It has been 10 years since Dr. Margaret P. Battin published an excellent summary about the problems with the word “suicide” in the end-of-life context. Since that time, Medical-Aid-in-Dying (MAID) has expanded to a total of 14 US jurisdictions. Concomitantly, Voluntary Stopping of Eating and Drinking (VSED) has entered the public conversation, especially with regard to its use for those who choose to eschew the ravages of dementia. This growing awareness and adoption of VSED has led to confusion about the appropriate vocabulary for talking about and classifying self-inflicted death.
If a person lives in a state that offers MAID, and they have a qualifying terminal diagnosis, and they use MAID to end their life, the “Manner of Death” on their death certificate will be classified as “Natural.” If their state doesn’t offer MAID, but they nevertheless hasten their death to end their suffering, their “Manner of Death” will generally be classified as “Suicide.”
But what is the “Manner of Death” if a person dies by VSED? According to an article in the October, 2023, Journal of American Medical Directors Association titled “Challenges in Completing a Death Certificate after Voluntary Stopping of Eating and Drinking (VSED),” there is no consensus on whether a VSED death should be classified as “Natural” or as “Suicide.” The authors call for “debate involving a wide variety of experts” in order to resolve the issue.
And what is the appropriate description of the death which ensues when an individual on life-supporting medicine or machinery asks that they be immediately be suspended? That death was self willed, even if nature took its course. Does that person's agency qualify as self-willed death?
Additionally, those who use death by nitrous oxide may well be classified as suicide, even though they made a conscious, rational decision in the face of an excruciating cancer or neurological terminal illness.
Surely as a society, we need to differentiate between the individual in robust physical health who, in reaction to the despair or desperation arising from a divorce, death of a child, loss of a job, financial crash, shoots themself, and one who advised they have less than a few months of life due to a cancer or ALS, takes medicine prescribed by a medical professional.
A MAID death is clearly not a “Natural” death, but neither is it a “Suicide.” But instead of creating a new class of death for death certificates, the MAID legislation codified the “Manner of Death” for a MAID death as “Natural.” Contrast this with VSED, which is not something that has been legislated. VSED is simply seen as a choice that people are at liberty to make for themselves. Thus, there is no law specifying how to classify VSED on a death certificate. Each jurisdiction is free to decide for themselves how to classify the death. Is it a “Natural” death or is it a “Suicide?”
We are being presented with a false choice here. Both MAID and VSED belong to what has been hiding in plain sight as a different class of death, a hidden species that comes into view once we consider our longer life spans, last century’s dramatic advances in public health, and the increasing desire for an alternative to a long, painful, expensive, or ugly death.
It’s much closer to the truth to say that people who use MAiD and VSED are euthanizing themselves than to say they died a natural death or died by suicide. Suicide is by definition an act that is inconsistent with one’s self-interest. It is also an act society wishes to discourage and prevent because it is largely subject to successful interventions through therapy, support groups, medication or counseling.
MAiD and VSED, by contrast, are acts of self-compassion which arise when a person is facing an imposed mortality likely to ensue within a few months, if not weeks. The great majority of Americans recognize their methods of hastening the inevitable as worthy of support. And, clearly, the death of a competent adult who doesn’t have access to MAiD but chooses to hasten their death by means other than VSED falls into the same class as MAiD and VSED. And yet, we will commonly refer to this death as some sort of suicide, and record it as “Suicide” on the death certificate.
In addition to the harm done to our public discourse by the misuse of the word “suicide” in this context, our suicide statistics are corrupted and we have no way to gather data about this hidden method of death. Society would be well-served to understand what proportion of the population chooses to hasten their death when it becomes inevitable and medically supervised. Only by measuring a phenomenon can we hope to understand it and craft beneficial public policy in response to it.
But to measure it, we have to name it, like we do for every other species we identify or discover. As one example, consider the beginning of a person’s life. When the need arose to talk about a surgical alternative to natural childbirth, we didn’t refer to it as “physician-assisted birth,” “medical-aid-in-birthing,” or “hastened birth.” We gave it a name: “caesarian.” But where death is concerned we fail to make use of clear and simple language. The terminology for a hastened death is wholly inadequate and has become a word salad.
For the time being, let’s name this hidden species “euthanauto,” a word coined by Dr. John Darland. A MAiD death and a VSED death would both be classified as “euthanauto.” So would the death of any competent adult suffering from an irremediable medical condition who choses to hasten their death. And now we can banish the dozens of descriptions, both euphemistic and pejorative, such as “hastened death,” “self-deliverance,” “rational suicide,” and the still extant and execrable “physician-assisted suicide.”
What is needed to make this a reality is for the name to go viral, and for academia to adopt it. The use of the name needs to gain some degree of critical mass in writing and conversation in order to reset the public debate.
Once this happens, we also have the solution to how to record VSED on a death certificate. “Euthanauto” would be added as an available “Manner of Death.”
With thanks to Final Exit for the language and idea behind this essay
With thanks to the Good Death Society and Final Exit Network.
