The Frush article proposes to health care providers “an alternative approach” to a competent patient's request for “comfort care” (including mild sedation) in the course of VSED 1. This alternative approach asserts that a provider could and should regard VSED as a form of suicide and that sedation might then be deemed an unethical breach of professional norms (facilitation of suicide). The authors urge providers to make a judgment whether the requested comfort care “contributes instrumentally to the patient's death”—that is, whether the requested medications “make it possible to carry out the goal of hastening death.” If so, the provider “might reasonably withhold such medications notwithstanding the patient's requests” in order not to be complicit in a suicide. The authors' suggested approach mischaracterizes its foundation. In actuality, the comfort care conduct in issue cannot be regarded as an unethical violation of professional norms. As the authors acknowledge, professional medical societies have endorsed VSED as “a legitimate option”—a competent patient's exercise of bodily integrity and self-determination to resist the forced hand feeding or artificial nutrition infusion that would be necessary to override the patient's wish to die from dehydration. The authors' “alternative approach” is grounded not on professional ethics, but on conscientious objection, that is, a personal belief that the VSED practice is a form of suicide and should not enjoy medical cooperation in making the dying process comfortable for the self-starving patient. A health care provider is indeed entitled to invoke personal conscience with regard to a patient's choice of medical treatment. However, a basic ethical requirement for a conscientious objector is to inform the patient and to provide a referral to a provider willing to cooperate with the patient's considered choice. The authors make no mention of referral to another provider and instead urge unilateral refusal to provide even mild sedation as a form of palliative care being sought by the patient. Such unilateral withholding of a basic form of comfort care is, I suggest, a shocking disregard of a conscientious objector's ethical obligation to minimize disruption to the patient's chosen path. A VSED patient is competent and normally prefers to remain interactive with their environment. A request for a sedative normally reflects legitimate patient concern about delirium, confusion, anxiety, or agitation as consciousness wanes. It seems cruel and inappropriate for the conscientiously objecting provider to inject their personal vision of suicide in a fashion that disrupts and complicates the legitimate patient effort to remain resolute and comfortable during their chosen VSED course. The authors are correct that conscientiously objecting clinicians may advise the patient against VSED. But once the patient opts for VSED, the clinician cannot inject a personal belief about the nature of suicide to withhold comfort care sought by the patient to ease the chosen dying process. I declare that I am the sole author. The author has nothing to report. The author declares no conflicts of interest. This publication is linked to a related reply article by Frush et al. To view this article, visit https://doi.org/10.1111/jgs.70449.
Norman L. Cantor (Fri,) studied this question.