For this reason a man will leave his father and mother and be united to his wife, and the two shall become one flesh.

Matthew 19:5

To the editor

I diligently read a paper by Pawlikowski et al1 that discussed discontinuation of hydration and nutrition in vegetative or minimally conscious state. The authors emphatically opposed the discontinuation of hydration and nutrition based on a recently disputed case of a Pole (RS) with severe brain damage, resulting from a prolonged cardiac arrest that lasted at least 45 minutes.

There is, however, no straightforward solution to the problem. First, from the strictly medical point of view, there is insufficient evidence to draw firm conclusions on the impact of clinically assisted hydration or nutrition in the last days of life.2 It may supposedly offer some patients comfort, and potentially relieve perceived thirst (assuming it is present); however, it may lead to fluid retention, heart failure, abdominal distension as well as pose the risks associated with placement of a nasogastric tube or infusion devices. Second, discontinuation of hydration and nutrition is not a nondebatable ethical issue, even in children.3 It is also worth adding that, albeit in another context, refusal of treatment with the awareness that death will soon follow is not suicide, according to international medical ethics, and forced feeding may be considered a torture.4

In this particular case the healthcare provider application for food and hydration be withdrawn and to provide appropriate palliative care (according to the United Kingdom legal and medical standards), in order to maximize his dignity and ensure no unnecessary suffering in a patient lacking capacity to consent or refuse medical treatment was supported by RS’s wife, but was opposed by his mother, 2 sisters, and niece, who lodged an appeal against the decision made on December 31, 2020, in which the judge rejected a declaration that it would be in RS’s best interests to receive clinically assisted nutrition and hydration. The judge also refused to order that RS should be transferred to Poland for further treatment. Similar application by the mother and sister was rejected also by the European Court of Human Rights on December 24, 2020. The details of the Judge’s decisions are publicly available and may be found in the list of England and Wales Court of Protection Decisions (see University Hospitals Plymouth NHS Trust).5

The judge rejected the suggestion that RS should be moved overseas (to Poland) based, among others, on the following premises: 1) patient’s transport was associated with significant risk of death; 2) “it would be deeply uncomfortable for RS, far worse than being nursed on a hospital bed”; and 3) “it is unthinkable that he should be moved against the wishes of his wife and children.”

Since it was impossible to ascertain RS’s wishes, the Judge had reached the decision that it can be ascertained from his wife’s reports, rather than based on the claims made by his mother and sister of RS’s beliefs and pro-life convictions. It is important to add that, according to testimonies, RS had relatively little contact with his Polish family, for example has not seen his sister who lived in England since about 2011 and had little contact with his mother and sister in Poland. Moreover, it is perhaps prudent to assume that RS accepted United Kingdom’s ethical and legal medical standards, being a resident there from 2006.

Given the abovementioned medical2 and ethical3 uncertainty of what decision would be in the best patient’s interest, and patient’s inability to express his will, this particular case raises a lot of ethical questions that were not addressed by the position statement by Pawlikowski et al1:

1 Should wife’s reports be rejected in favor of declaration of the other members of the family in the process of ascertainment of patient’s preferences, and why?

2 What would be the ethical approach to the ethical dilemma of wife’s suffering, if her testimony was ignored, and how this relates to the man and wife relationship as perceived by patient’s Catholic faith (Matthew 19:5)?

3 How should ethical dilemmas related to the risk of death during transport be handled?

4 Should ethical system in the country of origin (Poland) prevail over the ethical system in the country of residency and why?

5 Should the use of artificial nutrition and hydration towards the end of life be unequivocally recommended without sufficient clinical evidence?