The purpose of this paper is to examine the possibilities and limitations of an ethical and practical approach to terminal dehydration. We have argued that dehydration among terminally ill patients offers an important key to a better understanding of the dying process, and that the caregivers' reactions can lead to a deepening of holistic palliative care. This article makes clear that the moral question of terminal dehydration can only be treated by an interdisciplinary approach. Therefore, before studying (...) the question of the most humane course possible, we must first understand the meaning of dehydration and its repercussions for the dying patient. Inspired by an attitude of respect for a good dying process, we have suggested that it is possible to put forward as a general guideline that medical therapy should be progressively reduced when it has been determined that a patient has reached the terminal stage, or is in an irreversible deteriorating process. We describe the critical somatic, social, psychological, moral and spiritual points, which make up an ethical approach to terminal dehydration (TD). In the total care of the irreversibly terminally ill patient, tolerating TD can be an expression of an authentic and caring involvement in the dying patient's welfare. (shrink)

We hypothesize that threat of dehydration provided selection pressure for the evolutionary emergence and persistence of the anterior communicating artery (ACoA – the inter‐arterial connection that completes the Circle of Willis) in early amniotes.The ACoA is a hemodynamically insignificant artery, but, as we argue in this paper, its privileged position outside the blood‐brain barrier gives it a crucial sensing function for the osmolarity of the blood against the background of the rest of the brain, which efficiently protects itself from (...) dehydration. Till now, the questions of why the ACoA evolved, and what its physiological function is, have remained unsatisfactorily answered. The traditional view—that the ACoA serves as a collateral source of vascularization in case of arterial stenosis—is anthropocentric, and not in accordance with principles of natural selection that apply more generally. Diseases underlying arterial stenosis are associated with aging and the human lifestyle, so this cannot explain why the ACoA formed hundreds of millions of years ago and persisted in amniotes to this day.The peculiar hemodynamic properties of the ACoA could be selected traits that allowed for more efficient forebrain detection of dehydration and complex behavioral responses to water loss, a major advantage in the survival of early amniotes. This hypothesis also explains insufficient hydration often seen in elderly humans. (shrink)

The Royal College of Physicians of London published the 2013 national clinical guidelines on prolonged disorders of consciousness in vegetative and minimally conscious states. The guidelines acknowledge the rapidly advancing neuroscientific research and evolving therapeutic modalities in PDOC. However, the guidelines state that end-of-life decisions should be made for patients who do not improve with neurorehabilitation within a finite period, and they recommend withdrawal of clinically assisted nutrition and hydration . This withdrawal is deemed necessary because patients in PDOC can (...) survive for years with continuation of CANH, even when a ceiling on medical care has been imposed, i.e., withholding new treatment such as cardiopulmonary resuscitation for acute life-threatening illness. The end-of-life care pathway is centered on a staged escalation of medications, including sedatives, opioids, barbiturates, and general anesthesia, concurrent with withdrawal of CANH. Agitation and distress may last from several days to weeks because of the slow dying process from starvation and dehydration. The potential problems of this end-of-life care pathway are similar to those of the Liverpool Care Pathway. After an independent review in 2013, the Department of Health discontinued the Liverpool Care pathway in England. The guidelines assert that clinicians, supported by court decisions, have become the final authority in nonconsensual withdrawal of CANH on the basis of “best interests” rationale. We posit that these guidelines lack high-quality evidence supporting: 1) treatment futility of CANH, 2) reliability of distress assessment from starvation and dehydration, 3) efficacy of pharmacologic control of this distress, and 4) proximate causation of death. Finally, we express concerns about the utilitarian-based assessment of what constitutes a person’s best interests. We are disturbed by the level and the role of medical authoritarianism institutionalized by these national guidelines when deciding on the worthiness of life in PDOC. We conclude that these guidelines are not only harmful to patients and families, but they represent the means of nonconsensual euthanasia. The latter would constitute a gross violation of the public’s trust in the integrity of the medical profession. (shrink)

Helga Kuhse suggested in 1985 at a session of the World Federation of Right to Die Societies in Nice, that once dehydration to death became legal and routine in hospitals, people would, on seeing the horror of it, seek the lethal injection. The strategy of legalising passive euthanasia is itself flawed. Laing argues that the Mental Capacity Bill threatens the vulnerable by inviting breaches of arts 2,3,5,8, and 14 of the European Convention on Human Rights. Most at risk are (...) the disabled and incapacitated. Sections permitting non-therapeutic research and non consensual sterilisation are at odds with the Nuremberg Code. New third party powers to dehydrate the vulnerable permit new systemic human rights abuse of a clinical though not historically unfamiliar variety. (shrink)

When a severely suffering dying patient is deeply sedated, and this sedated condition is meant to continue until his death, the doctor involved often decides to abstain from artificially administering fluids. For this dual procedure almost all guidelines require that the patient should not have a life expectancy beyond a stipulated maximum of days (4–14). The reason obviously is that in case of a longer life-expectancy the patient may die from dehydration rather than from his lethal illness. But no (...) guideline tells us how we should describe the dual procedure in case of a longer life-expectancy. Many arguments have been advanced why we should not consider it to be a form of homicide, that is, ending the life of the patient (with or without his request). I argue that none of these arguments, taken separately or jointly, is persuasive. When a commission, even one that is not itself life-shortening, foreseeably renders a person unable to undo the life-shortening effects of another, simultaneous omission, the commission and the omission together should be acknowledged to kill her. I discuss the legal and ethical implications of this conclusion. (shrink)

Conservation scholarship and policies are concerned with the viability of idealized ecological communities constructed using human metrics. We argue that the discipline of conservation assumes an epistemology and ethics of human sovereignty/dominion over animals that leads to violent actions against animals. We substantiate our argument by deconstructing a case study. In the context of recent bushfires in Australia, we examine recent legislation passed by the parliament of New South Wales, policy documents, and academic articles by conservationists that support breaking communities (...) of horses and/or killing 4,000 horses in Kosciuszko National Park, NSW. Theoretically framing our deconstruction against human sovereignty over animals and anthropocentrism, we affirm an intersectional, ecofeminist approach that values animals as relational and vulnerable agents. We uncover first the epistemic violence of categorizing horses as “pests,” and the anthropocentric nature of recently passed legislation in NSW. We analyze next the deficient ethics of NSW's government, and the argument that killing animals is justifiable when they suffer from starvation and dehydration. We close with a realistic proposal that does not involve breaking horses’ communities and/or killing horses, and a plea to the government of NSW and conservationists not to harm any horses in KNP. (shrink)

In assisted dying, the end-of-life trajectory is shortened to relieve unbearable suffering. Unbearable suffering is defined broadly enough to include cognitive (early dementia), psychosocial or existential distress. It can include old-age afflictions that are neither life-threatening nor fatal in the “vulnerable elderly”. The voluntary refusal of food and fluids (VRFF) combined with continuous deep sedation (CDS) for assisted dying is legal. Scientific understanding of awareness of internal and external nociceptive stimuli under CDS is rudimentary. CDS may blunt the wakefulness component (...) of human consciousness without eradicating internal affective awareness of thirst and hunger. Patients may suffer because of the slow dying process following dehydration and starvation. The difficulty to adequately control distress, without bringing the dying process to a rapid conclusion by lethal pharmacological interventions, can cause feelings of guilt among hospice and medical staff. Furthermore, the double-effect principle is not applicable in these situations because the primary objective of VRFF is to hasten death. Legal and societal debate should focus on sharpening the boundaries between assisted dying and palliative care. This separation is necessary to: 1) uphold trust in the patient-phyician relationship, and 2) preserve integrity and ethics of the medical profession. (shrink)

This article examines how the formation of markets in bottled water has relied on assembling a particular subject: the subject of hydration. The discourse of hydration is a conspicuous feature of efforts to market bottled water, allowing companies to appeal to scientifically framed principles and ideas of health in order to position the product as an essential component in self-health and healthy lifestyles. Alongside related principles, such as the ‘8 × 8 rule’, hydration has done much to establish new practices (...) of water drinking and consumption in which the consumer appears to be always at risk of dehydration and must engage in practices of ‘frequent sipping’. This article traces the emergence of the concept of hydration from its origins in exercise science and explores its circulation, contemporary uses and purchase. I argue that the appeal to biomedical languages and concepts found in the discourse of hydration connects with much broader ways of conceiving and acting upon the self that have become prevalent in contemporary society – what Rose and Novas call ‘biological citizenship’ – indicating how the ensemble of hydration participates in wider-ranging transformations in forms of rule. The story of hydration reveals how biomedical techniques of the self can be made to double up as ‘market devices’ by offering specific procedures for assessing the self and calculating the body’s needs. In order to grasp these developments, I position the health sciences, and health and fitness in particular, as a potent site of popular culture in which bodies learn to be affected by the procedures of scientific experiment. A critical grasp of this context is best enabled, I argue, by situating the producers and consumers of scientific principles and commercial products as embodied and looking at their interconnection in processes of emergence. Through these means, we can begin to develop a fully materialized account of the question: how have we become so thirsty? (shrink)

> Wealthy nations must do much more, much faster. The United Nations General Assembly in September 2021 will bring countries together at a critical time for marshalling collective action to tackle the global environmental crisis. They will meet again at the biodiversity summit in Kunming, China, and the climate conference 26) in Glasgow, UK. Ahead of these pivotal meetings, we—the editors of health journals worldwide—call for urgent action to keep average global temperature increases below 1.5°C, halt the destruction of nature (...) and protect health. Health is already being harmed by global temperature increases and the destruction of the natural world, a state of affairs health professionals have been bringing attention to for decades.1 The science is unequivocal; a global increase of 1.5°C above the preindustrial average and the continued loss of biodiversity risk catastrophic harm to health that will be impossible to reverse.2 3 Despite the world’s necessary preoccupation with COVID-19, we cannot wait for the pandemic to pass to rapidly reduce emissions. Reflecting the severity of the moment, this editorial appears in health journals across the world. We are united in recognising that only fundamental and equitable changes to societies will reverse our current trajectory. The risks to health of increases above 1.5°C are now well established.2 Indeed, no temperature rise is ‘safe’. In the past 20 years, heat-related mortality among people aged over 65 has increased by more than 50%.4 Higher temperatures have brought increased dehydration and renal function loss, dermatological malignancies, tropical infections, adverse mental health outcomes, pregnancy complications, allergies, and cardiovascular and pulmonary morbidity and mortality.5 6 Harms disproportionately affect the most vulnerable, including children, older populations, ethnic minorities, poorer communities and those with underlying health problems.2 4 Global heating is also contributing to the decline in …. (shrink)

Dr Gillian Craig (1) has argued that palliative medicine services have tended to adopt a policy of sedation without hydration, which under certain circumstances may be medically inappropriate, causative of death and distressing to family and friends. We welcome this opportunity to defend, with an important modification, the approach we proposed without substantive background argument in our original article (2). We maintain that slowing and eventual cessation of oral intake is a normal part of a natural dying process, that artificial (...) hydration and alimentation (AHA) are not justified unless thirst or hunger are present and cannot be relieved by other means, but food and fluids for (natural) oral consumption should never be 'withdrawn'. The intention of this practice is not to alter the timing of an inevitable death, and sedation is not used, as has been alleged, to mask the effects of dehydration or starvation. The artificial provision of hydration and alimentation is now widely accepted as medical treatment. We believe that arguments that it is not have led to confusion as to whether or not non-provision or withdrawal of AHA constitutes a cause of death in law. Arguments that it is such a cause appear to be tenuously based on an extraordinary/ordinary categorisation of treatments by Kelly (3) which has subsequently been interpreted as prescriptive in a way quite inconsistent with the Catholic moral theological tradition from which the distinction is derived. The focus of ethical discourse on decisions at the end of life should be shifted to an analysis of care, needs, proportionality of medical interventions, and processes of communication. (shrink)

Recent developments in agriculture have stirred up interest in the concept of “sustainable” farming systems. Still it is difficult to determine the extent to which certain agricultural practices can be considered sustainable or not. Aiming at identifying the necessary attributes with respect to sustainability in Dutch dairy farming in the beginning of the third millennium, we first compiled a list of attributes referring to all farming activities with their related side effects with respect to economic, internal social, external social, and (...) ecological sustainability. A wide range of people (i.e., experts and stakeholders) were consulted to contribute to our list of attributes. Our consultation showed that only one attribute was selected for economic and internal social sustainability: profitability and working conditions, respectively. The list for external social sustainability contained 19 attributes and the list for ecological sustainability contained 15 attributes. To assess their relative importance, the same experts and stakeholders ranked the attributes for external social and ecological sustainability by using a questionnaire. The most important attributes for external social sustainability were food safety, animal health, animal welfare, landscape quality, and cattle grazing. For ecological sustainability they were eutrophication, groundwater pollution, dehydration of the soil, acidification, and biodiversity. The present method for identifying and ranking attributes is universal and, therefore, can be used for other agricultural sectors, for other countries, and for other time periods. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Lessons Learned in Room 208Katherine BakkeAuthor's Note. Parts of this story were previously shared here: https://theinterstitium.home.blog/2020/06/01/journeying-to-a-time-of-death/I remember the first time I saw a patient die. I was a medical student on my surgery rotation. Pushed to the sidelines of the resuscitation bay while the trauma team tended to a teenager injured in a motorcycle crash, my attention was drawn to the drama unfolding next door. There, a team of (...) physicians performed CPR on a man. While a curtain and a comforting social worker separated the patient's wife and daughter from the horrors of the resuscitation, I had a full view of everything. I watched as each chest compression threw the man's belly upward, like he had a bad bout of the hiccups. I watched as each pulse check yielded no return of blood flow. I watched as his wife and daughter clenched their hands in prayer, muttering, "Please, please, please." Then, the physician called the code. The instant the doctor pronounced him dead, I felt the presence of one less person in the room. I was surprised by how visceral this departure felt. It seemed like a sacred moment, a small proof that our bodies do indeed house our souls.I started paying close attention to how surgeons talked about death. Discussions of death seemed frequent in windowless work rooms amongst doctors, or in hushed conversations at the nurses station. Discussions of death were notably absent when talking with patients or their families. Sometimes, it seemed that the sicker the patient, the less likely their possible death was acknowledged. I [End Page E12] was fascinated by how challenging it was to speak honestly about our inevitable mortality. I began reading everything I could find about discussing end-of-life issues. I even conducted and published a systematic review on the subject. When it came time for me to begin my own surgical training, I carried with me a naive confidence, eager to engage in these conversations at the bedside.My time finally came eight months into my intern year. I was working in the intensive care unit and was "up" for the next admission. I got a call from the emergency department, saying a 68-year-old woman needed an ICU bed for a heart failure exacerbation. Her breathing was labored. They had given her IV Lasix, but I was told she might need BiPAP or other respiratory support while her heart failure was managed.Ten minutes later, she rolled into Room 208, and the ICU nurses started their work transferring her from the stretcher to the bed, applying EKG leads, a blood pressure cuff, and a pulse oximeter. I stood at the foot of the bed and quickly realized I had never taken care of a patient so ill. Her head drooped to her chest, every ounce of energy used to draw her next breath. She could only mumble indiscernible words; she hardly had the energy to open her eyes. I glanced at the monitor displaying her vitals: heart rate 120, SpO2 84%, BP 70/40. A foley catheter hung at the bedside, and no urine was present. "They gave her Lasix downstairs, right?" I asked the nurse. We both looked at the foley bag, and then at each other. I glanced at the patient's lips, which were dry and cracked. I pinched the skin at the top of the patient's hand, and it tented. I was pleased with my exam skills, and my ability to deduce that she was dehydrated. "This isn't heart failure," I thought, as I considered other reasons for her illness. The nurse awoke me from my self-congratulating stupor and reminded me sternly, "We need orders."The situation rapidly became more critical. The patient's arterial blood gas (ABG) showed a pattern of impending respiratory failure. Her daughters arrived at the bedside; one was wearing hospital scrubs. I introduced myself to them as the resident doctor caring for their mom. I asked if the daughter wearing scrubs had a healthcare background, foolishly thinking that doing so would build rapport. She curtly replied, "I... (shrink)

Plastination is a relatively novel technique wherein human tissue is dehydrated and the water is replaced with a plastic-like substance. The process is valuable to educational institutions, because it preserves the body for a long period of time, allowing for prolonged anatomical study. However, a number of ethical issues have been raised regarding the process, particularly related to the procurement of human specimens and the act of displaying these bodies, even for educational purposes. This article explores both the process itself (...) and the associated ethical pitfalls, particularly from a Catholic perspective. (shrink)

Jainism, which arose in India more than 2500 years ago, states that the soul is eternal: it has never been created nor can it ever be destroyed. The soul becomes cloaked, birth after birth, with karmas that obscure its true nature. The utmost task for the human being entails purifying oneself of karma through untying its many knots that bind the soul, masking its innate energy, consciousness, and bliss. One technique to guarantee a better life in the next birth is (...) to die a conscious death through a systematic process of fasting, entering into a state of dehydration. This highly regulated practice, pursued by monks, nuns, and laypersons who have gone through a rigorous period of internal reflection and external assessment before embarking on this path, provides a peaceful way to embrace death. Known as sallekhana or santara, it has recently been challenged in the courts as a form of suicide, an illegal practice, though for the Jain community it remains an important option through which one can express religious faith. (shrink)

This paper refutes the mechanistic interpretation of cellular dynamics and contends that the life-giving principle is sustained growth a biological system and is uninterrupted growth balanced in a dynamic state by synthesis and dissolution. The process began by an oxidation/reduction reaction on the surface of pyrite energized photovoltaically by sunlight. Hydrogen sulfide was oxidized, carbon dioxide was reduced, and phosphate on the surface of the pyrite was a reactant. The first organic compounds were sulfides and phosphoglycerates. These organophosphates were at (...) the center of the energy cycle of all life where the dehydration of a relatively unreactive “low-energy” two-phosphoglycerate transforms it into the “high-energy” phosphoenolpyruvate. Life began as a growth process and continues to grow ceaselessly out of necessity. It cannot discontinue the life-giving energy flow without irreparable loss of the process. All forms of life past and present were and are stabilized systems in which the growth process is contained in metabolic turnover. (shrink)

The author defends the distinction between active and passive euthanasia. A characteristic feature of passive euthanasia is that it preserves the situation of waiting for death. Active euthanasia is characterised by the fact that it terminates this situation or anticipates its occurrence in a phase when death has not yet announced itself. Provided the situation of waiting for death is preserved, passive euthanasia may very weil include actively life-shortening measures such as dehydration. The situation of waiting for death has (...) primarily a ritual significance. It has the effect of leaving the participants with the consciousness that death as a definitive separation from a person was fate and not an act for which responsibility must be tak:en. This consciousness is important for the integrity of the personal relation to the deceased. Active euthanasia can therefore be considered only in extreme situations which leave no alternative. The author criticises the fact that the ritual aspect of medical action receives too little consideration in the discussion on euthanasia. Finally, conclusions relating to theological ethics are drawn. (shrink)

Bowel necrosis is a commonly observed condition in elderly patients with longstanding diabetes. In such condition, intestinal resection is usually performed for the removal of the gangrenous part. Post-surgical dietary management after bowel resection poses several challenges for the health care team. The case presented in this study is that of an elderly diabetic male who developed acute renal failure as a result of neglect in post-surgical feeding after intestinal resection. After the intervention by a trained dietitian, a transitional diet (...) was planned and successfully executed, resulting in reversal of acute renal failure, dehydration, and post-surgical stress. Several complications including hepatic dysfunction and mouth ulcers were resolved through well-planned transitional diet. The patient was finally discharged in a stable health condition and was regularly followed up for any nutritional or medical issues. Neglects in nutritional care of patients can have severe implications including development of medical complications, resulting in increased length of hospital stay, augmenting the disease stress of the patient and family, and finally the preventable drainage of several human and monetary resources. Therefore, recognition of nutritional intervention as an important part of in-hospital health care may have social as well as economic impacts. (shrink)

According to Jewish law, to make a judgment that a life has no purpose and is not worth saving is contrary to the concept of justiceTraditional medical practice dictates that when patients are unable to eat or drink enough to sustain their basic nutritional requirements, artificial feeding and hydration is indicated. Common clinical examples of this problem are patients with senile dementia and those in a persistent vegetative state . In recent decades, however, the practice of mandating artificial feeding has (...) been increasingly questioned. A combination of legal, ethical, and clinical considerations has resulted in broad support for withholding and withdrawing artificial nutrition. The guiding ethical principle in the current clinical standards is that patient autonomy must be honoured. In the context of an incompetent adult , advance directives or surrogate decision making are legally binding. Such requests to withhold artificial nutrition are considered appropriate and even encouraged.1 Such a view, however, is not unanimous. For example, Catholic writers have questioned the current consensus. The New Jersey Catholic Conference has written that withholding nutrition and hydration from such patients “ultimately results in starvation, dehydration, and death,” and that withdrawing such basic care from patients who are not dying but in a PVS “is a clear statement that the patient’s life has no moral value”.2 This question is also of great concern in Jewish law . In contrast to secular medical ethics, halachah requires that artificial feeding be given to patients with dementia or in a PVS. The following discussion gives an overview of the pertinent arguments that have led to the consensus in secular ethics that artificial feeding may be withheld from the severely demented and the halachic considerations that argue against this practice.CLINICAL ARGUMENTS IN FAVOUR OF WITHHOLDING ARTIFICIAL FEEDINGThe most obvious …. (shrink)

Many of the elderly in nursing homes are very ill and have a reduced quality of life. Life expectancy is often hard to predict. Decisions about life-prolonging treatment should be based on a professional assessment of the patient’s best interest, assessment of capacity to consent, and on the patient’s own wishes. The purpose of this study was to investigate and compare how these types of decisions were made in nursing homes and in hospital wards. Using a questionnaire, we studied the (...) decision-making process for 299 nursing home patients who were treated for dehydration using intravenous fluids, or for bacterial infections using intravenous antibiotics. We compared the 215 patients treated in nursing homes to the 84 nursing home patients treated in the hospital. The patients’ capacity to consent was considered prior to treatment in 197 of the patients treated in nursing homes and 56 of the patients treated in hospitals. The answers indicate that capacity to consent can be difficult to assess. Patients that were considered capable to consent, were more often involved in the decision-making in nursing homes than in hospital. Next of kin and other health personnel were also more rarely involved when the nursing home patient was treated in hospital. Whether advance care planning had been carried out, was more often unknown in the hospital. Hospital doctors expressed more doubt about the decision to admit the patient to the hospital than about the treatment itself. This study indicates a potential for improvement in decision-making processes in general, and in particular when nursing home patients are treated in a hospital ward. The findings corroborate that nursing home patients should be treated locally if adequate health care and treatment is available. The communication between the different levels of health care when hospitalization is necessary, must be better. ClinicalTrials. gov NCT01023763 [The registration was delayed one month after study onset due to practical reasons]. (shrink)

The Liverpool Care Pathway is intended as a palliative care regime at the end of life. Even its critics agree that certain of its recommendations may be useful and appropriate. Additionally, critics are aware that there are occasions when death may be a foreseen side effect of perfectly licit palliation whose primary ends are not homicidal at all. It is evident that treatment may be over-expensive, over-burdensome or simply futile. There is no suggestion that critics of the Pathway adhere irrationally (...) to what is known in medical ethics as the error of vitalism, the commitment to excessive, extraordinary or futile treatment, or over-burdensome care at the end of life. However, to ask whether treatment is futile, over-burdensome or over-expensive is very different to the discriminatory question about the futility, burden or expense of a frail and vulnerable patient. The sedation-dehydration aspect of the Pathway attracts much proper opposition. Doctors and families have found that those on the Pathway recovered when they intervened to take the patient off it. Senior medics have stepped forward, in the face of managerial opposition to argue that it is often impossible to know with certainty whether a person is imminently dying. One problem with the Pathway is that where a patient is misdiagnosed as terminal, the combination of morphine and dehydration has a self-fulfilling character and is likely to undermine a patient’s capacity. Persistent dehydration of even fit and healthy sedated patients will kill them. This was the difficulty highlighted by concerned medical professionals many years ago. The independent inquiry ordered in response to Freedom of Information Act requests performed in 2012 demonstrating a staggering increase in the number of people dying on the Pathway once it was financially incentivised needs to ensure certain investigations take place. What is needed, however, is not a whitewash but an independent inquiry with all interests declared and data sets interrogated and collated. These will cover a time-series medical history of each anonymised patient on the Pathway, duration until death, information about interventions provided during the period, monthly raw data from each trust, hospice or care home, medical histories, removals from the Pathway, information about journals that were corrected once a patient recovered, demographic data, location information and an audit trail of all data management. (shrink)

Encouraging VSED (voluntarily stopping eating and drinking) to hasten a patient’s death is immoral. The practice results in an obvious conflict between the autonomy of the patient and the principles of beneficence and non-maleficence that must guide the physician and other health care workers. Because VSED is an act of passive euthanasia, it harms the patient and thus compromises the integrity of the physician–patient relationship. Health care providers must avoid any involvement in VSED, whether by providing information about the practice (...) or by administering palliative care while a patient is voluntarily starving and dehydrating himself to death. Instead of cooperating in the evil of euthanasia, health care providers need to advocate for the patient by refusing to do any harm and by addressing the reasons why the patient is requesting a hastened death. (shrink)

In 2001, Rie Fujii, a 23-year-old Japanese national living without legal status in Calgary, Alberta, Canada left her two infant children alone in her apartment for 10 days while visiting her out-of-town boyfriend. The children, Domenic and Gemini, died of dehydration and starvation. Charged with two counts of second-degree homicide, Fujii plead guilty to manslaughter and received an 8-year sentence. Through an analysis of the publicly available judicial documents relating to the crimes of Rie Fujii, this paper explores how (...) the law’s individualization and medicalization of crime and violence may obscure the multiple forms of everyday and structural violence that racialized women in white settler states such as Canada experience and may perpetrate. Drawing on Scheper-Hughes and Bourgois’ concept of the violence continuum, I argue that the law’s conceptualization of crime and violence conceals and thus advances the violence endemic to white settler colonialism. (shrink)

Despite recent advances in the research related to air pollution and associated adverse cardiovascular events, the combined effects of air pollution, climate change, and SARS‐CoV‐2 infection on cardiovascular health need to be researched further. This Commentary addresses their impacts on cardiovascular health in the approximately 25 million people with a severe form of inherited hypercholesterolemia, called familial hypercholesterolemia (FH). The arterial endothelium in these individuals is potentially under multiple attacks caused by particles of both endogenous and exogenous origin. Thus, they (...) have a lifelong highly elevated level of circulating low density lipoprotein (LDL) cholesterol which drives premature atherosclerosis. The high levels of LDL particles, often associated with an elevated level of circulating lipoprotein(a) particles, are both capable of inducing and maintaining endothelial dysfunction. Such pre‐existing endothelial dysfunction can be exacerbated by exposure to SARS‐CoV‐2 viral particles, by exposure to fine particulate matter generated by climate change‐associated wildfires, and by dehydration during deadly heatwaves linked to the globally rising temperatures. The external factors can severely worsen the pre‐existing endothelial dysfunction, and thereby significantly increase the risk of a cardiovascular event in the exposed FH patients. (shrink)

Patients who are dying of cancer usually give up eating and then stop drinking. This raises ethical dilemmas about providing nutritional support and fluid replacement. The decision-making process should be based on a knowledge of the risks and benefits of giving or withholding treatments. There is no clear evidence that increased nutritional support or fluid therapy alters comfort, mental status or survival of patients who are dying. Rarely, subcutaneous fluid administration in the dying patient may be justified if the family (...) remain distressed despite due consideration of the lack of medical benefit versus the risks. Some cancer patients who are not imminently dying become dehydrated from reversible conditions such as hypercalcaemia. This may mimic the effects of advanced cancer. These conditions should be sought and fluid replacement therapy should be given along with the specific treatments for the condition. (shrink)

While another von Hagens style public autopsy should not be encouraged, the public should nevertheless be able to experience such events as a public autopsy.During 2002 and 2003 there was considerable discussion about the work of Gunter von Hagens, famed for his Body Worlds exhibition,1 which was publicised extensively and with considerable success. The exhibition is a tribute to, and celebration of, his method of preserving organic life through the process of plastination, developed by von Hagens in the 1980s. The (...) process entails a form of preservation, whereby body parts are dehydrated and filled with polymer resin, making them more robust than conventional formaldehyde does.While it was in the United Kingdom, the exhibit was housed at a back street gallery in Brick Lane, London, though the exhibition has toured throughout the world. Despite many millions having flocked to see the exhibition, the reasons for its success are open to interpretation and have provoked strong opinions from the medical community as to whether this physician ought to be entitled to create exhibits from real bodies. Von Hagens would argue that these works are justifiable because they have artistic merit. Others would claim that viewers are being brought to the gallery by the immense publicity. Alternatively, one might suppose that those who attend the exhibition do so mainly because of a fascination with the extraordinary and with the grotesque. Indeed, such fascination with death, and human remains specifically, was the focus of a meeting hosted by the Institute of Ideas and the Royal College of Physicians in May 2003, which was entitled Morbid Fascinations: the Body and Death in Contemporary Culture.The controversy arising from the Body Worlds exhibition pales in comparison, however, to von Hagens’s most recent performance—the first “public autopsy” in Britain …. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:“We Need to Cut the Neck!”Confronting Psychological and Moral Distress during Emergency Cricothyrotomy1Stephanie CooperEnoughYou didn’t die in the ER, but rather, began your inexorable demise. The last, first, and only words I ever heard you utter was the weak mewl “tight, tight” as the blood pressure cuff constricted your left arm. You were 98–years–old, bed–bound, at the end. Your world was already partitioning itself from us, your brain tunneling (...) down the uneven corridors of consciousness. A concretion of otoliths muffled your hearing, and fatigue burdened your ancient heart.Your name–band encircled your skinny ankle like a bird. Deformed by arthritis, you were caged within yourself, imprisoned by senescence. You could not declare yourself to us. Words disintegrated into moans and your grimace became animal.When you came back from x–ray—hypotensive with multiple neck fractures confirmed—you could speak no more. Your pulse slowed, your blood pressure plummeted. I jammed a gloved finger against your femoral pulse, faint and tired. [End Page E5]“What’s her DNR status?” I gravely asked your nurse.The DNR paperwork for once had arrived with the patient. “No CPR” she said with relief. But then the paperwork went on, forcing me—the waitress of tragedy—to serve up the hash of an impossible menu.As health care providers, we are all often tasked with performing contradictory actions: the pain of IV insertion followed by the morphine push, drilling deeper into broken bone in order to plate it, the inadvertent cracking of ribs during chest compressions. We sometimes must perform violent action in the hope of sustaining and resurrecting life. We are asked to perform the impossible, the contradictory, the painful. And sometimes the actions we must take catalyze an inexorable chain reaction of actions, which can end in death–prolonging and painful interventions that we did not intend.Although our culture may imagine that one can choose one’s meal at the end–of–life fast–food franchise of death, such is not the case. You can’t suddenly decide you’re a vegetarian. You can’t order the cheeseburger without the cheese—and we all are getting the burger, in the end. Ordering the heart–squeezing drugs without the CPR to circulate them, or the antibiotics without the fluid to counter dehydration, is like ordering the burger without the bun. Sometimes the possible choices are not necessarily realistic choices. You get served what you get served, and perhaps we should question the assumption that we have the ability to choose at all.Your DNR form proclaimed no CPR but then said that antibiotics and intubation were okay—the cheeseburger without the cheese. An unfortunate choice for you, me, and the rest of us, as your death menu led to a very unhappy meal.You were comatose. I stuck a tongue blade deep into your desiccated throat. You did not gag. This means I should have intubated you, but morally, I couldn’t. To what end? You were 98 years old, broken, moribund. If you hadn’t suffered multiple neck fractures, or if you were a vibrant elder who had just walked off Mt. Rainier, maybe the story would have been different. But you? I doubted that you truly had a chance of ever feeling joy again. You were somebody’s wife, somebody’s mother. I knew this step would lead to the domino of unstoppable steps. I refused to flog your corpse.I called your daughter Kay on her cell phone, told her that you were in critical condition and that she should come to the ER immediately. But how to begin to tell a daughter her mother is dying, let alone over a cell phone? Gentle but surreal and impersonal, my voice tried to tell your daughter that the interventions you needed would likely kill you. I have seen enough human suffering to know. To me, the choices were clear: death by nature’s irrefutable course, versus a more painful, protracted, and violent death by what we’d do to you.Kay arrived in a wheelchair and scooted up to your bedside. Like all daughters, she wasn’t ready for you... (shrink)

Pam is an eighteen-year-old with a history of depression. She has been hospitalized for the past six months for severe weight loss and dehydration. When admitted, she was diagnosed with acute inflammation of the pancreas and gall bladder, but it became clear that these issues were secondary to a diagnosis of anorexia nervosa. Her weight upon admission was seventy-six pounds. Pam refuses to accept this diagnosis and will not cooperate with any provider who refers to “anorexia” or attempts to (...) discuss her eating disorder. As a pragmatic strategy for providing care, the medical team has largely avoided referring to anorexia or eating disorders when treating her. But Pam is not the only problem. Pam’s.. (shrink)

It has recently been suggested that doctors have a duty to act in their patient's best interest and that this duty demands that life-sustaining treatment—including food and fluids—should sometimes be withheld or withdrawn and the patient allowed to die. In this article, the author explores the scope of the ‘best interests principle’ in the context of treatment decisions for seriously handicapped newborn infants. She argues that those who hold that it is permissible to starve or dehydrate an infant to death (...) are mistaken to think that this course of action is in the infant's best interests. While it may be true that there are times whendeath is, everything considered, in an infant's best interests, a slow and distressingmethod of bringing death about is not. Since death by dehydration and starvation is not benign, the withholding of food and fluids is generally not in an infant's best interests. The author concludes by suggesting thatwhenever the withdrawal or non-employment of life-sustaining means imposes a heavy burden on the infant, the ‘best interests principle’ would demand that the infant be killed rather than allowed to die. (shrink)

The recent revelation that the rolling out of the Liverpool Care Pathway as the NHS National End of Life Care strategy in 2008 had been financially incentivised and implemented with astonishing compliance emerged as a thought-provoking development. Many of us have been warning for years of the financial, political and research interests that there are in institutionalising sedation-and-dehydration regimes, and then, inevitably, medical homicide. Freedom of Information Act requests exposed the millions of pounds that have been paid for the (...) implementation of this national end-of-life care strategy. Much more interestingly, it showed that some hospital trusts had been paid these funds for ensuring that up to two thirds of all deaths were Pathway deaths. Given that the very livelihood of health professionals was being judged against the new Commissioning for Quality Innovation (CQUIN) ’Gold Standards Framework’, professional observance of the pathway was predictable. The revelation of management targets, despite the best efforts of the regime’s proponents to play them down, radically alters the debate. Unlike education or housing targets, these ones are potentially homicidal. (shrink)

I am lying on a small table in a tiny room, dizzy with nausea and apprehension. A young woman busies herself with the preparations of a plaster mold that will be used to position my arm and chest for the twenty five ‘shots’ of radiotherapy that I will undergo during the ensuing five weeks. I had called the hospital that morning to say that I was too sick to come for this appointment. I had better come, said a young man (...) from the department, because if I missed this appointment I would I might not get a new appointment in time start the treatments within the recommended time frame. So I am here, on the table. I mention the nausea to the technician. My apprehension at this moment is that I might become so dizzy as to somehow swirl out of control. The young woman gives me a mask to blunt the smell of the plaster. The procedure will take twenty-five minutes. I keep my mind focused on each breath and get through the ordeal breath by breath. She seems, in contrast to me, gloriously free of distress and worry, listening to the radio while she works. I envy her good fortune. As we finish up the procedure I take a chance and share my experience: I say that being a cancer patient can be tricky because you are sometimes utterly in the grip of the idea that the cancer will spread and you’ll die soon and in a very unpleasant way. After each round of chemo I was admitted to hospital for extreme nausea and dehydration. During those days in the cancer ward some of those who were dying called out and moaned distressingly, sometimes for hours, during the night. I was, at those moments, unable to shake off the belief that I too would be in that state within a few months. The signs of cancer had been missed on the mammogram two years earlier and, when the lump made itself evident, I was in Stage III. When I mentioned this experience of being gripped by the idea of death she said “Oh I know exactly what you mean, my mother has breast cancer, and every time she has an examination I go searching the internet to find out what I can.” This young woman was twenty four, and I fifty six at the time, and she had given me an unexpected small precious gift that I took with me out of that little cupboard of a room.. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Pains And Gains Of Rural Health Practice:Lessons Books Never TaughtSridevi Seetharam, Bindu Balasubramaniam, G. S. Kumar, and M. R. SeetharamHow The Journey BeganIn the early 1980s, as fresh graduates from Mysore Medical College in southern India, we were brimming with a zeal to "cure the sick" and "change the world." We had an ideal of evidence-based, rational, ethical and equitable health care and set out to serve rural and (...) under-served communities which included displaced forest-based tribes. In the initial years, with the naivety of the inexperienced, we believed that by correcting the dehydration of the doe-eyed six-year-old Mare and giving her a free course of antibiotics, we had made health care accessible to her. Much to our dismay, within a month, Mare was back in the outpatient clinic, with diarrhea all over again and looking thinner than ever. We realized that it was a losing battle to keep her healthy as long as she continued to drink water from the same contaminated stream, live in unhygienic surroundings, and eat only the paltry meals that her family could barely afford. We gradually began to connect these living examples to what our preventive medicine text books had stressed all along—there are many social determinants of health which, if left unaddressed, do not permit realization of the vision of health for all.Such instances continually pulled us out of the hospital building and into the villages and tribal hamlets. We discovered that our textbook of Preventive and Social Medicine (Park, 1986) (P&SM as we used to call it), was our most valuable possession. [End Page 106] We devoured the descriptions of national health programs, sanitation procedures, water treatment protocols, and maintenance of cold chain for vaccines with a completely new perspective. We discovered the Manual of Basic Techniques for a Health Laboratory, (World Health Organization, 1980) detailing how to set up a laboratory with low cost, reliable and simple methods. We learned to drive a jeep to haul supplies and patients. To step up the level of clinical care, some of us pursued post-graduate programs and equipped ourselves to provide more specialized care too. It has been over two decades since we embarked on this journey. We have encountered a variety of perplexing dilemmas with no clear solutions. We have sometimes been compelled to adopt health practices that were not really evidence-based, seemingly irrational, inequitable and even downright unethical. This narration describes only a few of our thousands of cases, and hopefully conveys our periods of self-doubt, despair and hope, as well as, the challenges we face to reconcile with the difficult choices we are forced to make every day.Unforeseen Challenges in Saving Mothers and ChildrenHigh maternal and child mortality rates have been one of the most disturbing aspects of the health care scenario in rural India. To ensure immunization of all children, health workers with vaccine carriers go from village to village and hamlet to hamlet to reach those infants that would have missed visits to the immunization clinics. Our grass-root workers facilitate these visits by identifying households with such children. Occasionally, they encounter families who spirit away the infant into the adjoining woods as soon as the health worker is seen approaching, and blandly proclaim that the child is not at home. Despite reassurance and counseling about the safety and necessity of the vaccine, their apprehensions and misconceptions are insurmountable. What is the extent of the responsibility of the health worker? Is it ethical to hunt down the child and force the administration of the vaccine in view of the public health gains, besides the child's welfare?A few months ago, a pre-term neonate was admitted to our hospital, but worsened and needed referral to a higher centre in the city. The family refused to go despite repeated persuasion and detailed explanation about the technical limitations of care at our centre. From the family's perspective, the variety of social, cultural, and monetary challenges they would face in the city were themselves limitations for care. We were compelled to retain the baby and continue giving the best care we could.Two... (shrink)

Readers expecting a history of nineteenth‐century pathology are in for a surprise. They will find instead a self‐conscious example of cultural studies, critical of some assumptions made in this field and of some feminist writing, but containing some alarming sentences like “My goal has been to give shape to the accidental palimpsests of an inveterately verbal, and increasingly visual, culture; to assemble a particular series of hermeneutic loose ends into a coherent account of how an extraordinarily bizarre system of signification (...) came into being” . With learned English like that, who needs Latin? But once we get into the main part of the book, things get much better. We are confronted with a study of the fringes of science, in popular writings, in literature, and in raree‐shows, one working from sources that the more austere scientifics of the Victorian period despised and that historians of science are prone to ignore. Metaphor and analogy are everywhere, and sensitive stomachs will be churned by vivid accounts of disease, deformity, and surgery.The first chapter is concerned with the cholera morbus, the plague of the nineteenth century, and with the way it could be perceived as an indicator of social ills. John Ruskin's word “illth” as an opposite of health is revived, and the terrible blackness of the shriveled and dehydrated victims of this disease imported from the East is linked with colonial and racist notions. The theme that a healthy body is like a well‐run state leads into the next chapter, on breast cancer. Surgery was not only agonizing but ineffective in the first half of the nineteenth century, but then the survival rate after three years rose gradually from 4.7 percent to 45 percent by 1900. O'Connor asks whether this saga, with cancer seen as cellular overproduction, reveals close connections with gender construction and the symbolic importance of breasts, concluding that it does not and that the language used really was neutral rather than sexual.She then looks at amputations and artificial limbs, seeing amputation as a threat to the whole masculine body that could be countered by prostheses almost undetectable to the observer. This allows reflection on illustration, where curiously disembodied hands are shown carrying out amputations; on dissembling and artificiality; on materialism; and on metaphors of wholeness and replacement and of extending senses and capacities. We see some extraordinary advertisements where men with artificial legs climb ladders and skate, perhaps on thin ice. The final chapter examines deformity, with monsters and freaks . P. T. Barnum is prominent here, but interesting links are also made to the Great Exhibition at the Crystal Palace and its successors and the numerous museums that were such a feature of the Victorian period. They are strikingly placed in a continuum, rather than opposed, in a discussion of chaos and order, capitalism and health, deformity and degeneration. Wonder is presented as the key to modern sensibility, and there is a nice quotation on page 152: “If Beauty and the Beast should be brought into competition in London at the present day, Beauty would stand no chance against the Beast in the race for popularity.” Readers will have been led into a fascinating world at the periphery of the respectable science that most of us study and will rejoice in the extraordinary sights they see. (shrink)

In this paper I start by briefly presenting an analysis of token cause and of token causal relevance that I developed elsewhere, and then apply it to the famous thirsty traveler riddle. One general outcome of the analysis of causal relevance employed here is that in preemption cases (early or late) the preempted cause is not a cause since it is causally irrelevant to the effect. I consider several variations of the thirsty traveler riddle. In the first variation the first (...) enemy emptied the canteen and the second enemy threw it away. On this variation, the act of neither enemy comes out, on the analysis employed here, as causally relevant to, and thus not as a cause of, the fact that the traveler died, but the conjunction of the two acts is a cause of it. This version is a case of mutual preemption. I argue that it has the same structure as the voting paradox, which thus has an analogous solution. In the standard version, in which the first enemy added poison to the water in the traveler's canteen, the act of the second enemy (who threw the canteen away) comes out, on the analysis used here, as causally relevant to and as a cause of the fact that the traveler died, but the act of the first enemy comes out as neither. I also make a comparison with Lewis' accounts, and discuss alternative treatments of the puzzle such as those of Hart and Honore and of Gavison, Margalit, and Ullmann-Margalit. (shrink)

The experience of the twentieth century bears witness to the abuse, mutilation and homicide of the vulnerable made possible by the power of the state, mass markets, and medical and financial interests. Suggestions for reform of the law regarding food and fluids typically take place in the context of utilitarian personistic “quality-of-life” presuppositions, and interests in shifting legal responsibility for life-and-death decisions, medical research, drug trials, organ harvesting as well as more mundane bureaucratic concerns like bed-clearing. With the Western world (...) undergoing massive demographic change and a growing ageing and non-productive population, it cannot be assumed that these alterations to the positive law are problem-free. By allowing new agents power to require that food and fluids be withdrawn, non-therapeutic research and other procedures (like abortion and sterilisation) be performed on non-consenting patients, novel legislation such as that discussed cannot be regarded as autonomy enhancing so much as a threat to human rights. These laws although touted as progressive, more often than not invite routine abuse and destruction of the vulnerable, obscure accountability and create an inconsistent body of law, with conflicting obligations for health professionals. (shrink)

The Mental Incapacity Bill not only paves the way for euthanasia, but invites wholesale abuse and homicide, writes Jacqueline Laing. On 19 October 2004, when the Mental Capacity Bill was at its crucial committee stage, the Law Society issued a statement of ‘strong support’, claiming that it empowers patients and in no way introduces euthanasia. Laing argues that the Bill threatens the incapacitated by granting a raft of new third parties power to require that health professionals withhold ‘treatment’, which, after (...) the controversial decision in Airedale NHS Trust v Bland [1993] AC 789, includes food and fluids delivered both by tube and, in certain cases, by spoon. The Bill further endangers the vulnerable, first, by allowing non-therapeutic research on the non-consenting mentally incapacitated, in breach of the Nuremberg Code and First Declaration of Helsinki, and secondly, by permitting new agents power to undertake on people with learning disabilities certain questionable procedures currently authorised by the High Court, such as non-voluntary sterilisation. (shrink)