Nutritional care ethics: A time for reflection

“Care: Any practice aimed at relieving a living being of its material needs or vital suffering, for the sake of the being itself.”Frederic Worms, Le moment du soin, à quoi tenons-nous ? 2010. When disease impacts nutritional status and the natural oral intake of food and liquids is disturbed, the role of health care professionals is to assist the person in order to cover the individual's need for nutrients and support the metabolic perturbations by nutritional care. This implies the administration of nutrition therapy (i.e., diets, oral nutrition supplements, enteral and parenteral nutrition), which is a medical intervention requiring an indication and a therapeutic goal that should be applied in accordance with principles and values in multicultural and pluralistic societies [1Cardenas D. Ethical issues and dilemmas in artificial nutrition and hydration.Clinical Nutrition ESPEN. 2021; 41: 23-29Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar, 2Schwartz D. Barrocas A. Annetta M. Stratton K. McGinnis C. Hardy G. Aspects of artificially-administered nutrition and hydration: an ASPEN position paper.Nutr Clin Pract. 2021 Apr; 36: 254-267https://doi.org/10.1002/ncp.10633Crossref PubMed Scopus (17) Google Scholar, 3Druml C. Ballmer P.E. Druml W. Oehmichen F. Shenkin A. Singer P. et al.ESPEN guideline on ethical aspects of artificial nutrition and hydration.Clin Nutr. 2016; 35: 545-556Abstract Full Text Full Text PDF PubMed Google Scholar]. Some challenging and extreme situations such as palliative care, dementia, persistent vegetative state, terminal illness, aged patients, and intensive care question the limits and the ethical values at stake. Consequently, this leads to a central question: nutritional care as an ethical subject is able to present itself as a legitimate form of care in medical practice? In order to answer this question, the Ethics of Care can help to understand and to analyze the ethical foundations of the practice of clinical nutrition. This means that through this moral theory it is possible to define a core set of principles and values that legitimize the practice of this discipline. Thus, I propose an analysis of the ethical principles that rationally justify the setting of and compliance with norms in the practice of nutritional care. The Ethics of Care is a normative theory that places the phenomenon of care at the center of ethical reflection. This moral theory is defined by Tronto as a “practice and a disposition”, and is an ongoing process consisting of five phases of caring and five ethical characteristics of care (i.e. specific attitudes and skills necessary for effective caring). It is based on the understanding of the human being as a vulnerable and interdependent relational being [[4]Tronto J. Un monde vulnérable, pour une politique du care. Editions La Découverte, Paris2009Google Scholar]. While traditional moral theories (i.e., utilitarianism, deontology, theory of justice, virtue ethics) are based on the primacy of autonomy, the ethics of care, which is more context-based and concrete, emphasizes the notion of vulnerability. In this context, it is necessary to identified a double vulnerability in malnourished patients: one characterized by the alterity of the malnourished body, physical impairment, loss of autonomy and the possibility of losing life; and another vulnerability caused by the lack of diagnosis and the indifference of health care professionals for disease related malnutrition. This is why nutrition is an ethical requirement for doctors and other health care professionals, who must respond to this double vulnerability [[5]Cardenas D. La Nutrition en Médecine: approche épistémologique, problèmes éthiques et cas cliniques. L´Harmattan, Paris2020Google Scholar]. Previously we made an analysis where we matched the phases of the Ethics of Care with the phases of nutritional care as a process [[5]Cardenas D. La Nutrition en Médecine: approche épistémologique, problèmes éthiques et cas cliniques. L´Harmattan, Paris2020Google Scholar,[6]Cárdenas D. Davisson Correia M.I.T. Hardy G. Ochoa J.B. Barrocas A. Hankard R. et al.Nutritional care is a human right: Translating principles to clinical practice.Nutr Clin Pract. 2022; 37: 743-751Crossref PubMed Scopus (7) Google Scholar]. Figure 1. This leads us to propose that nutritional care must be exercised by health care professionals with due respect for several fundamental ethical values: attentiveness, responsibility competence, responsiveness, and solidarity. In this context, the technical “competence” is considered an ethical value. This means that one cannot simply acknowledge the need to care and accept the responsibility, but we need to follow through with enough competence and adequate skill. In fact, “prescribing nutrition interventions in patients requires far more than providing for the food that the patient cannot or will not eat” (6), it requires training and understanding of the personalized nutritional requirements, metabolic perturbations and the underlying disease in a given patient in order to determine the medical indication and the therapeutic goal of nutritional therapy. This is aligned with the need of improvement in clinical nutrition education expressed by Cuerda et al. in the NEMS project [[7]Cuerda C. Muscaritoli M. Donini L.M. Baqué P. Barazzoni R. Gaudio E. et al.Nutrition education in medical schools (NEMS). An ESPEN position paper.Clin Nutr. 2019; 38: 969-974Abstract Full Text Full Text PDF PubMed Google Scholar]. The Ethics of Care highlights two key considerations [[8]Worms F. Le moment du soin, à quoi tenons-nous ?. PUF, Paris2010: 21Google Scholar]. First, the care concerns a human being who is suffering from a pathological condition that we are able to treat or prevent. Second, when we take care of someone, this it means that we care about the emotional, social and psychological dimensions. Consequently, according to our previous publication, “care is not only a matter of supplying a treatment in order to alleviate or to cure but is also a matter of humanity. In that sense, nutritional therapy, as a medical therapy, is capable (most of the time) to cure or prevent malnutrition and help recover from disease but it is also supporting basic nutrient feeding which is essential to survival” (6). This approach also implies that ethically, the best decision for the patient must be taken and this may include, under certain circumstances (e.g., the end of life), the decision not to feed (i.e., in the case where nutrition is considered a futile therapy). In the latter context, “any technological or legal obstacles to the application of ethical decisions should be anticipated if possible and resolved” [[9]Barrocas A. Cárdenas D. La tricotomía preocupante en la nutrición clínica y su aplicación a los derechos humano.Rev Nutr Clin Metab. 2021; 4: 23-39Crossref Google Scholar]. The ethical approach in nutritional care is all the more necessary as to feed the ill patient must be practiced according to the respect of human dignity and human rights values. This has been expressed in the Latin American Declaration on the Right to Nutritional Care and the fight against Malnutrition, named the “Cartagena Declaration” [[10]Cárdenas D. Bermúdez C.E. Echeverri S. Pérez A. Puentes M. López L. et al.[Cartagena Declaration. The International Declaration on the Right to Nutritional Care and the Fight against Malnutrition].Nutr Hosp. 2019; 36: 974-980PubMed Google Scholar,[11]Cardenas D. Bermúdez C. Barazzoni R. The Cartagena Declaration: A call for global commitment to fight for the right to nutritional care.Clin Nutr. 2019; 38: 2458-2459Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar] and The International Declaration on the human right to nutritional care, named the “Vienna Declaration “(12). Recognizing the right to nutritional care [[13]Cardenas D. Correia M. Ochoa J.B. Hardy G. Rodriguez-Ventimilla D. Bermúdez C.E. et al.Clinical nutrition and human rights. An international position paper.Clin Nutr. 2021; 40: 4029-4036Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar] means that from a practical point of view, a set of core values, including fairness, respect, equality, dignity, and autonomy (FREDA) must be respect [[6]Cárdenas D. Davisson Correia M.I.T. Hardy G. Ochoa J.B. Barrocas A. Hankard R. et al.Nutritional care is a human right: Translating principles to clinical practice.Nutr Clin Pract. 2022; 37: 743-751Crossref PubMed Scopus (7) Google Scholar]. The Vienna and Cartagena Declarations have a fundamental structural ethical component which are based on the concepts of dignity and vulnerability, and respect for bioethical principles. The principles established by both Declarations recognize the importance of the principlism approach and thus promote the respect for autonomy, beneficence, nonmaleficence and justice and promotes the values of justice and equity in nutritional care as a condition for the practice of clinical nutrition [[14]Cardenas Braz D. Echeverri S. Aspectos éticos de la Declaración de Cartagena.Revista de Nutrición Clínica y Metabolismo. 2019; 2: 56-62Crossref Google Scholar]. Nutritional care as a human right can be considered as a strategy to give visibility and draw the attention of public policy makers on the need to promote access to nutritional therapy. The need to promote public policy addressing disease-related malnutrition at the country and global levels is a priority [[15]Gramlich L. Cardenas D. Correia M. Keller H. Basualdo-Hammond C. Bauer J. et al.Canadian Nutrition Society Dialogue on disease-related malnutrition: a commentary from the 2022 Food For Health Workshop.Appl Physiol Nutr Metab. 2023 Sep 1; 48: 710-717https://doi.org/10.1139/apnm-2022-0417Crossref PubMed Scopus (1) Google Scholar,[16]Hiesmayr M. Tarantino S. Moick S. Laviano A. Sulz I. Mouhieddine M. et al.Hospital Malnutrition, a Call for Political Action: A Public Health and NutritionDay Perspective.J Clin Med. 2019; 8Crossref PubMed Scopus (27) Google Scholar]. In fact, by including disease-related malnutrition within the global approach to the problem of population malnutrition, we would be contributing to achieving the Sustainable Development Goals (SDG) targets and, in particular, to the sustainable development of countries. In conclusion, nutritional care is an ethical subject able to present itself as a legitimate form of care in medical practice. It is also a treatment that needs a medical indication, a therapeutic goal and the consent of the patient. Thus, this approach leads us to question the principles and the foundations of the practice of clinical nutrition. This implies to questioning the values of care and the establishment of universalizable standards with true legitimacy in the medical field. We need to recognize that nutritional care implies to administer nutritional therapy to the sick person in conditions that respect their dignity, considering the vulnerability of the malnourished person or at risk of malnutrition and respecting the principles of bioethics. ‘ The physician should integrate nutritional care into the patient's global care, considering that nutrition is not only a means but an end in itself. In this special issue of Clinical Nutrition Open Science we analyze the ethical dimension of clinical nutrition in a view to promote the ethical reflection of the nutritional care practice. As a result, I propose that nutritional care ethics, a new field of applied ethics, consisting of interdisciplinary knowledge, could be differentiated from medical ethics as clinical nutrition is recognized as a discipline in its self [[17]Cardenas D. What is clinical nutrition? Understanding the epistemological foundations of a new discipline.Clin Nutr ESPEN. 2016; 11: e63-e66Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar], Accordingly this new field can be defined as: The ethical characteristics and values aspects that guides medical and health care professions in decision making, medical practice, medical education, research and policy development in clinical nutrition (i.e., to feed the ill person). The papers published in this special issue are the best evidence that nutrition care ethics can be considered as a new field of applied ethics. Indeed, the authors set out specific relevant ethical questions in the field of Clinical Nutrition. In a key paper by Monica Talavera, pertinent questions are asked: what does the nutritional care imply as an ethical duty? Why must justice and equity be considered in its exercise? What are the ethical implications of the lack of access to the nutritional care in the clinical setting? The answers to those question were well resumed as: Nutritional care as a human right implies the ethical duty to ensure it in an optimal and timely manner with the available resources by feeding the sick person in conditions of dignity, ensuring justice and equity [[18]Talavera M.L. Ethical duty, ethics and right to nutritional care.Clinical Nutrition Open Science. 2023; 48: 11-16Abstract Full Text Full Text PDF Scopus (1) Google Scholar]. Dobak S and Russell M in a commentary on the ASPEN position paper on ethics, summarizes the position paper as a “call to action” to medical professionals to engage in the ethical aspects of nutritional therapy [[19]Dobak S. Russell M. Commentary on the American Society for Parenteral and Enteral Nutrition (ASPEN) position paper: Ethical aspects of artificially administered nutrition and hydration.Clinical Nutrition Open Science. 2023; 47: 74-77Abstract Full Text Full Text PDF Scopus (1) Google Scholar]. They underlying that “roles may vary depending on professional discipline and setting, but each interdisciplinary team member provides critical value. In that regard, according to Barrocas et al. two current challenges facing nutrition support teams and clinical nutrition professionals are the recognition and management of disease-related malnutrition (DRM) and the need for world-wide access to nutrition care. The authors explored the ethical dimension to both previous challenges and propose that a required foundation can be provided by the “Troubling Trichotomy” [[20]Barrocas A. Schwartz D.B. Guinhut M. Oquendo G. Cárdenas D. The ethical dimension of nutrition support teams and clinical nutrition professionals in dealing with disease-related malnutrition and access to nutrition care with The Troubling Trichotomy as a foundation.Clinical Nutrition Open Science. 2023; 49: 1-16Abstract Full Text Full Text PDF Scopus (1) Google Scholar]. In the paper by Hellerman Itzhaki et al., the ethical issue regarding feeding a person at the end of their life is analyzed according to the Jewish law in Israel. In this context, the religious positions and a strong collective memory related to the Holocaust and post-Holocaust behavior are of the major importance in the discussion of this issue. The authors proposed, after an expert group of professionals meeting 5 key points to regularly faced with these dilemmas [[21]Hellerman Itzhaki M. Noy O.H. Kagan I. Papier I. Cherlow Y. Zaharoni H. et al.Ethical considerations of medical nutritional therapy at end of life: the Israel perspective.Clinical Nutrition Open Science. 2023; 50: 16-26Abstract Full Text Full Text PDF Scopus (1) Google Scholar]. This paper shows that the emotional aspects and the religious beliefs cannot be dissociated from the technical issues concerning nutritional therapy decision. Decisions about feeding at the end of life were analyzed thought a clinical case presented by the surgeon Humberto Arenas. The author underlines the need for good communications skills as a key component in the ethical decision-making process. In another paper where the ethical and anthropological approaches are delicately blended, the authors analyzed the link between nutrition, ethics and cancer. This paper is an invitation to name correctly nutritional therapy as a medical intervention because “To name things wrongly is to add to the misfortune of the world” [[22]Cardenas D. Raynard B. Blot F. Nutrition, Ethics and Cancer, “To name things wrongly is to add to the misfortune of the world”.Clinical Nutrition Open Science. 2023; 48: 17-26Abstract Full Text Full Text PDF Scopus (1) Google Scholar]. As mentioned above, nutrition care ethics goes beyond its application in the clinical practice as it also addresses ethical issues concerning clinical nutrition research. Current issues in research were analyzed by Isabel Correia [[12]Cardenas D. Correia M. Hardy G. Gramlich L. Cederholm T. Van Ginkel-Res A. et al.The international declaration on the human right to nutritional care: A global commitment to recognize nutritional care as a human right.Clin Nutr. 2023; 42: 909-918Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar]. The author shows how inappropriate methods are related to misleading results and interpretation of science. She also analyzes the “publish or perish” issue, the authorship abuses, the plagiarism and fake data issues from an ethical approach. What is at stake according to the author is the security and the life of patients. The ethical approach to clinical nutrition is presented as a necessary tool to protect them from harm. Ceriani et al. in a narrative review exposes current evidence regarding the most prevalent nutrigenomics and nutrigenetics ethical issues. They found that the ethical issues are expressed in three primary areas: professional training, consumers/recipients' dilemmas, and direct-to-consumer genetic testing positions [[23]Ceriani F. Montalvan M. Quintero B. Suárez R. Bautista-Valarezo E. Frias-Toral E. Ethics of the clinical practice of nutrigenetics and nutrigenomics.Clinical Nutrition Open Science. 2023; 49: 58-66Abstract Full Text Full Text PDF Scopus (1) Google Scholar]. The authors highlight that the optimistic future thriven by the idea that people can gain advantages by eating in harmony with their biology, is in contrast to the current problems to integrate precision nutrition based on genetic data with preferences, eating habits, lifestyle, and sociocultural aspects of people's. The ethical issues of artificial intelligence in nutrition is presented by Detopoulou et al. in a mini-review [[24]Detopoulou P. Voulgaridou G. Moschos P. Levidi D. Anastasiou T. Dedes V. et al.Artificial intelligence, nutrition, and ethical issues: A mini-review.Clinical Nutrition Open Science. 2023; 50: 46-56Abstract Full Text Full Text PDF Scopus (1) Google Scholar]. This review is motivated by the new applications of IA in nutrition that have been developed, such as microbiota/genes-diet interactions, investigation of diet-disease relationships, chatbots for lifestyle intervention, dietary assessment with food photographs, and food composition applications. The authors recall that AI-assisted interventions in clinical nutrition remain still at the research level and there is a strong need for their implementation in both individuals and populations. For the authors, AI-assisted personalized nutrition needs coordinated global focus, further justification, and a regulatory framework at constant update to keep up with scientific advancements and address ethical issues. We hope that this special issue of Clinical Nutrition Open Science will be a founding issue for the field of nutritional care ethics, and will show the horizon of a reflection that has just begun. Diana Cardenas carried out the whole writing of the manuscript. No funding sources.

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