Starvation as the New “Death with Dignity”

Self-starvation has become the latest craze among the “death with dignity” crowd. This has been coming on for some time. Removing feeding tubes from cognitively disabled people who can’t swallow has been allowed for decades, under the right to refuse unwanted “medical treatment.” But what about people who can eat and drink by mouth? Assisted suicide advocates argue that it isn’t fair that they can’t die too.

So, activists promote a form of “self-deliverance” that they call “voluntary stopping eating and drinking,” (VSED), by which suicidal people declare their wish to starve to death. As a matter of respecting autonomy, doctors won’t force feed these suicidal people. Some even agree to facilitate the death by helping palliate the potential agony that can be associated with starving and dehydrating.

Some bioethicists even argue that nursing homes and hospitals should be legally required to starve patients who can eat and drink, if they have serious dementia and have ordered their starvation deaths in an advance medical directive. In Canada, a lawsuit has already been filed, and I consider it the most important—and dangerous—litigation in bioethics today.

The case involves Margo Bentley, a woman from British Columbia. A believer in assisted suicide, Bentley signed an advance directive instructing that she be refused life-sustaining medical treatment and even be euthanized if she had Alzheimer’s and could no longer recognize her children. Bentley is now in that condition, but she doesn’t require life support—so there is no treatment to withdraw—and willingly accepts food and water by mouth, meaning that the conditions of her directive aren’t met. And as for euthanasia, it’s illegal in Canada. Thus, there is no immediately available legal way to make her dead even though that is what she clearly wanted.

Her family sees this as a profound injustice. They sued the nursing home seeking a court order requiring the facility to intentionally starve Bentley. The trial judge refused, but the case is currently on appeal.

Adding to the momentum for self-ordered starvation, the Hastings Center Report—perhaps the world’s most prestigious bioethics journal—just published a major article arguing that people with advanced dementia who can still eat normally be starved to death, if they signed an advance medical directive expressing that desire.

Bioethicist Paul T. Menzel and physician M. Colette Chandler-Cramer create a sophistic argument to justify their conclusion: People have the right to commit VSED; people also have the right to refuse life-sustaining treatment in an advance medical directive; hence, people have the right to order themselves starved to death (commit VSED via advance medical directive).

The authors justify their proposal with a utilitarian rationalization:

Our argument for withholding food and water by mouth focuses not on food assistance per se, but on discerning two key points: when the dementia meets the triggering conditions described in the person’s directive and when the person’s continued stake in survival is sufficiently low that her current interests align with her earlier directive.

Think carefully about this: Advanced directives control decisions about medical treatments. But spoon-feeding is considered “humane care”—not the same thing at all. Thus, under Menzel and Chandler-Cramer’s theory, a patient should also be empowered to order the non-medical withholding of other forms of humane care to hasten their deaths. For example, why not permit a directive to order that blankets be removed during a cold snap to increase the chances of contracting pneumonia? Less certain, to be sure: But basically the same idea.

Demonstrating how far this agenda may have already penetrated the medical system, California’s Physician’s Order for Life-Sustaining Treatment (POLST) form contains some worrying language that could potentially be construed as authorizing the removal of food and water from patients capable of eating. Once signed by patient/surrogate and doctor, it becomes a permanent part of a patient’s medical chart.

Section C of the form, “ARTIFICIALLY ADMINISTERED NUTRITION,” instructs whether, and for how long, to use a feeding tube. But it also states (my emphasis): “Offer food [to the patient] by mouth if feasible and desired.”

Feasible, I get: When a person is dying they may naturally stop eating as the body shuts down. In such cases, eating can cause harm. But if desired? Is this terminology setting the stage for advance medical directives to order the withholding of spoon-feeding even though that isn’t “life-sustaining treatment”?  I’m not sure. But, at the very least, further clarity is required.

If the law ever allows people to pre-order their own starvation, we will have crossed a deadly Rubicon: The supposed bright line dividing the right to refuse medical treatment from a purported right to euthanasia will be obliterated. Doctors and nurses may be legally required to become killers in a way that in other contexts would be considered torture and an egregious abuse of human rights. Finally, once we can starve patients, even though they willingly eat, the obvious question arises: “Why not just give them lethal injections?”

Actually, I believe that has been the goal all along. The starvation agenda is merely the horrid means intended to lead us to that horrible end.

Wesley J. Smith is a senior fellow at the Discovery Institute’s Center on Human Exceptionalism. He also consults for the Patients Rights Council and the Center for Bioethics and Culture. 

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