Making sense out of bioethics
More than 20 years ago, Dr. David Eddy, writing in the Journal of the American Medical Association, described how his mother, though not suffering from a terminal illness, chose to end her life through VSED (voluntarily stopping eating and drinking). She had been “very independent, very self-sufficient and very content.” When she began to be afflicted by various ailments, including rectal prolapse, she talked with her physician-son about “how she could end her life gracefully.”
When she asked him, “Can I stop eating?” he told her that if it was really her intention to end her life, she could also stop drinking, since “without water, no one, not even the healthiest, can live more than a few days.” After a family bash celebrating her 85th birthday, she “relished her last piece of chocolate, and then stopped eating and drinking.” She died of dehydration six days later, with her son arranging for pain medications to be administered during her final days and hours.
Choosing not to eat or drink can be packaged as a noble and well-intentioned way to avoid intense pain and suffering, but VSED ultimately represents a flawed choice. It subtly draws us into the mistake of treating the objective good of our life as if it were an evil to be quelled or extinguished. We have a moral duty to preserve and protect our life, and to use ordinary means of doing so. Suicide, even by starvation and dehydration, is still suicide and is never morally acceptable.
For some critically ill patients, continued attempts to ingest food and liquids may cause significant complications, including severe nausea, vomiting or complex problems with elimination. Such patients may find themselves effectively incapable of eating or drinking. This is not VSED, but a direct manifestation of their advanced disease state, and does not raise any of the ethical concerns associated with VSED.
As disease or severe illness advances, and a patient draws near to death, various bodily systems may begin to fail, and a natural decrease in appetite can occur. This is also different from a voluntary decision to stop eating and drinking. VSED refers specifically to a conscious, elective decision on the part of a patient not to eat or drink when eating and drinking would be anticipated to provide benefit to them without undue burdens.
As people are dying, the real evil that often needs to be quelled or extinguished is pain, and severe pain is properly addressed by non-suicidal means, that is to say, through effective pain management and palliative care strategies.
Dr. M. Scott Peck, in his book Denial of the Soul, argues that the “failure to treat pain is medical malpractice.... [and] one of the worst crimes in medicine today.” We live in an age that possesses a remarkable arsenal of methods and pharmaceuticals to address physical pain, depression and death-related anxiety, leaving little excuse for individuals to fear undergoing agonizing and pain-racked deaths.
Some have sought to suggest that patients who choose VSED may feel less pain because the nervous system becomes dulled and the body may end up releasing chemicals which provide natural analgesia or pain relief: “What my patients have told me over the last 25 years is that when they stop eating and drinking, there’s nothing unpleasant about it – in fact, it can be quite blissful and euphoric,” said Dr. Perry G. Fine, vice president of medical affairs at the National Hospice and Palliative Care Organization in Arlington, Va. “It’s a very smooth, graceful and elegant way to go.”
Such claims, however, remain highly controversial and strain credulity.
Dehydration and starvation constitute a form of assault against the integrity of the body and the whole organism, and if the body reacts by releasing chemicals, this is a form of “shock” response to an escalating traumatic situation. As noted for Dr. Eddy’s mother, pain medications were required to control the significant suffering and discomfort that would otherwise have ensued from her dehydration/starvation. Even those who promote VSED advocate uniformly for concurrent pain control. In fact, Helga Kuhse, a well-known advocate of assisted suicide, once argued that when people see how painful a death by starvation and dehydration really is, then, “in the patient’s best interest,” they will soon come to accept active euthanasia through, for example, a lethal injection. Indeed, VSED is frequently promoted by right- to-die advocates as one method among others to carry out suicide or euthanasia.
By its nature, VSED appears to be defined by the intent to cause death by the patient’s forgoing the most basic requirements to conserve human life. Intentionally engaging in such damaging and self-destructive behaviors, by foisting dehydration and starvation onto our mortal frames so as to shutter our earthly existence, can never represent an ordered kind of human choice.
Rev. Tadeusz Pacholczyk, Ph.D., earned his doctorate in neuroscience from Yale and did post-doctoral work at Harvard. He is a priest of the diocese of Fall River, Mass., and serves as the director of education at The National Catholic Bioethics Center in Philadelphia. See www.ncbcenter.org.