International Association for Hospice & Palliative Care

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IAHPC Hospice and Palliative Care Newsletter


2005; Volume 6, No 5, May


Letters To The Editor

William Farr, PhD, MD

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Letters To The Editor

William Farr, PhD, MD

“Dear Editor:

I read with interest the personal submission of Ms Jan Jones regarding the Terri Schiavo case. While agreeing with many of her comments, I found several generalizations and statements that could confuse people and lead to wrong conclusions. I believe it would be a matter of fairness for the IAHPC to allow other people to publish different opinions as I found her views to be somehow biased.

First, by stating that “Michael began battling in court over the right to remove the tube so that Terri’s death could occur naturally” (3 rd paragraph), Ms Jones is assuming that Terri’s death should be considered to be the result of natural causes. The act of removing the tube caused her death. It was an act of passive euthanasia. Terri’s general organic condition was stable from the medical point of view and she was not imminently dying otherwise. Yes, her mortality risk was high, but she was nowhere close to death. The act of tube removal preceded and caused her death, it was not a natural death such as dying from a treatment refractory pneumonia, for instance. Death happened due to the metabolic-organic complications of dehydration. A cause and effect relationship is easy to ascertain in this case.

Second, if I assume she is using Terri’s case to highlight that there is general agreement among religious leaders about removing life-sustaining artificial means as ethical acceptable, I find Ms Jones is wrong in this example. The Roman Catholic Church and the late Pope John Paul II, Terri being a Catholic, have been very clear that nutrition and hydration are considered proportional (ordinary) means and as such they should be provided to people with persistent vegetative state (1). A different situation is for the imminently dying. On these cases, the Catholic Church does not have any problem with stopping even hydration and nutrition since it understands the often futile role and potential burden of its application.

Third, death by starvation is very painful and there is a great deal of suffering. Children in Africa can testify of this. Again, I believe that for those very close to death, there might not be suffering associated with holding hydration and nutrition; but for any other situation, I don’t think there is clear medical evidence to state otherwise. On Terri’s case, I don’t think there is compelling evidence to state with certainty that she did not suffer as result of starvation and dehydration.

Last, I believe there is room for the Health Care team members to bring their consciences and opinions into the moral dilemma surrounding these situations. As a palliative care physician who opposes both passive and active euthanasia, I believe I have the right to protect my conscience and be free to withdraw from or to act upon a situation which I am afraid would betray my work-ethics. Without getting into legalities of the situation, which might dictate a modified course of action on my part, I see my role as one providing comfort until its natural death and also ensuring this principle is protected as far as it regards to my actions.

Respectfully Submitted,

Rene Leiva M.D.;C.M.; CCFP (Care of the Elderly/Palliative Care)
Ottawa , Ontario

John Paul II. “Papal Address on Food and Water: Excerpts from the March 20 th, 2004 statement”. Ethics and Medics. June 2004. Vol. 29 No 6”


“Dear Editor:

The goings on in the Terry Schiavo case have been broadcast far and wide by the media and have become a hot topic of discussion all over the world. In light of the article written by Ms. Jones, CEO of Alive Hospice, I would like to raise the following points for further discussion in your newsletter as they impact on all of us involved in hospice.

  • What is the role of a hospice where a patient has been admitted? Do they indeed not have a role “to decide, or opine, what the right thing to do is in regards of the feeding tube?” Who will then decide this and on what basis?
  • How do we define “comfort care”? Does it not include the obligation of the hospice to maintain her right to privacy and personal dignity? Do family members have a right to bring in TV crews and cameras, causing inconvenience to other patients and their families?
  • How does one put across the argument to the public that “removal of artificial devices or means does not constitute euthanasia?” It is a nuanced argument that I find the majority of people do not follow.
  • How does one clear the “misunderstanding on the part of the general public about suffering occurring from starvation or dehydration” especially as the reasons for feeding a loved one? This concept is not necessarily dictated by logic, but meets a deep emotional need of the family.
  • With the emergence of the citizen and the nation-state, the territory that defines personal and public space is constantly being negotiated. For example, parents can no longer abuse their children claiming that what they do in the home is their concern alone. In light of this, besides the family, who are the other players we are dealing with and how do we currently see their role?
  • How does one ensure the neutrality of the courts so that personal morality does not influence ethics? Especially in the U.S. where judges are political appointments?
  • What does one do with a family in conflict where wishes can be distorted to suit personal agendas? Moreover, while people may document their wishes when they are well, they often reverse such decisions when they are sick and potentially terminal. How is one to handle this?
  • In the Indian context, the rights of the patient are poorly understood and the family is the decision-maker on his/her behalf. Also, people are not told their prognosis. How will one handle this?

These are a few questions I have, for what ever they are worth. Perhaps you could consider widening the discussion as all of us engaged in hospice need answers.

Warm wishes,

Harmala Gupta
New Delhi, India


Letters to the editor may be submitted at the following page


William Farr, MD
IAHPC Newsletter Editor

© 2005 IAHPC Press


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