O'Rourke's position is in large measure rooted in his understanding of the passage from Pope Pius XII's address that we have already examined, in particular, that portion of his talk in which Pius said that excessively burdensome treatments would "render the attainment of the higher, more important good too difficult" and that "life, health, all temporal activities are in fact subordinated to spiritual ends." 1It is in my opinion unfortunate that the expression "persistent vegetative state" has been employed to describe the condition of human persons. If they should fall sick or be otherwise in danger of death, they surely have a right to "ordinary" care, and others have a serious moral responsibility to protect and preserve their lives unless the efforts to do so are futile or excessively burdensome. Caring for Persons in the . In some cases a minimally conscious state is a stage on the route to recovery, but in others it's permanent. But the brain stem, which controls involuntary functions such as breathing, blinking, cycles of waking and sleeping, etc., is still functioning. This is done under sedation to ensure the patient feels no pain or distress. VideoThe new ‘Nigerian princes’ of hacking? 7Pope Pius XII, The Prolongation of Life: Allocution to the International Congress of Anesthesiologists (November 24, 1957), in "The Pope Speaks" 4 (1958) 396. IV. Caring for an older adult is expensive. It is likewise legitimate to take into account the burdens, including financial burdens, which the treatment will impose upon others. "I think about it all the time. 6See William E. May, Robert Barry, Orville Griese, Germain Grisez, Brian Johnstone, Thomas J. Marzen, Bishop James T. McHugh, Gilbert Meilaender, Mark Siegler, William B. Smith, Feeding and Hydrating the Permanently Unconscious and Other Vulnerable Persons, in "Issues in Law & Medicine" 3 (Winter, 1987) 203-217. The Royal College of Physicians' review began in May 2011, and is expected to last at least 18 months. The rest of us must not abandon these families, but reach out to give them every possible assis-tance so they will not face their burdens alone. Other U.S. Bishops and conferences (e.g., the Conferences of Washington, Florida, and Bishop John Myer of Peoria) have likewise issued documents on this question, but those noted here are representative. Many of us have heard through the media about the trials of Terri Schiavo and her family. Mrs Wilson would not want anyone else to care for her son, but after suffering a heart attack and conscious of her advancing years, her biggest worry is what will happen to her son when she dies. They may open their eyes, wake up and fall asleep at regular intervals and have basic reflexes. An individual with severe cerebral damage who has been in a chronic state of unconsciousness for at least four weeks is considered to be in a persistent vegetative state (PVS). I will then (2) apply these criteria to the artificial feeding of patients in the "persistent vegetative state," developing and clarifying considerations set forth in the 1987 article. I don't like to say it, but it's true. "1 From the perspective of medicine, individuals in this condition are not comatose. It stated that no matter what terms are used to signify the distinction, it would nonetheless be possible to make a correct judgment, by studying the type of treatment to be used, its degrees of complexity or risk, its cost and the possibilities of using it, and comparing these elements with the result that can be expected, taking into account the state of the sick person and his or her physical and moral resources.8, Moreover, the same document maintained that "one cannot impose on anyone the obligation to have recourse to a technique which is already in use but which carries a risk or is burdensome. There are situations in which this is not the case, but those are the exceptions and should not be made into the rule" (550). © 2020 BBC. A major document of the Magisterium relevant to our question is the Declaration on Euthanasia issued by the Congregation for the Doctrine of the Faith in 1980. Patients who are in comas, or persistent vegetative states, require extensive care. Expert clinicians have highlighted a number of concerns about the care of vegetative state patients and their families. At that point the outcome for her was unclear." (15th ed. He is fed through a tube in his chest. (3) New Jersey State Catholic Conference, Friend-of-court Brief to New Jersey Supreme Court, entitled Providing Food and Fluids to Severely Brain Damaged Patients" (November 3, 1987) in "Origins: NC News Service" 16 (1987) 582-584. This may be done when the gastrointestinal tract is not intact or does not function. Now in his 50s, all that is left of his adventurous past are the photographs on the wall. The Pennsylvania Bishops, whose document is by far the most extensive and carefully prepared and annotated, declare at the end of their study: "As a general conclusion, in almost every instance there is an obligation to continue supplying nutrition and hydration to the unconscious patient. The "persistent vegetative state" is a form of deep unconsciousness. A persistent vegetative state (PVS) or post-coma unresponsiveness (PCU) is a disorder of consciousness in which patients with severe brain damage are in a state of partial arousal rather than true awareness.After four weeks in a vegetative state (VS), the patient is classified as in a persistent vegetative state. Here I will call attention to two such documents. News, analysis & spirituality by email, twice-weekly from CatholicCulture.org. In most cases, they will require catheterization, a feeding tube, and oftentimes, a tracheotomy tube. As a young, proud, super-fit marine, it is a life he never would have wanted. In elaborating these criteria several document of the Church's Magisterium are quite relevant. They cannot do so because in order to do so a person must be able to make judgments and free choices. 904-911. "Personally I'd like to see some clarity about what the pathway is. This lack of reasonable hope or benefit renders the artificially invasive medical treatments futile and thus extraordinary, disproportionate and unduly burdensome," and consequently it would be morally permissible to stop providing food by these artificial means (547). The Pennsylvania Bishops inform their readers that they have here summarized information on tubal feeding set forth in standard medical texts such as The Merck Manual of Diagnosis and Therapy, Robert Berkow, M.D., ed. In the course of his remarks, Pius had this to say: But normally one is held to use only ordinary means [to prolong life]--according to the circumstances of persons, places, times, and culture--that is to say, means that do not involve any grave burdens for oneself or another. A person in a vegetative state may be able to: open their eyes; wake up … A person may enter a minimally conscious state after being in a coma or vegetative state. This happened to 53-year-old Helen Watson from Leicestershire, whose sixteen-year-old son Christopher was severely injured in a road accident on his way back to boarding school in 2006. Terri Schiavo was an unfortunate young woman who suffered a cardiac arrest many years ago with subsequent brain damage from lack of oxygen. This has resulted in tension betw… 13O'Rourke, Evolution of Church Teaching on the Prolongation of Life, 32. But he has told the BBC of cases where families have been kept in the dark for years because of the religious, cultural or moral beliefs of the clinicians involved. Iain is thought to be the longest surviving vegetative state patient in the UK, an unenviable record. There are then two basic methods of feeding these patients artificially: enteral and parenteral. 4. Complete Honest Opinion from Caregivers of Vegetative State/Minimally Conscious Survivors After having made the decision to keep your loved one alive and hope for the best, was it the right decision? Parenteral (outside the bowel) feeding refers to the supplying of nourishment intravenously. Vegetative state is a state with no evidence of awareness of self or environment and showing cycles of sleep and wakefulness. The former Royal Marine, who also served in the Foreign Legion, suffered severe brain injuries after being knocked over by a car in 1989. Caring for Patients in a Persistent Vegetative State. 6. This is a good example of an unanswerable question, because: 1. Hypothalamic and medullary brain stem functions remain intact to support cardiorespiratory and autonomic functions and are sufficient for survival if medical and nursing care is adequate. While caring for a person in a vegetative or minimally conscious state is an enormous challenge, use of appropriate resources, as described above, can be a big help. In contrast, a coma is a state that lacks both awareness and wakefulness. It's awful.". My purpose here is to offer reflections on the care to be given to persons said to be in the "persistent vegetative state," and specifically to address the question whether or not it is obligatory to provide persons said to be in this condition with nutrition and hydration (hereafter I will simply use the term "food" to cover both nutrition and hydration) by the use of artificial means. Also see the separate article Coma. Between these two extremes, patients may be said to be in a vegetative state or exhibit unresponsive wakefulness, characterized by open eyes and basic reflexes, but no signs of awareness. Here Pius indicates that "ordinary" medical treatment is that kind of treatment which offers some reasonable hope of benefiting the subject without imposing unacceptable burdens upon him or others, whereas "extraordinary" treatment is the kind that imposes unacceptable burdens on the subject and/or others. (5) Pennsylvania Conference of Catholic Bishops, Nutrition and Hydration: Moral Considerations (January 14, 1992) in "Origins: NC News Service" 21 (January 30, 1992) 542-553. Since 1992, following the landmark case of Hillsborough victim Tony Bland, it has been possible for an application to be made to the Court of Protection for permission to end a vegetative state patient's life by withdrawing food and hydration. 2See Council on Scientific Affairs and Council of Ethical and Judicial Affairs, Persistent Vegetative State and the Decision to Withdraw or Withhold Life Support, in "Journal of the American Medical Association" 263 (January 19, 1990) 427: "Abrupt loss of consciousness usually consists of an acute sleep-like state of unarousability called coma that may be followed either by varying degrees of cognitive and physical recovery or by severe, chronic neurological impairment. This document came to a conclusion opposite to that reached by the Pennsylvania Bishops and the U.S. Bishops Pro-Life Committee. Erroneous criteria for judging means "extraordinary" or "disproportionate", In the previous section I called attention to Pope Pius XII's address to anesthesiologists not only because it is an important magisterial document relevant to identifying criteria necessary for distinguishing between "ordinary" (=morally obligatory) and "extraordinary" (=morally elective) means of treatment but also because one interpretation of a singularly important passage from this document has been used by several theologians to justify withholding or withdrawing artificially provided food from persons in the "persistent vegetative state.". On the other hand, one is not forbidden to take more than the strictly necessary steps to preserve life and health so long as he does not fail in some more important duty.7. Yet, on O'Rourke's analysis, they would be "extraordinary" inasmuch as they would in no way be effective in helping this person to pursue the spiritual purpose of life. As with vegetative state, a continuing minimally conscious state means it's lasted longer than 4 weeks. This high profile and ethically challenging form of coma has thousands of web pages devoted to it, some crankier than others. First of all, such persons, even including those in the "persistent vegetative state," can be fed orally provided that the swallowing reflex is sufficiently unimpaired. Patients in a vegetative state do not respond to what is happening around them and exhibit no signs of conscious awareness. "9 In addition, this document continues, "when inevitable death is imminent in spite of the means used, it is permitted in conscience to take the decision to refuse forms of treatment which would only secure a precarious and burdensome prolongation of life, so long as the normal care due to a sick person in similar cases is not interrupted."10. Did you feel you were given enough information about the burden of caring for someone … Mother seeks to let brain-damaged daughter die, The new ‘Nigerian princes’ of hacking? How the burden of caring for a patient in a vegetative state changes in relation to different coping strategies. PVS has become marked by ethical and medical dilemmas, often, if not always, requiring legal assistance. And because of advances in medical science meaning that more people survive what would previously have been fatal injuries, the figures are set to continue to grow. Statements on the matter representative of individual bishops are those of (1) The Most Reverend Louis Gelineau Bishop of Providence, R.I., and (2) The Most Reverend James McHugh, Bishop of Camden, N.J. Bishop Gelineau issued a statement, On Removing Nutrition and Water from Comatose Woman (January 10, 1988; printed in "Origins: NC News Service" 17 (January 21, 1988) 546-547) in which he declared that "the medical treatments which are being provided the patient, even those which are supplying nutrition and hydration artificially, offer no reasonable hope of benefit to her. "I have to do his feeds and then, last thing at night, see he's alright, move him about and put cushions all around him to stop him getting bedsores. On recovery from the coma state, VS/UWS is characterised by the return of arousal without signs of awareness. Video, Covid-19: Pfizer/BioNTech vaccine approved for use next week in UK, Trump inciting violence, warns Georgia election official, Trump pardons: US justice department unveils bribery inquiry, Nike's diversity advert causing a backlash in Japan, China #MeToo: Court to hear landmark case of intern versus TV star, Humans waging 'suicidal war' on nature - UN chief Antonio Guterres, Jozsef Szajer: Hungary MEP quits after allegedly fleeing gay orgy, Conception boat fire: Captain charged over 34 deaths in California, Elliot Page: Juno star announces he is transgender, Slack sold to business software giant for $27.7bn, devoted couple died together from carbon monoxide poisoning. 11See the following: Kevin O'Rourke, OP, Evolution of Church Teaching on the Prolongation of Life, in "Health Progress" 69 (January-February 1988) 28-35; The A.M.A. In December 2008 he took her out of hospital, parked their car in the garage of their home and left the engine running. In addition, many people have had to leave their jobs or cut back on hours in … The damage left him blind, incontinent and unable to move or communicate. A few families also try home care (see ‘Caring … Some people will wake up after a few weeks, while others may go into a vegetative or minimally conscious state (see recovering from a coma). It is first of all important to have a correct understanding of what is meant by a "persistent vegetative state. The two researchers travelled all around the UK to talk to 65 people in their own homes. Talking to vegetative state patients can help recovery TALKING to loved ones in a vegetative state may not be a waste of time as new research showed they are more aware than previously thought. "Picture yourself in that situation. Benefits programs pay families to care for seniors. Listen again via the BBC iPlayer or download the podcast. Criteria for withholding/withdrawing treatment, My purpose here is to articulate the criteria necessary for distinguishing between treatments which the Catholic tradition has called "ordinary" or, more recently, "proportionate," and those termed "extraordinary" or, more recently, "disproportionate.". This interpretation, or in my judgment, misinterpretation of the teaching of Pius XII has been advanced in particular by Kevin O'Rourke, OP, in several very influential essays dealing with the care of permanently unconscious persons.11 A view very similar to O'Rourke's, although different in some respects, has been set forth by James Walter and Thomas V. Shannon.12 Here I will simply recount O'Rourke's position insofar as on the matters to be taken up Walter and Shannon are in agreement with him. Description. "Then I have a last look at him at quarter to one in the morning, and if he's sleeping, I'm fine then and I go to sleep myself. The BBC is not responsible for the content of external sites. The lives of the Pistorius family centered around caring for Martin. "If he's got a chest infection or anything wrong, I've got a baby alarm and I can hear him.". The new ‘Nigerian princes’ of hacking? Most patients in a prolonged vegetative or minimally conscious state will eventually be transferred from hospital to a rehabilitation or long-term care setting. NPR reported that Rodney Pistorius would wake up at 5 a.m. every day to get his son dressed and take him to a special care center. Read about our approach to external linking. The stage of coma itself, however, is invariably temporary and in progressive disease is often absent altogether.". As a result, patients in this condition may open their eyes and sometimes follow movements with them or respond to loud or sudden noises (although such responses will not be long sustained nor are they apparently purposeful).3 It is quite unlikely that persons in this state will ever recover consciousness. John Paul II Institute for the Studies of Marriage and Family at. Coma, vegetative state, lock-in syndrome and akinetic mutism are defined. Since it is this portion of the brain, in its cortex or outer layer, which is neurologically involved in specifically human activities such as understanding, willing, and communicating, persons in this condition are not capable of engaging in specifically human activities. She has not had a holiday for more than 21 years. This can be accomplished by means of a nasogastric (through the nose and into the stomach) or nasoduodenal (through the nose and into the upper end of the small bowel) tube or it can also be done through a gastronomy (an opening directly into the stomach) or jejunostomy (an opening into the upper part of the small bowel). Catholic Bioethics and the Gift of Human Life. The Bishops describe enteral and parenteral methods as follows: "Enteral (within the bowel) feeding means that the nourishment is placed directly into the upper end of the small intestine. .css-14iz86j-BoldText{font-weight:bold;}As the Royal College of Physicians begins a review of the diagnosis and care of people in a vegetative state, the BBC asks whether the current system is failing patients and their families. There are now several cases where patients diagnosed as being in PVS have subsequently regained consciousness. Consistent nursing care is a must; this means thousands of dollars in specialized medical care. It referred to the traditional distinction between "ordinary" and "extraordinary" means of preserving life, noting that the imprecision of these terms is the cause of some ambiguity and that, therefore, some more recent writers had suggested that the term "proportionate" be used to designate means that are morally obligatory and that the term "disproportionate" be used to designate means which are not morally obligatory. But these unfortunate human beings are still persons; their lives are still good, and it is good for them to be alive. The first is an important address of Pope Pius XII in 1957, when he spoke to a congress of anesthesiologists. I will conclude (3) by considering conditions that could justify putting limits to the care morally due to persons in this state. Therefore, if it is to be used for longer periods, it is done by inserting a tube into the central nervous system....This method of nutrition carries with it greater risks of complications.". Once someone has received a permanent vegetative state diagnosis, the chance of waking up is extremely unlikely, but still possible. Bishop McHugh, in a letter to priests of his diocese entitled Artificially Assisted Nutrition and Hydration (September 21, 1989; reprinted in "Origins: NC News Service" 19 (October 12, 1989) 314-316) in which he taught that artificially providing food to "unconscious, non-dying persons" (and this is the status of individuals in the "persistent vegetative state") is morally required "absent any other indication of a definite burden for the patient" (316). For Tudor David, 65, the delays involved in an application to the court to allow his wife Diane to die after a road accident left her in a vegetative state proved too much. While unequivocally condemning as absolutely immoral suicide and all forms of euthanasia, whether by acts of commission or by acts of omission, this document reaffirmed traditional Catholic teaching that one is not obliged to use all possible means to preserve and prolong human life. In this section you can find out about the experience of having a relative in a vegetative or minimally conscious state. Professor Turner-Stokes hopes the team's work will ultimately help improve the process which the David family and others believe has let them down. "I think it's very traumatic for the families, it's quite a long, drawn-out process. (4) Texas Conference of Catholic Bishops, On Withdrawing Artificial Nutrition and Hydration (May 7, 1990) in "Origins: NC News Service" 20 (1990) 53-55. 3See Ronald Cranford, The Persistent Vegetative State: The Medical Reality (Getting the Facts Straight), in "Hastings Center Report" 18 (February-March, 1988) 27-32. "At the current time there is not a great deal of clarity about what the process should be, for example there isn't a clear protocol for what should have been done prior to approaching the court," she said. Professor Derick Wade, consultant in neurological rehabilitation, believes it is crucial to inform families of this and all of the options open to them at every stage. A vegetative state, or unaware and unresponsive state, is a specific neurological diagnosis in which a person has a functioning brain stem but no consciousness or cognitive function. 5Here I will briefly summarize the positions taken by representative bishops of the United States, either as individuals or as members of state or national conferences. O'Rourke claims that the Pope's emphasis on the spiritual goal of life, specifies more clearly the terms "ordinary" and "extraordinary." File on 4 is on BBC Radio 4 on Tuesday 21 June at 2000 BST and Sunday 26 June at 1700 BST. This document concluded: "We hold for a presumption in favor of providing medically assisted nutrition and hydration to patients who need it, which presumption would yield in cases where such procedures have no medically reasonable hope of sustaining life or pose excessive risks or burdens" (at 711). A patient is considered in a vegetative state when he or she is awake but not showing signs of awareness, according to the Mayo Clinic. "For some clinicians [the withdrawal of nutrition to allow a patient to die] is not morally acceptable. Patients usually progress from a coma to either a minimally conscious or vegetative state, and these states can last a few weeks, months or years. For the present I can simply say that this document clearly indicates that medical treatments judged, on objective grounds, to impose grave burdens either upon the subject being treated or his family or, indeed, the human community of which the subject is a member, are not morally required and hence can be legitimately withheld or withdrawn. Life, health, all temporal activities are in fact subordinated to spiritual ends. .css-8h1dth-Link{font-family:ReithSans,Helvetica,Arial,freesans,sans-serif;font-weight:700;-webkit-text-decoration:none;text-decoration:none;color:#FFFFFF;}.css-8h1dth-Link:hover,.css-8h1dth-Link:focus{-webkit-text-decoration:underline;text-decoration:underline;}Read about our approach to external linking. Culture of Life Foundation 1350 Connecticut Avenue NW Suite 1210 Washington, D.C. 20036 Voice: 202-331-9800 Fax: 202-331-9540 E-mail: [email protected], This item 3481 digitally provided courtesy of CatholicCulture.org. Absence of awareness can only be inferred by lack of responsiveness to the environment and not as lack of consciousness that we may not be able to detect by behavioural measures. Here you can hear and see people share their personal stories. (2) U.S. Bishops Pro-Life Committee, "Nutrition and Hydration: Moral and Pastoral Reflections" (April 2 1992) in "Origins: NC News Service" 21 (April 9, 1992) 705-712. It will be useful here to summarize, in a note, representative positions taken by U.S. bishops.5 Since even bishops offer conflicting advice on the morality of providing food artificially to persons in the persistent vegetative state, it is evident that the issue is a most difficult one to address properly. There have been a total of 43 applications since 1992, all of which have been granted. Thus, for example, if an elderly person suffering from a malady that renders him incompetent and incapable of engaging in human acts should suffer a cut artery and be in danger of dying because of loss of blood, it would surely be morally obligatory to stop the bleeding by appropriate means. There are out-of-pocket costs for medical supplies, prescription drug co-pays, home modifications, home care help, and more.. It is to be noted that 2 of the 18 bishop members of the Texas Conference refused to sign the document. Cipolletta S(1), Gius E, Bastianelli A. 12See James Walter, Food and Water: An Ethical Burden in "Commonweal" (November 21, 1986) 616-619; James Walter and Thomas A. Shannon, The PVS Patient and the Foregoing/Withdrawing of Medical Nutrition and Hydration in "Theological Studies" 49 (1988) 623-647. Caring for and monitoring a person in a coma Doctors assess a person's level of consciousness using a tool called the Glasgow Coma Scale . This method does not usually result in complications, and even if some complications do arise, they are usually not of a serious nature, but the method does presuppose that the gastrointestinal tract is intact and functioning. A vegetative state is when a person is awake but is showing no signs of awareness. The Pope himself did not address the specific criteria for distinguishing between treatments which are ordinary or proportionate and those which are extraordinary or disproportionate. In setting forth these criteria I will also criticize criteria proposed by influential Catholic theologians because of their inadequacies. The N.J. Bishops concluded that "nutrition and hydration are basic to human life and consequently must always be provided to a patient" (584). and Tube Feeding, in "Parameters in Health Care" 10 (Winter, 1985) 8-11; The A.M.A. The dilemmas and heartache suffered by the families of those in a vegetative state should be eased with improvements in diagnosis and more information for families, experts tell the BBC. Patients in a vegetative state are awake, breathe on their own, and seem to go in and out of sleep. A vegetative state differs both from a coma and brain death. Initially told the court process would take six months, the family was still no closer to a decision from the court 18 months later. Ten years ago I collaborated in writing an article on this issue. A vegetative state may at times be confused with a coma, and vice versa; but this is not true. Without Advance Directives, treatment decisions for patients with Persistent Vegetative State are left to healthcare professionals and families. The vegetative state is a chronic condition that preserves the ability to maintain blood pressure (BP), respiration, and cardiac function, but not cognitive function. "Extraordinary" means would seem to be those means which are optional because they are ineffective or a grave burden in helping a person strive for the spiritual purpose of life.13. A vegetative state is a condition in which a person is awake, but is unable to feel and/or show any signs of sensation. Such individuals are still human persons whose lives are inviolable. However, several moral theologians and, in the United States, bishops' conferences, individual bishops, and a committee of the National Conference of Catholic bishops have written articles or issued statements on this matter, with some concluding that it is normally required to provide such persons with food by artificial means (although in specific cases it might be morally permissible to withhold or withdraw artificially provided food) and others holding that it is morally legitimate to withhold or withdraw the provision of food by these means. The nurses caring for her used the time when they would have been preparing statements in this case to provide care. We must not forget the needs of families caring for a loved one in a "vegetative" state. Respite care, financial support, the sympathetic cooperation of medical pro- Each person will respond differently to this challenge, but almost everyone can cope and move forward. This week, two articles discuss the problems encountered by relatives and professionals caring for people in the persistent vegetative state (pp 352 and 372). in "Issues in Law & Medicine" 5 (1989) 181-196; Open Letter to Bishop McHugh: Father Kevin O'Rourke on Hydration and Nutrition, in "Origins: NC News Service" 19 (October 26, 1989) 351-352. Statement on Tube Feeding: An Ethical Analysis, "America" 155 (November 22, 1986) 321-323, 331 (an essay reprinted by the Society for the Right to Die, an advocacy group for legalizing euthanasia, in its newsletter); Different Viewpoints: Should Nutrition and Hydration Be Provided to Permanently Unconscious and Other Mentally Disabled Persons? Many people, including some seriously handicapped children and mentally impaired adults, are incapable of pursuing the spiritual goal of life. A true coma, which is never permanent, is a state of "unarousable unresponsiveness" which may last as long as six months but will eventually resolve itself into another state.2 The person may emerge into consciousness (of varying degrees) or sink into the "persistent vegetative state," and it may take a long time, even months, to make a correct diagnosis of the patient's true condition. She is concerned that even when families have made an informed decision to withdraw treatment and allow their loved-one to die, the court process involved can be beset with lengthy, yet easily avoidable, delays. These bishops judged that forgoing or withdrawing of artificial nutrition and hydration from a permanently unconscious person, whom they judged "stricken with a lethal pathology which, without artificial nutrition and hydration, will lead to death," is "simply accepting the fact that the person has come to the end of his or her pilgrimage and should not be impeded [by continuing the artificial feeding] from taking the final step" (54).
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