Authors’ reply

We are very grateful for all the important comments and questions raised in Piotr Szymański’s correspondence.1 We would like to note that our position statement relates to the feeding and hydration of patients in vegetative state (VS) or minimally conscious state (MCS) without referring to the management of patients in end-of-life care requiring advanced life-supporting medical devices (eg, a ventilator) or after brain death.2

Referring to the first question, regarding the omission of the spouse’s opinion, we want to emphasize that we do respect the opinions of the patient’s wife and other relatives without prejudging their importance and that our document focused mainly on the axiological assumptions underlying the decision of the court. Therefore, we did not analyze the wife’s opinion, as it was in line with the court’s decision, but we noticed that the view shared by the patient’s sister and mother was inconsistent with the court’s reasoning. We are aware of the complexity of a situation in which the patient’s will must be reconstructed based on the opinion of relatives. In many similar cases, such a reconstruction was difficult due to lack of unanimity among family members (eg, Vincent Lambert case, Terri Schiavo case). There were also cases where the court accepted the mother’s and sister’s objections to the wife’s request to stop tube feeding and hydration (eg, Michael Martin case, Robert Wendland case).3 The variety of these cases shows that there is no legal consensus as to the prevalence of opinions of some family members over others in formulating the best interest of patients. The raised question of marriage from a Catholic perspective and the Gospel passage quoted (Matthew 19:5) seem to be irrelevant here. RS and his wife were in a civil marriage, but not in a religious (sacramental) marriage, due to obstacles to the annulment of the wife’s previous marriage (point 18).4

Regarding the question concerning the ethical aspect of transport, it should be noted that the ethical assessment should encompass not only the risk of the action as such but also its goal and missed opportunities. The court was aware that RS could survive without a ventilator for “up to 5 years or more” and that after the “removal of nutrition and hydration he would die within a matter of a couple of weeks” (point 12 of the judgement).4 In this situation, transport to another center gave the patient a chance to continue his life (and even to improve his condition). Thus, it seems that the benefits of transport outweighed the associated risks, which should be minimized with professional care.

As to the issue of which ethical system should prevail (country of origin vs country of residency), it seems that the main question is not about the prevalence of one national ethical system over another, but about what ethical principles should shape decisions about the patient: respect for every human life or assessment of human life depending on its quality. Also, we are not convinced that “it is reasonable to assume that RS accepted United Kingdom’s ethical and legal medical standards, being a resident there from 2006.” The patient did not renounce his Polish citizenship, nor did he apostatize from the Catholic Church. In fact, he continued to regularly attend Catholic services. The protest statement of the Catholic Bishop of Plymouth also included the description of the existing ethical differences within the British society regarding the RS case. In a pluralist society, respect for the views of minorities (in this case, the Catholic minority in the United Kingdom) should be a standard, especially if they mean broader protection of fundamental human rights.

We agree with author and the cited review5 that parenteral hydration in the care of dying patients may be inconsistent with the welfare of some patients (due to fluid retention or heart failure risks). However, for others it may be beneficial by relieving symptoms (eg, delirium). Thus, this decision should be always carefully individualized. However, our position statement does not apply to this population of patients. In the case of patients in a VS / MCS, nutrition and hydration do fulfill their physiological functions. We are not aware of any reliable scientific evidence that feeding and hydration withdrawal in VS / MSC benefits patients. Therefore, it may be assumed that such judicial decisions are based more on individual beliefs and convictions than on scientific evidence.

In our opinion tube feeding and hydration in VS / MCS should be treated as basic care and not as a therapy that can be stopped on the grounds of persistence. The axiological assumptions of the RS judgement carry the risk of “slippery slope” in terms of protecting the lives of deeply disabled people, distorting the goals of medicine, and deepening discrimination based on health status. We agree that there is no straightforward solution to the problem, but we believe that any doubts should be resolved according to the principle of in dubio pro vita.