VSED: A New Form of Assisted Suicide

“Suicide is always as morally objectionable as murder.”  ~ Pope St. John Paul II

Super Bowl LII is in the books now, and everybody knows that the Philadelphia Eagles were victorious on the field—finally! But what about the real battle of Super Bowl Sunday—that is, who won the contest for best commercial?

Doritos and Mountain Dew have my vote for the lip-sync duel between Morgan Freeman (Missy Elliott) and Peter Dinklage (Busta Rhymes)—how could you not laugh? But the Amazon Alexa parody was a close second, especially when chef Gordon Ramsay responded to a query about a grilled cheese sandwich recipe. “Pathetic,” he declares with venom. “You’re 32 years of age and you don’t know how to make a grilled cheese sandwich. Its name is the recipe!”

I thought about this recently when I came across the American Nurses Association’s recent position statement on “Nutrition and Hydration at the End of Life” and its brief discussion of VSED—or, as the ANA spells out, the choice to “voluntarily stop eating and drinking.” Have you heard of VSED? If you haven’t, you will. It’s the latest attempt by the Culture of Death to persuade us that human autonomy is paramount, and everything else—including life itself—subordinate. It sounds so straightforward, but apparently not, for the ANA found it necessary to include a second descriptive definition about halfway into the document: “The decision to voluntarily and deliberately stop eating and drinking with the primary intention of hastening death is known as VSED.” I imagine some lawyer or bioethicist decided that an additional clear articulation of the acronym’s terms was required, but it does seem to be restating the obvious—that is, to paraphrase Ramsay’s Alexa, VSED’s name is indeed the recipe.

“Hold on, there,” you might object. “The ANA affixes intention to its second VSED definition, so it’s not just a simple restatement, but also a clarification.” Is it though? Jump back to the Amazon commercial for a moment. What if that poor sap looking for lunch had posed his naïve question this way: “Alexa, show me a recipe for a grilled cheese sandwich because I want to eat one.” I doubt that would’ve softened Ramsay’s brutal response. If anything, it would’ve invited additional abuse—as in, “Why else would you be making a grilled cheese sandwich? Art? A cheese vendetta? An investment?”

Same with VSED. If one is “voluntarily” foregoing necessary sustenance of life, then one’s objective is clear: Bringing down the curtains on that life sooner rather than later. There might be other reasons involved, but the volitional part of the equation makes it plain that one’s own death is the chief desired outcome.

I want to be clear, though, what I’m talking about here. VSED is when men and women—whether imminently dying or not—make a free decision to speed up the inevitable by skipping what they know they need to survive. These aren’t men and women suffering from various underlying pathologies that make it either impossible or extremely problematic to take in or digest nutrients. Neither are we talking about those who truly are in the last stages of dying who no longer have any appetite—and who will die of their diseases or conditions long before they starve or dehydrate.

Moreover, we’re confined to talking about VSED in the abstract here. Every patient’s story is unique; there’s no way we could examine every conceivable clinical situation from every angle, moral or otherwise. Yet don’t think this is a sneaky way to introduce relativistic “situation ethics” into the conversation. In fact, it’s actually a nod in the direction of subsidiarity—an admission that those closest to the particulars in any given person’s case are best equipped to apply moral principles and make sound clinical judgments.

What I’m really interested in is the rhetorical subterfuge that the ANA adopts in its position statement because, as in so many areas, words are important—“vitally” important you might say—and if you mess with words, you mess with how we think and act. Hence, Orwell: “You don’t grasp the beauty of the destruction of words,” Syme tells Winston in 1984. “Don’t you see that the whole aim of Newspeak is to narrow the range of thought?” On its face, the ANA statement—and its use of an innocent-sounding acronym—represents an effort to sideline the suicidal reality of VSED, both for the benefit of those who might consider it for themselves and the nurses who might be called on to care for them.

Yet, as bioethicist Fr. Tad Pacholczyk points out, “Suicide, even by starvation and dehydration, is still suicide and is never morally acceptable.” And it’s never morally acceptable because it prioritizes death over life. “In fact,” St. John Paul II wrote, “it involves the rejection of love of self and the renunciation of the obligation of justice and charity towards one’s neighbor, towards the communities to which one belongs, and towards society as a whole.” Given all that, you’d think the ANA would be forcibly arguing against VSED rather than for it. You’d think the ANA would be telling nurses and other healthcare workers to resist cooperating with VSED and to avoid advocating for its implementation. Isn’t it clear that it’s simply incompatible with what healthcare ought to be about?

Oddly, the ANA had no trouble in an earlier position statement identifying such an incompatibility when it comes to capital punishment: “Participation in executions, either directly or indirectly, is viewed as contrary to the fundamental goals and ethical traditions of the nursing profession.” What’s more, the ANA is even more forceful in its previous rejection of physician-assisted suicide (PAS):

The American Nurses Association prohibits nurses’ participation in assisted suicide and euthanasia because these acts are in direct violation of Code of Ethics for Nurses with Interpretive Statements, the ethical traditions and goals of the profession, and its covenant with society.

Note that the ANA lumps assisted suicide in with euthanasia, despite the clear differences in moral agency—another attempt at obfuscation. Assisted suicide, by definition, is, well, suicide—that is, the one doing the killing is the one killed. He is “assisted” in his self-destructive action by a doctor, primarily through the latter’s provision of a suitable medication, but the one ultimately responsible for the decisive and final act is the patient himself.

Euthanasia, on the other hand, requires the action (or inaction) of others. The one being killed may consent to the euthanasia, whatever form it takes, but he himself isn’t carrying it out—that is, he isn’t committing suicide. It’s a distinction that came up recently in my “med-surg” nursing class as we discussed end-of-life care. My students, all sophomores and fresh out of nursing fundamentals, were still learning to hang IV fluids and insert NG tubes—pretty basic stuff. I imagine some of them thought it was a stretch to delve into end-of-life ethics at this early stage. Yet I like to lay out the moral topography of the healthcare landscape early on so that they’ll have two more years to get their bearings before they’ll ever have to face real life clinical crises of conscience.

“Euthanasia, ironically, is Greek for ‘good death,’” I told them, “but in fact it has come to mean the exact opposite.” In common usage today, euthanasia is exclusively identified with medical acts—whether by commission or omission—that accelerate the dying process. Though some will argue (strenuously) that euthanasia is compatible with “good” death, I uphold and affirm the ANA’s take that it’s always bad. “Nurses have an obligation to provide humane, comprehensive, and compassionate care that respects the rights of patients,” reads the ANA statement on the topic, “but upholds the standards of the profession in the presence of chronic, debilitating illness and at end-of-life.” In other words, euthanasia, like assisted suicide, is always bad because it is directed toward destroying human life rather than preserving it. This doesn’t mean that life needs to be preserved at all costs; it doesn’t mean that we are somehow obliged to sustain life artificially in the face of expected physiological decline. It just means that we nurses are committed to protecting and supporting life through to its natural end.

The students furiously scribbled away in their notes as I listed the various means of clinical killing that go under the misleading euthanasia label. “There’s active euthanasia, which includes any intervention we might implement as clinicians with the intent of hastening death—like purposely overmedicating someone with narcotics to suppress respiratory function,” I explained. “Then there’s passive euthanasia, when we do not do something we ought to do—like not repositioning immobile patients who could develop infectious pressure ulcers.” Passive euthanasia, I told them, also includes the practice of withholding fluids from the brain-injured or debilitated, which results in death by dehydration rather than death from any underlying pathology—much like the expected outcome of VSED. A student raised her hand at this point. “So, is VSED a form of passive euthanasia then?”

Good question. Technically no, because the patient is ostensibly choosing to forego life-sustaining nutrients and fluids, and so it’s more akin to PAS than euthanasia. However, unlike PAS, which typically takes place away from clinical settings and involves a more compact sequence of events, VSED is generally going to unfold over the course of days—even weeks—and healthcare workers will still be asked to provide supportive care. Thus, the ANA position paper.

For the nurses involved, however, this requires a tricky ethical dance. Sure, we’re required by the standards of our profession to promote and defend patient autonomy, not to mention patient dignity, but there’s a clear conflict here when the patient is choosing a course of action (or, in this case, inaction) that flies in the face of healthcare’s first principle: Primum non nocere, or “first do no harm.” As I already mentioned, withholding food and fluids from someone who can no longer absorb them can be morally licit, and Catholic moral teaching has always affirmed the right of patients and their caregivers to withdraw extraordinary care, particularly in the final stages of the dying process.

Yet Catholic ethical standards forbid the removal or withholding of ordinary care from individuals, regardless of their prognosis or condition. Despite debate that continue to rage regarding what constitutes ordinary care, it is settled Church teaching that providing (and availing ourselves of) food and water is a bare minimum. “It is therefore obligatory,” reads the Vatican’s New Charter for Health Care Workers, “to the extent to which, and for as long as, it is shown to accomplish its proper finality, which is the hydration and nourishment of the patient.”

One more reason to make that grilled cheese sandwich.

(Photo credit: Stockphotosecrets)