Death by deliberate dehydration and starvation: silent echoes of the hungerhauser.

• Author: Dolan, John M.
• Position: Symposium: Current Controversies in the Right to Live, the Right to Die

During the final days of his life, Oscar Wilde, aware that death was imminent, lost interest in food but drank whenever one of his visitors brought him a bottle. In reply to a friend's warning that his drinking was self-destructive, Wilde said: "You are qualifying for a doctor. When you can refuse bread to the hungry, and drink to the thirsty, you may apply for your Diploma." (1)

Wilde was a master of hyperbole. He was, after all, the playwright who assured us that "nothing succeeds like excess" (2) and who is reported to have declared, while sipping champagne on his deathbed: "I am dying as I have lived: beyond my means." (3) His deathbed quip about the ability to refuse bread to the hungry was a preposterous characterization of the qualifications of a nineteenth-century physician; but, incredibly enough, as our own century draws to a close, we have among us individuals prepared to take seriously Oscar Wilde's specifications of the requirements for a physician's diploma.

It is a remarkable circumstance that, in a nation whose wealth and resources are so vast as nearly to defeat the imagination, scholarly conferences, articles in learned journals, and courts ponder the question whether we can be justified in deliberately causing death by withholding food and water.

Dostoevsky remarks that one may judge the degree of civilization in a society by entering its prisons. (4) He measures a society's civilization by gauging the fate it accords some of its most wretched members. In the same spirit, others argue that the correct measure of the degree of justice in a society is the lot it accords its least fortunate citizens. Rawls's theory of justice holds that a just society is one which, in addition to according each of its citizens the largest amount of political liberty compatible with each enjoying the same liberty, also allocates all other goods that arise from social cooperation (wealth, income, privileges, and so on) in accordance with a scheme designed to maximize the welfare of the least advantaged representative persons. (5) And Christ's teaching was: "Inasmuch as ye have done it unto one of the least of these my brethren, ye have done it unto me." (6)

The present task is one of casuistry. In the case proposed for analysis, certain family members are asking the officers of a nursing home to stop supplying nourishment and fluids to a relative who resides in the home administered by those officers. The relative in question is an unconscious man who has been diagnosed as being in a "persistent vegetative state." Thus, we have before us someone wholly defenseless and vulnerable. If any one fits the biblical description, surely Mr. Stevens, the defenseless disabled man whose nutrition may be cut off, counts as "one of the least of [our] brethren." Our assignment is to state principles that should be applied in the case at hand and to recommend a course of action. The next section of this article articulates three principles that bear on the case and draws the conclusions they dictate. The sections that follow examine some of the details involved in the case and express some reflections on the moral climate of a society in which cases such as the present one are viewed as presenting a serious challenge to moral intelligence.

The thesis defended here is that the central question raised by the case under discussion is whether it is every permissible to arrange deliberately for a disabled person who is not terminally ill to die of thirst and starvation. It is worth recalling that the Phoenicians, who devised the method of execution known as crucifixion, originally employed the technique as a method of killing by deliberate dehydration and starvation. (7)

The earliest 'cross' was actually just a vertical stake to which the condemned was tied and left to expire from thirst and starvation. (8)

It is remarkable that physicians and laymen are now seriously contemplating adoption of a method of killing that was regarded as particularly cruel and degrading in the ancient world and was, among the Romans, who inherited the technique from the Phoenicians, "reserved for slaves and the worst of criminals." (9)

Short Answer

The first of the three principles employed in this initial analysis has two versions, one moral, the other legal. The moral version of the principle reads as follows:

(1) A deliberate omission that causes death is morally an act of intentional killing when three conditions are satisfied:

(i) it is within the agent's power to supply what is being withheld;

(ii) the agent has an obligation to supply it; and

(iii) the agent understands that withholding what is needed is likely to cause death. (10)

The relevant notion of obligation appealed to in clause (ii) is, of course, moral obligation. If one replaces the word morally, which occurs earlier in the formulation above, with the word legally and reinterprets the obligation in clause (ii) as legal obligation, then one has a legal principle that is valid in a number of legal systems, including our own, namely:

(1) A deliberate omission that causes death is legally an act of intentional killing when three conditions are satisfied:

(i) it is within the agent's power to supply what is being withheld;

(ii) the agent has an obligation to supply it; and

(iii) the agent understands that withholding what is needed is likely to cause death. (11)

Let us now consider the bearing of this principle (in both of its versions) on the case we are examining. The officers of the nursing home certainly have the capacity to supply nourishment to Mr. Stevens. Further, they assert (correctly, in my judgment) that they have an obligation to supply nourishment to Mr. Stevens (an obligation that is both moral and legal). Finally, they understand clearly that withholding nourishment from Mr. Stevens will certainly result in his death.

It follows from the principle enunciated above (in both of its forms), and from the propositions just stated about the officers of the nursing home, that deliberate withholding of nourishment from Mr. Stevens on the part of those officers would, in the circumstances we are considering, count both morally and legally as an act of intentional killing.

A second principle relevant to the case we are considering reads as follows:

(2) Intentional killing of the innocent always counts as murder.

The term innocent, as it figures here, means simply "not harming." Thus, someone who is assaulting another person is not innocent in the relevant sense. Someone found guilty of a capital offense by due process of law is also not innocent in the relevant sense. Advocates of euthanasia and abortion differ in their response to this principle. Some acknowledge it but insist either that the particular form of destruction they favor does not count as intentional killing or else that the individuals whose destruction they favor are not persons. In its 1986 statement concerning withholding food and water from patients who are not terminally ill, the American Medical Association (AMA) took the first of these lines, declaring, in effect, that one can deliberately withhold food and water from a patient who is not terminally ill and thereby cause that patient's death without intentionally killing him. (12) A host of other advocates of euthanasia and abortion--e.g., most of the defenders of Roe v. Wade (13) speaking of the status of the unborn child, the Nazi theorists Karl Binding and Alfred Hoche on severely retarded persons, (14) and scores of contemporary bioethicists on such severely disabled persons as Karen Ann Quinlan and Nancy Beth Cruzan (15)--choose the second approach, assuring us that the individuals whose destruction they advocate are not persons. Other writes, even more frightening, acknowledge that the euthanasia (or abortion) they advocate does amount to deliberate killing of innocent persons but deny principle (2). Some imagine that the consent of the victim waives the victim's right to be free from lethal assault, thereby exonerating the killer. (16) Others ignore even this weak gesture of justification and confidently assert that destruction even of unconsenting innocent persons is perfectly justified under certain circumstances. Judith Jarvis Thomson's defense of abortion (17) falls into this category, as do current proposals to "retrieve" organs from living anencephalic infants and proposals to destroy incompetent patients for their own good. Sounder authors embrace principle (2); indeed, G.E.M. Anscombe invokes (2) as a specification of the central core of application of the concept of murder. (18)

Given the conclusion we have already reached, namely, that the deliberate withholding of nourishment from Mr. Stevens on the part of the nursing home officers would be an act of intentional killing, it follows from principle (2) that such a deliberate withholding would also count as murder.

The upshot of this elementary reasoning is obvious, for we can appeal now to a third principle, which is both basic and wholly uncontroversial:

(3) Murder is always wrong.

Anyone who undertook to challenge this principle would be challenging moral judgment at bedrock. Some writers suppose that murder can be defined as "wrongful killing." If that view were correct, then challenges to principle (3) would be as silly as challenges to the proposition that all bachelors are unmarried. Correspondingly, in that case, principle (3) would be as empty as the assertion that all bachelors are unmarried. But, as G.E.M. Anscombe and Philip E. Devine both argue in their discussions of murder, the definition of murder as wrongful killing is incorrect. (19) The prohibition of murder is a substantive prohibition; it is not the empty injunction to refrain from carrying out the sorts of killing that you should refrain from carrying out. Questions of correct definition and exact explication of concepts are ordinarily quite daunting. Revising H.L. Mencken, we might remark that, for every...