What is abortion?

Before advancing this discussion, it is important first to clarify the meaning of the term ‘ abortion’ . In keeping with lay dictionary definitions, abortion may be defined simply as the ‘premature termination of a pregnancy by either spontaneous or induced expulsion of a nonviable fetus from a uterus’ ( Collins Australian dictionary 2011 : 4), and usually entails the death of the fetus ( Warren 2014 ). Greasley (2017 : 2) offers the following more definitive definition of abortion, notably: ‘as the deliberate ending of a pregnancy with the known or desired result that the embryo or fetus will die’. Not all participating in the abortion debate subscribe to such ‘simple’ or ‘definitive’ definitions, however. Instead, most lean towards definitions of abortion that, although appearing to be value-neutral (objective), are in essence ethically loaded and hence at risk of misleading moral debate on the issue. For instance, those who are opposed to abortion tend to use the following terms in their discourse: ‘unborn child’ / ‘unborn human life’ (versus fetus) and ‘mothers’ (instead of pregnant women) ( Greasley 2017 ). Accordingly, they typically define it in such terms as ‘artificially causing the miscarriage of an unborn child’, or ‘killing an innocent human being’. Definitions of abortion using these or similar terms are not just defining the ‘act’ of abortion, however. They also seem to be conveying the conclusion that abortion is morally wrong (at the very least, the terms used – ‘unborn child’ / ‘innocent human being’ – seem to appeal to our moral intuition that killing another person who is a non-aggressor is a morally terrible action). In contrast, those who support abortion tend to use the terms ‘pregnancy’ and ‘fetus’ (versus ‘child’ / ‘unborn human being’) in their discourse. Accordingly, they tend to define abortion in such terms as ‘terminating pregnancy’ or ‘ridding the products of unwanted / unviable conception’. Definitions of abortion using these and similar terms seem to imply that abortion is not only not morally wrong but may even be morally neutral (the term used ‘ridding the products of unwanted conception’ seems to invite the ‘reasonable’ question: ‘What is so morally terrible about getting rid of something that is ‘unwanted’ and / or incapable of normal growth and development?’).

It is unlikely that a consensus will be reached among contesting parties on a working definition of abortion and that various ethically loaded definitions will continue to be used. This is so despite research suggesting that both the terms ‘abortion’ and ‘termination of pregnancy’ are distressing even to those providing abortion services, although use of the term ‘termination of pregnancy’ is less so ( Kavanagh et al 2018 ). Either way, it is important to remember that the issues at hand need to be decided by careful deliberation, not by definitions; they also need to be examined in a manner that will question rather than reinforce the status quo.

Arguments for and against the moral permissibility of abortion

Arguments for and against abortion have tended to be advanced from three distinctive positions: a conservative position, a moderate position and a liberal position. These three positions are considered briefly below, noting that little has changed since they were first debated in the early 1970s and 1980s, with foundational works on the subject still being widely cited and / or reprinted in contemporary anthologies today.

The liberal position

The third stance on abortion, the liberal position (see in particular Thomson 1971 ; Tooley 1972 ; Warren, 1973, Warren, 1977, Warren, 1997, Warren, 2007, Warren, 2014 ), holds that abortion is morally permissible on demand. Michael Tooley (1972) argues, for example, that as fetuses are not persons they cannot meaningfully claim a right to life. He points out that the notion ‘person’, in this instance, is a purely moral concept, and that the unfortunate tendency by some to use it as if it were synonymous with the notions of ‘ human being ’ and ‘human life’ is grossly misleading. Warren (1973) argues along similar lines. She contends that a fetus is not a human being and to claim that it is only begs the question. She points out that it is one thing to use human to refer ‘exclusively to members of the species Homo sapiens ’, but quite another to use it in the sense of being ‘a full-fledged member of the moral community’ ( Warren 1973 : 53). In other words, it is one thing to be human in the genetic sense, but it is quite another to be human in the moral sense. These two senses are quite distinct, and care must be taken to distinguish between them. She concludes ( Warren 1973 : 53): ³

In the absence of any argument showing that whatever is genetically human is also morally human … nothing more than genetic humanity can be demonstrated by the presence of the genetic human code.

The consequence of this is unavoidable. It has yet to be demonstrated that the genetic humanity of fetuses alone qualifies them to have fully fledged membership of the moral community. Further, were this to be demonstrated convincingly, it then leaves unanswered the question of what moral status ought to be accorded human–animal chimeras – that is, other non-human species (e.g. pigs, sheep, mice, etc.) into which human genes have been cloned (see debate on the subject advanced by: Behringer 2007 ; Chan 2014 ; DeGrazia 2014 ; Fox 2005 ; Harvey & Salter 2012 ; Hui 2014 ; Piotrowska 2014 ). For example, ought a mouse or other animal into which human genes have been successfully planted (see Behringer 2007 ) be accorded the same moral status as a human fetus at least, if not a fully fledged human being? If genetic humanity is sufficient to accord moral humanity then human–animal chimeras ought also to be accorded moral status.

Judith Jarvis Thomson (1971) also argues that a fetus is not a person. She contends that it is nothing more than a ‘newly implanted clump of cells’ (p 48). In defence of this claim, she argues that a fetus is ‘no more a person than an acorn is an oak tree’ (p 48). The analogy can be extended further to show that, just as stepping on an acorn is significantly different from cutting down an oak tree, so too is aborting a fetus significantly different from killing an actual person.

The conclusion of these and similar views is that, once it is admitted that a fetus is nothing more than a clump of genetically human cells, the abortion issue becomes a non-issue. It would make no more sense to speak of the right of a fetus to life than it would be to speak of some other piece of genetically human tissue’s right to life – say a strand of human hair or a piece of human toenail (both of which are genetically human).

The three positions on abortion discussed so far can be expressed diagrammatically as shown in Fig. 10.1 .

Three positions on abortion

Abortion and the moral rights of women, fetuses and fathers

In considering further the above three positions on abortion, it can be seen that the abortion issue rests on two key points: (1) the moral status of the fetus, and (2) the moral rights of pregnant women to control their bodies and their lives (also referred to as ‘ reproductive autonomy ’) ( Greasley 2017 ). To recap, anti-abortionists argue that the human fetus is a human being, and therefore has a right to life at least equal to that of the mother’s. Pro-abortionists, however, reject this view, arguing that, although a human fetus is genetically human, this in no way implies that it is morally a human being with a full set of rights claims. Neither, they argue, is a fetus a person. In defence of this position, pro-abortionists contend that in order for a fetus to be a person it must satisfy the moral criteria of personhood (which are very different from the criteria of fetalhood) – something that a fetus simply does not do. Let us consider this claim further.

The much-cited North American philosopher, Mary Anne Warren, has classically argued that, for an entity to be a person, it must satisfy a number of criteria, namely:

• 1.
  

  consciousness (of objects and events external and / or internal to the being), and in particular the capacity to feel pain

  
  
• 2.
  

  reasoning (the developed capacity to solve new and relatively complex problems)

  
  
• 3.
  

  self-motivated activity (activity which is relatively independent of either genetic or direct external control)

  
  
• 4.
  

  the capacity to communicate, by whatever means, messages of an indefinite variety of types, that is, not just with an indefinite number of possible contents, but on indefinitely many possible topics

  
  
• 5.
  

  the presence of self-concepts, and self-awareness, either individual or racial, or both.

( Warren 1973 : 55)

Warren admitted that there were numerous difficulties involved in formulating and applying precise criteria of personhood. Even so, it could be done. Commenting on the criteria she had formulated, Warren argued that an entity does not need to have all five attributes described, and that it is possible that attributes given in criteria 1 and 2 alone are sufficient for personhood, and might even qualify as necessary criteria for personhood. Given these criteria, all that needs to be claimed to demonstrate that an entity (including a fetus) is not a person is that any entity which fails to satisfy all of the five criteria listed is not a person. She concluded that if opponents of abortion deny the appropriateness of the criteria she has identified, she knows of no other arguments which would convince them, stating: ‘We would probably have to admit that our conceptual schemes were indeed irreconcilably different, and that our dispute could not be settled objectively’ ( Warren 1973 : 56).

Michael Tooley (1972) , like Warren, also interpreted ‘person’ in rationalistic terms. He argued that in order for something to be a person it must have a serious moral right to life, and, in order to have a serious moral right to life, it must possess ‘the concept of self as a continuing subject of experience and other mental states, and believe that it is itself such a continuing entity’ (p 44). Since fetuses do not satisfy this basic ‘self-consciousness requirement’, as Tooley called it, they are not persons – they do not have a serious moral right to life, and therefore to kill them is not wrong.

More recently, in a revised version of her earlier work, Mary Anne Warren (2014 edn) has expanded on and refined the characteristics which she believes are central to the concept of personhood, namely:

• 1.
  

  sentience – the capacity to have conscious experiences, usually including the capacity to experience pain and pleasure;

  
  
• 2.
  

  emotionality – the capacity to feel happy, sad, angry, loving, and so on;

  
  
• 3.
  

  reason – the capacity to solve new and relatively complex problems;

  
  
• 4.
  

  the capacity to communicate, by whatever means, messages of an indefinite variety of types; that is, not just with an indefinite number of possible contents, but on indefinitely many possible topics;

  
  
• 5.
  

  self-awareness – having a concept of oneself, as an individual and / or as a member of a social group; and finally

  
  
• 6.
  

  moral agency – the capacity to regulate one’s own actions through moral principles or ideals.

( Warren 2014 edn: 140)

Although conceding that it is difficult to define these traits precisely, or to specify ‘universally valid behavioural indications that these traits are present’, Warren (1997 : 84) nevertheless holds that these criteria of personhood are functional – pointing out that an entity ‘need not have all of these attributes to be a person’. She explains:

It should not surprise us that many people do not meet all the criteria of personhood. Criteria for the applicability of complex concepts are often like this: none may be logically necessary, but the more criteria that are satisfied, the more confident we are that the concept is applicable. Conversely, the fewer criteria are satisfied, the less plausible it is to hold that the concept applies. And if none of the relevant criteria are met, then we may be confident that it does not [apply]. ( Warren 1997 : 84)

Warren, 1997, Warren, 2014 suggests that, in order to demonstrate that a fetus is not a person, all that is required is to claim that a fetus has none of the above six characteristics of personhood.

For some, the personhood argument does little to settle the abortion question. For example, it might be claimed that, even if it is true that a fetus is not a person, it nevertheless has the potential to become one, and therefore it has rights (see also Warren 1977 ). Thus abortion is still wrong on the grounds of the potentiality of the fetus ( Glover 1977 : 122) – or, to borrow from Warren’s analogy cited earlier: even though an acorn is not an oak tree, it nevertheless has the potential to become one; therefore crushing an acorn is tantamount to chopping down an oak tree.

There are a number of difficulties with this view. First, the argument tends to presume that what is potential will in fact become actual. In the case of zygotes, however, this is quite improbable. As Engelhardt points out, only ‘40–50% of zygotes survive to be persons (i.e. adult, competent human beings)’ ( 1986 : 111). It might then be better, suggests Engelhardt, to speak of human zygotes as being only ‘0.4 probable persons’.

Second, the argument strongly suggests that it is not the fetus per se that is valued, but rather what it will become ( Glover 1977 : 122). It is difficult to interpret just what kind of moral demand this creates. As Glover (1977 : 122) points out:

It is hard to see how this potential argument can come to any more than saying that abortion is wrong because a person who would have existed in the future will not exist if an abortion is performed.

If we take the potentiality argument to its logical extreme, we are committed to accepting, absurdly, that contraception, the wasteful ejaculation of sperm, menstruation and celibacy are also morally wrong, since these too will result in future persons being prevented from existing ( Warren 1977 : 277).

The main unresolved question, however, is: ‘Can a potential person be meaningfully said to have actual rights and, if so, can these rights meaningfully override the existing rights of actual persons?’ or, to put this another way: ‘Can a fetus (a potential person) have actual rights and, if so, can these meaningfully override the existing rights of its mother (an actual person)?’ The crux of the dilemma posed here is whether the more immediate and actual rights of the pregnant woman should be recognised before the more remote and potential needs of the fetus, or vice versa.

One answer is that, given our understanding of the nature of moral rights and correlative duties, there is something logically and linguistically odd in ascribing rights to fetuses (non-persons), particularly during the pre-sentient stage. If we were to accept that non-sentient fetuses have moral rights, we would be committed, absurdly, to accepting that all sorts of other non-sentient things have moral rights – including human toenails, strands of hair or pieces of skin. For argument’s sake, however, let us accept that the fetus does have moral rights and, further, that these can meaningfully conflict with the mother’s moral rights. The question which arises here is: ‘Which fetal / maternal rights are likely to conflict?’

The most obvious is the fetus’s and the mother’s common claim to a right to life . This is particularly so in cases where the mother’s life would almost certainly be lost if the pregnancy were allowed to continue. In such situations it seems reasonable to claim that the mother’s right to life must at least be as strong as the fetus’s right to life. Further, since both stand to die unless the pregnancy is terminated, then surely it is better, morally speaking, that only one life is lost instead of two? It is difficult to see how anyone could reasonably and conscientiously choose an outcome which would see both the mother and the fetus die. Furthermore, as stated elsewhere in this book, morality does not generally require us to make large personal sacrifices on behalf of another, and thus it would be morally incorrect to suggest that the mother has a duty to sacrifice her life in defence of the fetus. In the case of life-threatening pregnancies, then, it seems reasonable to conclude that the pregnant woman’s right to life has the weightier claim.

A second set of rights which may conflict is the mother’s right to have control over her body and life’s circumstances versus the fetus’s right to life . It might be claimed, for example, that a woman’s right to choose her lifestyle, career, economic circumstances, standard of health and similar override any claims the fetus might have to be ‘kept alive’. The mother may then withdraw her ‘life support’ even if this means the fetus will die in the process (an unfortunate, but nevertheless unavoidable, consequence). Against this, however, it might still be claimed that the inconveniences and other psychological, physical or social ills caused by an unwanted pregnancy are still not enough to justify killing the fetus and violating its right to life ( Brody 1982 ; Noonan 1983 ). The demand not to kill the fetus becomes even more persuasive when it is considered that there are alternatives available for helping to prevent or alleviate the ills of unwanted pregnancies, such as child welfare and other social security benefits, adoption, counselling, medication, or ectogenesis. Ectogenesis, which involves extracting the embryo or fetus and placing it in a surrogate or an artificial uterus, would essentially allow an extracorporeal pregnancy to occur (also called ‘extrauterine fetal incubation’ or EUFI) ( Bulletti et al 2011 : 126; see also Coleman 2004 ; Gelfand & Shook 2006 ; Yuko 2012 ). It should be noted that ectogenesis, described as the ‘third era of human reproduction’ ( Abecassis 2016 ), is not as far-fetched as it might seem and can no longer be dismissed as ‘just the stuff of science fiction’. Such ‘theoretical devices’ are already used in experimental animal science ( Adinolfi 2004 ). For example, in 2017 it was reported that scientists had sustained the lives of lamb fetuses in a ‘plastic womb’ for between 105 and 115 days ( Cohen 2017 ; Winter 2017 ). As Winter (2017 : 416) noted, reports of this experimental success ‘invited inference’ that human ectogenesis may soon be a reality. Although the technical problems remain formidable, some scientists contend that it is only a matter of time before efficient artificial uteri in humans will be available – especially for late-term fetuses where it would be easier to connect embryonic umbilical arteries and veins to equipment designed to pump, filter and nourish blood ( Abecassis 2016 ; Adinolfi 2004 ; Bulletti et al 2011 ). Moreover, research dating back to the 1990s has already been carried out on ‘maintaining uteri extracted from women outside of a woman’s body’, and implanting embryos into these wombs ( Rowland 1992 : 288–9). Aborted fetuses were ‘kept alive for up to forty-eight hours’ in these early research projects ( Rowland 1992 : 289; see also Caplan et al 2007 ; Coleman 2004 ; Gelfand & Shook 2006 ; Yuko 2012 ). In light of these alternatives (notwithstanding the complex ethical issues raised by ectogenesis in particular – for example, see Cohen 2017 ; Reiber 2010 ), some critics contend that the claim that a mother’s rights ought to be given overriding consideration over those of the fetus becomes increasingly difficult to sustain ( Langford 2008 ). Notwithstanding the ethical and legal concerns raised by ectogenesis, scientists are of the view that successful human ectogenesis will be achieved within the next two decades ( Abecassis 2016 ). Commentators also foresee that, if achieved, human ectogenesis will radically change the parameters of the conventional abortion debate including rendering it a non-issue ( Cohen 2017 ; Coleman 2005 ).

A third set of rights which might conflict is the mother’s right to health (and to a quality of life) versus the fetus’s right to life . In this instance, the mother’s health and quality of life are threatened not by her pregnancy but by a progressive debilitating disease, such as Alzheimer’s, Parkinson’s or diabetes. The mother might, for example, contemplate getting pregnant for the sole purpose of growing tissue which can be harvested and transplanted into her brain or pancreas in an attempt to restore her health. The issue of fetal tissue transplantation has long been the subject of intense debate ( Engelhardt 1989 ; Sandel 2004 ). Although governments are striving hard to prevent this type of scenario from occurring, there have already been cases of women getting pregnant and / or having abortions for the sole purpose of supplying fetal tissue for transplantation – if not for themselves, then for others especially a fetus’s siblings (e.g. ‘saviour sibling’ or ‘donor sibling’ pregnancies / abortions) ( Deech 2017 ; Morrow 1991 ; Raz et al 2017 ).

A fourth set of rights which may cause conflict involves not only the competing claims of a fetus and its mother, but also the paternal rights of the father (also called ‘male abortion’) ( McCulley 1988 ). During the 1980s there were a number of legal cases (notably in the United Kingdom (UK), the United States (US), Canada and Australia) involving fathers undertaking legal action in an attempt to stop their (ex-)wives and (ex-)girlfriends from having abortions ( AFP 1989 ; Beyer 1989 ; Leo 1983 ; Lowther 1988 ; McCulley 1988 ; PA 1987 ).

Court challenges brought by biological fathers against their partners have tended to be viewed with little sympathy from women who historically have been left alone with the burden and hardships of child rearing after the fathers of their children have long abandoned them. Some even worry that, if the paternity rights debate is allowed to progress to its logical extreme, it could have paved the way for rapists to prevent their victims from having abortions, and to press for access rights after the baby has been born.

To date, Australian courts have tended to deny the injunctions sought by biological fathers preventing their partners from having an abortion on the grounds that there is ‘no rule in common law or statute which gives the father the right to be consulted about a termination’ ( Forrester & Griffiths 2015 : 216). In the US, one Supreme Court stated that when a father and mother disagree on whether an abortion should go forward:

The obvious fact is that […] the view of only one of the two marriage partners can prevail. Inasmuch as it is the woman who physically bears the child and who is the more directly and immediately affected by the pregnancy, as between the two, the balance weighs in her favor. ( Planned Parenthood of Central Missouri v Danforth 1976 : 72)

Abortion, politics and the broader community

As noted in the introduction to this discussion, the abortion issue is extraordinarily complex; it is also extremely political, as some spectacular overseas incidents have shown. For example, in 1990, Belgium was thrown into a constitutional crisis after King Baudouin, Belgium’s reigning monarch, stepped down from his throne temporarily ‘because his conscience would not let him sign a law legalising abortion’ ( Reuters 1990a : 7). As a result, the government had to take over the King’s powers and pass the abortion law. It is reported that once the abortion law was passed the King’s inability to reign ceased, and he resumed his position on the throne ( Reuters 1990a : 7).

In the same year, it was reported that disagreement over abortion law threatened to ‘derail a treaty on German unity’ ( Reuters 1990b : 7). The disagreement was primarily over whether ‘West German women may take advantage of East Germany’s liberal abortion laws after unification’ ( Reuters 1990b : 7).

In 1992, Ireland witnessed political uproar and large public demonstrations after the High Court banned a 14-year-old rape victim from travelling to Britain for an abortion (the girl had been raped repeatedly by a friend’s father over a 1-year period) ( Barrett, 1992a, Barrett, 1992b ; Holden 1994 ; Makri 2018 ). It was reported that many European constitutional lawyers considered the ban a breach of the Treaty of Rome, which had brought the European Community (EC) into being almost four decades earlier, and, among other things, ‘permitted the right to free movement within the EC’ ( Barrett G 1992a ). The situation reached crisis point when it was evident that the ban threatened the European Community’s Maastricht Treaty on European political union, which Irish voters were due to vote on a few months later ( Barrett, 1992c, Barrett, 1992d, Barrett, 1992e, Barrett, 1992f ; Independent 1992 : 6).

In 2007, Ireland’s abortion laws once again threatened to erupt into a political crisis when a pregnant 17-year-old began court proceedings to enable her to travel to Britain for an abortion. The teenager decided to have an abortion upon learning that the fetus she was carrying had a rare brain condition (anencephaly) and was not expected to live longer than a few days after being born ( Bowcott 2007 : 14). Although abortion was illegal in Ireland at the time (and the subject of a constitutional ban, overturned only in May 2018), it was permitted to be performed in cases where the risks to the mother were substantial. Neither the law nor the constitution allowed abortion to be performed on grounds of fetal abnormality, however, and it was this point that threatened to cause a constitutional crisis. The case is reported to have prompted ‘fresh calls for constitutional reform’ and for the provision of ‘safe, free, and legal abortion in Ireland’ ( Bowcott 2007 : 14). Other notable cases prompting calls for constitutional reform included the much-publicised case of Savita Halappanavar, who died on 28 October 2012 as a result of being refused an abortion for a non-viable pregnancy even though her life was at serious risk, and the 2014 case of ‘Miss Y’, a suicidal pregnant asylum seeker who revealed to authorities that her pregnancy was the result of being raped in her country of origin ( Berer 2013 ; McCarthy et al 2018 ; Makri 2018 ; Quinlan 2017 ).

Abortion was also a major issue in the American presidential election of 1992, with the then presidential contenders Bill Clinton and Ross Perot both trying ‘to lure pro-choice voters to their side’ ( Barrett L I 1992 : 54). During the campaign, the Bush camp (whose law reforms saw the loss of civil rights protection for US abortion clinics ( Denniston 1993 ) and the banning of abortion counselling at federally funded clinics ( Toner 1993 )) admitted publicly that anything raising the profile of the abortion issue was ‘a problem for us’ ( Barrett L I 1992 : 54).

The abortion debate in the US took a dramatic and historic turn in 1993, when an anti-abortion protester shot and killed a doctor during a pro-life demonstration outside a lawful abortion clinic ( Rohter 1993 : 7; see also Hadley 1996 ). Abortion rights groups took the shooting of the doctor as a ‘symbol of the increasing harassment’ of health workers involved in abortion work, which has since seen abortion clinics increasingly vandalised and destroyed by arsonists.

According to Robinson (2004) of Ontario Consultants on Religious Tolerance, since harassment and violence first began to be levelled at abortion clinics in the early 1970s, there have been literally tens of thousands of incidents directed against abortion clinic personnel. Citing US National Abortion Federation (NAF) figures, Robinson estimates that, in the 16-year period from 1989 to 2004, anti-abortion protesters were implicated in 24 murders and attempted murders; 180 (actual or attempted) bombings and arson attacks; 3349 incidents of invasion, assault and battery, vandalism, trespassing, death threats (including over 554 anthrax hoaxes), burglary and stalking; 11 448 instances of hate mail, harassing phone calls and bomb threats; 516 blockades; and 80 305 episodes of picketing across the US ( Robinson 2004 ). Although the number of seriously violent crimes against abortion clinics (e.g. murders and attempted murders) has declined over the years, the NAF reports there has nonetheless been a steep rise in clinic invasions, obstructions and blockades by anti-abortion extremists emboldened by the current political environment ( NAF 2017 : 1). Specifically, for the period 2016–17, trespassing has more than tripled, death threats / threats of harm have nearly doubled and incidents of obstruction have risen from 580 to more than 1700 ( NAF 2017 : 1). It should be noted, however, that this situation is not unique to the US. Countries such as Australia, Canada, New Zealand and the UK have all had to grapple with anti-abortion protestation against women in need as well as abortion service providers. Women seeking an abortion in these countries often must run the gauntlet of anti-abortion protesters stationed outside reproductive health clinics handing out anti-abortion pamphlets, conducting ‘pavement anti-abortion counselling’ and harassing the women (and their partners) as they attempt to enter the clinic ( Lowe & Hayes 2018 ; Regan & Glasier 2017 ; Sifris & Belton 2017 ; Whyte 2018 ). The problem of anti-abortion protestors stationed outside reproductive health clinics has become so serious that new legislation establishing ‘safe access zones’ (also called ‘buffer zones’) to protect women from harassment has had to be introduced ( Lowe & Hayes 2018 ; Paxman 2017 ; Regan & Glasier 2017 ; Sifris & Belton 2017 ).

Australia has also experienced the politicisation of abortion, with a small number of politicians over the years attempting, unsuccessfully, to introduce legislation aimed at restricting abortion services for women. Arguably the most dramatic event to occur in Australia’s abortion history, however, occurred in July 2001 when Steve Rogers, a security guard at the Fertility Control Clinic in East Melbourne, was fatally shot by a man intent on destroying the clinic ( Dean & Allanson 2003 ). As already discussed in Chapter 5 , this attack was the first of its kind in Australia and sparked fury and dismay at the vulnerability of abortion clinic personnel and the failure by law enforcement bodies to protect those attending and working at such clinics ( Dean & Allanson 2003 ; Rees & Head 2001 ). Significantly, in 2006, another man attempted to kill – and was subsequently charged with threatening to kill – another security guard at the clinic, underscoring the risks and potential threats to the safety of abortion personnel in Australia ( Nader 2007 ) and the tensions that exist between the right to access and the right to protest abortion ( Dean & Allanson 2003 ). Also in 2009 a medical clinic in Mosman Park, Western Australia, was daubed with graffiti with the words ‘Baby Killers’ and subjected to an attempted firebombing using Molotov cocktails ( Sapienza 2009 ).

Anti-abortion violence against individual workers and services continues in Western liberal democracies such as the US, UK, Canada, New Zealand and Australia. Occurring as a result of either strategic activism or one-off random attacks, anti-abortion violence includes, but is not limited to, stalking, assault, kidnapping, attempted murder, murder and the vandalism of property (including arson and bombing) ( Wikipedia 2018e : http://www.wikipedia.org/wiki/Anti-abortion_violence ).

Euthanasia

Euthanasia, like abortion, is also regarded as one of the most controversial bioethical issues to have captured the public’s attention in Western liberal democracies. Like the abortion issue, it is unlikely to be resolved to the satisfaction of all concerned. A significant distinguishing feature of the euthanasia issue, however, is that, despite media-generated public opinion polls suggesting a global majority support for euthanasia, in reality it is a minority issue. As Johnstone (2013a) notes in her comprehensive critique of the politics of euthanasia, the actual practice of euthanasia affects only a small percentage of people – even in jurisdictions in which euthanasia has been legalised (e.g. the Netherlands). Moreover, the World Federation of Right to Die Societies (founded in 1980) has affiliated organisations in only 26 (13%) of the world’s 195 recognised countries ( https://www.worldrtd.net/ ). In light of this, as Johnstone (and others) have concluded elsewhere, ‘the development and implementation of what has been termed “death policy” is neither a universal phenomenon nor a public policy imperative. Despite this reality, euthanasia is falsely promoted “as if” it is of universal importance and priority’ ( Johnstone 2013a : xvii).

Another distinguishing feature of the euthanasia issue is the extent to which pro-euthanasia activists have successfully used propaganda and ‘dirty tricks fallacies’ to advance their cause ( Johnstone 2013a ). Although anti-abortion campaigners have used similar devices, their efforts have tended to be less sophisticated and less well organised. As an examination of these devices has already been made elsewhere (see Johnstone 2013a ), no further attention will be given to them here.

Euthanasia and its significance for nurses

Euthanasia and the so-called ‘right to die’ are not new issues for nurses. In Australia, one of the first articles addressing the subject was published as early as 1912 in the Australasian Nurses Journal . Reprinted from the British Medical Journal , the article contained concerns and viewpoints which remain current – including the question of whether euthanasia should be legalised.

Although euthanasia may not be a new issue for nurses in Australia, it has nevertheless become a more complex and significant one. For example, in 1996, Australia became the subject of international attention when it became the first country in the world to fully legalise active voluntary euthanasia. This followed the passage, in May 1995, of the Northern Territory’s controversial Rights of the Terminally Ill Act 1995 (NT) , which came into effect on 1 July 1996. Almost 1 year later, however, the Act was overturned by the Australian Federal government – although not before five people had sought assistance to die under the Act. Recognising the possible implications of Rights of the Terminally Ill Act for members of the nursing profession, the Royal College of Nursing, Australia (RCNA) (now the Australian College of Nursing (ACN)) took the unprecedented step of releasing for comment a discussion paper entitled Euthanasia: an issue for nurses ( Hamilton 1995 ). The RCNA received over 70 responses to this discussion paper from concerned and interested nursing organisations, groups and individuals from around Australia. The responses received represented nurses working in a variety of clinical areas and fields of nursing (including education) and reflected a wide diversity of knowledge, opinion, values and beliefs about euthanasia as well as the need for guidance on how best to respond the issue. Perhaps most confronting of all, however, was the emerging difficult question of whether the nursing profession should take a definitive stance in either supporting or opposing the legalisation of euthanasia and adopt a formal position statement clarifying its stance.

Recognising the complexity and perplexity of the issue, the RCNA subsequently commissioned, as part of its professional development series, a monograph entitled The politics of euthanasia: a nursing response ( Johnstone 1996a ). The purpose of this monograph was not to provide nurses with definitive answers to the difficult questions posed by the euthanasia debate. Rather, it was to advance a discussion that would enable nurses ‘to formulate their own thinking and viewpoints on the subject and to be able to contribute to broader professional discussion on the whole issue of the right to die’ ( Johnstone 1996b : 22). In July 1996, the RCNA also issued its first position statement on voluntary euthanasia and assisted suicide – subsequently revised and reaffirmed respectively in 1999 and 2006 ( RCNA 1996, RCNA 1999 , 2006). This position statement primarily focused on clarifying the illegal status of euthanasia / assisted suicide in Australia, acknowledging that there exists a diversity of moral viewpoints on the euthanasia issue, reminding nurses of their professional responsibility to be reliably informed about the ethical, legal, cultural and clinical implications of euthanasia and assisted suicide, and recognising and supporting the appropriateness of nurses taking a ‘conscientious’ position on the matter.

Significantly, in May 1996, less than 2 months before the Rights of the Terminally Ill Act 1995 (NT) came into effect, the then Nurses’ Board of the Northern Territory took the unprecedented step of formulating and ratifying a formal position statement on euthanasia (see Nurses’ Board of the Northern Territory Position statement on the nurse’s role in euthanasia , included in full as Appendix 5 in Johnstone 1996a ). This position statement was keyed to the Rights of the Terminally Ill Act 1995 (NT) and sought to clarify the role and function of nurses in relation to the Act’s provisions. Specifically, the position statement supported:

• •
  

  the role of nurses assisting in the voluntary euthanasia of competent patients; and

  
  
• •
  

  the rights of nurses to conscientiously refuse to participate in the euthanasia of patients.

( Johnstone 1996a : 36)

The position statement also outlined the obligations of nurses in regard to the ethical and legal aspects of euthanasia, employment policies, professional competence and education ( Johnstone 1996a : 36–7).

Currently, with the notable exception of the Australian State of Victoria, ⁴ it is an offence in Australian jurisdictions ‘to assist, encourage or aid a person to commit suicide or attempt to commit suicide’ ( Forrester & Griffiths 2015 : 247). Thus, although the term ‘euthanasia’ as such is not a legally recognised word for the purposes of criminal law, ⁵ the term ‘assisted suicide’ (aiding someone to die) is ( Forrester & Griffiths 2015 : 244). Similarly in New Zealand, in which, as in Australia, there have been convictions for assisting the suicide of another.

Emboldened by the passage of the Victorian legislation, proponents of euthanasia / assisted suicide in Australia speculate that it will only be a matter of time before euthanasia and assisted suicide will be legal in all jurisdictions in Australia.

Definitions of euthanasia, assisted suicide and ‘mercy killing’

Euthanasia

The term euthanasia ⁶ is generally used to refer to an instance in which a legally competent patient / client makes an informed and voluntary choice to have a medically assisted death, explicitly requests assistance to die and gives an informed consent for the actual procedure of euthanasia to be performed. In short, the patient / client explicitly requests, and voluntarily consents to, a medical practitioner to administer a lethal substance (e.g. by intravenous injection) so as to bring about immediate death . This form of euthanasia is also sometimes called active voluntary euthanasia because: (i) it involves actively bringing about death (e.g. by the deliberate administration of a lethal injection), as opposed to passive euthanasia encompassing passively bringing about death (e.g. by wilfully withholding or withdrawing clinically assisted nutrition and hydration), and (ii) it is chosen voluntarily – that is, in a manner that is free of coercive or manipulative influences (as opposed to being imposed under duress or when unable or incapable of giving a free and informed consent). Euthanasia of the active voluntary type is also sometimes referred to as ‘consensual euthanasia’. This is generally contrasted with non-voluntary euthanasia (sometimes referred to as ‘non-consensual euthanasia’) as this type of euthanasia involves the act of killing a patient / client whose wishes cannot be known because of either immaturity, incompetence, or both.

Over the decades, the bioethics literature has variously drawn a distinction between six different types of euthanasia: (1) voluntary active euthanasia, (2) voluntary passive euthanasia, (3) involuntary active euthanasia, (4) involuntary passive euthanasia, (5) non-voluntary active euthanasia and (6) non-voluntary passive euthanasia. The six types of euthanasia just outlined can be expressed diagrammatically, as shown in Fig. 10.2 .

Six categories of euthanasia

In the case of voluntary euthanasia , as already stated, a fully competent patient makes an informed and voluntary decision to have a medically assisted death, asks for assistance to die and gives an informed consent for the actual procedure of euthanasia to be performed. Involuntary euthanasia (or non-consensual euthanasia), in contrast, involves the exact opposite – namely, killing a patient without the patient’s informed consent and / or contrary to that patient’s expressed wishes (where these are known or could be known). The involuntary killing of patients as part of the Nazi medicalised killing programs during World War II is an example of this. Non-voluntary euthanasia (also a form of non-consensual euthanasia) stands in contrast again and involves the act of killing a patient whose wishes cannot be known because of either immaturity or incompetency, or both. As McGuire (1987) explains, whereas the term ‘involuntary’ implies an action which is carried out against the wishes of the patient, ‘non-voluntary’ simply implies that there is no voluntariness – in the sense that the patient is not capable of either denying or giving consent (as in the case of the permanently comatose or brain-injured patient). In the case of the permanently comatose, McGuire contends, euthanasia would be ‘neither voluntary nor involuntary, but is simply non-voluntary’ ( McGuire 1987 : 12).

Despite the above categorisations, contemporary debate on the legalisation of euthanasia as a medical procedure primarily has as its focus just two forms: voluntary euthanasia and non-voluntary euthanasia. The reasons for this are threefold:

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  The distinction between active and passive euthanasia is held to be unsustainable and effectively collapses once it is admitted that, whether actively administering a lethal substance or passively withholding a life-prolonging therapy (including food and fluids), the intention is still the same – namely, to hasten the foreseeable death of the patient.

  
  
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  Involuntary euthanasia (euthanasia against a person’s will) is regarded by proponents of active voluntary euthanasia as an act that could never be justified on moral grounds and hence as unconscionable and beyond the pale; accordingly there is nothing to debate (both proponents and opponents are agreed: involuntary euthanasia is wrong and impermissible).

  
  
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  Non-voluntary euthanasia (euthanasia of entities without the capacity to request or consent to euthanasia – e.g. children and adults who are cognitively impaired, have a serious brain injury, etc.), in contradistinction to involuntary euthanasia, is regarded by proponents of active voluntary euthanasia as an act that could be justified on moral grounds (e.g. the alleviation of unbearable and intractable suffering) and hence morally worthy of debate as to its moral permissibility or impermissibility.

Views for and against euthanasia / assisted suicide

Like other controversial bioethical issues, euthanasia and assisted suicide have proponents and opponents. Attitudes towards them range from liberal and moderate acceptance to absolute conservative prohibition. It is to examining some of the various viewpoints for and against euthanasia and assisted suicide that this discussion will now turn.

The doctrine of double effect

The doctrine of double effect is a Catholic doctrine developed by Catholic theologians that is appealed to when seeking to resolve the well-recognised dilemma posed by intolerable pain and the use of potentially lethal doses of narcotics as a means of suppressing pain. Although the Vatican prohibits euthanasia, it nevertheless permits the use of narcotics as a means of alleviating pain – and, furthermore, permits dosages that might suppress a patient’s level of consciousness and even shorten a patient’s life ( Vatican 1980 ). There are, however, clearly defined conditions that must be met. First, there must be no other means of alleviating the patient’s pain; in other words, potentially lethal doses of narcotics must never be prescribed except as a last resort. Second, the intention of using narcotics must be only to alleviate pain , and not to cause death. It is the second condition encompassing the intentionality of an act that finds its force in the doctrine of double effect.

The doctrine of double effect basically prescribes that it is always wrong to do a bad act for the sake of good consequences, but that it is sometimes permissible to do a good act even knowing it might have some bad consequences. To illustrate this doctrine, consider the case of a patient suffering intolerable and intractable pain. In this case, ending the patient’s life would also result in ending the patient’s intolerable and intractable pain. Whereas ending the patient’s pain would be a ‘good thing’, ending the patient’s life would not. Moreover, accepting the sanctity-of-life doctrine, deliberately ending an innocent patient’s life would be a morally evil thing to do. Thus, in keeping with the doctrine: it would always be wrong to end an innocent patient’s life (a bad act) in order to alleviate that patient’s pain (a good consequence).

Given the ‘good’ of alleviating pain, however, giving the patient analgesia is morally permissible – even though this might have the foreseeable and unfortunate consequence of shortening the patient’s life. This is permitted because, even though the act of narcotic administration is associated with the foreseen possibility of hastening death, ending the patient’s life is not the conscious intention behind the act . In short, the decision and action of giving the narcotics was not done with ‘murder in your heart’. To express the doctrine of double effect another way: it is always wrong to end patients’ lives for the sake of alleviating their pain, but it is sometimes permissible to give potentially lethal doses of narcotics to alleviate pain, even though this might result in the patient’s death – as long as the patient’s death is not the intended outcome .

It is noteworthy that although primarily originating from Roman Catholic religious tradition, the doctrine of double effect has influenced secular legal reasoning in regard to end-of-life decision-making ( McStay 2003 : 53–6; Mendelson 1997 : 112). One US legal commentator has even suggested that:

the double effect principle represents sound public policy to the extent that it allows physicians to provide adequate palliative care without engaging in clearly illegal conduct. ( McStay 2003 : 54)

The doctrine of double effect has been the subject of much philosophical criticism, most notably on account of its over-reliance on what is called the foreseeability / intentionality distinction and the hypocritical manoeuvres used by some to ‘hide, rather than reveal, their true intentions’ ( Watt 2017 : 15). This distinction holds roughly that foreseeing that a bad consequence will occur as a result of a given act is not the same thing as intending that bad consequence. For example, foreseeing that a patient will die as a result of being given large doses of narcotics (or other medical regimen such as that used in palliative sedation) is not the same thing as intending to end that patient’s life; therefore the person who administers the narcotic is not morally culpable.

Critics reject this, however, and argue that the distinction drawn here is misleading. They contend that foreseeing a bad consequence of an action is exactly the same as intending it, since the agent knows that a bad consequence is pending but deliberately refrains from preventing it. At the very least, intentions are relevant to determining the moral permissibility and impermissibility of given acts, just as they are to determining culpability in criminal law ( Nelkin & Rickless 2016 ). There is also concern that the recent ‘stretching’ of double-effect reasoning in end-of-life cases ‘requires ethical contortions about distinguishing intent and about treating death as a side effect’ and, in so doing, moves a step closer to providing a ‘shield to hide what is in effect assisted dying’ ( Duckett 2018 : 36).

Palliative sedation

The issue of palliative sedation (PS) is believed to date back to the 1990s, when discussion first emerged in the scholarly literature about the practice of ‘terminally sedating’ dying patients in palliative care ( Tännsjö, 2004a, Tännsjö, 2004b ). The practice became the subject of debate for two reasons: first, because the methods in palliative care to control symptoms had improved substantially and thus it was no longer necessary to comatose patients with sedation in order to treat their refractory symptoms, and second, the system of ‘terminal sedation’ was being construed as ‘euthanasia in disguise’ or ‘slow euthanasia’, which many regarded as impermissible ( Tännsjö 2004b : xiii). Some still hold the view that PS is merely ‘slow euthanasia’ and ‘euthanasia in disguise’ owing in no small way to the use of double-effect reasoning to justify its moral permissibility (discussed above) ( Smith 2015 ).

The grounds on which palliative sedation is generally distinguished from euthanasia include:

(1) The intent of the intervention is to provide symptom relief; (2) the intervention is proportionate to the symptoms, its severity and the prevailing goals of care; (3) finally and most importantly, the death of the patient is not a criterion for the success of treatment. ( de Graeff & Dean 2007 : 77)

The nature of PS and the clinical as well as philosophical bases on which it can be distinguished from euthanasia have been more comprehensively clarified since the 1990s and made the subject of guidelines, frameworks and regulations developed by various medical and palliative care associations around the world (for a detailed analysis of the distinction between PS and euthanasia as held by the world’s various medical and palliative care associations, see Shariff & Gingerich (2018) and also: American Medical Association 2008 ; Australian and New Zealand Society of Palliative Medicine ( Australian and New Zealand Society of Palliative Medicine Inc (ANZSPM), 2017a, Australian and New Zealand Society of Palliative Medicine Inc (ANZSPM), 2017b ; Cherny et al 2009 ; Dean et al 2012 ; Royal Dutch Medical Association 2009 ).

Withholding or withdrawing clinically assisted nutrition and hydration

When seriously ill and / or nearing the end of their lives, many patients reach a point where they cannot take food and fluids ‘naturally’ – that is, voluntarily by mouth, with or without assistance, in order to satisfy their hunger and thirst. Because of this, their intake of food and fluids reduces. Reasons for this situation are varied but may include one or more of the following:

physical obstruction, anorexia / cachexia syndrome, generalised weakness, bowel obstruction, nausea, decreased levels of consciousness, loss of desire to drink or no specific cause may be identified. ( Good et al 2014 : 2)

When patients are unable or unwilling to take food and fluids, clinicians and proxies may be faced with the difficult decision of whether to withhold or provide the patient with clinically assisted nutrition and hydration (referred to by the acronym CANH). In the case of patients who voluntarily stop eating and drinking (referred to by the acronym VSED), decision-making in clinical contexts may be particularly fraught clinically, ethically and legally. This is because, theoretically, VSED (regarded as distinct from illness-associated anorexia–cachexia) does not require the involvement of a medical practitioner ( Quill, Ganzini, Truog, Pope, 2018a, Quill, Ganzini, Truog, Pope, 2018b ; Wax et al 2018 ). With VSED a patient voluntarily chooses not to eat or drink even though physically able to do so ( Mueller et al 2018 ; Rodriguez-Prat et al 2018 ; Wax et al 2018 ).

CANH may be delivered by several methods:

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  intravenous fluids (noting that, although sufficient to sustain hydration, this route cannot deliver substantial nutrition)

  
  
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  parenteral nutrition (the provision of a nutritional formula though a vein – e.g. central venous nutrition (CVN); types include total parenteral nutrition (TPN) and peripheral parenteral nutrition (PPN))

  
  
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  hypodermoclysis (the subcutaneous infusion of fluids for minimal hydration purposes only)

  
  
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  nasogastric tubes (for temporary feeding)

  
  
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  percutaneous endoscopic gastrostomy (PEG) tubes (for long-term feeding)

  
  
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  jejunostomy tubes (less often used for long-term feeding) ( Ganzini 2006 ; Kozeniecki et al 2017 ).

CANH may be provided for two reasons: first, to prolong life (or at least to prevent the patient from experiencing a premature death) and, second, to improve quality of life – that is, alleviating the symptoms associated with the patient’s declining condition ( Caccialanza et al 2018 ; Ganzini 2006 ; Good et al 2014 ; Hui et al 2015 ; Malia & Bennett 2011 ). There invariably comes a point, however, where the burdens of CANH outweigh the benefits, making it necessary for a decision to be made to either withdraw or withhold CANH as a treatment option. Even so, because of the strong emotional and cultural meanings attached to the intake of food and fluid as a ‘basic’ element of human comfort and survival, such decisions can be a source of emotional distress for families and care providers ( Baillie et al 2018 ; del Río et al 2012 ). They can also invite moral controversy and intervention by the courts ( English & Sheather 2017 ; Geppert et al 2010 ; Rady & Verheijde 2014 ; Richards & Coggon 2018 ; Willmott & White 2017 ). Right-to-life groups, for example, often equate the withdrawal of CANH with ‘slow euthanasia’ ( Heuberger 2010 ) and may sloganeer the removal of a PEG tube as being tantamount to ‘murder’ ( Ganzini 2006 : 137).

Despite over three decades of established agreement about the ‘appropriate use’ of CANH, the issue of withholding or withdrawing nutrition and hydration from patients at the end stage of life remains highly contentious. During the early years of debate, there were two key points of view at issue:

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  hydration and nutrition should be administered (‘artificially’ or with clinical assistance if necessary) to patients regardless of the terminal phase of their illness ( Craig, 1994 , Craig, 1996 )

  
  
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  there should be a gradual reduction and eventual cessation or non-initiation of treatment as the patient’s condition deteriorates ( Ashby, Stoffell, 1991 , Ashby, Stoffell, 1995 ).

Those who argued that hydration and nutrition should continue to be provided – even at the end stage of life – contended that if fluids were to be withheld or withdrawn from patients then the patients would inevitably enter into a state of dehydration, which, in turn, would result in ‘circulatory collapse, renal failure, anuria and death’ ( Craig 1994 : 140). In short, without hydration and nutrition, patients who are heavily sedated would die – whatever the underlying pathology ( Craig 1994 : 140). Furthermore, dehydration could lead to severe complications that may unacceptably alter the patient’s quality of life while they are dying; such complications were identified to include: ‘increased asthenia, nausea, postural hypotension, fever with no underlying infectious process, increased risk of bed sores, and constipation’ as well as the ‘accumulation of opioid metabolites, grand-mal seizures, and hyperalgesia’ ( Steiner 1998 : 8, 12).

Another complication believed to be associated with dehydration was that of patients suffering from thirst and hunger during the terminal phase of their illness. On this, Craig argued ( 1994 : 142):

It is widely assumed that a terminally ill patient is not troubled by hunger or thirst but this is difficult to substantiate as few people return from the grave to complain.

Finally, some worried that doctors might ‘get it wrong’ (i.e. make diagnostic errors) and accordingly patients might not only die ‘poorly’, but needlessly. On this point Craig argued ( 1994 : 140):

Diagnostic errors can also occur. A reversible psychosis or confusional state can be mistaken for terminal delirium, aspiration pneumonia for tracheal obstruction, obstruction [of the bowel] due to faecal impaction for something more sinister, and so on. The only way to ensure that life will not be shortened is to maintain hydration during sedation in all cases whereby inability to eat and drink is a direct consequence of sedation, unless the relatives request no further intervention, or the patient has made his / her wishes known to this effect.

Despite – or perhaps because of – the growing body of research in recent years, these issues remain unresolved. For example, some continue to argue that failure to provide assisted hydration during the last days of life will give rise to a range of common complications such as: thirst, hunger, discomfort, agitation, delirium, urinary tract infections, kidney failure, cardiovascular collapse, and the diminished efficacy of drugs such as analgesics and sedatives otherwise administered to treat symptoms of distress ( Rady & Verheijde 2014 ). In the case of the latter, distress can manifest as various spontaneous and reflex movements such as roving eye movements, chewing, teeth-grinding, tongue-pumping, groaning, facial grimaces, and crying, which maybe become more pronounced as the patient’s condition deteriorates ( Royal College of Physicians 2013 : 5).

Others, however, argue to the contrary, reminding clinicians of the risk associated with certain methods of CANH – for example, in the case of enteral nutrition, this can include ‘gastrointestinal issues (e.g. constipation, diarrhea, bloating, nausea, vomiting), pulmonary aspiration with or without pneumonia, [negative] drug–nutrient interactions, and clogged or dislodged tubes’ ( Kozeniecki et al 2017 ). One study has suggested that the use of PEG tubes in older populations can also lead to higher mortality rates, particularly in those with co-morbidities ( Tabuenca et al 2018 ).

These views concur with earlier research which has shown that clinically assisted hydration (particularly intravenous infusions) can lead to a range of associated medical conditions and complications including: vital organ failure from fluid overload (this can lead to such conditions as pulmonary and cerebral oedema and their associated complications); infection and bacteraemia from catheter and cannulation sites; arterial perforation, thrombosis, cardiac arrhythmias, cardiopulmonary arrest and pneumothorax during / following insertion of central venous lines; and pulmonary emboli ( Steiner 1998 ). Intriguingly, there is some suggestion that the ‘risks’ of dehydration during the actual death process may in fact be beneficial, with research suggesting that, due to their respective ‘sedative properties’, dehydration and ketosis are in effect mechanisms that help protect people against the ‘potentially painful symptoms of dying’ ( Kozeniecki et al 2017 : 263).

Although tools are being developed enabling the conduct of randomised feasibility trials of CAHN during the last days of life ( Davies et al 2018 ), there remains a lack of high-quality studies examining the symptom benefits and / or adverse effects of CANH – including its impact on improving either the length or quality of life of those who are in the end stages of their lives ( Good et al 2014 ; Hui et al 2015 ; Royal College of Physicians 2013 ). What evidence is available is regarded as being at best ‘inconclusive’ ( Forbat et al 2017 ; Good et al 2014 ; Raijmakers, Fradsham, van Zuylen, Mayland, Ellershaw, van der Heide, 2011a, Raijmakers et al, 2011b ). Because of the lack of high-quality studies there is a related paucity of evidence-based guidelines to inform and guide CANH practices, particularly regarding the mode and quantity of hydration that should be administered during the last days of life ( Forbat et al 2017 ). Even so, some still assert that the advantages of clinically assisted hydration, at least, outweigh the disadvantages in terms of its ease of application, low economic costs and fewer complications (e.g. infection) ( Caccialanza et al 2018 ).

Disputes aside, CANH remains a substantial part of medical and nursing care. There is also some suggestion that the controversies over decisions about CANH may ‘have less to do with ambiguous data, and more to do with differing judgments about the ethics of providing or withholding nutrition [and hydration] from patients with advanced illness or severe cognitive deficits’ ( Wolenberg et al 2013 : 1052) and the point at which a decision ought to be made (i.e. when death is imminent). Whether this is so, only time will tell.