Challenges in Completing a Death Certificate after Voluntary Stopping of Eating and Drinking (VSED)

In recent years, health care providers and the general public in the United States have gained a greater awareness of Voluntary Stopping of Eating and Drinking (VSED) as a last resort option to escape from unbearable suffering, thanks to a growing number of publications, books, and documentaries. However, the challenges and issues that can arise in completing a death certificate after VSED are not well described in literature. In this article, we first present an example case of VSED in which the death certificate was issued listing suicide as the manner of death by the medical examiner. Then, we describe the challenges and issues related to death certificates in VSED cases. Because there is no consensus on whether VSED is natural death or suicide, the death certificate may need to be referred to a medical examiner in many jurisdictions, potentially resulting in suicide being designated as the manner of death. Such designations can cause reticence in providers and institutions that might otherwise support patients who choose VSED but are concerned about the legal or reputational implications of enabling a "suicide" at their facility. A suicide designation may also contribute to moral distress in health care staff and impose emotional and practical burdens on the patient's surviving loved ones. We suggest that there are 3 approaches to addressing challenges and issues associated with death certificates after VSED: (1) navigate the existing system with guidance developed by professional organizations, (2) make a legal exemption, and (3) change the death certification system. Debate involving a wide variety of experts is warranted.

Biathanatos revisited: Anabaptist perspectives on voluntarily stopping eating and drinking in the face of terminal illness

Introduction

Voluntarily Stopping Eating and Drinking (VSED) is a legal means of hastening death through refusal of food and fluids – a topic rarely addressed in Christian Protestantism. Among this group, U.S. Mainline Protestants comprise nearly 15% of the population and are more likely to include social moderates and liberals who emphasize quality of life (over mere life) and may therefore be open to the practice.

Objectives

Leveraging the well-established and validated Theory of Planned Behavior – that posits a person’s intentions to carry out an action are motivated by one’s attitude, perception of subjective norms, and perceived behavioral control – this research elucidates clergy and congregants’ normative beliefs and anticipated tactical support for VSED, including their reactions to Christian-based justifications for this end-of-life option. Such reasoning includes that VSED is a “fast into eternal life” and is based on the example of Jesus Christ, who, in the face of ongoing suffering, determined the end of his own life when he stated, “It is finished,” and gave up his spirit – an insight originally argued by John Donne in Biathanatos (1647/1982).

Methods

This case study of one southern Anabaptist congregation employs a focus group and one-on-one interviews, capturing reactions to a vignette in which a hypothetical fellow parishioner intends to VSED in the face of ongoing suffering from a terminal illness.

Results

In response to the presented vignette, study participants reported their affirmation of VSED. Responses to faith-based justifications for the practice varied widely.

Conclusion

Individuals aiming to VSED in the face of terminal illness may have their intention affirmed by a church community, but will likely require additional caregiving support to achieve a hastened death. A nascent framework for future comparative studies of faith communities’ assessments of VSED is also proposed.