'The art and science of fasting - Abstinence from food and drink as a means of accelerating death', a 28-page research paper by Chris Docker in the booklet Beyond Final Exit (published by The Right to Die Society of Canada, PO Box 39018, Victoria, British Columbia, V8V 4X8; 1995, ISBN 1 896533 04 3; 14 American or Canadian dollars incl. p&p). Reviewed by Nicholas Albery.
The Natural Death Centre has always argued, on balance, against active euthanasia (see the Good Death book review above, concerning the slippery slope danger); although the Centre recognises that there are very convincing arguments on both sides of the debate. At the same time, the Centre has supported the concept of passive euthanasia, particularly death by fasting. In the Natural Death Handbook, there were stories from the partners of two people who had peacefully fasted to death. The advantages seemed to include that the method was slow and relatively dignified and called for determination whilst allowing for second thoughts (rather than just popping some pills and pulling a plastic bag over one's head); that it was already legal to refuse force feeding either verbally at the time or in advance through one's living will; and that as a way of dying it would tend to be hard on the relatives - and therefore it was less likely that the patient would feel pressured to adopt it.
The Natural Death Handbook called for further reports on this under-researched topic, and this paper on 'The art and science of fasting' by Chris Docker is a truly admirable contribution to filling the gap. Chris Docker helps run the Voluntary Euthanasia Society in Scotland; he maintains an excellent Web site for the Society; and he remains patient and courteous with those on the other side of the debate. He is also an authority on living wills and points out in this paper that, in 20 out of 39 American states, the legislation in favour of living wills specifically excludes termination of life by the withdrawal of nourishment and hydration.
Whilst in his paper he comes to a different conclusion to that of the Natural Death Centre - for he believes that "fasting may be an uncertain course for an individual to embark on, especially when suitable drugs for self-deliverance can be obtained without too much difficulty in most countries and so provide an alternative route to dying in dignity" - and whilst he does not deal with the matter of whether or not a slow dying is preferable, he does report a number of reassuring medical studies which seem to indicate that, with doctors to assist where necessary, fasting and even dehydration are not painful ways to go.
The following are summarised extracts from the core of his paper:
Let us examine some of the evidence of peaceful and dignified deaths by fasting. While there are individual, anecdotal reports that seem to offer much hope, the two principle sets of data I propose to draw attention to cover:
a) voluntary fasting by a particular religious sect and
b) voluntary fasting in a hospital or, more usually, hospice setting.
With this second category will also be grouped withdrawal or nutrition and hydration in competent patients. These groups, however, may be considered to some extent atypical. The former covers an ascetic and well controlled graduated fast by relatively healthy subjects; the second relates primarily to subjects who are mostly elderly, terminally ill and, most importantly, have access to adequate palliative care.
Voluntary fasting to death within a religious sub-group appears to be confined to the Terapantha order within the Jaina Digambara community in India, where it is said that several well known cases occur every year.
The fast is described in Bioethics (Bilimoria P, 'A report from India: The Jaina ethic of voluntary death', Bioethics 1992; 6(4):331-355):
In early 1983, a prominent Jaina scholar and writer by the name of Jinendra Varnî, then in his early eighties, although in reasonable health, decided that he wanted to fulfil his life's journey through a dignified yogic death (samadhimarana). On April 12th '83, Varnî formally withdrew from his worldly commitments and upon request received from the head preceptor of his order, with due acclamation for his courage, initiation into the vow of terminal fast (sellekhana). He had already reduced his food intake; now as each day went past he cut back on certain vegetables, milk, clarified butter, yoghurt, dried fruits, giving up something every day, but retaining small portions of boiled vegetables and sultanas for one meal of the day.
Occasionally he would fast all day long, and break the fast with broth from a boiled vegetable. By the end of the month his fluid intake was reduced as well and gradually given up, with plain water remaining as his only intake, which too was set aside on alternate fast days. On May 23rd, water was given up altogether. Varnî reclined with his body to one side during the last days, but there was apparently no evidence of hunger pangs, pain of any other kind (particularly from by-now deteriorating internal organs), barring some coughs and discomfort while sitting upright owing to his frail frame; nor did he show any significant loss of attention and consciousness. On May 24th, exuding a tremendous peace and calm in his general demeanour, Varnî closed over his eyelids and breathed his last.
This reassuringly peaceful death is a far cry from the horrors of starvation recounted elsewhere. Glimmerings that death from starvation and/or dehydration may not be as horrific as often contemplated have filtered through in mainstream medical literature for some time, probably starting with early fasting studies, through observations in palliative care when hospice workers realized that artificial nutrition and hydration were not necessarily beneficial to terminally ill cancer patients, and finally in recent years amidst the right to die debate, advocacy of willed fasting as a means to legal self-deliverance combined with the palliative assistance of hospice care.
In looking at comfort measures for the terminally ill, Billings went a stage further in noting: "... fluid depletion in dying patients should be regarded as a disorder with relatively benign symptoms. Successful treatment of the discomfort of thirst and a dry mouth generally does not require rehydration." By 1988, Printz had publicised the little-known situation where:
... A hospice nurse in 1983 noted a correlation between comfort and lack of medical hydration. It appeared to her that terminally ill patients in end-stage dehydration experienced less discomfort than patients receiving medical hydration. The dehydration, resulting from lack of nasogastric or IV fluid, seemed to produce a natural anaesthetic effect, often allowing for a reduction in pain medications.
A study by Andrews and Levine published in 1989 showed widespread support among hospice workers for dehydration in some terminal patients:
Of the hospice nurses surveyed, 71 per cent agreed that dehydration reduces the incidence of vomiting, 73 per cent agreed that dehydrated patients rarely complain of thirst, 51 per cent reported that there is relief from choking and drowning sensations when fluids are discontinued, and 53 per cent agreed that dehydration can be beneficial for the dying patient. Also, 85 per cent of nurses surveyed disagreed with the need for hydration by IV and/or tube feeding when dehydrated patients have a dry mouth. Finally, 82 per cent of the nurses disagreed with the statement that dehydration is painful.
They concluded that, in contrast to the assumption of most health professionals, dehydration was not painful, and that it was therefore a viable alternative to facilitate a comfortable death.
As death from lack of nutrition alone is a potentially very lengthy process, a combination of ceasing nutrition and hydration by some method is likely to be a preferred course. This area undoubtedly needs much more research. While a peaceful death by this method seems feasible in some instances, without particularized medical advice and medical backup, and/or until more is known about the process of self-deliverance through fasting, an isolated individual acting alone would appear to have greater assurance of success by means of drugs. Abstinence from food and drink as a means of accelerating death does however have the distinction of being the only method at the present time in which all sides in the 'right to die' debate may reach common agreement under the law.
Having tried to separate myth, misinformation and 'scare stories' from well-documented evidence, it is still difficult to say that refraining from food and drink will guarantee a peaceful death. Someone wanting a 100% foolproof method might consider it foolhardy to emulate Jinendra Varnî. A young, obese woman who has never followed a healthy diet might be ill-advised to attempt total fasting - even in the face of unrelievable distress or lingering, terminal illness.
But this is an area where a personal medical advisor may be able to narrow the odds and, if things go wrong, keep you comfortable in your dying without violating any laws and being branded a criminal.
This book can be obtained in the UK for £8 (incl. p&p) from The Voluntary Euthanasia Society of Scotland, 17 Hart Street, Edinburgh EH1 3RN (tel 0131 556 4404; fax 0131 557 4403; e-mail: didmsnj@easynet.co.uk; Web: http://www.euthanasia.org/).
Adapted extract from an item in an unidentified Right-to-Die e-mail. The Right-to-Die e-mail group, which provides news on euthanasia issues, is contactable via http://www.finalexit.org/subscribe.html.
"Isn't starving people to death cruel?" Persons in an irreversible coma or persistent vegetative state are in deep coma. They have no sense of time and they do not feel pleasure or pain. They do not sense the withdrawal of artificial nutrition and hydration.
For all of history, until very recently, people have been dying without artificial nutrition and hydration. In a natural death, the terminally ill person does not want and even refuses food and all but sips of water.
It is natural for the dying to refrain from ingesting food and water. It is unnatural to "force-feed" the dying.
In 1986, Belding Scribner, MD, Professor of Medicine at the University of Washington, inventor of long term artificial kidney treatment and consultant on nutrition and hydration, testified before the Washington State Senate about whether it is humane to withdraw hydration.
He stated the following:
Withholding of hydration has to be considered in two parts: First, the withholding of salt water (normal saline) causes no pain and suffering of any kind. It takes weeks or months for significant salt depletion to develop and, when it does, the effect is a gradual drop in blood pressure and eventually a painless death from severe low blood pressure.
Secondly, concerning withholding of plain water, here is where opponents conjure up images of the '49ers dying of thirst in Death Valley with horrible thirst, swollen tongues and cracked lips. The case is quite different for the comatose, terminally ill patient lying in bed, usually in an air-conditioned environment.
The condition of the mouth depends upon the oral hygiene provided by the nursing staff, not on the state of hydration. Thirst, if present, is very subtle and easily treated, where appropriate, with ice chips or sips of water. There is no other pain and suffering that occurs.
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