ABSTRACT: Denying food and water to profoundly impaired people who may not be conscious, or may only be "minimally" conscious, raises challenging ethical issues. While there is growing support for withdrawing/withholding food and water (assisted nutrition and hydration, or "AHN") from people described as being in a "persistent vegetative state" ("PVS") and people with other profound neurological impairments, such as advanced dementia, the issue remains controversial, and for many, unresolved.
In this article, the author argues that if a profoundly impaired person is not imminently dying from a disease process, denying food and water causes
him or her to die of dehydration and starvation. When provision of food and water does not create excessive burdens (such as extreme pain and discomfort), and if the food and water can be digested and absorbed, denying such nourishment is immoral and unethical. Under these circumstances, this denial (by commission or omission) is motivated by a real intention to cause death, whether or not that intention is explicitly recognized.
Whether denial of food and water is prompted by thoughts regarding the value of a person's life, or "quality of life," or repugnance over the person's physical and mental condition, or concern over costs of care, or a desire to end the anguish of family members, or for more understandable motivations of wanting to end a person's suffering, such thoughts can be referred to as "killing thoughts."' Some might regard these motivations as "good" killing thoughts. But when a thought leads to an action (or an omission of an action) that directly results in someone's death, it is a killing thought. Killing thoughts express themselves through intentions to hasten death--intentional killing. I will discuss in this article how killing thoughts are disguised or "masked" in order to detoxify the reality of intentional killing. I will not go so far as to call such killing "murder," as that implies malicious, premeditated, conscious intent. While killing people in a "PVS" by dehydration and starvation can be premeditated, i.e., considered beforehand and consciously understood, usually such killing is not overtly malicious, unless of course there is malicious intent, such as wanting an inheritance sooner than later. Usually, however, the denial of food and water to people in a "PVS" is motivated by misguided compassion, and could more properly be referred to as what used to be called "mercy killing." While mercy killing may be more understandable and to some acceptable or even desirable, mercy killing is euthanasia, which is "an action or an omission which of itself or by intention causes death, in order that all suffering may in this way be eliminated."2
This article does not deal with complex legal decisions regarding the "AHN/ PVS" issue, nor with advance directives, informed consent, costs, or definition of death. These are relevant to the debate, but here the focus will be on the primary issue of intention and how intentions become masked and disguised. The author touches upon the analysis of benefits and burdens in decisions to withhold or withdraw food and water, but will concentrate on what he believes is the most compelling issue in the "AHN/PVS" debate-intention. He gives particular attention to the issue of providing food and water to people described as being in a "PVS" because this is the "front line" where the "AHN" battle is being fought. While the same issues apply to advanced dementia or other neurological impairments, the "PVS" issue is unique in that the very impetus for inventing the term "persistent vegetative state" was driven by masked intentions. It is instructive to note that from the very beginning when Jennett and Plum first invented the term "persistent vegetative state" in 1972,3 they suggested that perhaps "supportive measures" should be withdrawn. They state: "If it were possible to predict soon after the brain damage had been sustained that, in the event of survival, the outcome would be a vegetative mindless state, then the wisdom of continuing supportive measures could be discussed. …