In one of the most blatant instances of the "choice devours itself" phenomenon to come along in a while, the Dutch medical association has written out guidelines on starving and dehydrating people to death that order doctors to continue dehydrating patients who ask for water or food. Such requests are to be treated as "delirium" on the part of a person who had previously (allegedly) consented to be dehydrated to death. The person is to be medicated into quietness if necessary so that he will "reach his goal" of dying.
These guidelines apply even to food and fluids received by mouth.
Interestingly, the guide is somewhat inconsistent on this point and pretends (and I do call this "pretending" without apology) to be making a medical distinction between a request for water made in "delirium" (treating this as an objective judgement) and a request that constitutes a genuine change of mind. When describing different stages of the process of dehydrating a patient to death and discussing the "preparatory stage," the guide says,
It is important to discuss how those close to the patient and the care providers should respond if the patient requests something to drink despite his decision. In such situations the patient should be asked whether he is certain that he would like something to drink. If the patient answers in the affirmative and has capacity to decide on the matter, the request should always be complied with. After all, the patient must be given an opportunity to reconsider his request. (p. 27)
Rrright. Well, let's just start with the fact that this makes it pretty clear that even at this stage the care givers are obviously trying to make it hard for the person to request a drink. "Are you sure? Remember, you said you wanted to die by stopping eating and drinking."
But all this talk about giving the person a chance to reconsider his decision goes to the wall later in the guide where it is assumed that the person's request is delirious, even if he asks insistently and repeatedly for water. So much for "the request should always be complied with."
In the context of a patient who has stopped eating and drinking an exceptional situation may arise whereby the delirious patient asks for something to drink. If the patient insistently and repeatedly demands fluid, this could create a difficult situation. On the one hand, it may be extremely difficult to refuse the patient’s request, while, on the other, a person close to the patient or the care provider wishes to adhere to the agreements made by the patient at the time he had capacity to decide. When this occurs, the parties concerned can fall back on the agreements made during the preparatory phase and/or in the patient’s living will (see Sections 5.4.1 and 5.4.4).
It is imperative for care providers, particularly if a difficult situation arises, not to suddenly interfere with the agreements previously made with patients and offer them something to drink. If patients are offered fluid, they will fail to reach their desired goal. For this reason it is essential to prevent and treat delirium using the non-pharmacological measures described below, in addition to pursuing an anticipatory policy, combined ‘where necessary’ with medication policy in the event the patient becomes restless or delirious. p. 37
The cold-bloodedness here is striking. The guide admits that it may be "difficult" for those caring for this person (who might not even have been dying to begin with, let me add) to refuse his repeated, insistent cries for water. But they should harden their hearts and remain firm, in supposed deference to his choice, so as to help him reach the goal of dying that he set when he was deemed to be really in his right mind.
Exactly when and how the person crosses the line to the point that his requests for water will be refused and that he can no longer reconsider his decision to die in this horrible way is unclear, despite the talk of "delirium" and "capacity." It looks very much like the medical people are going to wing it as far as deciding whether he has capacity to ask for water and that the presumption is going to be that the person lacks capacity to change his mind after the process has been going on for a while. So consent is turned on its head. Receiving water is turned into the kind of thing that you need to have heavy "capacity" for consenting to and that you are presumptively deemed not to have capacity to request if you previously agreed to be dehydrated to death.
Wesley J. Smith highlights several other noteworthy aspects of this diabolical guide to killing patients. The guide is blatant in its bias against older people and its treatment of their lives as less valuable than those of younger people. It explicitly states that those age 60 and older need not even be verbally dissuaded from the decision to die, even if they are completely healthy! Younger patients should be "emphatically advised" not to kill themselves as long as they are not "suffering from a life-threatening illness." What ontological magic occurs on one's sixtieth birthday to make one Lebensunwertes Leben is left to the imagination.
The guide is also insistent that conscientious objection to starving and dehydrating one's patients to death can take, at most, the form of finding another doctor who will do the deed. Someone with a conscientious objection is graciously permitted to "assign the care for the patient concerned to a colleague care provider," but the person must receive "assistance" to be dehydrated to death, one way or another.
Smith also points out that the guide is utterly radical in its designation of who must be "helped" in this way. Even though younger people are to be advised not to commit themselves to be killed by dehydration, they can't be refused. A person who at some point desires to be dehydrated to death automatically becomes a "patient" in relation to the doctor who becomes aware of his desire, even if the person is not ill otherwise! And the doctor and other medical professionals are then obligated by medical guidelines to "help" the patient to die in this way.
These issues certainly arise in countries other than Holland. Holland, of course, is notorious. But there was a case recently in Canada where a court for once ruled correctly that a woman named Margot Bentley could continue to be fed by mouth despite earlier requests to be starved and dehydrated to death. Her case would fall squarely within the guidelines of the Dutch medical association; the guide would say that food and water should not even have been offered to her by mouth and that this was an abrogation of her free will. That is exactly what her family argued, against the merciful nursing home that was feeding her.
Pastor Joshua, also in Canada, was less fortunate and suffered without food and water for eleven days before finally being given it by mouth. He had not even indicated anything about his wishes in the matter.
Many years earlier, Marjorie Nighbert was dehydrated and starved to death in the U.S. despite clearly asking staff for something to eat. It wasn't even clear in that case that her earlier living will applied to her receiving food and fluids by mouth.
Ethicist Thaddeus Mason Pope explicitly holds to the position of the Dutch Medical Association on these issues, and I think it fairly likely that these principles are being applied in practice in many parts of the United States.
Hence what should be regarded as severe patient abuse and elder abuse (when carried out on the elderly) comes to be a professional virtue if the mantle of "choice" can be thrown over it.
The only advice I have to give here is just this: You can't be too careful. Never consent or appear to consent to having food and water withdrawn. Indeed, even if you sign something consenting to have no food and water given by tube, it could very well happen that no food and water are offered by mouth either. In the U.S., offering these by mouth will vary depending on the institution and who is running it, but the risk is definitely there that you will be deemed, as in Marjorie Nighbert's case, to have refused all food and water and that a protocol like that of the Dutch Medical Association will be applied even if you later ask for food and water verbally.
Do not be too trusting. Make it clear in writing that you wish to receive food and water. To be cynically frank, it's possible you'll be killed by being denied it anyway if you become helpless, but the probability is greatly increased if you give any excuse in the way of a document or even a conversation in which you express a wish not to receive food and fluids.
And contrary to the disingenuous proclamations of (some parts of) the Dutch Medical Association's guide, you will not be given every opportunity to reconsider.