Cárdenas D. Rev. Nutr. Clin. Metab. 2021;4(Supl.1):3-4.
Feeding the ill person: an ethical imperative and a human right
Alimentar a la persona enferma: un imperativo ético y un derecho humano
Alimentando os doentes: um imperativo ético e um direito humano
Diana Cárdenas, MD, PhD1
https://doi.org/10.35454/rncm.v4supl1.341
1 dianacardenasbraz@gmail.com
This issue in which bioethics and human rights in clinical nutrition are discussed is the result of the need to bring the ethical problems and challenges that surround the act of feeding the ill person into the limelight. As the main purpose of the discipline of clinical nutrition, feeding the ill person implies a responsibility that must be exercised in accordance with principles and values.
Technology developments coupled with challenging and extreme situations such as patients in vegetative state, patients with dementia, in intensive care, in palliative care or at the end of life, mean that expert hands are needed to provide nutrition tailored to individual needs. In these situations we ask ourselves about the principles and values underpinning the practice of clinical nutrition. The hypothesis considered is that when the ethical dimension of nutritional care is explored, the broader values of “care” and medicine also come into question. My proposal after several years of reflection and research, which this issue tries to convey, is that as clinical nutrition becomes the object of ethics, it may be introduced legitimately as a form of care in medical practice.
The term “care” can have different meanings. According to Frederic Worms, this term (cuidado in Spanish, soins in French) refers to “every practice designed to meet the needs or mitigate the vital suffering of a living being out of consideration towards that being”(1). This definition implies two indivisible elements: first, “care” provided to a being that “suffers” from something, a need or identifiable distress amenable to treatment (therapeutic care). In the case of clinical nutrition, it refers to meeting a vital need for nutrients to which it is possible to respond with medical nutritional therapy, in particular artificial nutrition. And, second, “care” or treatment provided to “someone”, which implies an intentional and relational dimension (relational care).
Clinical nutrition requires interaction between the healthcare professional and the patient, in which the expert in nutrition makes a diagnosis of the patient’s nutritional status and identifies an indication for nutritional therapy, for which patient or caregiver consent is paramount. To obtain full patient consent, the healthcare professional must provide complete information and inquire about patient preferences and wishes, either for natural or artificial feeding. Nutritional therapy administered through an artificial line should not change the meaning of “feeding”. The transition from oral feeding to artificially administered nutrition implies going from a purely care action (i.e., meeting a vital need) to a therapeutic action that requires a medical indication and therapeutic goals, with the associated risks and benefits. This points to the relational dimension of care in this discipline. Therefore, clinical nutrition practice can become established as a manifestation of consideration towards others which implies going beyond the purely biologic realm to include the symbolic and affective dimensions involved in the act of feeding.(2) Consequently, feeding the infirm individual naturally or artificially must be considered as true care in its ethical dimension and as an essential part of clinical practice.
Healthcare professionals have the duty and commitment of being concerned with the diet of every ill person. This concern requires attention to the problem of malnutrition that could compromise patient prognosis. Patients at risk or in a state of malnutrition must be considered doubly vulnerable.(2) On the one hand, their integrity is compromised and is fragile due to their dependency relationship, involving the need for expert hands to provide for their nutrient needs. On the other hand, malnutrition is an almost invisible problem in current medical practice. Physicians are not trained(3,4) and are not aware of this problem, and its definition and diagnostic criteria (although an international consensus appears to have been reached with the Global Leadership in Malnutrition [GLIM] criteria) are still a matter for debate in the scientific community.(5) Given this situation, it is important to recognize that the most profound ethical meaning of vulnerability implies a pledge of duty, consideration and concern for others. Thus, recognizing malnourished patients as vulnerable implies the duty to feed them.
Moreover, the ethical responsibility of feeding ill persons includes recognizing the individual worth of every being; that is to say, their dignity, understood as a principle linked to an intrinsic and absolute value, beyond any price, that is only germane to human beings(6). Dignity is the fundamental value underpinning human rights. Therefore, recognizing that access to nutritional care is a human right, and imbuing it with political, clinical and ethical, meaning is recognizing a great step forward in clinical nutrition.(7) However, this begs a new question: how can this right influence clinical decisions? It is a matter of understanding the meaning of nutritional medical therapy, or more precisely, considering, besides the medical and biological effect, the reasons for feeding a patient at risk or in a state of malnutrition. Ultimately, the challenge lies in assessing the role of clinical nutrition in preserving human dignity.
In conclusion, the practice of clinical nutrition through nutritional care must be considered as a humane expression. The aforementioned questions inspire a reflection from the ethical perspective, particularly the ethics of care, and allow to state, as does French philosopher Corine Pelluchon in her book Les Nourritures: “Ethics is not just the dimension of my relation with others; it also depends on my relation with food.”(8). That is to say, that besides considering the relationship with the other as the starting point for ethics,(9) it may be that the individual’s relationship to food is the place of origin of ethics.(8)
On behalf of the Journal’s editorial team, I would like to thank Lina María Sierra Tobón, nutritionist, Clinical Nutrition specialist and Master in Bioethics, for a great job in preparing and carrying out the editorial work for this issue. We have several things in common, including a vision of ethics centered on the value of care, hard work and passion for what we do. Thank you, Lina!
Diana Cárdenas, MD, PhD
Editor, Journal of Clinical Nutrition and Metabolism (ACNC). Professor and researcher of the Nutrition, Genetics and Metabolism Institute, El Bosque University Medical School. Bogotá, Colombia.
References
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- Cardenas D. Nutrition en Médecine: approche èpistemologique, problèmes éthiques et cas cliniques. París: L´Harmattan; 2020.
- Crowley J, Ball L, Hiddink GJ. Nutrition in medical education: a systematic review. Lancet Planet Health. 2019;3(9):e379-e389. doi: 10.1016/S2542-5196(19)30171-8.
- Cardenas D, Díaz G, Cadavid J, Lipovestky F, Canicoba M, Sánchez P, et al. Nutrition in medical education in Latin America: Results of a cross-sectional survey. JPEN J Parenter Enteral Nutr. 2021. doi: 10.1002/jpen.2107.
- Cardenas D, Deutz NEP. Is the definition of malnutrition a Sisyphean task? Clin Nutr ESPEN. 2019;29:246-247. doi: 10.1016/j.clnesp.2018.10.005.
- Kant E. Fondements de la Métaphysique des mœurs. Traduction et notes de Victor Delbos. París: Delagrave; 1957.
- Cardenas D, Correia MITD, Ochoa JB, Hardy G, Rodriguez-Ventimilla D, Bermúdez CE, Papapietro K, Hankard R, Briend A, Ungpinitpong W, Zakka KM, Pounds T, Cuerda C, Barazzoni R. Clinical Nutrition and Human Rights. An International Position Paper. Nutr Clin Pract. 2021 Jun;36(3):534-544. doi: 10.1002/ncp.10667.
- Pelluchon C. Les nourritures. Philosophie du corps politique. París: Seuil; 2015.
- Levinas E. Autrement qu’être, ou, Au-delà de l’essence. La Haya: Martinus Nijhoff; 1974.