Mill and Kant on Feeding Practices: The Case of Mrs. P

By: Samantha Page

In this piece, I apply John Stuart Mill’s “greatest happiness” principle and Emmanuel Kant’s framework emphasizing autonomy to a case study on the issue of feeding practices among dementia patients, especially those with no directly expressed wishes regarding their end of life care. Mrs. P, a patient with declining health due to old age and dementia of increasing severity, is no longer capable of feeding herself and her caregivers must implement either a “comfort feeding only” (CFO) practice or a feeding tube in order to provide her with adequate nutrition (Palecek 580). What complicates the situation further is that Mrs. P has not directly expressed her wishes regarding this scenario, via living will or a conversation with her health care proxy and husband, Mr. P (Palecek 582). Emphasizing both Mill’s value of pleasure over pain and Kant’s priority of preserving individual autonomy justifies a CFO practice as the best accommodation for the patient and her caregivers (Mill 6; Kant 39).

“Greatest happiness” principle. John Stuart Mill stresses the “promotion of pleasure and the prevention of pain” in the lives of human beings, which ultimately justifies prioritizing Mrs. P’s comfort through hand feeding above the physical health she might gain from tube feeding (Mill 10). Although Mrs. P does not recognize family and friends, she still finds comfort in their presence and touch. While Mill does not consider comfort one of the “higher pleasures,” and does categorize health that way, the significance of this distinction shifts relative to the circumstances of Mrs. P’s state (Mill 13). Mill’s recognition of health as a higher human pleasure is contingent on Mrs. P’s cognizance of her health, which no longer exists. Hand feeding also maximizes the comfort, and hence pleasure, of Mrs. P’s visitors and caretakers, because CFO is a much more tolerable practice to bear and implement compared to a mechanized feeding tube. The tube may also cause Mrs. P pain, as the history of the device shows that it can distress patients with dementia who sometimes wake up unaware of the placement of the device and attempt to remove it (American Geriatrics Society). Choosing CFO minimizes the suffering attributed to feeding tubes, while maximizing the comfort associated with hand feeding for all parties.

Autonomy. Emmanuel Kant’s emphasis on autonomy supports hand feeding because the definitive death that results from CFO involves less estimation of the patient’s ambiguous or altogether unknown wishes, and therefore is less compromising of her autonomy. Because Mrs. P’s wishes about end-of-life feeding practices were not explicitly stated, she has little direct autonomy over the situation at hand. In order to best preserve Kant’s prioritization of autonomy, Mrs. P’s caregivers should minimize the circumstances, like the one at hand, in which her wishes are unknown (Kant 39). With CFO, death coincides with the patient’s cessation of eating and resultant malnutrition, starvation, or other similar consequences, and thus is definitive. Comparatively, the constant nutritional intake of tube feeding prolongs patients’ lives indefinitely, risking an eventual coma or persistent vegetative state. Because Mrs. P’s wishes regarding end-of-life care in these circumstances are not necessarily known either, they would force caregivers to consider a new set of questions and to pursue further bioethical debates. This would again force an estimation of the patient’s wishes and may compromise her former autonomy, a risk that implementing CFO could avoid. Further debate about a patient’s wishes also intensifies the distress of family and caregivers involved, ultimately increasing the net pain.

The synthesis of Mill and Kant’s philosophies on a just life and treatment of a “rational being” shows that CFO is the feeding option best suited for Mrs. P because it will promote pleasure and minimize pain, as well protect the patient’s autonomy (Mill 10; Kant 38). If comparable cases were to arise, where notable comfort is gained from touch and there is little to no instruction regarding the situation at hand, CFO should also be implemented because it ensures similar benefits in similar instances. This reasoning suggests that CFO should become the standard care treatment from a “best interests” approach for all dementia patients who find comfort in touch. Fully examining a best interests approach begins a foray into a deeply complicated bioethical issue; however, this case can be generalized, and allows us to use an individual’s most basic sense of pleasure to help estimate what is ethically beneficial care to offer them when their wishes are unknown. 

Samantha Page is a first-year student at Smith College, where she was first introduced to the field of Bioethics. She is interested in studying American history and art history.

Works Cited

Kant, Immanuel. Grounding for the Metaphysics of Morals, with On a Supposed Right to Lie Because of Philanthropic Concerns. Translated by James W. Ellington. Third edition. Indianapolis: Hackett, 1993.

Mill, John Stuart. Utilitarianism. Kitchener, Ontario: Batoche Books, 2001. http://socserv.mcmaster.ca/econ/ugcm/3ll3/mill/utilitarianism.pdf.

“Older Adults with Advanced Dementia Who Can No Longer Feed Themselves Should Be Fed By Hand, Not Fitted With Feeding Tubes, American Geriatrics Society Confirms,” The American Geriatrics Society. September 17, 2013. http://www.americangeriatrics.org/press/news_press_releases/2013_press_release_archive/id:4639 

Palecek, Eric J., et al. “Comfort Feeding Only: A Proposal to Bring Clarity to Decision-Making Regarding     Difficulty with Eating for Persons with Advanced Dementia,” Journal of the American Geriatric Society 58 (2010), 580-84.

Thoughts on NUBC: Learning What It Means to "Do" Bioethics

By: Dr. Tiffany Cvrkel

A few weeks ago a group of my undergrad students and I returned from our very first National Undergraduate Bioethics Conference (NUBC). I thought I’d write down a few thoughts about our experiences, and (hopefully) make a case for why attending this conference is a uniquely worthwhile experience.

We have a pretty thriving group of undergraduate bioethicists at UCLA. Most are pre-med students who do independent research in bioethics as a compliment to their intensive lab work and hard science curriculum. They are a passionate (and inspiring!) bunch, and they are always looking for ways to connect with their peers at other institutions.

And that’s the story of how they – not me, their faculty mentor! – found out about NUBC. As they were browsing this “Bioethx Under 25” blog, they found a listing for a conference aimed especially at them. I got an email pitching a trip to Chicago.

It was fitting start. While faculty members are involved in the orchestration of NUBC, much of it is run by undergrads for undergrads. A few of my students decided to submit papers to the conference, and Jessica Kriksciun (one of our seniors) had her paper accepted. They also decided to form a Bioethics Bowl team and compete during the tournament. None of us had any idea what a “Bioethics Bowl” looked like, but it sounded like a decent way to spend a Saturday.

If you’ve never been to a NUBC before, you should know it is an odd marriage of two very different events. The first is the conference itself, run in a mostly traditional way -- paper presentations along with brief Q&As. The second is a tournament event called the “Bioethics Bowl,” where student teams compete by giving well developed/supported arguments and objections regarding bioethics cases. The team with the better arguments wins.

I’ll give you a few moments here to quip about competitive bioethics. Many of my colleagues found this whole set-up an endless source of hilarity. And to be honest, I was a little wary. Some of my colleagues were worried that this kind of thing just reinforces combative relationships between bioethicists – a problematic dynamic that already exists in some places of our discipline. It’s hard enough to work in a cross-discipline space. Shouldn’t we all be trying to get along, not score points against each other?

I had another, slightly different worry. When I paged through the cases that the Bioethics Bowl would be using, I noticed the “ripped from the headlines” format. But the fact that these are real cases involving real people adds an additional burden for our students. I am close with some of the ethicists who worked on one of the cases in this year’s packet. I saw first-hand the devastation and anguish that this case caused for everyone involved. I feared real people’s stories might be turned into nothing more than rhetoric-laden debate fodder, cheapened to score points.

I am not against debate as an intellectual exercise. I was on my school’s debate team as a student, and once upon a time, I coached it. But the goals of debate are not always to find the most subtle, respectful, and nuanced lines of reasoning. The people from these cases? They deserve nothing less.

And when the Bioethics Bowl came around, there was indeed some debate-style rhetoric and hyperbole. But happily, this was not the norm. Most of the teams we saw weren’t trying to be cut-throat in point scoring. They were trying to work through the issues in genuine and sincere ways. There was a lot of “we agree with our opponents on their position, but we’d like to raise an issue that might have been overlooked” kind of dialogue – the kind of dialogue that happens in professional ethics committee meetings. And with a few exceptions, my students left each round feeling like they both made new friends and got to practice articulating true, difficult positions.

But the Bioethics Bowl – by far – was not the highlight of the conference, which you would never know by looking at the attendance numbers. It quickly became clear that there are also two demographics at NUBC, the people who were there for the conference and the people who were there only for the Bioethics Bowl. And the vast majority of people fell into the second category.

This was such a shame. The conference part of the NUBC was amazing. Sitting around the breakfast table before a day of presentations, all of us huddled together, the following conversation happened. One of my students asked, “Um, Dr. Cvrkel? What kinds of questions should we ask the presenters? I’ve been to lots of conferences where I’m not really supposed to ask questions, and this is the first time I’ve been at a conference where I’m the intended audience! What does a good question look like?”

And that’s when we discussed the difference between being a student and being a colleague. We talked about the art of asking useful and supportive questions instead of “gotchas.” We talked about when follow-up questions are appropriate and when they’re not. We talked about how to approach someone to discuss related projects. We talked about how to do bioethics in the real world.

I teach two large lecture classes every quarter; that’s hundreds of students, multiple times a year. And while I try to teach each of my students some of the finer points of bioethics, the famous authors, the important arguments, I can never offer them the experience of doing bioethics with their peers. We always have a power differential in traditional learning environments, and this means students never get to practice wielding their knowledge as equals. But at NUBC, they present their ideas not as students looking for approval, but as scholars looking to advance an idea. And they sit in the audience not merely to learn, but to engage.

The NUBC has been the one environment where my students experienced what it is like to be bioethicists. And that’s not easy to teach. But of all the things I’ve tried to teach my students, I can’t think of any that are more valuable.

The folks at Loyola University of Chicago put on a wonderful conference, and though it was our first, it won’t be our last. We’ll be in Florida for NUBC 2015—you should join us.

Dr. Tiffany Cvrkel is a philosopher, bioethicist, and lecturer in UCLA’s Molecular, Cell, & Developmental Biology department. She is also the faculty adviser for UCLA’s Undergraduate Bioethics Club (aka: The Bioethics Brigade) and runs the UCLA Bioethics Lab, where students do advanced/independent bioethics research.

Timbre at Death: Fragments on End of Life Care

By: Mohini Banerjee

This post is a small collection of impressions and quotes, hopefully prompting us to ruminate and reflect on the end-of-life.

“Nothing that you do in science is guaranteed to result in benefits for mankind. Any discovery, I believe, is morally neutral and it can be turned wither to constructive ends or destructive ends. That’s not the fault of science.”—Arthur W. Galston Quoted in an obituary piece for the New York Times.

Last week I attended an informal lunch discussion around the circumstances of a “good” death. In full bioethics form, we discussed the voluntary stopping of eating and drinking and physician assisted suicide. However, within ten minutes the discussion turned to music—that is, what would you want to hear when you go? I’ve never considered that question. It seemed oddly specific, macabre, and perhaps a little too eager. The scholars I conversed with seemed more comfortable discussing various likes and dislikes (certainly no Vivaldi), and I suggested my own favorite, Holst’s “Jupiter”. We talked about music and how Pete Seeger died with his friends and family singing in his hospital room. Persons and lovely harmonies seemed to soothe the often painful experience of dying. Some around the table discussed personal experiences, family or others, and the decisions taken towards the end-- meant to provide for oneself, while trying hardest to protect ones left behind. Their understanding of loss was completely enveloped in an ethical discourse on agency and patients’ needs.

“In quixotically trying to conquer death doctors all too frequently do no good for their patients’ “ease” but at the same time they do harm instead by prolonging and even magnifying patients’ disease.” 

― Jack Kevorkian, Prescription: Medicide: The Goodness of Planned Death 

Which words we choose around hastening death are particularly important since “euthanasia”, “physician assisted suicide”, “death with dignity”, “aid in dying”, “suicide”, “voluntary stopping”, "palliation", and “no extraordinary measures” are only some of the terms that contain their own emotional valences and particular historical backgrounds. Often this language gets conflated, bringing about both confusion and some misunderstanding. Some, for instance, would object to my inclusion of a quote by Dr. Kevorkian given the potential harm in including his ideas into any “reasonable” discussion on aid in dying. I agree that the mistaken assumption that aid in dying means euthanasia is harmful to a movement towards choices at the end of life. However, if we’re considering values at the time of death then our discussion should consider the reasoning of those who advocate for marginal positions.

“With terminal illness, your fate is sealed. Morally, we’re more comfortable with a situation where you don’t cause death, but you hasten it. We think that’s a bright line.” –Arthur L. Caplan Quoted in “True Freedom” Time Magazine.   

As a society we may want to be thinking more about the music and people we want in the room than the particular medical intervention that would make us most comfortable. We may not want to think of this at all. A melody chosen in the midst of a hypothetical conversation only signals our hope for a certain mood, however distant and contrived. Death, on the other hand, is uncomfortable both in actuality and in how we refuse to acknowledge its reality. Discussing medical decision-making at the end forces a contemplation of physical and mental anguish, but considering our soundtrack does not. In that potential future we are free of pain. And, whatever fear of the unknown we began with is pacified. We simply surrender to the trumpets blaring, drowning out the likely beeping machines. 

Mohini graduated from Smith College in May 2013 and is a research assistant at The Hastings Center, an independent non-profit research institute in bioethics. She founded Bioethx Under 25 in January and acts as Editor in Chief. For interest in the blog please email her at bioethicsunder25@gmail.com.

Hobby Lobby and its Hypocrisy: Religious Demands on Others and Investment in Contraception

By Naomi Scheinerman 

Last week, the US Supreme Court heard oral arguments from Hobby Lobby (a chain of craft stores) and Conestoga Wood (a cabinetry company) who both claim religious exemptions from the Patient Protection and Affordable Care Act (ACA) contraception coverage. A recent story from Mother Jones reveals that Hobby Lobby has actually “spent millions of dollars on an employee retirement plan that invested in the manufacturers of the same contraception products the firm’s owners cite in their law suit.” In addition, the company also provided insurance plans to its employees that covered the very contraception they now reject for years before the ACA mandate required it. Although this information may not be crucial for the Court in its decision making, these revealed factors call into question the veracity and legitimacy of Hobby Lobby’s religious objection alongside considerations of justice and ethics in potentially granting an exemption.

For example, one concern is whether the Court should consider arguments based on faulty scientific claims. Hobby Lobby argues that they have no moral objection to the use of the majority of the contraceptives required in the mandate and will continue to cover access to these. Rather, they object to the copper and hormonal intrauterine devices (IUDs) and Plan B and Ella, “emergency” contraception taken after intercourse. Hobby Lobby claims that because these prevent a fertilized egg from implanting in the uterus, they function as abortions. Hobby Lobby is sadly not alone in erroneously labeling Plan B and Ella as so-called “abortion pills,” when in fact they do not terminate pregnancy because they work before pregnancy begins. Even if Hobby Lobby has a valid religious objection to abortions, they are fallaciously applying it to this case.

Legally, the Court has also been asked whether corporations can even claim religious exemptions. Hobby Lobby has Christian owners, but its employees are not exclusively Christian and therefore it is hard to define it as a distinct Christian corporation. Although the Court has ruled that corporations operate as individuals in terms of campaign finance laws, it has yet to extend this argument to other realms. This brings me to one of the most pressing questions: Does claiming religious exemption actually impose a religious ruling on others? Though Hobby Lobby claims it does not want to be imposed upon, its attempts to deny coverage of IUDs, Plan B, and Ella impose on its employees because they may have no moral objection to accessing these forms of birth control.

Further, when do religious exemptions to health coverage end? At what point should we consider right of access to be absolute and religious exemptions as inferior claims because they overshadow a more pressing moral concern in society? Can Hobby Lobby claim objections to vaccinations? Cancer treatments? Kidney transplants? Some religious groups do, and the Court would be quite quick to throw out those cases as extreme and an overt denial of rights of access. Hobby Lobby’s claims against IUDs, Plan B, and Ella are not so different. Emergency contraception can be vital for a woman who was raped or just wants the freedom to live a life without a child imposed upon her. Research has shown that unintentional pregnancies are linked with delayed prenatal care, low birth weight, maternal depression, prevention of education and jobs otherwise accessible to the mother, and family violence. These are good health reasons to offer the access and claim any denial of access as an abuse of religious arguments and an imposition on others’ freedoms from religion.

Naomi Scheinerman is a Research Assistant at The Hastings Center. She graduated Phi Beta Kappa, with high honors and in distinction from the University of Michigan in Ann Arbor, where she received bachelor’s degrees in philosophy, political science, and Hebrew and Jewish Cultural Studies. She contributes a bi-weekly column on reproductive health.