Voluntary Death
A Comparison of Terminal Dehydration and Physician-Assisted Suicide
Franklin G. Miller, PhD and Diane E. Meier, MD
1 April 1998 | Volume 128 Issue 7 | Pages 559-562
The controversial issue of legalizing physician-assisted suicide should be considered in light of legally available alternative methods of voluntary death. The increasingly polarized debate over this issue has failed to give due attention to an alternative: terminal dehydration. By voluntarily forgoing food and water, competent patients with terminal or incurable illness can escape intolerable, irremediable conditions without requiring transformation of the law and medical ethics. Terminal dehydration offers substantial advantages over physician-assisted suicide with respect to self-determination, access, professional integrity, and social implications but also has distinctive drawbacks as a humane means of voluntary death. This article analyzes clinical, ethical, and policy issues related to terminal dehydration compared with physician-assisted suicide.
The deeply divisive question of whether to legalize physician-assisted suicide has become a pressing matter of public policy at a time of radical change in the U.S. health care system. Managed care has expanded rapidly and now serves as the form of health care coverage for more than half of Americans with health insurance [1]. Although this organizational change seems to have reduced the growth of health care expenditures [2], approximately 40 million Americans (15% of the population) continue to lack health insurance [3]. That a legal option of physician-assisted suicide could become a "quick fix" for dying patients is a serious risk in view of the built-in incentives of managed care plans to limit treatment, coupled with the documented deficiencies of physicians in providing adequate pain relief and diagnosing and treating depression in terminally ill patients [4,5].
Given the potential for abuse if physician-assisted suicide were to be legalized in a climate of over-arching cost containment in health care, careful consideration of alternative ways for patients to retain some control over the timing and circumstances of death seems warranted. The debate over legalizing physician-assisted suicide has failed to give due attention to terminal dehydration as an alternative [6]. With terminal dehydration, competent patients who have terminal or incurable illness seek voluntary death by forgoing artificial nutrition and hydration or by ceasing to eat and drink. Terminal dehydration, accompanied by standard measures of palliative care, offers patients a way to escape agonizing, incurable conditions that they consider to be worse than death, without requiring transformation of the law and medical ethics.
In this article, we analyze clinical, ethical, and policy issues relating to terminal dehydration as an alternative to physician-assisted suicide, building on the foundation laid in 1993 by Bernat and colleagues [7] in their seminal article on patient refusal of hydration and nutrition. This topic warrants revisiting in light of the Oregon referendums to legalize physician-assisted suicide and recent federal court decisions on this issue. A balanced assessment of physician-assisted suicide and terminal dehydration is important because each method has substantial advantages and disadvantages.
Merits of Terminal Dehydration
Evidence indicates that death by terminal dehydration is not painful and that attendant physical discomfort can be adequately alleviated [6-8]. Pain and suffering caused by the underlying disease can be treated by standard palliative measures, including administration of sedation to the level of unconsciousness as a last resort [9].
A stronger moral basis exists for voluntary death by terminal dehydration than by physician-assisted suicide. The right to forgo food and water, whether by mouth or by artificial means, derives from the fundamental right of competent patients to refuse medical treatment and to be free of unwanted bodily intrusion [7,10]. Physicians are morally obligated to honor a competent patient's refusal of food and water, but they are not morally obligated to comply with a competent patient's request for lethal medication [7]. Although physician-assisted suicide may be justifiable as a last resort in extraordinary cases, a patient's right to assisted suicide does not carry the same moral force as a patient's right to forgo treatment. This difference can be seen by considering the significance of thwarting these two paths to voluntary death [11]. Force-feeding a competent patient who clearly refuses food and water violates autonomy, liberty, and dignity. In contrast, refusal of a carefully considered request for physician-assisted suicide interferes with a patient's self-determination but does not amount to a personal assault. Moreover, the patient whose request for physician-assisted suicide is denied remains free to exercise the right to voluntary death by forgoing food and water.
Self-Determination
Terminal dehydration offers a method of voluntary death that is entirely under the control of competent patients; it is not necessary for the physician to intervene by prescribing or administering lethal medication. Death by terminal dehydration demands a resolute determination to resist food and water. Because it typically takes several days to a few weeks for death to occur by this means, the patient who seeks death by terminal dehydration retains an opportunity to change his or her mind [7]. In contrast, the patient who ingests a lethal dose of medication quickly loses consciousness and rapidly progresses to death. This difference in time to death means that terminal dehydration, unlike physician-assisted suicide, cannot be accomplished impulsively.
Physician-assisted suicide, because it involves prescribing lethal medication, could subject patients to greater external influence in favor of death than that associated with terminal dehydration. Owing to the cultural authority of medicine [12], a prescription of lethal medication may carry social legitimization for some patients and signify that it is medically appropriate for the patient to hasten death. Terminal dehydration lacks this legitimization. The physician may accept the patient's decision to die by terminal dehydration, but no affirmative act by the physician is required.
Access
In 1996, the U.S. Court of Appeals for the Second Circuit held that prohibiting physician-assisted suicide violates "equal protection." It argued that it is unfair to permit competent, dying patients to die by forgoing life-sustaining treatment but prohibit physician-assisted suicide for equally competent, dying patients who are not able to hasten death by stopping a treatment [13]. The option of terminal dehydration, which the court did not consider, undercuts this argument: It is available to all suffering patients who are able to make decisions, including patients who are not receiving life-sustaining treatment. Accordingly, terminal dehydration is more widely available than physician-assisted suicide, which is limited to patients who can ingest lethal medication. Even a patient with a condition as debilitating as the "locked-in syndrome" can seek death by terminal dehydration [14]. The setting, however, may influence the availability of terminal dehydration because caregivers in some nursing homes and hospitals may be reluctant to comply with a patient's refusal of food and water.
Professional Integrity
Several noted physician-ethicists have argued that physician-assisted suicide is always wrong because it violates the healing vocation of medicine [15,16]. Although this absolute claim is open to challenge, the prescription or administration of lethal medication by physicians poses a serious threat to their professional integrity [17]. A request for physician-assisted suicide by a competent, dying patient who is suffering intolerably places the physician in a moral conflict between the duty to relieve suffering and the duty not to kill or to help kill. With terminal dehydration, the physician is not responsible for providing the means of death and therefore is not subjected to such a conflict. Terminal dehydration remains morally challenging, however, in view of professional commitments to preserve life and to help terminally ill patients cope until death arrives naturally. Physicians retain the right to advocate in favor of the patient's continued life as long as they refrain from coercion.
Social Implications
No controversial change in the law or public policy is required to permit patients to die by terminal dehydration [7]. Because the legitimacy of terminal dehydration derives from the patient's legal and moral right to refuse medical treatment [10], wider understanding and use of this option is apt to be less socially divisive than legalization of physician-assisted suicide. Terminal dehydration can be used openly by patients, which is a distinct advantage as long as physician-assisted suicide remains illegal.
The reluctance of many physicians to confront death and to undertake the demanding work of palliative care, coupled with incentives that operate within managed care, creates the potential for physician-assisted suicide to become a "quick fix." Physician-assisted suicide offers a swift exit, putting an end to the patient's suffering and the need for costly continued care. The determination and patience required to die by terminal dehydration, compared with the relative ease of ingesting lethal medication, make terminal dehydration much less likely to become routine for terminally ill patients.
Is Terminal Dehydration Humane?
Many of the features that make terminal dehydration potentially superior to physician-assisted suicide derive from the relatively long interval between the patient's decision to die by forgoing nutrition and hydration and the occurrence of death. However, this factor also accounts for some of the major difficulties of this method. Terminal dehydration can be made painless but not swift. Although death by terminal dehydration normally takes several days to occur, some case reports indicate a period of 3 to 4 weeks from when the process is started to when the patient dies [8,14]. The time required for death by terminal dehydration is likely to make this method seem less humane than physician-assisted suicide. Indeed, it may seem repugnant that a competent, informed patient who resolutely seeks voluntary death must stop eating and drinking and wait for an undetermined period for death to arrive. The vigil of family members awaiting their loved one's death may be burdensome and stressful. Moreover, minimal drinking in response to thirst or the urging of concerned relatives may further prolong the process of dying. Those who die by terminal dehydration typically lapse into unconsciousness before death, which may seem intolerable to some patients and their family members [18].
The difference between the lengths of time it takes to die of terminal dehydration and of physician-assisted suicide should be assessed in light of regulations likely to govern any legalized access to physician-assisted suicide [7]. The Oregon Death with Dignity Act mandates a 2-week waiting period after a request for physician-assisted suicide [19]. A waiting period of similar length is described in a model statute for legalizing physician-assisted suicide [20]. Most patients who seek death by terminal dehydration would achieve their goal within 2 weeks.
Does terminal dehydration require more determination and fortitude than can be reasonably expected [21]? Patients seeking death may be reluctant to accept terminal dehydration out of fear that their physicians and family members will not provide the support and care required to make this a tolerable option. Patients who choose this means of voluntary death remain vulnerable to persuasive pressure from family members or physicians to change their mind. They may succumb to such pressures either because life has again begun to seem worthwhile or because emotional and physical fatigue limits their ability to persist, forcing them to endure an unwanted existence.
Physician-assisted suicide also has deficiencies as a humane means of voluntary death. The patient may botch the suicide attempt and possibly be left in a condition worse than that resulting from the terminal illness. Family or friends have felt compelled in some cases to place a plastic bag over the head of a person attempting physician-assisted suicide to complete the deed [22,23]. Those who assist in a loved one's death by giving them pills or applying a plastic bag may suffer debilitating guilt and a prolonged and complicated bereavement.
Some patients who seek death may feel that terminal dehydration is, at best, less desirable than physician-assisted suicide. They may choose terminal dehydration only because legal or ethical concerns prevent their physicians from complying with a request for lethal medication. However, anecdotal evidence suggests that terminal dehydration can provide a peaceful and dignified process of dying [24].
Integrating Terminal Dehydration into Clinical Practice
Like patients who request physician-assisted suicide, patients who seek death by terminal dehydration may be depressed or may be motivated by concerns about being a burden to others. Clinicians involved in the care of patients who decide to forgo food and water must be sure that the patient is able to make decisions and that the patient's decision is informed and voluntary. Moreover, support from a physician may help counteract the patient's fear of being a burden. Because some data show an association between depression and a desire to hasten death [25-27], physicians are justified in encouraging a trial of antidepressant therapy, counseling, or both before supporting a patient's decision to die by terminal dehydration. To obviate undue influence from the physician, the initiative to explore the option of terminal dehydration should come from the patient.
Clinicians should continue to provide palliative care to patients who seek voluntary death by terminal dehydration, even if they view the patient's decision as problematic or unwarranted. Competent patients have the right to forgo food and water. Although physicians may legitimately deny a patient's request for assisted suicide, they have the responsibility to provide palliative care to patients who have resolutely chosen voluntary death. Just as a physician must continue to provide palliative care for a competent patient who refuses to have surgery and is dying of sepsis from a gangrenous extremity, palliation remains a physician's obligation for a patient who chooses to die by terminal dehydration. Patients who voluntarily choose this option after being informed about their alternatives should be assured that they will not be abandoned and that every effort will be made to promote comfort until death arrives. This commitment to provide palliative care also helps alleviate the distress of family members.
Response to Extraordinary Cases
No adult of sound mind should be forced to endure an existence that he or she rationally considers to be intolerable. Accordingly, the physician has a moral obligation not to foreclose the option of voluntary death. We acknowledge that, in rare cases, physician-assisted suicide offers a superior alternative to terminal dehydration. Nonetheless, the existence of a small number of compelling cases does not, by itself, warrant a change in policy in favor of legalizing physician-assisted suicide. We do not view legalization of physician-assisted death as a matter of individual rights [28,29]. The debate should focus on whether legalization of physician-assisted suicide will enable our society to provide better care for dying and incurably ill patients, without causing intolerable abuses. The already-available option of terminal dehydration deserves careful consideration as an alternative to physician-assisted suicide.
Grant Support: Dr. Meier was supported by the United Hospital Fund, the Emily Davie and Joseph F. Kornfeld Foundation, and the Mount Sinai Hospital Auxiliary Board.
Requests for Reprints: Diane E. Meier, MD, PO Box 1070, Mount Sinai Medical Center, New York, NY 10029.
Current Author Addresses: Dr. Miller: 3910 Underwood Street, Chevy Chase, MD 20815.
Dr. Meier: PO Box 1070, Mount Sinai Medical Center, New York, NY 10029.
Here's an opposing point of view, from another doctor:
http://doctorisin.blogspot.com/2004_12_01_doctorisin_archive.html
"Euthanasia is the quick fix to man's ageless struggle with suffering and disease. The Hippocratic Oath - taken in widely varying forms by most physicians at graduation - was originally administered to a minority of physicians in ancient Greece, who swore to prescribe neither euthanasia nor abortion - both common recommendations by healers of the age.
The rapid and widespread acceptance of euthanasia in pre-Nazi Germany occurred because it was eminently reasonable and rational. Beaten down by war, economic hardship, and limited resources, logic dictated that those who could not contribute to the betterment of society cease being a drain on its lifeblood.
Long before its application to ethnic groups and enemies of the State, it was administered to those who made us most uncomfortable: the mentally ill, the deformed, the retarded, the social misfit.
While invariably promoted as a merciful means of terminating suffering, the suffering relieved is far more that of the enabling society than of its victims. "Death with dignity" is the gleaming white shroud on the rotting corpse of societal fear, self-interest and ruthless self-preservation.
It is sobering and puzzling to ponder how the profession of medicine - whose core article of faith is healing and comfort of the sick - could be so effortlessly transformed into a calculating instrument of judgment and death.
It is chilling to read the cold scientific language of Nazi medical experiments or Dutch studies on optimal techniques to minimize complications in euthanasia. Yet this devolution of medicine, with some contemplation, is not hard to discern. It is the natural gravity of man detached from higher principles, operating out of the best his reason alone has to offer, with its inevitable disastrous consequences.
Contributing to this march toward depravity: The power of detachment and intellectualization.
Physicians by training and disposition are intellectualizers. Non-medical people observing surgery are invariably squeamish, personalizing the experience and often repulsed by the apparent trauma to the patient. Physicians overcome this natural response by detaching themselves from the personal, and transforming the experience into a study in technique, stepwise logical processes, and fascination with disease and anatomy. Indeed, it takes some effort to overcome this training to develop empathy and compassion. It is therefore a relatively small step with such training to turn even killing into another process to be mastered.
The dilution of personal responsibility: In Germany, the euthanasia of children was performed with an injection of Luminal, a barbituate also used for seizures and sedation of the agitated. As a result, it was difficult to determine who was personally responsible for the deed: was it the nurse, who gave too much?
The doctor, who ordered too large a dose? Was the patient overly sensitive to the drug? Was the child merely sedated, or in a terminal coma? Of course, all the participants knew what was going on, but responsibility was diluted, giving rationalization and justification full reign. The societal endorsement and widespread practice of euthanasia provided additional cover. When all are culpable, no one is culpable.
Humans have the remarkable ability to utterly separate disparate parts of their lives, to accommodate cognitive dissonance. Indeed, there is probably no other way to maintain sanity in the face of enormous personal evil.
The banality of evil: Great evil springs in countless small steps from lesser evil. Jesus Christ was doubtless not the first innocent man Pilate condemned to death; soft porn came before child porn, snuff films, and rape videos; in the childhood of the serial killer lies cruelty to animals.
Small evils harden the heart, making greater evil easier, more routine, less chilling. We marvel at the hideousness of the final act, but the descent to depravity is a gentle slope downwards.
The false optimism of expediency: Solve the problem today, deny any future consequences. We are nearsighted creatures in the extreme, seeing only the benefits of our current actions while dismissing the potential for unknown, disastrous ramifications.
When Baby Knauer, an infant with blindness, mental retardation and physical deformities, became the first child euthanized in Germany, who could foresee the horrors of Auschwitz and Dachau?
We are blind to the horrendous consequences of our wrong decisions, but see infinite visions of hope for their benefits. As a child I watched television shows touting peaceful nuclear energy as the solution to all the world's problems, little imagining the fears of the Cuban missile crisis, Chernobyl and Three Mile Island, the minutes before midnight of the Cold War, and the current ogre of nuclear terrorism.
Reason of itself is morally neutral; it can kill children or discover cures for their suffering and disease. Reason tempered by humility, faith, and guidance by higher moral principles has enormous potential for good - and without such restraints, enormous potential for evil.
The desire to end human suffering is morally good. Despite popular misconception, the Judeo-Christian tradition does not view suffering as something good, but rather something evil which exists, but which may be transformed and redeemed by God and grace, to ultimately produce a greater good. This is a difficult sell to a materialistic, secular world, which does not accept the transformational power of God or the existence of spiritual consequences, or principles higher than human reason.
Yet the benefits of suffering, subtle though they may be, can be discerned in many instances even by the unskilled eye.
What are the chances that Dutch doctors will find a cure for the late stage cancer or early childhood disease, when they now so quickly and "compassionately" dispense of their sufferers with a lethal injection?
Who will teach us patience, compassion, unselfish love, endurance, tenderness, and tolerance, if not those who provide us with the opportunity through their suffering, or mental or physical disability?
These are character traits not easily learned, though enormously beneficial to society as well as individuals. How will we learn them if we liquidate our teachers?
Higher moral principles position roadblocks to our behavior, warning us that grave danger lies beyond. When in our hubris and unenlightened reason we crash through them, we do so at great peril, for we do not know what evil lies beyond.
The Netherlands will not be another Nazi Germany, as frightening as the parallels may be. It will be different, but it will be evil in some unpredictable way, impossible to foresee when rationalism took the first step across that boundary to kill a patient in mercy."