selected and reviewed by James Leonard Park,
existential philosopher and medical ethicist.
The text in black
presents the basic facts about each book.
The comments in red are
the evaluations and opinions of this reviewer.
1. Stanley Terman, MD, PhD
The Best Way to Say Goodbye:
A Legal and Peaceful Choice at the End of Life
CA: Life Transitions Publications,
2007) 482 pages
(ISBN: 978-1-933418-03-2; paperback)
(Library of Congress call number: R726.2.T47 2007)
This is probably the first book promoting
what I call "voluntary death by dehydration" (VDD)
and what Dr. Terman calls "voluntary refusal of food and fluid" (VRFF).
Other expression used in medical ethics are "terminal dehydration",
"medical dehydration", "voluntary terminal dehydration",
& SToping Eating and Drinking (STED).
The idea of
choosing death by giving up eating and
drinking is so simple that we should ask why so few have
discussed it before.
But someone had to speak first.
Dr. Stanley Terman is that first voice,
at least in a book-length discussion.
patient is too far gone to participate in
decisions, it might be called "merciful
death by dehydration" (MDD). The most common form of
practice is withdrawing a feeding tube
from a patient in a persistent vegetative
state (PVS). This life-ending decision falls
within the right to refuse any medical
Often this decision to give up food and water
is coordinated with other life-ending decisions
such as incresing pain-medication, terminal sedation,
and/or giving up all forms of curative treatments and other
As Stanley Terman says in the sub-title,
voluntarily giving up food and water
is a completely legal choice anywhere in the world.
And this book argues that death by dehydration
can be a very peaceful and even painless way to die.
Several ways to alleviate the discomforts
experienced in such a method of choosing death
are discussed in detail, p. 102-112:
mouth care, thirst-reducing aids, pain-relief, & even deep sedation.
And Dr. Terman has experimented with such fasts himself.
So he writes from experience about the discomforts and how to cope with
Of course, he has not yet fasted himself into unconsciousness or into
death. But I will not be surprised to
learn in some future year that Dr. Terman has followed his
own advice and chosen VRFF as his best way to
Dr. Terman does
not spend much time discussing
life-ending decisions, but the very process he recommends
for ending our lives contains very important safeguards
within the process itself. For one, it will take a week or 10
days to die by this means. During any such period of
continuing to refuse food and fluids, we will have numerous opportunities to reconsider any foolish
decisions to end our lives. People who want to commit
irrational suicide will probably never consider
dehydration as their method.
The range of attitudes within major religious
But almost no religious authorities have addressed directly
the possibility of voluntary death by dehydration.
Most of the religious perspectives deal with refusing treatment
and withdrawing life-supports. Perhaps only after VDD becomes
more widely discussed will religious authorities
specifically address this option
voluntary death by dehydration are explored here: "Voluntary Death by Dehydration:
Why Giving Up Water is Better than other Means of Voluntary Death": http://www.tc.umn.edu/~parkx032/CY-VD-H2.html.
And comprehensive safeguards are suggested here:
"Voluntary Death by Dehydration: Safeguards to Make
Sure it is a Wise Choice": http://www.tc.umn.edu/%7Eparkx032/CY-VDD-SG.html
Another major theme of this book is creating a good
Most of the well-known right-to-die cases would never have happened
if the patients had created Advance Directives.
Dr. Terman has many specific suggestions for advance care planning,
so that our documents say exactly what we want under various
We also want to make certain that our Advance Directives cannot be
by people who would make different choices at the end-of-life.
I am not
a neutral observer of this book, since Dr. Terman and I have
exchanged over 100 e-mails discussing the details of this
book since the pre-publication edition was distributed to
interested persons like me.
Most of these
discussions are too detailed and
technical to include in any book-review. But some of them have been
incorporated into the first edition of BEST
My most basic
criticism is that the book is far
too long for the basic purpose it set out
to accomplish. Everything we readers need to know
about voluntary death by dehydration could be explained in 100 pages or
Dr. Terman or some other expert in VDD might create a how-to guidebook, which would be a guide to taking
the actual steps towards death by giving up food
and water. It should tell us how to cope with
the problems created by this method of
voluntary death and give us some good examples of
actual people who chose this pathway towards
death. I believe such a how-to-die book
could become more popular than Derek Humphry's best-selling Final Exit.
Most of the
pages of BEST WAY will be of interest to
in medical ethics. I found the rest of the book quite
interesting. This is because I am interested in
all issues of medical ethics. While I was reading the book, I
made 64 pages of notes and responses. I have summarized and expanded on
these issues in the many e-mails that Dr.
Terman and I have exchanged.
Dr. Terman has
created a sprawling book of almost
500 pages. He wants to share all of his
thoughts about medical ethics. And he brings in recent items from
the news in unexpected places. We do not know where to find his
comments about Terri Schiavo, for example, because they keep
popping up everywhere. There are 23 references to her
case in the index, which enables careful readers to
find all Dr. Terman's comments. But few readers begin with the
better-organized book would naturally fall into 2
or 3 separate
volumes. Each of these could focus on some
specific issues already alive in the minds of
potential readers. Dr. Terman's original contribution is
voluntary refusal of food and
fluid. But this gets lost in his
discussion of many other issues in medical
ethics, which others authors have already
dealt with. For example, he does not need to
deal with terminating life-supports and all other forms of refusing
medical treatment. In my opinion, those battles have
already been won: We already have the right to pull
See my essay: "Pulling the Plug: A Paradigm for Life-Ending Decisions": http://www.tc.umn.edu/~parkx032/CY-PLUG.html.
(But other countries keep having cases
where disconnecting life-supports is still a matter of controversy.)
If Dr. Terman
follows my advice, he will create at least two books
from this one. The first—very
will tell laypersons everything they need
to know about choosing to end their lives
by giving up food and water.
The rest of the
content of BEST WAY is mainly
of interest to professionals in medicine,
medical ethics, & law. Besides the small how-to-die book
for laypersons, he could reorganize his material
into one book on medical
ethics and one book on the right-to-die. There might even be a place for a
book just about creating Advance Directives for Medical Care. All of these books could refer to
one another. And each one would have a better
chance of reaching its intended
You can find the complete contents by searching the
using the title: "The Best Way to Say Goodbye". The
website for this book is: www.TheBestGoodbye.com
Boudewijn Chabot, MD, PhD
A Hastened Death by Self-Denial of Food and Drink
NL: B. Chabot,
2008) 64 pages
(ISBN: 978-90-9023678-0; paperback)
(Library of Congress call number: not given in book)
Dr. Chabot studied
several deaths by dehydration in Holland.
The Netherlands was one of the first countries to allow physicians to
aid in dying.
But sometimes the patient who wants to die does not meet the guidelines.
For example, he or she does not have unbearable suffering.
Some of these people chose another route towards death:
They decided to give up eating and drinking.
This book begins with examples of three people
who chose this pathway
The author's preferred expression for this choice is
"stopping eating and drinking" (STED).
Some of the important themes covered in this small
duration of dying, mouth care, Advance Directives, palliative care,
dying at home, ethical issues for those who help others to die by
Dr.Chabot projects another book that will deal with
all issues in greater depth.
Joanne Lynn, MD, editor
By No Extraordinary Means: The Choice to Forgo Life-Sustaining
Food and Water
IN: Indiana University Press, 1986) 272
(ISBN: 0-253-31287-6; hardcover)
(Library of Congress call number: R726.B9 1986)
(Medical call number: W50B993 1986)
27 contributors presented these papers at a
conference in 1984.
In those days, almost all medical decisions were made by doctors.
So the patient's perspectives are mostly absent from this book.
But it does explore in depth the medical ethics surrounding
the practice of discontinuing food and water
for patients near the end of their lives.
Experts speak from their perspectives: law, medicine, & religion.
One contributor even argues that food and water
should never be withdrawn from a patient in PVS.
This book is
now mainly of historical interest, since both medical practice and
medical ethics have advanced since the 1980s. But it does show some careful
thinking about this life-ending decision three decades ago. And all careful students of VDD
should at least have a look at this book.