Earlier in Japan, as in many industrialized countries, the only ethical position in this situation was the sanctity of life and therefore the clinically right action was always to give treatment. Now, with more advanced medical technology and national decade on these issues, a more recent concept quality of life, especially for dying patients, has gained influence. The lack of knowledge that scientifically justifies giving or not giving AFF to terminally ill patients also prevails internationally (Konishi, Davis & Aiba, 2002). As controversial and sensitive ethical issues continue to challenge nurses and other health care professionals, many of them have begun to develop a unique appreciation for the diverse ethical viewpoints of others.
ANH is not categorized as a treatment that must always be provided, and in coming to a decision about forgoing or continuing ANH, the patient's surrogates are allowed to either use their knowledge about the patient's desires and values or weigh the costs and benefits of tube feeding against the costs and benefits of waiving this treatment.
At the same time, Americans still have a good deal of anxiety about the prospect of discontinuing food and fluids, both for themselves and for their loved ones. This is one reason why there are approximately 1.5 million patients being tube fed in the United States today. Half of this group is over the age of sixty-five, and many if not most of these patients are severely and irreversibly demented (OTA 1987). The clinical reality is that tube feeding is often provided as a matter of course and that the choice of whether to tube feed or not is never fully explored. This situation contrasts markedly with the situation just a few decades ago.
Today, the modus operandi of physicians and families is turned on its head. In past decades and centuries, family members provided around-the clock palliative care in the home, and physicians occasionally stopped by to do what they could. Today, by contrast, caregivers provide various levels of technologically sophisticated care twenty-four hours a day, and family members drop by on occasion to do what they can. In the past, diseases were allowed to run their natural courses, largely because the technology had not been developed to accurately diagnose and treat mortal pathologies. Death was simply accepted as a natural and ultimate phase of living, an essential element of our humanity. Today, death tends to be regarded by many as a conquerable evil that must be resisted at all costs. With the widespread use of ANH and antibiotics, each of which can help to sustain the body in a vegetative or near-vegetative state for months and perhaps even years, dementia no longer has a terminal phase per se (Peck, Cohen, and Mulvihill 1990: 1195).
A number of researchers have suggested that we return to the mind-set of the 1950s, when aggressive medical procedures were not blindly applied in the absence of thought about the ultimate goal of the intervention. Walshe and Leonard (1985: 1047) locate themselves squarely in this camp, arguing that "as in patients who develop the [vegetative] syndrome after acute injury, patients with progressive neurological disease should be treated without undue intervention to preserve a mindless life." Mark Wicclair ( 1993: 60) advances the same position: "The severely demented elderly constitute another category of patients about whom it might be