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The Ethics of Food and Drink

Starvation is not mercy.

Jul 28, 2014, Vol. 19, No. 43 • By WESLEY J. SMITH
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Such directives are .  .  . arguably already legal. They follow logically from the intersection of two existing legal rights: directives for refusing life support and VSED. The principle behind [advance medical directives] is that people do not lose their rights when they become incompetent; someone else just has to exercise those rights for them.

The driving element behind VSED is that forcing people to ingest food is as objectionable an intrusion on bodily integrity, privacy, and liberty as imposing unwanted medical treatment. Thus, if incompetent people do not lose their rights to refuse life-saving treatment, then people do not lose their right to VSED when incompetent either.

This is rank sophistry. Even today, the courts do not deem spoon-feeding to be medical treatment. It is basic, humane care—no different ethically from turning a patient to prevent bed sores or providing hygiene. Just as an advance directive instructing that a patient not be kept clean should be disregarded, so should an order to starve a patient. 

Second, VSED is suicide. Legally requiring nursing homes to commit VSED-by-proxy would be forcing them to kill—and to kill cruelly. A legal regimen that did this would drive many doctors and nurses out of medicine.

Third, even in the states where assisted suicide is legal, the person being helped by a doctor to die has to be capable of making decisions. Demented patients are incompetent.

Finally, in cases such as Bentley’s, the patient is not being force-fed. She is taking nourishment willingly. 

Some ethicists are dismissing this last objection. Thaddeus Mason Pope in the Spring 2014 Journal of Clinical Ethics argues that Margot Bentley should be starved because she is now incompetent and thus is legally unqualified to change her mind about dying. 

It seems remarkable to hold that, when a spoon or glass is pressed to the lips of someone with severe dementia, the mere opening of her or his mouth evidences decisional capacity to continue eating and drinking. Mrs. Bentley may have the capacity to “communicate a choice.” But this is just one component of capacity. She does not understand the relevant information, does not appreciate the situation and its consequences, and cannot reason about treatment or care options.

In other words, Bentley should not be allowed to thwart her previous instruction by willingly taking nourishment. If Pope’s view prevails, an instruction to be starved, signed while the patient was competent, would prevail even over an incompetent patient’s begging for food—a horror that actually happened in a tube-feeding case in Florida. 

As if such advocacy weren’t alarming enough, it must be noted that patients deemed candidates for VSED-by-proxy are among the most expensive for whom to care—this in a time of intense government efforts to control medical costs. The financial pressures all argue for euthanasia. Indeed, the advocates’ agenda may already have quietly penetrated the culture of the medical technocracy.

A patient’s chart informs the attending medical staff what life-sustaining care to provide or withhold. This information is contained in the Physician’s Order for Life-Sustaining Treatment (POLST) form, and some state forms may already tacitly authorize the withholding of spoon-feeding. 

California’s POLST, for example, in Section C, “Artificially Administered Nutrition,” instructs whether, and for how long, to use a feeding tube. But it also states: “Offer food [to the patient] by mouth if feasible and desired.” 

What does that mean? If desired by the patient now? If desired by the patient in an advance directive? If desired by the family or the care facility? Is it possible that the words “if desired” are setting the stage for allowing the withholding of spoon-feeding as a matter of policy? Hawaii’s form has similar language.

If the law ever allows patients to order caregivers to starve them to death, the next step will surely be to legalize lethal injections for such patients. After all, why force anyone to undergo a slow and potentially agonizing death by VSED or VSED-by-proxy when he or she can be dispatched quickly? Euthanasia pursuant to advance directive is already practiced in the Netherlands and Belgium. 

It is possible that this has been the stealth goal from the time advocacy for removing feeding tubes from incompetent patients began decades ago—and that now, with the open advocacy of VSED and VSED-by-proxy, the camouflage is coming off.

Wesley J. Smith is a senior fellow at the Discovery Institute’s Center for Human Exceptionalism. He also consults for the Center for Bioethics and Culture and the Patients Rights Council. 

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