But I want to respond to a rather lengthy attack on me specifically. Last Thursday, Lydia McGrew published this 5-page attack on advance VSED.
First, let me clarify that I agree with McGrew: "The acceptance of good food and water should never be regarded as requiring explicit and mature consent." Consent to food and water, like consent to emergency treatment, can and should be presumed.
Second, when the individual makes an informed advance refusal of food and water (e.g. to avoid living in the advanced stages of dementia), then the presumed consent is rebutted. People have a negative right to refuse interventions with their body. Similarly, while consent to emergency treatment (like a blood transfusion) is presumed, that presumption does not operate when the individual has previously objected.
Third, the refusal stands until it is revoked.
Fourth, the refusal cannot be revoked unless the individual has the decision making capacity to revoke it.
Fifth, an individual in advanced dementia does not have the capacity to decide about eating and drinking, because she cannot appreciate the consequences of that decision.
Therefore, the refusal stands.
No one with advanced dementia has the capacity to say, "I'm thirsty." They often lack even the capacity to swallow, hence aspiration pneumonia becoming the terminal event of that disease process.
ReplyDeleteSo does this translate to presumed consent meaning feeding tubes? That's a ghastly intervention to prolong a natural death.
VSED should probably be considered more as a distinct treatment option for the end of life. There's a taboo against it. Dehydration is actually a pretty good way to go overall, and hydration prolongs the dying process. After all, dying people tend not to eat and drink much.
ReplyDeleteVSED should probably be considered more as a distinct treatment option for the end of life. There's a taboo against it. Dehydration is actually a pretty good way to go overall, and hydration prolongs the dying process. After all, dying people tend not to eat and drink much.
ReplyDeletePrecedent autonomy is tricky when it comes to VSED. Two things to consider when looking at advanced dementia scenarios where the principal has lost capacity.
ReplyDelete1. A VSED directive may want to explicitly leave wiggle room for taking food and fluids by mouth if one's later self requests it. Such events may be caused by hunger pains or dry mouth and as such could be considered strictly palliative in nature. Also, given the nature of dementia, such requested feedings might tend to be rather sporadic and thus not greatly extend the principal's life.
2. It is my understanding that with advanced dementia, even feeding tubes are not correlated with longer life expectancy. Thus, the presumed necessity of vigilantly policing VSED in this medical scenario may be exaggerated(?)
*If I can find the article (NEJM or JAMA, I think), I'll post the link.
Would add that IMO, VSED should either be accomplished by a still-competent individual or (in directives) restricted to withholding artificial nutrition and hydration.
ReplyDeleteIt seems intuitively correct that as long as one wants to eat one should eat. When one needs to be fed one should be fed until one no longer eats - and that is obvious. At that point, leave him alone and respect the VSED wish expressed while he was still capable of choice.
ReplyDelete