Given the potential for abuse if physician-assisted suicide were to be legalized in a climate of over-arching cost containment in health care, careful consideration of alternative ways for patients to retain some control over the timing and circumstances of death seems warranted. The debate over legalizing physician-assisted suicide has failed to give due attention to terminal dehydration as an alternative [6]. With terminal dehydration, competent patients who have terminal or incurable illness seek voluntary death by forgoing artificial nutrition and hydration or by ceasing to eat and drink. Terminal dehydration, accompanied by standard measures of palliative care, offers patients a way to escape agonizing, incurable conditions that they consider to be worse than death, without requiring transformation of the law and medical ethics.

In this article, we analyze clinical, ethical, and policy issues relating to terminal dehydration as an alternative to physician-assisted suicide, building on the foundation laid in 1993 by Bernat and colleagues [7] in their seminal article on patient refusal of hydration and nutrition. This topic warrants revisiting in light of the Oregon referendums to legalize physician-assisted suicide and recent federal court decisions on this issue. A balanced assessment of physician-assisted suicide and terminal dehydration is important because each method has substantial advantages and disadvantages.

Merits of Terminal Dehydration

Evidence indicates that death by terminal dehydration is not painful and that attendant physical discomfort can be adequately alleviated [6-8]. Pain and suffering caused by the underlying disease can be treated by standard palliative measures, including administration of sedation to the level of unconsciousness as a last resort [9].

A stronger moral basis exists for voluntary death by terminal dehydration than by physician-assisted suicide. The right to forgo food and water, whether by mouth or by artificial means, derives from the fundamental right of competent patients to refuse medical treatment and to be free of unwanted bodily intrusion [7, 10]. Physicians are morally obligated to honor a competent patient's refusal of food and water, but they are not morally obligated to comply with a competent patient's request for lethal medication [7]. Although physician-assisted suicide may be justifiable as a last resort in extraordinary cases, a patient's right to assisted suicide does not carry the same moral force as a patient's right to forgo treatment. This difference can be seen by considering the significance of thwarting these two paths to voluntary death [11]. Force-feeding a competent patient who clearly refuses food and water violates autonomy, liberty, and dignity. In contrast, refusal of a carefully considered request for physician-assisted suicide interferes with a patient's self-determination but does not amount to a personal assault. Moreover, the patient whose request for physician-assisted suicide is denied remains free to exercise the right to voluntary death by forgoing food and water.

Self-Determination

Terminal dehydration offers a method of voluntary death that is entirely under the control of competent patients; it is not necessary for the physician to intervene by prescribing or administering lethal medication. Death by terminal dehydration demands a resolute determination to resist food and water. Because it typically takes several days to a few weeks for death to occur by this means, the patient who seeks death by terminal dehydration retains an opportunity to change his or her mind [7]. In contrast, the patient who ingests a lethal dose of medication quickly loses consciousness and rapidly progresses to death. This difference in time to death means that terminal dehydration, unlike physician-assisted suicide, cannot be accomplished impulsively.

Physician-assisted suicide, because it involves prescribing lethal medication, could subject patients to greater external influence in favor of death than that associated with terminal dehydration. Owing to the cultural authority of medicine [12], a prescription of lethal medication may carry social legitimization for some patients and signify that it is medically appropriate for the patient to hasten death. Terminal dehydration lacks this legitimization. The physician may accept the patient's decision to die by terminal dehydration, but no affirmative act by the physician is required.

Access

In 1996, the U.S. Court of Appeals for the Second Circuit held that prohibiting physician-assisted suicide violates "equal protection." It argued that it is unfair to permit competent, dying patients to die by forgoing life-sustaining treatment but prohibit physician-assisted suicide for equally competent, dying patients who are not able to hasten death by stopping a treatment [13]. The option of terminal dehydration, which the court did not consider, undercuts this argument: It is available to all suffering patients who are able to make decisions, including patients who are not receiving life-sustaining treatment. Accordingly, terminal dehydration is more widely available than physician-assisted suicide, which is limited to patients who can ingest lethal medication. Even a patient with a condition as debilitating as the "locked-in syndrome" can seek death by terminal dehydration [14]. The setting, however, may influence the availability of terminal dehydration because caregivers in some nursing homes and hospitals may be reluctant to comply with a patient's refusal of food and water.

Professional Integrity

Several noted physician-ethicists have argued that physician-assisted suicide is always wrong because it violates the healing vocation of medicine [15, 16]. Although this absolute claim is open to challenge, the prescription or administration of lethal medication by physicians poses a serious threat to their professional integrity [17]. A request for physician-assisted suicide by a competent, dying patient who is suffering intolerably places the physician in a moral conflict between the duty to relieve suffering and the duty not to kill or to help kill. With terminal dehydration, the physician is not responsible for providing the means of death and therefore is not subjected to such a conflict. Terminal dehydration remains morally challenging, however, in view of professional commitments to preserve life and to help terminally ill patients cope until death arrives naturally. Physicians retain the right to advocate in favor of the patient's continued life as long as they refrain from coercion.

Social Implications

No controversial change in the law or public policy is required to permit patients to die by terminal dehydration [7]. Because the legitimacy of terminal dehydration derives from the patient's legal and moral right to refuse medical treatment [10], wider understanding and use of this option is apt to be less socially divisive than legalization of physician-assisted suicide. Terminal dehydration can be used openly by patients, which is a distinct advantage as long as physician-assisted suicide remains illegal.

The reluctance of many physicians to confront death and to undertake the demanding work of palliative care, coupled with incentives that operate within managed care, creates the potential for physician-assisted suicide to become a "quick fix." Physician-assisted suicide offers a swift exit, putting an end to the patient's suffering and the need for costly continued care. The determination and patience required to die by terminal dehydration, compared with the relative ease of ingesting lethal medication, make terminal dehydration much less likely to become routine for terminally ill patients.

Is Terminal Dehydration Humane?

Many of the features that make terminal dehydration potentially superior to physician-assisted suicide derive from the relatively long interval between the patient's decision to die by forgoing nutrition and hydration and the occurrence of death. However, this factor also accounts for some of the major difficulties of this method. Terminal dehydration can be made painless but not swift. Although death by terminal dehydration normally takes several days to occur, some case reports indicate a period of 3 to 4 weeks from when the process is started to when the patient dies [8, 14]. The time required for death by terminal dehydration is likely to make this method seem less humane than physician-assisted suicide. Indeed, it may seem repugnant that a competent, informed patient who resolutely seeks voluntary death must stop eating and drinking and wait for an undetermined period for death to arrive. The vigil of family members awaiting their loved one's death may be burdensome and stressful. Moreover, minimal drinking in response to thirst or the urging of concerned relatives may further prolong the process of dying. Those who die by terminal dehydration typically lapse into unconsciousness before death, which may seem intolerable to some patients and their family members [18].

The difference between the lengths of time it takes to die of terminal dehydration and of physician-assisted suicide should be assessed in light of regulations likely to govern any legalized access to physician-assisted suicide [7]. The Oregon Death with Dignity Act mandates a 2-week waiting period after a request for physician-assisted suicide [19]. A waiting period of similar length is described in a model statute for legalizing physician-assisted suicide [20]. Most patients who seek death by terminal dehydration would achieve their goal within 2 weeks.

Does terminal dehydration require more determination and fortitude than can be reasonably expected [21]? Patients seeking death may be reluctant to accept terminal dehydration out of fear that their physicians and family members will not provide the support and care required to make this a tolerable option. Patients who choose this means of voluntary death remain vulnerable to persuasive pressure from family members or physicians to change their mind. They may succumb to such pressures either because life has again begun to seem worthwhile or because emotional and physical fatigue limits their ability to persist, forcing them to endure an unwanted existence.

Physician-assisted suicide also has deficiencies as a humane means of voluntary death. The patient may botch the suicide attempt and possibly be left in a condition worse than that resulting from the terminal illness. Family or friends have felt compelled in some cases to place a plastic bag over the head of a person attempting physician-assisted suicide to complete the deed [22, 23]. Those who assist in a loved one's death by giving them pills or applying a plastic bag may suffer debilitating guilt and a prolonged and complicated bereavement.

Some patients who seek death may feel that terminal dehydration is, at best, less desirable than physician-assisted suicide. They may choose terminal dehydration only because legal or ethical concerns prevent their physicians from complying with a request for lethal medication. However, anecdotal evidence suggests that terminal dehydration can provide a peaceful and dignified process of dying [24].

Integrating Terminal Dehydration into Clinical Practice

Like patients who request physician-assisted suicide, patients who seek death by terminal dehydration may be depressed or may be motivated by concerns about being a burden to others. Clinicians involved in the care of patients who decide to forgo food and water must be sure that the patient is able to make decisions and that the patient's decision is informed and voluntary. Moreover, support from a physician may help counteract the patient's fear of being a burden. Because some data show an association between depression and a desire to hasten death [25-27], physicians are justified in encouraging a trial of antidepressant therapy, counseling, or both before supporting a patient's decision to die by terminal dehydration. To obviate undue influence from the physician, the initiative to explore the option of terminal dehydration should come from the patient.

Clinicians should continue to provide palliative care to patients who seek voluntary death by terminal dehydration, even if they view the patient's decision as problematic or unwarranted. Competent patients have the right to forgo food and water. Although physicians may legitimately deny a patient's request for assisted suicide, they have the responsibility to provide palliative care to patients who have resolutely chosen voluntary death. Just as a physician must continue to provide palliative care for a competent patient who refuses to have surgery and is dying of sepsis from a gangrenous extremity, palliation remains a physician's obligation for a patient who chooses to die by terminal dehydration. Patients who voluntarily choose this option after being informed about their alternatives should be assured that they will not be abandoned and that every effort will be made to promote comfort until death arrives. This commitment to provide palliative care also helps alleviate the distress of family members.

Response to Extraordinary Cases

No adult of sound mind should be forced to endure an existence that he or she rationally considers to be intolerable. Accordingly, the physician has a moral obligation not to foreclose the option of voluntary death. We acknowledge that, in rare cases, physician-assisted suicide offers a superior alternative to terminal dehydration. Nonetheless, the existence of a small number of compelling cases does not, by itself, warrant a change in policy in favor of legalizing physician-assisted suicide. We do not view legalization of physician-assisted death as a matter of individual rights [28, 29]. The debate should focus on whether legalization of physician-assisted suicide will enable our society to provide better care for dying and incurably ill patients, without causing intolerable abuses. The already-available option of terminal dehydration deserves careful consideration as an alternative to physician-assisted suicide.

Dr. Meier: PO Box 1070, Mount Sinai Medical Center, New York, NY 10029.