Really, I'm just not hungry.

The Ethicist column in the New York Times Magazine recently (November 24, 2013) addressed the ethical implications of the imposition of forced feeding (tubes) when a prisoner goes on a hunger strike.  The conclusion was that if the inmate’s intention was solely to make a political statement protesting terms of detention, to illustrate a social point, “using the deterioration of his body as a means of making a public argument,” then no forced feeding would be ethically required. If the intention of the inmate was to commit suicide, that the prisoner had simply lost the will to live, then the imposition of forced feeding was appropriate, even required. The prison had an obligation to prevent the suicide of an inmate, whether by sudden hanging or by self imposed slow starvation.

Now fast forward to your hypothetical last visit to the hospital.  You have provided your advanced directive.  You have told all your caregivers, including your primary care physician, your wishes for care should you become incapacitated.  You are at peace with life and ready for death.  There is no point to continue in pain.  You have rationally explained your actions.  You have stopped eating to hasten the end.

Would the same ethical obligation apply to the hospital medical staff? By not inserting a feeding tube and allowing you to refuse nourishment, are they assisting in a suicide?   I would think not, since your wishes have been carefully laid out in your advanced directive, at a time when you were clearly rational.  But as the debate about assisted suicide continues, I wonder how the medical community in our area will respond.  As noted in earlier posts (“A Sensitive Subject”, February 25, 2013), assisted-suicide is legal in several jurisdictions, including Belgium, Luxembourg, the Netherlands, Switzerland and three American states (Oregon, Washington, and Montana).  Does that mean that the withholding by request of a feeding tube from an otherwise functioning body but with questionable viability in any other jurisdiction constitutes assistance?


Without the advocacy of family members, how can you be assured that your final wishes will be carried out?  This is a conversation that we should all, at the right time, have with our primary care physician and closest caregivers?  I am not advocating this as an end of life strategy, but simply suggesting that it is something we should think about, and more importantly, talk about.  No one else will do this for us.

 Michael