In decisions about artificial nutrition and hydration for incompetent patients without an advance directive, which ethical principle is most central?

• A. Autonomy
• B. Beneficence
• C. Nonmaleficence
• D. Justice

Answer: (C)

When a patient cannot express preferences and there is no advance directive, the primary obligation is to avoid causing harm. Artificial nutrition and hydration can provide a benefit in some situations, but they can also introduce burdens—discomfort, infection, aspiration risk, and prolonging a dying process—without a meaningful chance of improving outcome. In such cases, choosing to withhold or withdraw these measures aligns with nonmaleficence: we should not inflict harm or unnecessary burdens on a vulnerable patient when the benefits are unlikely. Autonomy isn’t directly applicable here because there’s no stated patient preference, and while beneficence and justice matter, the best-respected approach in this scenario is to prioritize minimizing harm for the patient.