Whilst much has been written on the implications of withholding or withdrawing nutritional support therapy from the terminally ill, the comatose or vegetative patients, relatively little has been published on the ethical implications of nutritional therapy in other groups. This article brief ly describes the history of ethics and the evolution of contemporary bio-ethics. The latter has been stimulated by rapid technological advances that now allow severely ill or injured patients to be kept alive for considerable periods of time. Central to recent changes in attitude is the shift away from 'paternalism' in medical care towards increasing patient autonomy in decision-making. Self-determination, together with the principles of non-maleficence, beneficence and justice represent the four principles that underpin present approaches to medical ethics. Clinical guidelines for provision or withdrawal of artificial nutrition are described. Application of these principles to a number of clinical scenarios, including the unconscious patient, the intensive care patient, the malnourished patient and the terminally ill patient are explored. This surgeon's view of ethical issues as they apply to nutritional support concludes that failure to provide nutritional support in one form or another for patients who have, or who are expected to have, seven days or more of inadequate oral intake should now be considered unethical. (C) 2001 Harcourt Publishers Ltd.
