Ethical Issues

The provision of nutritional support to people who are chronically sick, who have rapidly progressive disabling diseases, or who are terminally ill raises many ethical questions. Opinions about withholding or withdrawing artificial nutritional support vary from country to country because of different clinical, religious, and social beliefs and differences in national economies, some of which cannot support large-scale expensive long-term treatments. Thus, there is little home artificial nutrition in countries with poor economies. In more developed economies, the types of patients being fed may also vary considerably. For example, parenteral and enteral nutrition in patients with cancer are used more frequently in Italy than in the United Kingdom, suggesting that clinical attitudes to this type of nutritional support vary. The sanctity of human life is a belief that is strongly held by many religions, but when these conflict with medical judgment, public policies normally override personal religious beliefs. A common ethical controversy concerns the need to provide food and fluid to prolong life in severely disabled patients, such as those with severe neurological problems (e.g., cerebrovascular accident) or those approaching the end of their lives. Although health professionals have a duty to prolong life, it seems inappropriate to prolong suffering. There has been controversy as to whether the provision of food and fluid by a feeding tube placed in the stomach or small intestine should be regarded as an essential part of care or medical treatment. The highest legal authorities in countries such as the United States and England have ruled that this is medical treatment. From an ethical perspective, there is no difference between withholding and withdrawing treatment, but in practice it is often more difficult to withdraw treatment once it has begun than to not initiate it. Joint discussions at the outset between mentally capable patients, family members, and health care workers can do much to prevent future ethical dilemmas.

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