By Helen Watt
Suicide can be carried out by act or by omission, or by a combination of the two. Each kind of suicide can be deliberately aided or negligently enabled, including by those with a duty of care.
Voluntarily Stopping Eating and Drinking (VSED), on which the BMA issued Guidance last month, definitionally involves the intention to bring about one’s own death, as opposed to the simple loss of interest in eating and drinking which is often seen as death approaches. With VSED the patient, as the BMA makes clear, need not be terminally or even chronically ill and refuses basic means of sustenance with an unequivocally suicidal motive.
The BMA Guidance should alarm anyone wishing to prevent suicide and suicide enablement. While it notes that the doctor need not agree with the patient’s suicidal plan in order to assess the patient and palliate symptoms “if appropriate and needed”, lack of such agreement with the plan could make things worse morally given the level of collusion to which doctors are urged. The Guidance presents “management” as involving such proactive means as advising on “decreasing caloric intake” before VSED begins so as to pre-empt hunger pangs. Overwhelmingly, the focus is on helping the patient prepare for and direct the suicidal process: keeping a copy of the “care plan” to hand, authorising or forbidding future offers of food, dealing with concerned family and friends and so on. Doctors are even warned against offering the patient tempting food such as icecream on a hot day: they are instructed not to “attempt to entice them to change their minds about VSED.” In technical terms, much of the “support” above is likely formal cooperation in suicide: given the patient’s wish, he or she is deliberately assisted to pursue that suicidal goal.
What might motivate the patient? Perhaps low mood, a mental health disorder or a wish not to be a burden. None of these factors would necessarily mean, the BMA stresses, that the decision is not a free one – and it seems that for the doctor this is the only consideration. Not only must the patient not be judged (this is reasonable) but must not be argued with at all or even asked to explain him/herself: doctors should not “try to persuade the patient to change their decision, and patients should not be put in a position where they are forced to justify or defend it.” How capacity is to be determined if the patient is not asked to defend their position is unclear: certainly, the BMA warns that doctors should “take care not to inappropriately refer their patients to mental health services simply because the patient has voiced their decision to elect to VSED, or asked for support during the process.” After all, “patients who have chronic physical disorders or terminal illness often experience low mood, but this is different to clinical depression.”
And if the patient wants food and water when he/she becomes delirious? Startlingly, the BMA presents this request as something that would not necessarily call for the normal, instinctual human response. The doctor should “[u]nderstand if the request to drink or eat may be due to symptoms of thirst or hunger, rather than a genuine desire to reintroduce food and/or fluids to stop or prolong the process of VSED.” Doctors are urged to seek legal advice, since “[t]raditionally, it has been understood that the oral intake of food and fluids through self or assisted feeding is not a form of medical treatment.” However, “even if not legally binding, an ADRT/Advance Directive refusing oral food and fluids would have an important bearing on any assessment of the best interests/benefit of a patient who lacks capacity.”
But hunger and thirst are indications of need: when food and water are needed and even wanted by the patient, they should surely be supplied. True, the patient could be deeply sedated and would then receive prompts to eat and drink neither from the doctor, from loved ones nor from his or her own starving, dehydrating body. The suicide could then be completed unopposed. Yet patients may not refuse in advance some basic measures such as cleaning, or even more sophisticated measures such as palliation of severe pain. If a patient is suffering, pointing to an advance refusal of pain control hardly seems an adequate response.
The BMA Guidance veers between patient neglect and deliberate facilitation of the suicidal plan. There are other, more violent means of suicide such as setting oneself on fire: we would know what to think if the BMA were to issue step-by-step instructions on preparing for suicide-by-burning (estimates of time and petrol needed, advice on dieting in advance, drugs one might have in readiness and so on). Responding to a soon-to-be-successful attempt is, of course, another matter: many suicide attempts result sadly in a dying patient, at which point palliation may be needed as with any other dying person.
Abstaining from offering oral food and fluids is against doctors’ instincts and normal good practice, as the BMA admits. Caring for VSED patients, including providing sedation, can be difficult and the Guidance flags the possibility of moral injury and moral damage while unflinchingly requiring doctors not only to see the patient initially but to find a colleague willing to undertake detailed assessment and “care” if they will not. (Reluctant doctors would in fact be well-advised to seek advice on human rights/equality/employment law protections they may have.) The BMA’s direction to eschew any attempt to dissuade a patient from suicide, or even to assuage hunger and thirst immediately in the now-delirious patient wanting food and water, show how bizarre the medical landscape has become. Our progression to doctors acting as neutral – or worse than neutral – servants of their patients proceeds apace.
Author: Helen Watt
Affiliations: Bios Centre, London and Blackfriars Hall, Oxford
Competing interests: None declared
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