Wednesday, April 30, 2014

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.

“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. 

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.

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