As various states and nations continue to debate euthanasia and the legal and ethical boundaries of interventions to cause death, different strategies emerge to circumvent legal processes and hasten death when desired.
Among those strategies being promoted more vigorously of late is VSED (voluntarily stopping eating and drinking). From the Catholic moral view, VSED cannot be justified and, as envisioned by groups in favor of euthanasia such as “Compassion and Choices,” is a form of assisted suicide.
I first read about VSED as a legal alternative to more active forms of assisting suicide over a decade ago. While tentative and theoretical at that time, VSED is now openly advocated as a way to gain control over the time of one’s death. Several important distinctions must be drawn.
It is crucial to note that VSED differs from the natural process of dying. Patients at advanced stages of cancer, congestive heart failure, Alzheimer’s disease or other physiological and neurological illnesses naturally lose their desire to eat and drink. This is a natural means the body itself provides for comfort and does not of itself cause ethical concern. In such situations of active dying in the final stages, providing nutrition and hydration may actually increase patient suffering and hasten, rather than delay, death. Though this sounds counterintuitive, research demonstrates that feeding tumors fosters their growth; liquids that cannot be assimilated by the body’s systems overload them; and the sensations of pain and distress can actually be heightened.
By contrast, VSED does not discontinue an extraordinary means of treatment that is prolonging the dying process. Rather, VSED by intention excludes the ordinary means of nutrition and hydration precisely so that death will occur. It may appear different from more immediate and active means of suicide such as asphyxiation, weapons or lethal drugs. But suicide is determined by intentionality — a means is chosen whose end is to terminate life. While the duration of the suicide attempt is more protracted — perhaps one to two weeks — the motivation is the same.
It is true that each patient (or, for patients who lack capacity, a duly-appointed proxy decision-maker) has the legal and ethical right to refuse treatments that are ineffective or extraordinary due to excessive burdens. At the same time, the Catholic moral tradition requires that the burden arise directly from the means used — that is, it must be the treatment that is burdensome, rather than the existential burdens of living in a particular condition.
This requirement does not mean that any and every tolerable means must be used; rather, the benefits and burdens of the intervention itself in the patient’s actual situation are considered.
The very fact that VSED requires the voluntary choice to cease eating and drinking implies that eating and drinking themselves are not physiologically impossible for the patient and do not constitute the burdensome means in question.
Rather, the person has some other reason to want life to end and chooses VSED as the means to that end. The distinction can be captured by reflecting on the contrast between these two statements: “Because I am dying, I no longer have the desire to eat” and “Because I wish to die, I wish no longer to eat.”
Again, this does not mean that suffering — whether physical or psychological or spiritual — is simply to be ignored or minimized. Rather, it means that other interventions for pain and symptom management — the specialties of palliative care — are indicated.
Where VSED potentially becomes a form of assisted suicide relates to health care providers who are asked to provide medical support and manage any symptoms of discomfort the VSED patient may experience.
When a VSED patient wishes to be kept free from any hunger, thirst or other distress while he or she persists in slowly ending life, providers are asked to cooperate in an action they may find objectionable and experience moral distress themselves. It is always difficult for caring persons to watch another suffer; it is especially troubling knowing that means to alleviate suffering are ready at hand but being refused for reasons they cannot support.
VSED as proposed also raises the questions of the slippery slope regarding suffering. What kinds of suffering would justify shortening life? Courts and legislators wrestle with this spectrum. At one end we find intractable physical pain; at the other extreme, VSED proponents place depression, anxiety, concerns about possible future dependency, and the loss of interest in life.
Essential distinctions are lost when we equate all forms of suffering as equal justification to end life, even when known effective interventions exist to relieve suffering in ways that are not irreversible and as drastic as death.
The suffering of others rightly touches us and motivates us to alleviate that suffering of body, mind and spirit to the extent possible. The Catholic tradition consistently teaches that extraordinary means that are ineffective or whose burdens outweigh their benefits may be forgone. Pain and symptom management are not only acceptable but required as ordinary care.
The church, along with legislation and many legal precedents, retains the essential distinction between allowing natural death to occur and actively causing death. While the outcome is the same — the person has died — the means is undeniably and fundamentally different.
Why is it important to oppose attempts to normalize and promote VSED? Because more than just an individual and tragic choice, popularizing VSED changes the way we commit ourselves to humane care for the suffering and vulnerable. It adopts an atomistic, isolated view of persons whose choices exist in a vacuum and are unrelated to others. It relies on a false picture of individual freedom that cannot coexist with a functional human community.
Like all questions of assisted suicide, the consideration of VSED must ask what kind of society we become if this practice becomes an accepted part of our response to those in need.
Father Tom Knoblach is consultant for health care ethics for the Diocese of St. Cloud. He is also pastor of the parishes of Holy Spirit, St. Anthony and St. John Cantius in St. Cloud.