December 1, 2022

VSED has been normalised. But is it ethical?

Ethicists are taking an interest in Voluntarily Stopping Eating and Drinking.

Euthanasia and physician assisted suicide are now legal in dozens of jurisdictions around the world. Yet many people who want to end their lives do not meet the strict eligibility criteria outlined in euthanasia and assisted suicide legislation. 

In light of this, medical ethicists have become increasingly interested in what is known as  Voluntarily Stopping Eating and Drinking (VSED). VSED refers to “an action of a competent, capacitated person, who voluntarily and deliberately chooses to stop eating and drinking with the primary intention to hasten death because unacceptable suffering persists”. Patients who opt for VSED often receive palliative care from a medical professional as they die. Some commentators have describe VSED as a legal alternative to euthanasia for patients who are suffering unbearably but who are not terminally ill or who for some other reason do not meet relevant eligibility criteria for assistance in dying.  

VSED is becoming increasingly common and accepted in some jurisdictions. Indeed, two articles have recently been published in medical journals offering clinical and ethical guidance to clinicians who have a patient seeking VSED. 

In an review article in the Annals of Palliative Medicine, three researchers from Lancaster University claim that VSED may in fact “be more common than physician-assisted forms of dying simply because it falls beneath the level of legal scrutiny”. The authors suggest that VSED is legally permissible in countries such as the United States, the UK and Australia. In the United States, they note that “little relevant legal precedent has been set, either related to patients undertaking it or clinicians aiding patients in their VSED effort”. Some states explicitly permit VSED in at least some circumstances. A law passed in Nevada in May 2019, for example, allows individuals to create an advance directive for dementia, including the ability to specify that care providers should stop administering food and fluid by mouth. 

Handling requests for VSED, however, can be complicated. In a recent article in the Medical Journal of Australia, three Victorian palliative care doctors discuss a case of a 71-year-old man who suffered a massive stroke that resulted in paralysis and severe cognitive impairment. The man required feeding and hydration by medical staff, though there was hope that he could recover his mobility. The man had an Advance Care Directive, however, stating that all care to be discontinued if he found himself in a dependent state. In light of this, his medical team ceased medications and no longer provided food and hydration, despite the fact that the man appeared to accept food and fluids and was capable of making a partial recovery. He died four days after medical care was withdrawn. 

Some authors have attempted to distinguish VSED from physician assisted suicide. Legal scholars Thaddeus Pope and Lindsey Anderson, for example, argued that VSED is not a form of assisted suicide as it does not involve the administration or dispensation of a lethal medication by a healthcare professional. Rather, “the patient’s own biology…causes the death”. Lynn Jansen and Daniel Sulmasy, however, take a more cautious approach. They state that it is permissible for a physician to support a patient’s choice to refuse treatment, including nutrition and hydration, where such care is futile. But they believe that many cases of VSED amount to suicide, particularly where a patient is not terminally ill. Physicians, therefore, should not recommend VSED as an option to patients. 

Xavier Symons is deputy editor of BioEdge

VSED has been normalised. But is it ethical?
Xavier Symons
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