[Ethical problems of artificial nutrition withdrawal: reflexions from the perspective of Mediterranean culture]

The withdrawal or withholding of life support measures in irreversible situations is an accepted practice among clinicians all over the world. Nonetheless, with respect to nutrition and tube feeding, notable differences can be found between the literature coming from the United States and the opinions of clinicians in Spain, probably due to the differing social and cultural traditions. Whereas the dominant criteria in the United States is to consider tube feeding and hydration as "extraordinary" or "disproportionate" measures, and thereby potentially omitted in such situations, the most widespread opinion in Spain is that they must be included as part of basic care, must be maintained at all times and that their suppression might represent severe discrimination in the case of weaker patients. As a result, a prudent strategy to cope with this problem might be first to consider the two indications of artificial nutrition and hydration: as a procedure to combat hypercatabolic problems and organ failures or as a maintenance measure in patients with normal needs where the oral route is not available. Although the first deserves to be considered as a life support measure and could be omitted in the same circumstances as mechanical ventilation or dialysis, the second case can be considered as part of personal care on a similar level as body hygiene, in which case omission could eventually breach the ethical principles of Justice and No Maleficence.