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Choice Devours Itself: Forcing people to continue to dehydrate to death

I blogged here about Margot Bentley and her family's desire to dehydrate her to death even though she is eating by mouth. The family is allegedly motivated by a desire to carry out her own former wishes; she was previously a big death advocate. She now has dementia and, they say, isn't knowingly "consenting" to eating by mouth. The judge, fortunately, was more sensible and is not going to force the nursing home to kill her. (The family has appealed.)

One ethicist, Thaddeus Mason Pope, is unhappy about the court's decision not to force the nursing home to dehydrate Margot Bentley. He considers it a form of "paternalism." Pope supports what he calls "Voluntary Stop Eating and Drinking" (VSED). He applies this category, inter alia, to cases where people later change and want food and water but where they are not fully compos mentis at the time of their later desire for food and water. In those cases, Pope holds that to hold them to their earlier desire for death, expressed when they were more "with it" mentally, is simply helping them to engage in voluntary death by dehydration.

This is a perfect example of the choice devours itself phenomenon that I have talked about so often: Make the availability of some choice uber-important, and in the end force that "choice" upon the very people who were originally supposed to benefit from it but who prove themselves uninterested or unappreciative of that option when push comes to shove. When choice devours itself we get the following: Apologetics for forcing or at least strongly pressuring women to have abortions, holding people's hands down if they suddenly decide they don't want to suffocate to death after all, pressuring the elderly to write living wills in which they refuse treatment, and here, forcing people to stick to their original claim that they wanted to dehydrate to death.

I engaged Pope a bit in the comments at Wesley J. Smith's blog, and he was quite frank about his views while at the same time being completely oblivious to the bizarreness of his use of the concept of "voluntariness." Pope reiterates his opinion about Margot Bentley:

It seems clear that Bentley now lacks capacity to make any decision -- about anything. Her swallowing is a reflex not a decision or choice. Therefore, she cannot revoke her earlier refusal (made with capacity). The earlier decision prevails.

I questioned him about how he would approach a case like that of Marjorie Nighbert, who verbally requested food and water but was starved and dehydrated to death anyway on the basis of reasoning exactly like Pope's. (Namely, that she lacked "real capacity" to "revoke her earlier decision" to be starved to death.) I wanted to know if Pope would apply his strange notion of what is "voluntary" to cases where patients are actually asking for food. He was quite clear:

If the deliberation that went into the advance choice to VSED were significant, then that choice deserves respect. It ought not be too easily overridden.
Ability to speak does NOT necessarily mean capacity. Just because she can say "I'm thirsty" or "Give me a drink" does not mean that she has capacity to make that decision under the circumstances.

Notice what Pope and his ilk are doing here: They are treating the former statements of the patient as setting up a later situation in which the receipt of food and water, even by mouth, is a legally "heavy" event rather than a legally normal event. In other words, for Margot Bentley or Marjorie Nighbert to receive food and water again, even upon request, should according to Pope's analysis require a capacity similar to their being able to sign a contract. Normally, receiving food and water is not like signing a contract. Usually, nobody has to meet a high threshold for mental capacity to receive food and water. Receiving food and water is not normally something that requires mental capacity and affirmative consent. But in Pope's preferred world, receiving food and water comes to be similar to signing a contract if the patient has previously made statements while in full possession of his faculties that are taken to imply a refusal of food and water. If he has done that, then his dying of dehydration subsequently is taken to be voluntary, even if he requests food and water verbally! The only way that he can revoke that earlier decision is if he is deemed to have recovered sufficiently full mental capacity to sign off on revoking his earlier decision.

This is so twisted a concept of what is "voluntary" and what is coerced that it boggles the mind. It is interesting to note, though, that it arises from an attempt at neutrality. Here's how that sort of deadly "neutrality" works: Nothing we do for a person is to be treated as normal care for which special consent is never required. Wesley J. Smith notes in his entry that Pope also says that a person should be allowed to state ahead of time that he does not want to be turned in his bed to avoid bed sores and that this predetermination should be followed! Applying Pope's twisted logic concerning food and water to the no-bed-turning request would mean that this previous choice should also be continued even if the person later feebly asks to be turned because he is suffering terribly from untreated bedsores! After all, the later request need not indicate true "capacity" to rescind the earlier request to be left to die without care!

The idea is that everything is on a par. Food and water, being turned in the bed, being kept clean, are just like, say, kidney dialysis. Once one has made a mentally competent decision to refuse these things, they become legally off-limits unless one regains full capacity and indicates clearly that one has changed one's mind with full capacity. Indeed, the situation created by such a living will then becomes similar to the situation we now recognize with regard to young children and sexual contact. Even if no violence is involved, acts of pedophilia are (quite rightly) not regarded as consensual, because the child is unable to give true consent. Pope is applying that logic to Margot Bentley's acceptance of food and water! She isn't really consenting, he says.

But the presupposition that everything one might do to a person is equal is of course wildly wrong. Ordinary care is not equal to extraordinary treatment. Torture is not equal to giving a cup of water, and so forth. (If one wrote, with full mental capacity, that one wanted to be tortured on the rack on a certain date in the future, would it be "paternalistic" not to carry out the torture later? What if one suffered severe brain damage before that date and, on that date, begged for the torture to stop? Would that be "mere instinct" and not an indication of "true capacity" to change one's earlier request to be tortured?) The acceptance of good food and water should never be regarded as requiring explicit and mature consent. It just isn't that kind of thing, and making it so creates the twisted situation in which a person can be "voluntarily" dehydrated to death while begging for water.

The Thaddeus Mason Popes of the world represent what bioethics has become. They are brutally consistent with their mad premises, but, because the premises are mad to begin with, the ultimate outcome is murderous nonsense.

As a final note, this is a reason for raising a caution if you are advising a young person who is thinking of specializing in ethics as a sub-field of philosophy. This is the secular philosophers' notion of being neutral and professional. Unfortunately, this type of "professionalism" is divorced from an important correlate: Sanity.

Comments (11)

An excellent takedown of Pope's position, and thank you for it.

Suppose someone fully "with it" signs an advance directive stating that, should he be rendered "not fully with it," he wishes *not* to be dehydrated to death. Suppose that he is in fact later rendered "not fully with it," and yet declares loudly that he wishes to be dehydrated to death. Will Pope hold the patient to his former wish, or to the latter?

My guess is that Pope would be consistent in that case and would stick with the wish made while the person was fully "with it." However, in practice, I doubt that that will be carried out, and I doubt that Pope or, especially, others like him, will do much about it. So, e.g., if a person with dementia moans, "Just let me die" and is then euthanized, where will the cadre of outraged ethicists be? An example would be Ronald Dworkin, who scoffed at the notion that people would be euthanized without consent yet never has lifted a finger to prevent it or to speak out against it. In Europe they are already euthanizing people with dementia, without request made before they were diagnosed, and we're hearing crickets.

"The idea is that everything is on a par. Food and water, being turned in the bed, being kept clean, are just like, say, kidney dialysis."

I think this is a symptom of a broad feature of modernism as a whole. Having no ultimate or transcendent standard of the Good, and being suspicious of hierarchy in general, modernists are not able to prioritize the various individual goods. Hierarchy will out, however, and the new hierarchy is headed by "consent." That this is now being reflected in bioethics is maddening, but perhaps not all that surprising.

To avoid later charges of encouraging crickets, the notion that voluntary consent can exclude non-coerced verbal wishes is a lie. If Thaddeus Pope doesn't know this then he has more dementia problems than anybody he professes to represent.

Receiving food and water is not normally something that requires mental capacity and affirmative consent. But in Pope's preferred world, receiving food and water comes to be similar to signing a contract if the patient has previously made statements while in full possession of his faculties that are taken to imply a refusal of food and water.

One might go even further: a person cannot make a valid contract to have someone kill him (say, to collect life insurance), nor can a person make a valid contract to sell themselves into slavery. Similarly, any "order" or "consent" or contract that a person makes to be starved or dehydrated to death should not be honored. But even if a state were to try to be "neutral" about whether such a directive could be valid AT THE TIME MADE, and not just a departure from reason, it should be viewed as being under heightened scrutiny and presumptively suspect, so that there should be a very low bar to overturning it, even such as a later simple request for water and food. Which, I think, is similar to what Step2 is saying as well.

I know that umpteen years ago on a blog far away when Step2 and I used to spar about various issues, Step2's position was definitely that later statements by the person requesting water and food should be honored. In charity I'm going to assume that that is still his position and that it would apply even if the person later requesting water has dementia or lacks full capacity or even to a person like Margot Bentley who is accepting food and water by mouth without being capable of speaking.

I enjoyed this well-written post. I have laid out my argument in a more structural, step-wise fashion in a blog post tomorrow morning at medicalfutility.blogspot.com. I think our disagreement centers on stage 5 and maybe stage 4.

I shall read your post with interest.

First, and most importantly, your frame is completely wrong. This is not a legal property contract between your "full capacity" self and the caregivers, it is a declaration of your wishes for your preferred treatment that is not binding on your future choices. Second, unless the person somehow has experience in starving themselves to the point of incapacity (i.e. an eating disorder), I don't grant for one moment they are making an informed choice with full awareness of the consequences. Third, autonomy isn't being violated with food and water in anything remotely similar to the way emergency medical treatment is technically considered an assault without consent. Fourth, your attempt to conflate these two very different treatments is absurd. Fifth, you don't fully appreciate the consequences of your decisions to forbid others from changing their minds, therefore my initial diagnosis of you still stands. Sixth, after reading one of your many blogs I found out that you are fine with "hard paternalism" when it comes to public policy on obesity, so your protest against it in this case rings hollow.

What Step2 said. !!

Great comments, Step2.

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