The Moral Obligation to Feed and Hydrate

by Rabbi Louis J. Feldman, Ph.D.


Those who are in reasonably good health can sit down at the dining table and enjoy the blessings of conventional eating. However, there are those who are not so fortunate. Loss of the ability to eat conventionally can happen for a number of reasons: 1) a temporary situation, such as recent surgery, which can be resolved by intravenous feeding 2) permanent inability to take food by mouth due to such donations as the advanced stages of multiple sclerosis 3) development of an unreliable gag reflex, which can make ingestion of food by mouth quite dangerous. 4) a tendency towards aspiration pneumonia 5) severe depression and 6) simply being too frail, weak and debilitated to take food by mouth. If the feeding problem is short-term, a nasogastric or NG tube is used. The NG tube is inserted through the nostril down into the stomach.

Although the NG tube nourishes the patient, it has many drawbacks and should be used only for temporary situations. If the inability to take nourishment by mouth is going to be a long-term problem, the gastronomy tube or G-tube is a far more desirable approach. An incision is made in the abdomen and a feeding tube is inserted through the incision directly into the stomach. Its positioning is monitored by x-ray, it can be well used for long term feeding and it is quite comfortable.

It should be emphasized that enteral feeding (feeding by NG tube or G-tube) should be a last resort. Good long-term care facilities will have staff members and volunteers to lovingly feed frail residents spoonful by spoonful. There are also highly nourishing liquids for patients who cannot tolerate even a puree diet. Facilities that are under-staffed and lack the desire and will to feed by mouth then to overuse NG tubes and G-tubes.

There is a burning question that plagues the health care professionals: is enteral feeding simply humane care such as keeping a patient clean and comfortable or is it treatment — heroic and extraordinary treatment at that? Talk about “heroic” or “extraordinary” treatments is often an exercise in futility because it depends upon place and situation. For example, what is “heroic” in Afghanistan may not be “heroic” at Cedars Sinai Hospital. The medical profession has leaned towards the position that enteral feeding is to be considered aggressive treatment and not simply humane care. This debate reached a decisive point in 1986, when the American Medical Association’s Council on Ethical and Judicial Affairs officially declared that enteral feeding is considered to be aggressive medical treatment, not simply humane care.

In order to justify this approach, members of the medical profession have stated that death by starvation and dehydration is “not really that bad”, it is “part of the natural cycle of life” and is “not really painful to the patient”. Testimonies of patients who had their feeding and hydration withdrawn but later resumed and have subsequently recovered describe, in a very graphic way, the agonies of starvation and dehydration.

The secular world has declared war against enteral feeding. Pamphlets and presentation by non-religious social workers are designed to terrify elderly patients and upset their families. Such biased questions as “You wouldn’t want tubes shoved into your body would you?” encourages residence and their families to refuse enteral feeding.

A very basic fact is not mentioned: A G-tube is not “high tech” medicine. Any competent nurse can properly manage a G-tube. There are patients who have thrived for years on enteral feeding — even alert patients who read as much as four books a week. These patients are generally quite comfortable.

This leads us to make a forthright statement about enteral feeding: “Enteral feeding is not aggressive medical treatment; it is the patient’s lunch!” Rabbi Moshe Feinstein (1895-1986), the greatest authority on Jewish Law in modern times, stated that nutrition, even by tube, is not considered medication because food is a basic, universal need: “The reason is simple. Food is a natural thing that every person, indeed every living being in the world needs in order to maintain life.”

In the past three decades, there have been a number of famous court cases involving enteral feeding of extremely frail, disabled people. Considerations of this issue have gone up to the highest courts in the land and to the halls of Congress. The most recent case that attracted nation attention was that of Terri Schiavo (1962-2005). At the age of 27, Terri suffered a cardiac arrest that was severe to the point of causing extensive brain damage. She was totally dependent upon care givers for her most basic human needs. Her husband, Michael Schiavo, wanted to withdraw her enteral feeding. A Florida district court took the word of a husband who had violated the marriage, was living in a “common law” relationship with another women and even had a child with her, over the word of loving parents who simply wished to care for Terri. Her case divided an entire nation. Furthermore, Terri Schiavo was a devout Catholic and Pope John Paul II made it very clear that caregivers have a moral obligation to feed and hydrate, even if the patient is in a persistent vegetative state.

After all legal possibilities were exhausted; Terri’s feeding tube was removed on March 18, 2015. After thirteen days of horrific dehydration and starvation, Terri died. Terri Schiavo was executed for the unforgivable crime of being disabled and defenseless. Her life was given less consideration that the lives of mass murderers on death row. So-called ethicists often did not refer to Terry Schiavo by her name. Instead, they simply referred to her as “the Florida feeding tube case”, thus further depriving Terri of her humanity.

Thirty years ago, it was unthinkable to have a patient die of dehydration and starvation; today, it is commonplace. Professor Avraham, Co-Director of the Department of Medicine at Shaare Zedek Medical Center in Jerusalem and world-renowned authority on Jewish Medical Ethics said the following in 1989:

We live in a world where today’s taboo is tomorrow’s routine; where yesterday’s unthinkable becomes today’s debatable and then tomorrow’s unexceptional.

We are just beginning to adsorb the truth of what Professor Avraham said.