This paper explores ethical issues relating to the management of patients who are terminally ill and unable to maintain their own nutrition and hydration. A policy of sedation without hydration or nutrition is used in palliative medicine under certain circumstances. The author argues that this policy is dangerous, medically, ethically and legally, and can be disturbing for relatives. The role of the family in management is discussed. This issue requires wide debate by the public and the profession.

The author reviews and continues the debate initiated by her recent paper in this journal. The paper was critical of certain aspects of palliative medicine, and caused Ashby and Stoffell to modify the framework they proposed in 1991. It now takes account of the need for artificial hydration to satisfy thirst, or other symptoms due to lack of fluid intake in the terminally ill. There is also a more positive attitude to the emotional needs and ethical views of the patient's (...) family and care-givers. However, clinical concerns about the general reluctance to use artificial hydration in terminal care remain, and doubts persist about the ethical and legal arguments used by some palliative medicine specialists and others, to justify their approach. Published contributions to the debate to date, in professional journals, are reviewed. Key statements relating to the care of sedated terminally ill patients are discussed, and where necessary criticised. (shrink)

Social justice is a contested concept. For example, some on the left argue for equality of outcomes, those on the right for equality of opportunities, and there are differing emphases on the roles of state, market and individual in achieving a socially just society. These differences in emphasis are critical when it comes to examining the impact that public policy has on minority ethnic groups. Social justice should not be culture-blind any more than it can be gender-blind yet the overwhelming (...) burden of evidence from the UK shows that public policy, despite the political rhetoric of fifty years of governments since large-scale immigration started, has failed to deliver social justice to Britain’s minorities. In terms of outcomes, in respect for and recognition of diversity and difference, in their treatment, and in the failure of governments to offer an effective voice to minorities, the latter continue to be marginalised in British social, economic and political life. This is not an argument for abandoning the project of multiculturalism, however, but for ensuring that it is framed within the values of social justice. (shrink)