sir

The finding that Japanese physicians are reluctant to withdraw artificial nutrition from patients in persistent vegetative state (PVS) is of note because, as the authors of a recent paper in the journal point out, Japanese physicians cannot be described as being strongly subject to the Judaeo-Christian influence.¹ Despite this, the Japanese physicians show the same reluctance as many Western doctors to withdraw nutrition and hydration from their patients.^{2, 3} However, the authors do not explore the reasons behind this unexpected finding as fully as they could. They do not question the view that artificial nutrition and hydration (ANH) is medical treatment. Although in the UK evidence presented to the House of Lords in the Bland case⁴ suggested that ANH is medical treatment, those who use gastrostomy tubes tell me that using a tube is easy and does not have the characteristics of medical treatment. Rather the insertion and removing of tubes are decisions and procedures that are subject to the rules of medical consent and benefit for the patient.

All doctors know that removing nutrition and hydration from a patient in PVS will cause death. The authors' ethical analysis that maintaining ANH is an act of life prolongation is, therefore incorrect. Rather continuing to feed a patient with a tube in situ is a continuation of care. Removing the tube, or preventing its use, is an act of intentional killing.⁵ What Japanese physicians appear to be reluctant to do is deliberately to end life. The blurring of the distinction between inserting a gastrostomy tube and feeding via a tube does not seem to be helpful either in understanding the attitudes of doctors or in helping them to reach an ethical concluson with with they appear comfortable.