Abstract
Dear Editor:
I am responding to a statement that was recently published in your journal, which I find to be egregious.
De Lima L, Woodruff R, Pettus K, Downing J, Buitrago R, Munyoro E, Venkateswaran C, Bhatnagar S, Radbruch L. International Association for Hospice and Palliative Care Position Statement: Euthanasia and physician-assisted suicide. J Palliat Med 2017;20(1):8–14.
This article endorses that “voluntary cessation of fluid or nutrition intake may offer an alternative for .… patients” in palliative care, that is, the physician suggesting to patients that they can stop eating (and perhaps drinking) and thus hasten their death, when that physician or the healthcare system refuses other options for the patient to end their suffering.
I do not believe that this can be credibly endorsed either by the International Association for Hospice and Palliative Care (IAHPC) or the Journal of Palliative Medicine in the light of several key issues:
Dehydration and especially starvation are not benign—they are agonizing and extended pathways to death, associated with great physical suffering. Agitation and distress may last from several days to weeks because of the slow dying process from dehydration and especially starvation that can endure for months. Lapse into cognitive impairment is strongly associated with the terminal stages of both dehydration and starvation. 1
The extended and agonizing process experienced by the patient enduring self-starvation will be in plain view of family members and caregivers. Witnessing this horrible prolonged scene will create an indelible perception of neglect by the healthcare providers and by institutions, in the eyes of the family members and community. A sense of guilt may reasonably be expected to burden staff and family who witness the slow emaciation, their loved one rendered skeletal.
Loewy 2 points out that in the end-of-life stage, patients endure a painful sense of loss of ability to share with families or friends: “the patient with advanced disease is still connected to others by the atavistic thread of sharing food and drink, even if only a sip, even if only in a symbolic fashion.” Encouraging them to stop eating and drinking (and to forego sharing food and drink with their family and loved ones) severs their last social ties and further pushes them into isolation.
Placing another person in a position to have no alternative but to die of thirst and/or starvation against their will is a criminal offence everywhere in the world. Placing an ill and vulnerable person who is dying in a situation in which he or she has no other recourse but to starve to death is ethically questionable,2,3 and in my personal view morally repugnant. Loewy 2 provides an important distinction. As life ebbs, patients may stop eating and drinking entirely by their own volition and initiation, when they are ready to die. There is no ethical or legal reason to try to prevent people from ending their lives in that way. There is a fundamental difference between this course of action and the physician acting as a proponent of self-starvation. 2 In this case, patients are still able and willing to eat and drink, but in the face of unbearable suffering they ask for help in ending their lives. Their physician, who formerly provided sustenance, now informs them that they can starve themselves to death, a cruel act of rejection.
Loewy 2 noted that suggesting to patients that they starve themselves does not obviate the healthcare professionals of direct legal and ethical culpability in the terrible suffering that ensues with this form of death. The cruelty of the IAHPC suggestion that patients should be advised to die of thirst or starvation is on no way mitigated by the gratuitous suggestion that this would occur under “appropriate and adequate symptom control measures”, because none exist. I could not find any validated, evidence-based set of procedures or guidelines entitled “Pain and symptom management during death by starvation and dehydration”; certainly the IAHPC has none. There is no evidence to suggest that palliative caregivers around the world are able to mitigate the distress, social isolation, pain, and suffering associated with death by starvation.