This article is reprinted from National Review with the permission of the author.

Moves are afoot in bioethics to require caregivers to withhold food and water by mouth from a patient made incompetent by dementia if that patient, while compos mentis, has signed such a request — and even if the patient willingly eats, enjoys meals, or asks for food. It is sometimes called “voluntary stop eating and drinking [VSED] by advance directive,” in the parlance.

I have frequently criticized VSED by directive as inhumane to the patient, cruel to caregivers (as it forces them to starve people to death), and designed to open the door to lethally jabbing those with advanced dementia as the less onerous alternative to their being made to starve to death.

Now, as supposedly some form of compromise, there is a proposal on the table to barely feed — i.e., malnourish — dementia patients who have previously signed such a directive. From, “Mr. Smith Has No Mealtimes,” published in the Journal of Pain and Symptom Management (citations omitted):

Minimal Comfort Feeding (MCF) . . . is the provision of only enough oral nutrition and hydration to ensure comfort. With MCF, eating and drinking is not scheduled; rather, caretakers offer food and liquids only in response to signs of hunger and thirst. Patients are neither wakened for regular mealtimes nor encouraged to eat or drink. Instead, they are offered frequent, fastidious mouth care, continued social contact, therapeutic touch, sensory distraction, and medications to relieve distress associated with apparent thirst or hunger before being provided with minimal amounts of liquid or food.

This sure seems to be the same as VSED by directive, only more slowly. And it’s all so subjective, based on observation rather than a caregiver’s testing to see if the patient actively refuses to eat. Indeed, often medications can in themselves keep the patient from appearing hungry.

These supposed protections are weak and would be easily ignored in practice:

MCF is initiated only (1) after a patient’s advanced dementia is established (e.g., is consistently at Stage 7A or beyond using the FAST, or at stage 7 on the Global Deterioration Scale) and (2) after thorough discussion with the surrogate confirms the patient’s prior preference not to continue living with advanced dementia.

Please. The patient as he or she is now should be what matters, a fully equal human being deserving of sustenance if desired. For example, if an individual’s advanced directive said, “Don’t keep me warm or clean if I lose competence,” would we comply? Of course not! So, what’s the difference?

Accordingly, the provision of food and water — which is part of basic humane care — should be offered to see whether the patient wants to eat. Sometimes that means experimenting. When my mother was dying of Alzheimer’s, she stopped eating. Her visiting nurse companion brought over canned peaches. Mom scarfed them down with great pleasure. So, we fed her what she liked as long as she was able to eat.

The authors argue that the “now self” should be bound to the desires of the “then self” — even if the “now self” wants sustenance — with the complicity of surrogates.

The “now-self” is analogous to the person with decisional capacity who attempts VSED and either ceases their efforts or requires some nutrition and hydration on the path to eventually obtaining their goal of hastening death. The difference is that the decisional individual can modify their expressed preferences and more importantly their actions in the moment, while the person without decisional capacity depends on their surrogate and caregivers to execute the directive.

And they argue that the patient be so bound regardless of his current desires, as expressed, for example, by his actually eating and drinking — and even if the reduced sustenance causes discomfort:

There are certainly circumstances in which, regardless of whether a patient experiences discomfort once SED [stop eating and drinking] has begun, adherence to SED directives is acceptable to all concerned, including those providing direct care. But it is not uncommon that a person completing a SED advance directive has been insufficiently educated about real-world considerations to clearly consider the potential for vacillating preferences or the ethical concerns and obligations of the individuals executing the directive on their behalf, many of whom may have strong personal and cultural beliefs that will make strict adherence to the directive difficult, if not impossible.

Notice that the point is to hasten death:

Here MCF constitutes a fortunate compromise, allowing what caregivers provide to be both compassionate and loyal to the patient’s wishes. In comparison with completely stopping eating and drinking, we hypothesize that MCF would extend by only weeks the life with severe dementia that the patient does not want. Once understood as an option, it may even be preferred by those who would otherwise complete an advance directive for SED. MCF has two key advantages over SED by advance directive. First, it offers assurance that discomfort due to hunger and thirst will be addressed with minimal oral nutrition and hydration. Second, it better considers and addresses the ethical concerns of others.

No, this practice would seek to make palatable that which should be beyond the pale — starving and dehydrating dementia patents to death.

So, this is where we are as a society. If we reduced a sick pet’s sustenance so that they died over time, it would be deemed cruel and inhumane. But doing the same thing to a human being who would willingly eat is increasingly deemed “palliative” in the world of bioethics.

But, Wesley, one might say, we would put the animal down rather than slowly starve it. Exactly. Which is where all of this is heading if we continue down the “throwaway culture” path — as it already has in countries that permit lethal jab euthanasia, such as Belgium and the Netherlands.