While euthanasia and assisted suicide are currently illegal in most countries, the practice of voluntarily stopping eating and drinking (VSED) is seen by some as an ethically and legally permissible alternative. VSED refers to seriously ill patients refusing to eat and drink for a sustained period of time in order to bring about their own death. 

Last year the International Association for Hospice and Palliative Care (IAHPC) issued a position statement on end-of-life alternatives which rejected both assisted suicide and euthanasia. However, it left a loophole open for VSED. For patients who insist on dying according to their own timetable, the IAHPC said, “Voluntary cessation of fluid or nutrition intake may offer an alternative for these patients, using appropriate and adequate symptom control measures.” 

End-of-life lobby groups are also promoting VSED as an alternative to assisted suicide in jurisdictions where it is not legal. Compassion and Choices, the leading American assisted suicide lobby group, explains that “A person may choose to control their own dying by making a conscious decision to refuse foods and fluids of any kind, including artificial nutrition and/or hydration.” Dying With Dignity, another American group, claims that “One of the advantages of this decision is that you may change your mind at any time and resume eating and drinking”.

However, there are far too many problems with VSED to approach it casually.

On the ethical front, a new paper published in the journal BMC Medicine argues that VSED is indistinguishable from assisted suicide and should be subject to the same legal regulations.

The paper, whose lead author is Ralf J. Jox of the Institute for Ethics, History and Theory of Medicine at the University of Munich, argues that “supporting patients who embark on VSED amounts to assistance in suicide, at least in some instances, depending on the kind of support and its relation to the patient’s intention”.

While VSED does not involve an invasive or aggressive act like many other means of suicide, the authors write that “VSED should [nevertheless] be considered as a form of suicide, as there is both an intention to bring about death and an omission that directly causes this effect”. Doctors who assist patients in VSED — by encouraging them, or promising pain-relief if VSED is undertaken — are potentially instrumental in the deaths of the patients, as the suicide would not occur without them, and they share the patient’s intention of inducing death.

The authors conclude that the same legal prescriptions or regulations that apply to physician assisted suicide should also apply to VSED.

“[We] maintain… that future ethical discussions on assisted suicide require consideration of medically supported VSED, and vice versa…Thus, the widely held position by palliative care societies, professional bodies of physicians, legal scholars, and ethicists to disapprove of assisted suicide but approve of and even promote medically supported VSED appears inconsistent”.

On the medical front, there is a big difference of opinion about VSED. Death with Dignity maintains that “Dying from dehydration is generally not uncomfortable once the initial feelings of thirst subside.”

However, there is scant data to support this assertion. A Canadian doctor from Edmonton, in Canada, penned an indignant response to the IAHPC’s position paper. Dr Vickie E. Baracos wrote:

Dehydration and especially starvation are not benign—they are agonizing and extended pathways to death, associated with great physical suffering. Agitation and distress may last from several days to weeks because of the slow dying process from dehydration and especially starvation that can endure for months. Lapse into cognitive impairment is strongly associated with the terminal stages of both dehydration and starvation.

The extended and agonizing process experienced by the patient enduring self-starvation will be in plain view of family members and caregivers. Witnessing this horrible prolonged scene will create an indelible perception of neglect by the healthcare providers and by institutions, in the eyes of the family members and community. A sense of guilt may reasonably be expected to burden staff and family who witness the slow emaciation, their loved one rendered skeletal …

Placing another person in a position to have no alternative but to die of thirst and/or starvation against their will is a criminal offence everywhere in the world. Placing an ill and vulnerable person who is dying in a situation in which he or she has no other recourse but to starve to death is ethically questionable, and in my personal view morally repugnant.

Furthermore, VSED is not quick. Even Compassion and Choices admits that “For a terminally ill person the process may take several days to several weeks after intake of food and water stops.” The psychological toll on children watching as their father or mother fades away with ulcers in the mouth, a blotchy face, rattling breathing and delirium must be immense.

Taking advantage of the confusion over the legal and ethical status of VSED, a government agency in the US state of Washington is encouraging people to write advance directives in which they specify that they want VSED if they succumb to dementia. Its guidelines are not ethically or legally binding, but if compliant doctors can be found, some elderly people may soon be wasting away in Washington’s nursing homes.

Xavier Symons is deputy editor of BioEdge, where a shorter version of this article first appeared. Both BioEdge and MercatorNet are projects of New Media Foundation.  

Xavier Symons

Xavier Symons is a bioethicist at the University of Notre Dame and a 2020 Fulbright Future Postdoctoral Scholar.