Reply to Comment on: The Role of the Physician in Caring for Patients Pursuing VSED : Challenging the Conventional Approach

Professor Cantor offers several criticisms of our article, all of which are mistaken. First, he incorrectly states that we claim that providers “could and should regard VSED as a form of suicide” [1]. We make no such claim. Our argument is explicitly conditional: if physicians view VSED as unethical, how might they care for patients who have chosen to pursue it? That at least some physicians disagree with VSED is self-evident and not a point of contention. The challenge our paper focuses on is how a physician who believes VSED is a form of suicide might reasonably care for a patient choosing VSED and do so without violating the central norm of Hippocratic medicine: to not intentionally cause harm or death to patients. Our paper fills this gap in the literature and offers such physicians ethical guidance. Second, he states that “the comfort care conduct in issue cannot be regarded as an unethical violation of professional norms” [1]. Yet the central norm that has governed the practice of Western medicine since Hippocrates has been the injunction to avoid intentionally causing harm or death to patients. This is an eminently reasonable professional norm that need not be viewed as a “personal vision,” but rather grounded in a sound tradition of clinical and ethical judgment. Any ethical objection by a physician is contingent on such a foundational normative vision of medicine. Physicians can disagree with patients without objecting to caring for them in all other aspects of their treatment and need not reflexively refer. Third, Professor Cantor presents a straw man argument in his claim that we are implicitly or explicitly arguing that physicians should engage in “forced hand feeding or [forced] artificial nutritional infusion” [1]. We make no such claim in this paper, and indeed argue explicitly against this idea by stating, “Physicians cannot justifiably administer fluids or nutrition over Mr. Johnson's objection” [2]. We restrict our focus to clinician-patient communication and symptomatic management in the conditional circumstance listed above. Professor Cantor's caricature distracts from our core contentions and does not engage our argument on its own terms. Fourth, Professor Cantor mischaracterizes our discussion of how a physician who views VSED as unethical might respond to a patient requesting a sedative medication for thirst or discomfort. He states, “A request for a sedative normally reflects legitimate patient concern about delirium, confusion, anxiety, or agitation as consciousness wanes” [1]. We are explicit in our example that the patient is requesting a sedative for thirst or general discomfort. Sedative medications are not an indicated medication for either of these conditions. We do not argue that physicians are obligated to avoid all forms of sedatives or other symptomatic management in certain cases of VSED. As we emphasize in our essay, the ethics of VSED is complex and requires close attention to the clinical details at hand for clinicians. It also requires close attention to the arguments at hand for those who theorize about its ethical rightness or wrongness. For those who would disagree with the approach we put forward, we believe that such disagreements must attend to the argument on its correct terms, which we have sought to clarify here. Benjamin W. Frush drafted the initial version of the manuscript and was involved in the revision and submission of the manuscript. Farr A. Curlin provided iterative feedback on the manuscript with substantive contributions. Daniel P. Sulmasy provided iterative feedback on the manuscript with substantive contributions. Benjamin W. Frush confirms that he has listed every author who contributed significantly to this work. The authors have nothing to report. Benjamin W. Frush received funding for his post-doctoral fellowship is provided by the McDonald Agape Foundation. Daniel P. Sulmasy received 5% salary support from the McDonald Agape Foundation. Farr A. Curlin declares no conflicts of interest. This publication is linked to a reply by Norman L. Cantor. To view this article, visit https://doi.org/10.1111/jgs.70451.