even by artificial means is, in principle, an ordinary and proportionate means of preserving life”; “A patient in a ‘permanent VS’ is a person with fundamental human dignity and must, therefore, receive ordinary and proportionate care which includes, in principle, the administration of water and food even by artificial means”).22 and in the New Charter for Health Care Workers of Pontifical Council for Pastoral Assistance to Health Care Workers (point 152),23 where nutrition and hydration, even if administered artificially, are classified as basic care.

In the assessment and appraisal of the RS/P case, the differences in ethical and legal medical standards between Poland and the United Kingdom and the Catholic beliefs of patients should be recognized. All actions must be taken with respect to the patient’s dignity, autonomy, and fundamental rights such as freedom of religion and conscience, and in accordance with the patient’s beliefs, if they are not opposed to the United Kingdom law. If such actions were not possible, the patient’s transport to Poland should be allowed. We hope that any doubts in this matter will be resolved according to the principle: in dubio pro vita humana.