VSED: A Dignified Death?
A recent New York Times report documented a trend in end-of-life care that is commonly referred to as VSED (pronounced Vee-sed), which stands for voluntarily stopping eating and drinking.1 Formally, the literature has defined VSED as “an action by a competent, capacitated person, who voluntarily and deliberately chooses to stop eating and drinking with the primary intention of hastening death because of the persistence of unacceptable suffering.”2 I will simply argue that the current arguments in favor of VSED do not adequately differentiate it from other forms of hastening death, such as suicide and physician-assisted suicide (PAS), and should face the same opposition that commonly comes with those options. The goal is to illustrate both the complexities that arise with VSED, and the need for further debate before the action is readily accepted by state of federal legislatures.
VSED is conceptually simple to understand. A terminally ill patient who has decided that he/she wishes to die, but does not want to commit suicide and do not have access (either through moral opposition or geographic location) to PAS, may opt to voluntarily stop food and drink intake.3 This, along with cessation of all medication aside from minor analgesics for pain, brings about death in 7-14 days on average.3 There are a number of arguments in favor of VSED: it allows for significant expression of autonomy up until the moment of death, it does not require direct intervention from anyone aside from the individual, and it is generally favored by the patients and families who undergo the process.
One argument in favor of VSED is the fact that the voluntary nature of the option gives patients complete autonomy. This argument is two fold. Primarily, the entire process is an exercise of individual will. Unlike suicide in its traditional sense, which might result from a moment of irrationality, VSED is a strenuous process that requires a deep sense of purpose on the part of the individual. Additionally, because VSED takes an extended period of time, the individual has the option to change his/her mind at any point.1,2 If someone starts the process and then decides that it was not, in fact, his/her time to die, the process is easily reversible.
However, neither of these arguments firmly differentiates VSED from PAS. To counter the argument above, I will utilize an argument against PAS. The New York Times article presented VSED as an alternative to the lengthy regulatory processes involved in getting a physician-assisted suicide approved.1 Thus, in a way, from start to finish, VSED could actually take less time than PAS,. Acquiring approval for PAS requires a set of requests, a mental health screen, and physician approval among other things, all of which force the individual to directly confront the idea of their own death, much in the same way that the will power necessary for VSED forces an individual to confront his or her own death. Even though it is true that VSED offers the options of turning back, the regulatory steps along the way offer similar forks in the road for individuals who choose to take the PAS route. Thus, this argument alone does not hold up.
A second major argument in favor of VSED is that given the fact that it is an entirely individual endeavor, it does not require the same ethical justification as PAS. This argument is incredibly relevant for those who live in states where PAS has not yet been formally sanctioned (there are only 5 states currently with full approval for PAS).4 In a medical field that has become so highly regulated, VSED offers a means of hastening death without the need to establish protocol or jump through vexing regulatory hurdles.
However, the premises that drive this argument are not sound. While VSED does not, in theory, require intervention from anyone, most individuals who complete VSED do so under the supervision of a physician.1,2 Though it is generally accepted that physician-nonintervention is less ethically complex than physician intervention, the waters become sufficiently murky when a physician is dealing directly with death. If a physician knowingly watches a patient refrain from food, water, or necessary medications, there is a smaller conceptual gap between this action and between prescribing a dose of pain-killers that brings about death.4 In both cases, the physician’s goal is to honor the wishes and protect the autonomy of the individual in hastening death for the relief of some unbearable condition. It is reasonable to see a difference between direct intervention and nonintervention with a similar outcome, but in terms of ethical analysis of the two means, the difference is smaller than proponents of VSED might want to think.
A final, practical argument in favor of VSED follows from a study on early death outcomes. In one study of 90 patients, the patients’ physicians said that the process unfolded exactly as the patient wanted in all but 2% of cases.1 Though it was not specified by the doctors exactly how they could ascertain whether or not a patient died the exact death that he or she wanted, it is reasonable that the person overseeing the death of individual could adequately comment on whether or not it was a positive experience overall. In terms of practical ethics, this is a strong positive statement in favor of the process, despite the small sample size.
However, similar to the past two arguments, this argument could just as easily be an argument in favor of PAS. PAS, which requires the self-administration of deadly drugs, brings about a relatively painless death that is quite rapid and predictable.4 In contrast, VSED is relatively less predictable, with a time to death that varies.1 Additionally, despite some known positive effects of starving on an individual’s psyche, the negative effects, which can include delirium and severe pain, take away from the general favorability of VSED as an option.4 The biggest complaint, however, is an incredible thirst that comes with days of water deprivation.1 These negatives outweigh the immediate positives and place VSED and PAS on a fairly level playing field in terms of how the death itself affects the individual involved.
This article is clearly not exhaustive, and the topic of hastening death is controversial for a number of additional reasons. However, the inadequacies of the current arguments in favor of VSED do point to a continued need for self-reflection and ethical assessment in the fields of palliative and end-of-life care.
Span, Paula. “The VSED Exit: A Way to Speed up Dying, Without Asking Permission.” The New York Times (The New York Times), October 21, 2016. http://www.nytimes.com/2016/10/25/health/voluntarily-stopping-eating-drinking.html?partner=rss&emc=rss.
Ivanović, Nataša, Daniel Büche, and André Fringer. “Voluntary Stopping of Eating and Drinking at the End of Life – a ’sYstematic Search and Review’ Giving Insight into an Option of Hastening Death in Capacitated Adults at the End of Life.” BMC Palliative Care 13, no. 1 (2014): 1. doi:10.1186/1472-684x-13-1.
Death With Dignity. “Other Options to Hasten Your Death.” 2015. Accessed October 23, 2016. https://www.deathwithdignity.org/options-to-hasten-death/.
Lachman, Vicki. “Voluntary Stopping of Eating and Drinking: An Ethical Alternative to Physician-Assisted Suicide.” MEDSURG nursing 24, no. 1 (2015): 56–59.