Biathanatos revisited: Anabaptist perspectives on voluntarily stopping eating and drinking in the face of terminal illness

Abstract

Introduction

Voluntarily Stopping Eating and Drinking (VSED) is a legal means of hastening death through refusal of food and fluids – a topic rarely addressed in Christian Protestantism. Among this group, U.S. Mainline Protestants comprise nearly 15% of the population and are more likely to include social moderates and liberals who emphasize quality of life (over mere life) and may therefore be open to the practice.

Objectives

Leveraging the well-established and validated Theory of Planned Behavior – that posits a person’s intentions to carry out an action are motivated by one’s attitude, perception of subjective norms, and perceived behavioral control – this research elucidates clergy and congregants’ normative beliefs and anticipated tactical support for VSED, including their reactions to Christian-based justifications for this end-of-life option. Such reasoning includes that VSED is a “fast into eternal life” and is based on the example of Jesus Christ, who, in the face of ongoing suffering, determined the end of his own life when he stated, “It is finished,” and gave up his spirit – an insight originally argued by John Donne in Biathanatos (1647/1982).

Methods

This case study of one southern Anabaptist congregation employs a focus group and one-on-one interviews, capturing reactions to a vignette in which a hypothetical fellow parishioner intends to VSED in the face of ongoing suffering from a terminal illness.

Results

In response to the presented vignette, study participants reported their affirmation of VSED. Responses to faith-based justifications for the practice varied widely.

Conclusion

Individuals aiming to VSED in the face of terminal illness may have their intention affirmed by a church community, but will likely require additional caregiving support to achieve a hastened death. A nascent framework for future comparative studies of faith communities’ assessments of VSED is also proposed.

Background

Definition, practice, and ethics

Voluntarily stopping eating and drinking (VSED) is ‘an action by a competent, capacitated person, who voluntarily and deliberately chooses to stop eating and drinking with the primary intention of hastening death because of the persistence of unacceptable suffering’ (p. 1). ¹ The practice has also been referred to as terminal dehydration,^2,3 fasting to death, and voluntary refusal of food and fluids. ⁴ A ‘volitional refusal’ (p. 57), ⁵ this behavior is different from a fading interest in food and fluid that naturally occurs as a result of terminal illness as death approaches. VSED is also distinct from stopping eating and drinking by advance directive (SED by AD), in which a person – by means of advance directive – charges a proxy to cease food and fluid offerings upon entry into a future stage of dementia. ⁶ Often this choice is made in the face of an incurable disease, but not always; motivations are both somatic and psychosocial.^7–14

Depending on the person’s baseline physical health, once the fast begins, death typically occurs between one and three weeks thereafter. ¹⁵ Lowers et al. ¹⁶ describe the process as occurring in three stages: The early phase consists of the individual being alert and able to engage others; during the middle period, a person is increasingly weak and tired; and in the final stage, the individual sometimes experiences delirium before falling into a coma and then dying. Hospice nurses who supported patients through VSED deemed this process to result in a high overall quality of death (in 94 out of 102 occasions), equating it to an experience that is ‘peaceful, with low levels of pain and suffering’ (p. 362). ¹⁷ Other researchers have similarly found that ‘death from VSED is largely considered a “good death”’ (p. 66). ⁴

VSED is considered legal and ethically justified on the basis of personal rights, but experts advise that VSED be supported by healthcare professionals and community members. The legal right to VSED ¹⁸ is considered to fall under the recognized right of an individual to forego life-sustaining treatment.^19,20 To further validate the practice, scholars rely on the principle of autonomy, ⁵ a pillar of western bioethics. ²¹ Indeed, those who carry out VSED are often individuals who prefer independence and being in control.^10,22 Furthermore, ‘the willfulness involved [in VSED] gives it an ethical advantage’ (p. 122). ²³ Yet, for a comfortable VSED experience, experts recommend accompaniment throughout the process by clinicians, who can provide palliative medications, as needed;^24–26 informal caregiving is also necessary. ¹⁰ Support, however, ‘should not be seen as a barrier to VSED so much as one of its enhancing dimensions’ (p. 121). ²³

Plenty has been written about VSED, but most scholarship consists of commentary and case reports; empirical research is scant.^4,25 Studies that are available primarily survey healthcare workers,^{17,20,25,27,28} but two investigations focus on the experience of informal caregivers.^10,13

Lowers’ ²⁹ dissertation work documented the experiences of 24 friends and family members who supported 20 individuals to VSED (achieving 19 deaths). In all cases, the VSED experience was clinically supported by hired aides or hospice, ³⁰ a resource for symptom management as well as a means to establish legitimacy for this end-of-life option. ¹⁰ Caregiving entailed choosing ‘what roles to play, such as focusing on physical care or being emotionally present’ (p. 3). ²⁹ Serving in this role presented opportunities for relational closure; informal supporters found VSED deaths to be comfortable and consistent with the individuals’ wishes. Although caretakers faced ‘unique’ challenges (p. 376), ¹⁰ they also reported feeling relieved and grateful to have served in this capacity. ³⁰ Importantly, some caregivers were uncertain about the perception of VSED by external parties, which caused increased feelings of risk and wariness of social stigma and restricted communication with outsiders. ¹⁰

Another qualitative study consisted of 18 interviews with relatives who cared for a person through VSED. ¹³ These scholars explored communication related to VSED decision-making, categorizing cases on a scale ranging from VSED that is known to others or not known to others. Especially relevant for this research, Stängle et al. ¹³ found that ‘other factors – which influence the ethical and moral judgment of the situation – such as the patient’s and relatives’ culture and religion need to be considered when managing VSED’ (p. 5).

Religion

When the behavior-of-interest is a hastened death, moral and philosophical controversies trigger, as do religious debates.^31,32 Western Abrahamic belief systems have historically lauded fasting as a spiritual discipline, ³³ but not ‘fasting to death’ as practiced within several eastern religions (p. 1429). ³⁴ Arguably the best known custom is called sallekhana or santhara, which is embedded in Jainism ³⁵ – a belief system that is among the oldest in India. ³⁶ Considered a ‘wise voluntary’ death (p. 193) ³⁷ that is a supreme act of nonviolence, ³⁸ which counters ‘the violent impulses of suicide’ (p. 211), ³⁷ this option is available ‘in such cases where a normal and dignified life is no longer possible’ (p. 537);^39,40 ‘when death is imminent because of disease or when one is unable to function self-sufficiently’ … ‘at the close of a normal life span’ (p. 196). ³⁵ A Jain scholar and judge, expressly defends the practice in a book entitled ‘Sallekhana Is Not Suicide’, ⁴⁰ since ‘ordinary suicide’ (p. 354) is violent self-destruction, motivated by negative emotions and mental infirmity, which leaves loved ones with unresolved grief. ⁴¹ Bioethicists have suggested the Jain practice affords an ‘ethical death’ (final para.) ⁴² and can inform Western perspectives on death and dying, more broadly. ⁴³

Christians have predominantly opposed self-directed death, labeling such behavior as a sinful act of suicide^32,44,45 since St Augustine’s City of God and St Thomas Aquinas’ Summa, respectively, written in the 5th and 13th centuries. ⁴⁶ Christian orthodoxy asserts that suicide violates the commandment, ‘Thou shalt not kill’ as well as ‘the notion of life as a gift from God’ (p. xxii). ⁴⁶ The earliest, most comprehensive, and original critique ⁴⁶ to this absolutist doctrine ⁴⁷ was written by John Donne, the revered English poet, author, and clergyman. Raised a Catholic before aligning with the Church of England, Donne ‘appears to be the first modern philosopher to have constructed a sympathetic view of self-killing’ (p. 106). ⁴⁸ In Biathanatos (1647/1982), ⁴⁹ Donne builds a case for elective death, so long as charity (or love for others) is the motive and God is glorified (as opposed to death motivated by desperation or self-interest). Referencing and analyzing numerous scriptures throughout the Bible, Donne also draws on the examples of key characters, such as Samson and Saul – whose self-killings were Biblically documented ‘in a nonjudgmental, factual way and not as wrong or shameful’ (p. 230).^44,50

For his premier example, Donne presents the behavior of the Christian Savior, Jesus Christ, explaining that Jesus died early in his crucifixion by choice, electively giving up his spirit, when he could have suffered for much longer; noting that his premature death even surprised Pilate, the Roman governor overseeing the crucifixion (see Mark 15:44). Numerous Biblical texts narrate Jesus’ death on the cross, Matthew 27:50 is one example, which states: ‘And Jesus cried out again with a loud voice, and yielded up His spirit’ (New King James Version). From this, Donne ⁴⁹ reasons:

So that, if the act of our blessed Savior, in whom there was no more required for death but that He should will that His soul should go out … then we are taught that all those places of giving up our bodies to death, and of laying down the soul, signify more than a yielding to death when it comes. (p. 173)

Donne ⁴⁹ elaborates further: ‘As He [Jesus] did in perfect charity, so we, in such degrees of it as this life and our nature are capable of, must die by our own will, rather than His glory be neglected’ (p. 174). This self-described ‘paradoxical’ essay, published posthumously by Donne’s son, ⁵¹ was criticized ⁵² and is ‘now forgotten’ (p. 166). ⁵³ Although these ‘subversive ideas’ are serious and legitimate … ‘most readers then and now would prefer to disbelieve’ them (p. 157). ⁵²

A few German theologians have written papers specifically exploring the intersection of VSED and Protestant faith. In Germany, this practice is referred to as ‘Freiwilligen Verzichts auf Nahrung und Flüssigkeit (FVNF)’ (voluntary renunciation of food and liquid) or ‘sterbefasten’ (fasting to death) ⁵⁴ and has gained widespread attention due to changes in the nation’s criminal code, which now prohibits the commercial promotion of suicide.^4,55 Protestant theologians and university faculty, Zimmerman and Zimmermann, ⁵⁶ state that ‘explicitly theological contributions to the topic … are almost completely absent’ (p. 37). These scholars further argue that FVNF is a permissible end-of-life option that is aligned with other behaviors of renunciation, as demonstrated in early Christianity. ⁵⁶ Another Switzerland-based professor and Protestant theologian concludes that FVNF is an option of last resort. ⁵⁷ Categorical prohibition or permission is not possible; rather, based on the unique and concrete circumstances at-hand, a determination may be made, which weighs avoidance of suffering and protection of life. ⁵⁷

The argument that Christian self-killing is acceptable, even laudable – in particular circumstances – is relevant for the United States, where nearly 71% of the population is Christian. ⁵⁸ Pew Research Center ⁵⁸ concluded that nearly 21% of the US population is Catholic and approximately 47% are Protestant, a group that has fewer shared beliefs and practices and also allows freer inquiry. ⁴⁴ Just over 25% are considered Evangelical Protestant while Mainline Protestants account for nearly 15%. ⁵⁸ Compared with other Protestants, the latter group is more likely to include social moderates and liberals who emphasize quality of life (over mere life) ⁵⁹ and may therefore be open to the practice of VSED. While numerous US Mainline Protestant denominations have published formal end-of-life statements, some of which specifically address medical-aid-in-dying, none, per the author’s knowledge, have directly addressed the practice of VSED.

Materials and methods

This research examines a distinct and important topic that is previously unstudied, thereby qualifying it as a useful and revelatory case study. ⁶⁰ Through engagement of one Mainline Protestant congregation of the Anabaptist tradition located in the southern United States, this study illuminates clergy and congregants’ perspectives regarding normative perceptions of and actionable support for VSED, to include their reactions to Christian-based justifications for the practice. Themes of the Anabaptist faith include the centrality of Biblical scripture, lived out in community, with a focus on peace, justice, and the separation of church and government. ⁶¹

Since qualitative method triangulation enhances knowledge comprehension and synthesis, ⁶² this study included a focus group and individual interviews, which were conducted virtually, given the pandemic. Focus groups are valuable when exploring controversial issues that are complex and sensitive, ⁶³ such as VSED. This format also offers the opportunity to efficiently ⁶⁴ introduce information that participants are unlikely to have considered previously, before probing in-depth perspectives through one-on-one interviews. Group processing may also reveal a broader array of responses, which individual participants can then contemplate before follow-up interviews. The risk in focus groups is that one or two individuals may dominate group discussion, ⁶⁴ but subsequent interviews allow the individual expression of personal and more detailed opinions on sensitive topics.

Individuals are subunits of analysis whose perspectives inform the primary high-level unit of analysis, the church. Clergy and congregant individual interviews are aggregated to reveal the church perspective. For example, a summary of individual responses reveals the level of uniformity in the community, as well as the strength of the collective conviction. External out-group participants serve as comparison for in-group informants.

An Institutional Review Board (Georgia Institute of Technology, Office of Research Integrity Assurance, H20142) approved this study prior to its commencement and waived the documentation of consent requirement. A notice of consent was distributed to all participants with the invitation to participate, sent via weekly church-wide e-mail announcements from the pastor. Participants verbally consented to participate and agreed to audio recordings of the focus group and interviews. The author gained access to this church congregation by virtue of regularly attending services, volunteering, and membership. Approval to conduct the study occurred after meeting with the pastor and the church governing body.

Given onset of the pandemic and its effects, the church determined to hold a series of conversations related to death and dying, which occurred in the early months of 2021. The first meeting consisted of a guest speaker and hospice administrator who presented information on pertinent end-of-life documents. The second speaker was a hospice chaplain who presented on Christian historical literature known as ars moriendi, Latin for ‘the art of dying’, which arose during the Middle Ages and aimed to provide practical and spiritual guidance for dying well amid circumstances that included the bubonic plague, war, and famine. ⁶⁵ The VSED focus group was the third and final gathering in the church series on death and dying.

The focus group was comprised of 16 participants, including the pastor, another clergy-congregant – a retired minister, 12 congregants, and two non-congregants who were invited by a church member to participate. Lasting approximately one hour, the agenda overviewed VSED and the denomination’s end-of-life statement. Discussion began by inviting reflections on the statement, emphasizing two sections the principal investigator deemed particularly relevant to informing the practice of VSED, namely ‘Reverence for Life’ and ‘Mutual Respect’. The final activity invited participants to discuss their reactions to the author-created vignette, below, in which a hypothetical fellow church parishioner plans to VSED.

Vignette: A fellow church parishioner is suffering from a terminal illness, for which there is no cure. Interventions that meaningfully improve symptoms do not exist. The individual continues to slowly decline. From that parishioner’s perspective, suffering is unrelenting, intolerable, and will steadily become worse. The individual has sought medical consultation and knows that improvement is not possible. This person, who is an uncoerced and competent adult, is seeking to hasten death through means of Voluntarily Stopping Eating and Drinking (VSED). The parishioner has historically practiced fasting as a spiritual discipline and now justifies VSED as a ‘fast into eternal life’. This individual believes VSED is a viable, faith-based option. From that parishioner’s perspective, the individual reasons that Jesus Christ determined the end of His own life when He stated, ‘It is finished’, and gave up His Spirit (John 19).

Discussion questions were posed at the half-way point and served to begin probing approval and level of support for this end-of-life option, but excluded discussion of faith-based justifications for this choice (see online supplemental materials for Focus Group Protocol). These questions were newly introduced during follow-up one-on-one interviews with 14 focus group participants; two were unable to participate due to health conditions. Table 1 presents demographics of one-on-one interview participants. Participants skewed White, female, and above 60 years of age. Only one participant was Asian – all others were White; approximately 70% were female and 30% were male. Just two participants were under 40 years of age; the rest were in their fifties (29%) or older (57%).

Table 1.

Interview participant demographics.

Category	Sex	Race	Age bracket
Clergy	F	White	30s
Clergy	M	White	>60
Congregant	F	White	>60
Congregant	F	White	>60
Congregant	F	White	>60
Congregant	F	White	>60
Congregant	M	White	50s
Congregant	F	Asian	50s
Congregant	F	White	20s
Congregant	M	White	>60
Congregant	F	White	50s
Congregant	F	White	50s
Non-congregant	F	White	>60
Non-congregant	M	White	>60

Each interview lasted approximately one hour. Initial interview questions revisited queries related to the focus group vignette before posing additional questions; for example, probing assessment of the Christian-based justification for VSED (see online supplemental materials for Interview Protocol).

With consent, all interactions were audio-recorded and transcribed. Individual interview transcripts were sent to participants as a courtesy, inviting modification, allowing an individual to further clarify and elaborate on their comments.^66,67 Uniformly, participants did not elect to further modify their transcripts.

The analytical coding strategy focused on individual interview data and took both a deductive and inductive approach. ⁶⁸ Coding proceeded deductively by leveraging elements of the Theory of Planned Behavior (TPB), ⁶⁹ which states that a person’s intentions to carry out an action are motivated by one’s (1) attitude, (2) perception of subjective norms, and (3) perceived behavioral control. Protocol questions were purposefully designed to illuminate the community’s normative stance toward and actionable support for VSED, to align with TPB’s latter two variables. Specifically, individual interview responses regarding approval or disapproval of VSED, including Christian-based justification for this choice, are summarized to inform the ‘subjective norms’ of the church. For example, responses to the early query related to (dis)approval of VSED were collectively reviewed with a similar, but differently phrased question, posed toward the end of the interview. Similarly, individuals’ willingness to provide tactical support, in the form of a farewell visit, and sitting respite with the parishioner beginning VSED, are aggregated to inform the ‘perceived behavioral control’ variable (i.e., as the number of church people who are willing to participate increases, so too does the perception of one’s ability to carry out the intended action).

Coding also occurred inductively through a (modified) ‘grounded theory’ approach ⁷⁰ with the use of thematic analysis. ⁷¹ Specifically, the researcher’s church involvement and exposure to TPB were ‘points of departure’ (p. 32), ⁷² which merged with respondents’ insights to foster development of theory to explain human behavior. Wholesale grounded theorists build the research as it ensues, ⁷² but this design proceeded in traditional stages. A research instrument was pre-established and used for purposes of interviewing every participant. The sample was fixed and analysis did not commence until all transcribing was complete.

The process of analysis began by re-reviewing all one-on-one interview materials, which entailed re-reading each transcript while simultaneously re-listening to each interview’s audio recording. Interviewee responses were aggregated into a master file, initially coded according to individual interview question. Thereafter, the author reviewed individual interview responses to each separate question, collectively, for example, studying all interviewee comments related to query two at one time, and coded initial, emerging themes in a descriptive manner. A second round of analysis entailed categorical-coding, during which higher level themes were applied to the data set, through use of more concise language that captured patterns in the sample. ⁷³ Themes were then accounted for by question and TPB variable, across all respondents, to determine those most predominantly cited by participants.

Results

The Theory of Planned Behavior (TPB) ⁶⁹ posits that a person’s intention to carry out an action is motivated by one’s attitude, perception of subjective norms, and perceived behavioral control. Issues pertaining to life and death are particularly salient to faith communities. Thus, a person’s decision to VSED would be especially influenced by their faith community’s subjective norms toward said behavior. Furthermore, faith communities often rally around the sick and ailing – especially those who are in their congregation. Accordingly, discerning tactical support for VSED among parishioners may also influence a person’s perceived behavioral control, that is, the ability to practically carry out the intended action. As a result, this research elucidates two of three TPB factors pertaining to VSED, namely a church community’s subjective norms and anticipated tactical support for this end-of-life option.

The focus group introduced these topics and began conversation to catalyze participants’ thoughtful and independent reflections that would be captured privately during one-on-one interviews. Collectively, the group’s response to discussion questions focused on (1) comprehending the difference between VSED as a volitional refusal of food and fluids versus a fading interest in eating and drinking that naturally occurs as death approaches due to terminal illness; (2) expressing a consensus around nonjudgment toward this choice; and (3) conveying a willingness to attend a farewell visit and provide respite, within boundaries. Only in one-on-one interviews were queries posed related to quantitative ratings of opposition/support for the practice and reactions to VSED being framed as a viable faith-based option.

Normative assessment of VSED

The church’s normative assessment of VSED was informed by a series of direct questions to individuals during one-on-one interviews about their (dis)approval and (dis)affirmation as well as their valuations of a Christian defense of this form of elective death. Congregant appraisals of Christian reasoning for VSED informs whether the behavior will be deemed doctrinally permissible and thereby the formation and content of communal norms.

Two separate questions with follow-up probes were posed during individual interviews that sought to directly elicit church members’ normative evaluations of VSED; one was presented at the start of the discussion and the other at the end. For the latter inquiry, interviewees were asked, ‘On a scale of 1 to 10, with 1 being absolute opposition and 10 being absolute support, how strongly do you affirm or disaffirm the parishioner’s decision to VSED?’ Requesting a quantitative assessment at the end stages of the interview fostered the ability to concretely capture respondent assessments after extensive discussion of the behavior-in-question. The lowest rating (of five) came from a congregant; all other participant scores were seven or higher. The average rating among churchgoers was 8.3; non-congregants’ average was 9.

Among clergy and congregants, motivating reasons for responses to their normative evaluation of VSED, as informed by both the early and later questions pertaining to (dis)approval and (dis)affirmation, were led by the concepts of nonjudgment and autonomy. For example, the concept of ‘nonjudgment’ was applied to the following statements, including:

• ‘I don’t think any of my role as pastor in many situations is to approve or disapprove, but to show up and be with people in whatever scenario they’re in’.

• ‘I feel like I have no grounds to judge someone’s own decision about how they want to proceed or not proceed with VSED’.

The category of autonomy encompassed statements such as:

• ‘The choice is certainly theirs and nobody else has the right to interfere with it’.

• ‘It’s not my business. If that makes sense … if that’s what they want to do … it’s their choice’.

Also cited was the notion of medical futility in the face of terminal illness and the removal of suffering. Congregants’ primary reservations were based on the intentionality of the behavior to hasten death.

Another series of questions posed during individual interviews requested feedback about the parishioner’s faith-based justifications for VSED, including evaluation of this choice as a ‘fast into eternal life’ and the reasoning that Jesus Christ determined the end of His own life when He stated, ‘It is finished’, and gave up His Spirit (John 19). Only four church members viewed the fasting justification as aligned with their Christian belief system – as based on tradition, Biblical text, and the example of Jesus Christ. One congregant explained, ‘There’s a tradition of fasting for spiritual reasons. So I think it makes sense. Perfect sense’. Another said,

I’m supportive of that idea. It seems like it would be consistent with other practices of fasting. I mean, there are so many different examples of fasting in the Bible. It seems like it’s a spiritual discipline that is common and encouraged. And so it’s a different purpose than some others, but it seems like it could be consistent with those.

Other respondents were not sure a ‘fast into eternal life’ fit within their belief system, but they deemed such reasoning to be a personal ‘prerogative’ and appreciated that such reasoning could provide comfort and stamina to fulfill the intended behavior. Two church members expressly opposed this justification. One called it ‘a stretch’, while the pastor expressed during the individual interview that fasting is a discipline for the living:

I understand fasting as a spiritual discipline that deprives us of something that is keeping us far from God. So a removal of that thing in active life opens up space for us to draw nearer to God. So fasting into eternal life – I can understand that food and water would be keeping them from the union that happens in death. It doesn’t make sense to me completely because fasting feels like a practice meant for humans engaged in living and not necessarily humans at the edge of life.

Interestingly, the two churchgoers who have Master of Divinity degrees and experience in professional ministry offered the strongest support for use of Jesus’ example on the cross as justification for VSED. The clergy-congregant reflected on his professional experience as a minister to the dying, having witnessed people ‘will’ themselves into death, seeing that act as consistent with Jesus’ death:

The giving up of spirit is something that I’ve seen in relationship to people dying. And think is very, very real … there is some will, in the giving up of, implicit in the idea of giving up the spirit. And I have experienced that will. And that goes back to, again, to my understanding of the passion being Jesus teaching us how to die, is that death isn’t something that we need to be afraid of, but that we can fast into or will into.

He goes on to say that VSED is one potential method to exert this will:

That’s really what it’s all about … not looking for death but accepting death and being so accepting of death when it happens that one understands that one doesn’t have to defend oneself against it … that gets really back to the VSED concept in that – that is a way of ultimately giving up one’s spirit.

The pastor reflected on the orthodox way of interpreting the crucifixion:

There’s so much around the crucifixion that is Jesus being submissive to God’s will. I took a course on death in undergrad and there’s this thread of theology that says … human life is not given or taken by humans – that God determines [it]. And so, it’s an act of hubris for humans to intervene in that – at either end, in any place in the middle, but that life is a gift and only God gets to choose beginning and end.

But the pastor wondered aloud about this alternative interpretation:

… I haven’t quite gotten my head around it completely, but I think I like it. That Jesus could have gone on suffering for minutes or hours on the cross but knew where he was going and knew what was ahead and chose that moment to give up His Spirit.

Implications for the way Christians understand salvation were further considered by the pastor:

I’m wrestling with it a little bit. It’s new. Like, I just haven’t heard it interpreted that way before, and so I like that because how many times do you hear a new interpretation of the crucifixion, but I also – this really is kind of appealing to me that Jesus could have gone on suffering and chose not to. I mean, that gets into this whole segment of theology about ‘soteriology’ – about like, what Jesus’ suffering means. How does Jesus’ death on the cross save us? And there’s this whole huge thread of – it’s the gore and the pain and the suffering that are salvific, you know, that the suffering is what saves us. But if you flip it in this way, Jesus chose to stop suffering and so it wasn’t the suffering that was salvific and I really like that and how that fits into a different understanding of salvation.

Other congregants were not convinced this reasoning held much merit. Responses varied widely. Some accepted the justification: ‘That’s that person’s view and they’re entitled to it’. Others understood the parishioner’s perspective, but deemed Jesus as a special case whose actions on the cross are not translatable to human action:

Because we’re supposed to be like Jesus, we’re supposed to pattern our life from him. So I could see somebody using that as a model and giving up their spirit and that – if they’re at the end of their life. I can understand that … It’s still a little difficult for me to put them on an equal basis.

Yet others dismissed the justification or disagreed with it outright. ‘I just don’t agree with the last sentence [of the vignette] about Jesus on the cross. I don’t think he had much choice’. Another said, ‘Well, I think that’s a stretch because somebody had nailed Him to the cross … They bled him to death … I mean, I hope the person was saying that a little bit in jest’. One person was especially uncomfortable with this line of reasoning, suggesting irreverence:

I don’t think that we can say this is a new faith-based practice. And that it’s equivalent to Jesus hanging on the cross and declaring it is finished … To equate it, I think we have stepped over some kind of line that I’m not comfortable with.

This congregant further explained the discomfort:

We’re dying. As difficult and as unpleasant as that is. It’s not taking on the sin of the world. It’s not being martyred. It’s not that. And to try to make it that in your own mind is – that’s kind of a lie, I think, to yourself.

Yet, this same congregant went on to affirm the value of uncomfortable discussions about belief and scripture as an opportunity either to ‘relearn or recommit’.

Perceived behavioral control of VSED

Additional questions were posed to discern the congregations’ tactical support for VSED, including willingness to attend a farewell visit and respite care provision upon VSED’s commencement. While these questions were originally created to address the TPB factor of perceived behavior control, responses to these queries may also reveal further insights about the deeper layers of individuals’ normative assessments toward VSED. Stating an opinion about another’s choice is relatively simplistic, whereas answering questions about how one would engage at the intersection of the other’s behavior-in-question and their own conduct – increases complexity and elicits a more profound level of self-examination and disclosure.

The first query posed the following scenario: ‘Your fellow parishioner would like to host a series of visitors before beginning VSED, in order to say goodbye. You are asked to participate in a farewell visit. Please describe your reaction to this request’. Uniformly, all participants affirmed that they would accept the invitation and attend this visit. Some saw this as an opportunity to celebrate the individual’s life and engage in heartfelt goodbyes; others deemed it a welcome responsibility that was part of communal life or ministry. Although participants acknowledged sadness – or pressure ‘to get it right’ – they saw such a visit as similar to visiting a dying person, generally, ‘the same [as] if this friend had not chosen that method to hasten [death]’.

A subsequent prompt introduced respite-provision, inquiring whether the interviewee would be willing to offer such care: ‘The parishioner’s primary caregiver will require respite once VSED begins. You are asked to serve in this capacity. Please describe your reaction to this request’. To this, respondents expressed uncertainty and agreed to conditional involvement. None of the study participants had heard of VSED, let alone been involved in an end-of-life experience that reflected this choice. Most drew upon their past experiences with the deaths of loved ones to inform their understanding of end of life; only one participant had extensive death and dying experience with individuals and their families. One congregant plainly stated the source of her unease: ‘I’ve not been around death enough to feel comfortable with it’.

Other factors motivated hesitancy for respite-care-provision; these topics were initiated during the focus group discussion and continued into individual interviews. First, all were concerned about the nature of expectations inherent in this role: Were volunteers supposed to encourage the individual in their intention to VSED? Furthermore, what if the person aiming to hasten death wavered in their intention and requested food or drink? ‘If they start asking for water, what’s my alternative? Or what’s the direction I should go in? Is that moistening the lips? Is that a cheek swab? Is it totally something else – redirecting some other way?’

Several church members wondered about the ethical tension that arose as the dying individual’s agency waned and the caregiver’s support became an active withholding of food and fluids:

I think that that piece [respite care] is a little more complicated. Both for the primary caregiver as well as for anybody who assists in caregiving and that’s that there’s a complicated part about the point at which somebody is no longer, maybe clearly able to hold on to that intention of the voluntary stopping eating and drinking and where the more fundamental biological instinctive need to eat and drink takes over and the point at which you – or as a caregiver, or even someone who’s doing voluntary respite care … is withholding life supporting things and the point at which the person is still having agency to make that decision.

Put differently, the congregant wondered: ‘At what point would an outside observer, say a medical person, say well, this is abuse?’

Many participants also acknowledged the potential for panic in end-of-life situations, in which a well-meaning volunteer might call emergency services, an act likely not preferred by the dying individual, nor their primary caregiver. In response to my question, one person wondered: ‘If we’re not calling the ambulance when something gets scary, what is the process and who do I call?’ Given all the uncertainties and high stakes, one individual suggested that if this practice were to become more prevalent, then it would be best to have those who are more familiar with death and, in particular, the process of VSED, supervise the endeavor, instead of relying on laypeople to do so.

Discussion

Prior research on VSED has focused on professional and informal caregiving by relatives and neighbors; this is the first study to examine responses from a community organization toward a member who intends to hasten death through refusal of food and fluids. Lowers et al. ¹⁰ showed that in VSED cases, hospice was not only a source of symptom management, but of legitimacy that countered social stigma that was either imagined or real. Through interviews with members of one US Mainline Protestant congregation, this study demonstrates another potential source of VSED legitimacy and support: a church community.

Leveraging the TPB, ⁶⁹ this research investigates norms and tactical support for a hypothetical parishioner intending to VSED within an Anabaptist congregation. Given that participants had never heard of VSED, there are not established norms, per se, related to this practice. Indeed, one congregant consistently brought up the ‘inconceivable’ nature of the disciplined regimen that would be required to carry out the behavior. That said, church clergy and congregants relayed a strong, unified affirmation of the parishioner’s intent to VSED on the basis of nonjudgment and autonomy. Such a consensus from one’s church community would bolster a person’s intention to carry out this behavior and further validate the practice.

All interview participants indicated a willingness to attend a farewell visit with the parishioner prior to VSED commencing. The parishioner could interpret unanimous acceptance of these invitations (and subsequent attendance) as evidence of their peers’ normative support for the intended act. Participation in the event may also influence the parishioner’s perception of control over the behavior, bolstering a belief in the individual’s ability to carry out this choice to hasten death, especially if fellow churchgoers also agreed to provide respite care upon commencement of VSED. That said, congregants generally expressed high levels of uncertainty and conditional willingness to serve in this capacity. Unfamiliarity with VSED and lack of exposure to end-of-life experiences instigated many questions about expectations, requirements, and contingency plans. Congregants’ service as respite caregivers would likely occur during the early stages of VSED, if at all. A primary caregiver would need to engage other means for respite and caregiving as the VSED process advanced into the middle and final stages. These results confirm the advice and findings of other researchers^10,26 who urge professional clinical participation throughout the process, in order to make the endeavor more peaceful for the dying individual and their caregivers.

This research also answers a call to investigate religious perspectives toward VSED, since such evaluations influence moral and ethical judgments of the practice and thereby impact if and how this end-of-life option will be carried out. ²⁸ In this study, responses to Christian-based justifications toward VSED varied widely. Several congregants found fasting to be a compelling way to frame the behavior; the use of Jesus’ example on the cross inspired the strongest reactions – both for and against this choice. Most interviewees relegated such reasoning to a religious ‘gray area’, best left to personal decision-making. Thus, it is unlikely that the church body, collectively, would normalize VSED as a viable option for Christians, generally, who are facing circumstances similar to the hypothetical parishioner. Were this a real-life scenario, it is possible that an eventual consensus would be reached as circumstances unfolded and – along the way – further interaction and discussion among congregants and clergy took place. Presumably, such conversations would involve interpersonal exchanges regarding how individuals experienced and assessed their realistic VSED encounters, causing in-group members to reconsider their previously siloed and stand-alone perspectives to coalesce around a consensus.

This hypothetical example becoming a lived experience for all involved could also catalyze church leadership into making more public comments on the behavior, further swaying collective opinion. That said, it is equally possible that the vignette becoming a reality could cause further bifurcation among churchgoers’ beliefs. Ultimately, this church was divided in terms of its support for a faith-based defense of VSED, which framed this choice as a ‘fast into eternal life’ and drew on the example of Christ during his final moments on the cross.

Yet, this study revives consideration of faith-based justifications for VSED within Christianity. Donne’s ⁴⁹ long-forgotten argument that self-killing, in some instances, is justifiable for Christians ⁵³ has been debated by scholars. Some academics question whether Biathanatos was ever meant to be taken seriously, instead considering the writing to be a piece of extreme satire.^46,52,74 Despite some ambiguity regarding the author’s intent, it is clear that Donne desired to inspire debate. ⁵² Indeed, the preface of Biathanatos states, ‘as in the pool of Bethsaida there was no health till the water was troubled [as referenced in John 5:2], so the best way to find the truth in this matter was to debate and vex it’ (p. 41).^49,52,74 A congregant from this study agreed that engaging in these unsettling discussions was a valuable exercise, as doing so offered ‘an opportunity to relearn or recommit’.

Interestingly, this study also draws connections between eastern and western religious justification for VSED as based on the principle of nonviolence, an historically lauded tenet of numerous religious traditions. ⁷⁵ As stated previously, Jainism honors the practice of fasting to death as an ultimate act of nonviolence. ³⁸ Within Jainism, ‘non-violence translates as non-action’ ⁷⁶ and ‘by not eating, no harm is done to any living being’. ³⁵ For Anabaptists, a commitment to nonviolence includes nonresistance, peace, and pacifism. ⁷⁷ A clergy-congregant in this study explained support for VSED through the lens of nonresistance and summarized: ‘I think that my own personal understanding of what it means to be living the way of Jesus is to understand in the Passion he taught us how to die very much like in the Sermon on the Mount, he taught us how to live’. (Note: ‘The Passion Narrative … proceeds from arrest [of Jesus Christ] through trial to condemnation, execution, and burial’ (p. vii).) ⁷⁸

Limitations

This study was conducted as part of a larger church series on death and dying that occurred during a global pandemic; such context likely influenced participant perspectives. Research participants were not random, but rather consisted of individuals who deliberately opted into these discussions. It is possible that those who did not participate were rebuffed by the end-of-life topic, generally, or VSED, specifically. The author’s participation in the congregation could be deemed as a limitation to study findings; perhaps those off-put by the study description opted not to engage the research, to avoid confrontation with the researcher/author. It is also possible that more opted into study participation, to support a fellow churchgoer. Thus, whether this research captures the full breadth of perspectives in this church community is uncertain. Given that the church hosted this study and the pastor participated, it is possible that other research participants may have interpreted these activities as implicit support for VSED and therefore been influenced to affirm the choice to VSED, even though the pastor did not publicly convey explicit affirmation of this end-of-life choice. Furthermore, responses entailed imagined behavior to a hypothetical scenario. Study participants may behave differently in real-life circumstances. Social desirability bias inclines research subjects to – consciously and unconsciously – respond in ways that cast themselves favorably, to themselves and the researcher before them. ⁷⁹ While such bias may pose a threat to study validity, questions were presented in a balanced manner (e.g., how strongly do you affirm or disaffirm the parishioner’s decision to VSED?) and methodical analytics generated study findings.^68,70

Conclusion: analytic generalization and future research

This research adds unique value by demonstrating that a community organization, in this case a church, may be a source of validation and support for an individual electing to VSED. The study also adds evidence to prior research, supporting the likelihood that individuals intending to VSED will likely require professional caregiving, to complement necessary caretaking by a primary caregiver and supplemental sources of informal support. Importantly, justifications for VSED in the face of terminal illness were explored from the perspective of Christian Protestantism. These included viewing this choice as a ‘fast into eternal life’ and a permissible option, given the example of Jesus Christ, who, in the face of ongoing suffering, determined the end of his own life when he stated, ‘It is finished’, and gave up his spirit – an insight originally argued by John Donne ⁴⁹ in Biathanatos (1647/1982).

While this research is not appropriate for statistical generalization, it does serve as a starting point for analytical generalization. ⁶⁴ This sample is not representative of the larger population: Evidence has been generated from a small number of interviews in ‘quite [a] liberal’ church and as one congregant stated, ‘I think there are plenty of Christian pastors that would disagree with this [VSED]’. Furthermore, Anabaptists in the Mainline Protestant tradition comprise less than 0.3% of the US adult population. ⁵⁸ Interview participants were 93% White; scholars have shown that end-of-life experiences and perceptions vary by race. ⁸⁰ Eighty-six percent of the sample was also over 40 years of age.

Despite these conditions, this study may inspire a nascent model to inform faith communities’ acceptance or rejection of VSED (and perhaps be relevant for other controversial, life-and-death issues). The dependent variable’s outcome may fall along a spectrum, varying from wrong, ambiguous, allowable, to virtuous. The primary independent variables may be comprised of at least three factors. One variable encapsulates a religious denomination’s doctrine; for example, the extent to which its theology, polity, and practice is hierarchically determined, either by deferring to higher level leadership or lower level individual interpretation of sacred texts. A second component concerns a community’s level of intimacy and connection among its members, with close and stronger bonds fostering empathy, compassion, and nonjudgment. The last factor encompasses legality, that is, how clear is the lawfulness of the behavior?

Research within this denomination and church community demonstrates that VSED was deemed by the group to be allowable and supported, with limitations. The church’s doctrinal context did not forbid the behavior; the community focused on nonjudgment and acceptance of their (imagined) intimate peer; and the legality of the choice was clear, up to a point. When the lawfulness of the behavior came into question, individuals were less likely to support the endeavor. Future researchers should consider executing comparative case studies to test this framework and advance its elaboration.