By Marco Annoni

In a recent forum commentary, Helen Watt levels substantial criticism at the 2026 guidance published by the British Medical Association (BMA) on voluntarily stopping eating and drinking (VSED). Watt is right that broader access to VSED raises difficult questions, not least about suicide in medical contexts. Yet VSED by a competent adult is already lawful in England and Wales.

One point warrants genuine concern. The guidance notes that the law requires no illness or terminal prognosis to elect to VSED. As a matter of law this is correct, but what is lawful is not therefore beyond moral dispute. To make the informing, supporting and accompanying of VSED a professional duty owed to anyone who elects it, ill or not, would extend the physician’s role well beyond its recognised bounds. It would recast what it means to practice medicine: from caring for patients, even those at the end of life, to actively enabling the self-chosen death of any competent person who requests it. That is a real overextension, and a social and political question, not one a professional body can settle by issuing guidance. On this, Watt’s unease is fully warranted.

The question is different, however, when VSED is considered for patients with terminal or degenerative conditions, at the close of a continuing relationship of care. Here it belongs beside palliative sedation, palliative care and, where lawful, assisted dying, as one option to weigh in end-of-life care. To reject VSED as such, including in these cases, needs a separate argument. This is where the commentary moves too quickly, from a fair concern about extending VSED beyond illness to a sweeping rejection of VSED as an end-of-life practice.

Underlying that rejection is an unspoken assumption: that supporting a patient through VSED means standing passively aside. It does not. The guidance Watt criticizes, in fact, states the opposite, casting the doctor in an active, deliberative role: ensuring that a decision already the patient’s is informed, competent and freely made. Four points show this.

First, the commentary suggests VSED is readily available to patients “with low mood.” It is not. The guidance excludes patients whose refusal is a symptom of a mental disorder such as anorexia nervosa or clinical depression, and requires doctors to establish, before agreeing to support anyone, that the refusal is not such a symptom, seeking specialist psychiatric assessment where there is reason to suspect that it is. This is not a doctor stepping back; it is a doctor actively testing the decision. Low mood is expressly distinguished from clinical depression, so that ordinary sadness is not medicalised.

Second, the commentary reads the instruction not to “entice” patients, for instance with ice cream on a hot day, as collusion in suicide. It is the reverse. The instruction exists so that the patient keeps a genuine, pressure-free opportunity to change course; enticement is named as a form of pressure to avoid. Far from standing aside, the doctor is required to keep that door open and to relieve hunger and thirst as they arise. What is prohibited is not care but pressure on a competent person’s settled decision.

Third, the commentary claims that “abstaining from offering oral food and fluids is against doctors’ instincts and normal good practice, as the BMA admits”. The BMA admits no such thing. It says offering food and fluids is usually good practice, but that this changes for a competent adult who has chosen VSED. Nor is abstaining abandonment: the guidance carefully separates fluids given to meet a physiological need, which a competent patient may refuse, from measures that manage symptoms, such as moistening the mouth, which are offered throughout. What continues is symptom care; what ceases is imposed sustenance. That a competent refusal of sustenance is neither killing nor assisted suicide has long been settled. The charge should be reversed: once the distinction between VSED and assisted suicide is respected, what remains is a competent refusal, and honouring it is not an added duty but the baseline of care. If anything overextends the doctor’s duties, it is the commentary’s own implicit demand: that doctors press food or hydration on a patient who has validly declined it.

Fourth, the commentary presents the delirious patient who asks for water as one the guidance would abandon, the death “completed unopposed.” The guidance says the reverse. Such a request must first be met by relieving any unmanaged hunger or thirst; if the patient still asks, the doctor must reassess capacity; and where the patient retains capacity, the doctor is to comply. A capacitous request for water is honoured, not overridden. Where capacity has been lost, the doctor must still make a best-interests decision, giving significant weight to the patient’s earlier plan while considering whether there is reason to think the patient may have changed their mind and what course best serves their interests. Either way the doctor is required to act, not to stand back. The governing consideration throughout is respect for the patient’s autonomy, not indifference to it.

These four points mark the space between two mistaken views. On one, VSED is objectionable as such, a failure of doctors who passively abandon their duties. On the other, its lawfulness alone makes it owed to anyone who elects it. Both fail to distinguish VSED as an end-of-life option from VSED as a liberty available to anyone. Between them lies a more defensible position: that for some patients with terminal or degenerative conditions, VSED can be a lawful and ethically permissible option, and sometimes the most appropriate course of action. In such cases, far from asking the doctor to stand aside, VSED calls for active care: to inform and test the choice, relieve the symptoms, and never abandon the patient.

Author: Marco Annoni
Affiliations: The Interdepartmental Center for Research Ethics and Integrity (CID Ethics), Rome
Competing interests: None declared
Social Media accounts of post author: X @marcoannoni1, LinkedIn