Voluntary Stopping of Eating and Drinking: A Patient’s Right to Choose or an Act of Suicide?

Last year I received an ethics consultation request from a psychiatrist regarding a patient, Ms. T, who was refusing to eat and drink in the hospital. Ms. T was an eighty–one year old woman who presented to the hospital after falling at her home. She suffered a subdural hematoma that did not require evacuation. She also presented with acute exacerbation of COPD and poor nutritional intake and associated weakness, which most likely caused the fall. Upon the history intake, Ms. T disclosed that she had been living independently at her home and had voluntarily stopped eating and drinking about a week prior to her fall. Her children confirmed that about five years prior to this, Ms. T had told them she did not want to live past the age of eighty. Ms. T gave no particular reason for this plan, other than her feeling that reaching the age of eighty was a long enough life. Per the children, Ms. T had always had chronic depression throughout her life, but that her depression did not appear to have increased at the time she told them about her plan. Ms T’s depression did become more acute after her husband died a few years prior to the current hospitalization, but she always refused psychotropic medication.

Upon admission into the hospital Ms. T was continuing to refuse to eat and drink during the hospital stay (specifically, she ingested 0–10% of her meals/liquids while hospitalized). The psychiatric evaluation determined that Ms. T had decisional capacity to make the decision to refuse to eat and drink and that she was not actively suicidal and could therefore not be placed on an involuntary hold. Interestingly, when the psychiatrist asked if she wanted to die, she answered “no.” When asked if she understood that continuing to refuse to eat and drink could result in her death, she answered “yes.” Psychotropic medication was again offered, and she again refused them. Ms. T’s children chose to leave medical decisions to their mother. The psychiatrist requested an ad hoc bioethics review to provide input regarding the ethical and legal implications of allowing the patient to voluntarily stop eating and drinking. Specifically, the psychiatrist wanted to know:

1. 1. Are eating and drinking considered “treatments” when in the hospital, and if so, does that fall under the Patient Self–Determination Law (PSDA), stating that an adult patient with capacity has a right to refuse or accept any medical treatment or procedure?

2. 2. If eating and drinking are not considered treatments, could her refusal, in fact, be defined as a suicidal gesture? If Ms. T had never fallen, could her voluntary stopping of eating and drinking at home have been defined as an act of suicide? Put another way, is death via VSED always a suicide when eating and drinking are not considered medical treatments?

3. 3. How much does the depression affect Ms. T’s decision of VSED, even though she did not meet the criteria for lacking capacity or for an involuntary hold? What are the effects of chronic depression on one’s capacity to make medical decisions?

During the ad hoc bioethics meeting, it was clear that both the psychiatrist and the primary care physician felt very uncomfortable with allowing Ms. T to continue her refusal of food and drink because she was not actively dying from a terminal illness. Again, although Ms. T did have an exacerbation of her COPD, it was determined to not be end–stage. As the ethicist, I continued to grapple with how this mode of dying without a diagnosis of a terminal illness differed from suicide, even though I am well aware that the PSDA does not require a terminal illness in order to refuse a medical treatment. Would we allow a person suffering from a mental illness to stop eating and drinking as a voluntary act of wanting to end his or her life? Or, would we place that person on an involuntary hold? The intent is certainly the same—to end one’s life. If eating and...