Imposed Death - Definitions / Euthanasia / Assisted Suicide / VSED

The Ethics of Food and Drink (2014)

Starvation is not mercy.

Should the law compel nursing homes to starve certain Alzheimer’s patients to death?

This is not an alarmist fantasy, but a real question, soon to be forced by advocates of ever-wider application of assisted euthanasia. The intellectual groundwork is already being laid for legislation or court orders requiring nursing homes, hospitals, and other facilities to withhold spoon feeding from dementia patients who, though they take food and drink willingly, once requested the withholding of life-prolonging measures in an advance medical directive.

Consider the Bentley case in Canada. A lawsuit was filed in 2013 in British Columbia by the family of an Alzheimer’s patient named Margot Bentley. Bentley had signed an advance directive instructing that she be refused life-sustaining treatment—or be euthanized—if she became unable to recognize her children.

Bentley is now in that lamentable condition. But she doesn’t need life-sustaining treatment like a respirator or feeding tube, and she willingly takes food and water by mouth. Moreover, euthanasia is illegal in Canada. Thus, there is no legal way of making sure she dies immediately.

Bentley’s family thinks this is unjust and asked a court to order her nursing home

to starve her to death. The trial court refused, in part because Bentley’s advance directive did not specifically reject spoon-feeding. The case is now on appeal. Of all the current litigation aimed at undermining the sanctity of human life, this may be the most dangerous.

If successful, it would open the door to what I call VSED-by-proxy. Let me explain.

Suicide itself is not illegal, and patients have long enjoyed the right to refuse medical treatment, even if their refusal hastens death. For decades, moreover, courts have deemed artificial nutrition and hydration to be medical treatment. Removing or withholding unwanted feeding tubes and respirators is a routine part of contemporary medical practice. But euthanasia advocates want more. They argue that people who don’t require medical treatment to remain alive also have a “right to die.”

Already, Oregon, Washington, and Vermont allow assisted suicide: Doctors may prescribe lethal drugs for patients expected to die within six months. Some activists urge that elderly people who are “tired of life,” those with disabilities, and the chronically ill should also have a legal means of obtaining help to end their lives. Here’s how the assisted-suicide advocacy organization Compassion & Choices makes the case in one of its booklets:

Some call us because they feel overwhelmed by the symptoms of chronic and progressive illnesses that fill their days with misery and suffering. There are also those who may not be seriously ill but are simply “done.” After eight or nine decades of life, they want information about ways to gently slip away in a peaceful and dignified manner.

Regardless of their clinical circumstances, these individuals share a common desire to maintain autonomy over their own end-of-life decisions. They want to die as they have lived, making the important decisions that affect their lives with collaboration and support from trusted healthcare providers, family members and other caregivers.

People like these are prime candidates for suicide by voluntary starvation, known in euthanasia parlance as “voluntarily stopping eating and drinking” (VSED). A person commits VSED by refusing all sustenance. To ensure that death is not impeded, the suicidal person leaves instructions explicitly refusing any medical intervention to nourish them. Because VSED can cause agonizing symptoms, advocates suggest that the suicidal person find a sympathetic doctor or hospice to provide pain relief.

(It is important to distinguish here between VSED and the point in the process of dying when a patient naturally stops taking food and drink. This is not suicide, and starvation is not the cause of death. Indeed, in such cases it is medically inappropriate to force food upon the patient.)

But what about a Margot Bentley —someone suffering from dementia, who eats and drinks willingly, but who once signed an advance directive calling for the withholding of treatment? Some bioethicists—reflecting the mix of utilitarianism and autonomy-worship that predominates in the field—have leapt to support VSED-by-proxy.

Writing in the May-June 2014 Hastings Center Report, Paul T. Menzel and M. Colette Chandler-Cramer argue for allowing people to use an advance directive to order themselves starved if they become incompetent:

Such directives are arguably already legal. They follow logically from the intersection of two existing legal rights: directives for refusing life support and VSED. The principle behind [advance medical directives] is that people do not lose their rights when they become incompetent; someone else just has to exercise those rights for them.

The driving element behind VSED is that forcing people to ingest food is as objectionable an intrusion on bodily integrity, privacy, and liberty as imposing unwanted medical treatment. Thus, if incompetent people do not lose their rights to refuse life-saving treatment, then people do not lose their right to VSED when incompetent either.

This is rank sophistry. Even today, the courts do not deem spoon-feeding to be medical treatment. It is basic, humane care—no different ethically from turning a patient to prevent bed sores or providing hygiene. Just as an advance directive instructing that a patient not be kept clean should be disregarded, so should an order to starve a patient.

Second, VSED is suicide. Legally requiring nursing homes to commit VSED-by-proxy would be forcing them to kill—and to kill cruelly. A legal regimen that did this would drive many doctors and nurses out of medicine.

Third, even in the states where assisted suicide is legal, the person being helped by a doctor to die has to be capable of making decisions. Demented patients are incompetent.

Finally, in cases such as Bentley’s, the patient is not being force-fed. She is taking nourishment willingly.
[Jul 28, 2014, Vol. 19, No. 43 • By WESLEY J. SMITH, ]