The University of Minnesota continues its Unpacking Bioethics Series with Unrepresented: The Ethics of Caring for Patients Without Surrogates.   When patients can’t decide for themselves, we rely on surrogates to decide on their behalf. However, clinicians often face the challenge of caring for patients who have no available surrogates. How do we make decisions for patients when the patients’ values and goals are unknown?  This talk explores the ethics of decision-making for patients who lack surrogate decision-makers or have decision-makers who are unfamiliar with the patients’ goals and values. Drawing on case studies and bioethics theories, this talk establishes the importance of avoiding paternalism, establishing thoughtful policies, and ensuring patients who lack decision-makers receive appropriate medical care. Learning Objectives: After this webinar, attendees will be able to: * Identify the ethical challenges of caring for unrepresented patients. * Explore potential solutions at the bedside and system policy level. * Apply solutions to cases in a diverse surrogate decision-making legal landscape.

Submit your abstract to the 13th International Shared Decision Making (ISDM) Conference, hosted at Dartmouth College from July8-10, 2026. Dartmouth lies in the scenic Upper Valley of New Hampshire and Vermont—a region known for its classic New England charm, rolling hills, and deep roots in collaborative, patient-centered care. Dartmouth is home to one of the first Shared Decision Making centers in the U.S., making it a meaningful place to explore where the field is headed next.   With the 2026 theme, ‘A Wider Lens,’ this year’s conference will bring together clinicians, researchers, patients, and policy leaders to expand our understanding of shared decision-making across specialties, care settings, and systems. In-person attendees will enjoy rich opportunities for connection, lively discussion, and curated social events, all set against the beauty of a New England summer. For those joining remotely, Dartmouth is building an inclusive, high-quality virtual experience designed to foster engagement and global dialogue.

This National Association of Catholic Chaplains (NACC) presentation on VSED. I was surprised and delighted by its positive and supportive perspective.

Join my Fordham University class on VSED for social workers on December 11, 2025. Join here.  More patients are seeking to hasten their deaths by voluntarily stopping eating and drinking (VSED) than by medical aid in dying (MAID). There are two main reasons for this development. First, this end-of-life option has received significant media attention over the past few years (in books, journal articles, and obituaries). Second, unlike MAID, which remains available in only twelve states, patients need not wait for their state legislature to authorize VSED. Patients in every U.S. jurisdiction have the right to refuse any bodily intervention, including oral nutrition and hydration. While VSED is legal and totally within the control of the patient themselves, how should clinicians respond to requests to support the patient during this 8- to 14-day process? Which patients are eligible? Should clinicians apprise patients of this option without first being asked? And how exactly does VSED work?  This class addresses these issues as well as more complicated questions concerning VSED for incapacitated patients. Can patients request VSED in their advance directive? Can agents and surrogates request VSED for incapacitated patients without explicit direction from the patient herself? What if the incapacitated patient makes utterances or gestures indicating they now want water? How is VSED different from related approaches to nutrition and hydration such as Comfort Feed Only and Minimal Comfort Feeding?  

The next World Federation of Right To Die Societies conference will be in Tokyo in November 2026.   The WFRTD meets every two years to exchange news and views, to elect Directors and Officers of the Federation, and to conduct other business. It was a pleasure to present in both Toronto (2022) and Dublin (2024).  I look forward to engaging with WFRTD participants in Tokyo in one year.   

This National Association of Catholic Chaplains (NACC) presentation on VSED. I was surprised and delighted by its positive and supportive perspective.

Join my Fordham University class on VSED for social workers on December 11, 2025. Join here.  More patients are seeking to hasten their deaths by voluntarily stopping eating and drinking (VSED) than by medical aid in dying (MAID). There are two main reasons for this development. First, this end-of-life option has received significant media attention over the past few years (in books, journal articles, and obituaries). Second, unlike MAID, which remains available in only twelve states, patients need not wait for their state legislature to authorize VSED. Patients in every U.S. jurisdiction have the right to refuse any bodily intervention, including oral nutrition and hydration. While VSED is legal and totally within the control of the patient themselves, how should clinicians respond to requests to support the patient during this 8- to 14-day process? Which patients are eligible? Should clinicians apprise patients of this option without first being asked? And how exactly does VSED work?  This class addresses these issues as well as more complicated questions concerning VSED for incapacitated patients. Can patients request VSED in their advance directive? Can agents and surrogates request VSED for incapacitated patients without explicit direction from the patient herself? What if the incapacitated patient makes utterances or gestures indicating they now want water? How is VSED different from related approaches to nutrition and hydration such as Comfort Feed Only and Minimal Comfort Feeding?  

Earlier this week, the U.S. Court of Appeals for the Fifth Circuit heard oral arguments in Hickson v. Saint David's Healthcare Partnership (No. 24-50956). Plaintiffs are suing for disability discrimination, alleging that the treating clinician determined that the patient had no quality of life because he was quadriplegic. The patient's guardian agreed to withhold and withdraw life-sustaining treatment. So, this was not a case of unilateral withholding/withdrawing. Clinicians had the authorized decision maker's consent.   But plaintiffs allege that the presence of consent is not dispositive. The informed consent discussion was "slanted" rather than "balanced." In other words, the clinician steered the guardian to hospice by presenting that as the only legitimate option. No real choice was presented. If the Fifth Circuit rules for the plaintiffs, they can proceed to litigate their federal disability discrimination claim in the district court.

Submit your abstract to the 13th International Shared Decision Making (ISDM) Conference, hosted at Dartmouth College from July8-10, 2026. Dartmouth lies in the scenic Upper Valley of New Hampshire and Vermont—a region known for its classic New England charm, rolling hills, and deep roots in collaborative, patient-centered care. Dartmouth is home to one of the first Shared Decision Making centers in the U.S., making it a meaningful place to explore where the field is headed next.   With the 2026 theme, ‘A Wider Lens,’ this year’s conference will bring together clinicians, researchers, patients, and policy leaders to expand our understanding of shared decision-making across specialties, care settings, and systems. In-person attendees will enjoy rich opportunities for connection, lively discussion, and curated social events, all set against the beauty of a New England summer. For those joining remotely, Dartmouth is building an inclusive, high-quality virtual experience designed to foster engagement and global dialogue.

I am delighted to deliver the 2025 Annual Krug Lecture in Biomedical Ethics at 6:00PM ET on Wednesday, November 12, 2025, at Oakland University William Beaumont School of Medicine. A remote option is available here.  Here is the description for VSED Increasingly Common among End-of-Life Options: Top 10 Things You Need to Know. Suppose you were just diagnosed with early-stage dementia. You can enjoy your life now and for the next few years. But you are determined to avoid living into late-stage dementia under conditions that you judge intolerable. Unfortunately, traditional end-of-life options may be unable to accomplish your goal. While you have the right to refuse life-sustaining treatments, you may never depend on such treatments. Even if medical aid in dying was available in your jurisdiction, you would not qualify. The long progressive nature of dementia means that you lack the requisite six-month prognosis. In response to these limitations, increasingly, patients are voluntarily stopping eating and drinking (VSED) to avoid living with late-stage dementia and other conditions they determine to be unbearable and unendurable. These patients of VSED die a peaceful, comfortable death from dehydration in 8 to 14 days. This presentation reviews the clinical, ethical, and legal status of VSED, and concludes by highlighting obstacles to wider access and implementation.

The next World Federation of Right To Die Societies conference will be in Tokyo in November 2026.   The WFRTD meets every two years to exchange news and views, to elect Directors and Officers of the Federation, and to conduct other business. It was a pleasure to present in both Toronto (2022) and Dublin (2024).  I look forward to engaging with WFRTD participants in Tokyo in one year.   

The North Carolina Court of Appeals has just finished briefing in a case where clinicians wrote a DNR order without proper authorization and contrary to the patient's expressed wishes. That DNR order led to withholding of CPR. (Wyer v. Alamance Regional Medical Center).   In 2021, the trial court dismissed the case because plaintiffs failed to include expert evidence. But in 2022, the court of appeals held that the plaintiffs could proceed on res ipsa loquitor. In 2025, the trial court granted summary judgment to defendants on that claim. Now the parties are back in the court of appeal to litigate the scope of the res ipsa loquitor doctrine. The plaintiff argues that the doctrine fits. An unauthorized DNR order entered into a patient’s chart—contrary to existing, valid directives and family statements—does not ordinarily occur in the absence of negligence. The electronic medical record was within the exclusive control of defendant and its providers. So, it must have been their negligence. 

Submit your abstract to the 13th International Shared Decision Making (ISDM) Conference, hosted at Dartmouth College from July8-10, 2026. Dartmouth lies in the scenic Upper Valley of New Hampshire and Vermont—a region known for its classic New England charm, rolling hills, and deep roots in collaborative, patient-centered care. Dartmouth is home to one of the first Shared Decision Making centers in the U.S., making it a meaningful place to explore where the field is headed next.   With the 2026 theme, ‘A Wider Lens,’ this year’s conference will bring together clinicians, researchers, patients, and policy leaders to expand our understanding of shared decision-making across specialties, care settings, and systems. In-person attendees will enjoy rich opportunities for connection, lively discussion, and curated social events, all set against the beauty of a New England summer. For those joining remotely, Dartmouth is building an inclusive, high-quality virtual experience designed to foster engagement and global dialogue.

The American Academy of Neurology has just released a new position statement: "Brain Death/Death by Neurologic Criteria Guidance on Communication, Objections, Pregnancy, and Public Trust."   It provides updated member guidance regarding: * Communication with surrogate decision makers about brain death/death by neurologic criteria (BD/DNC) * Management of surrogate decision-maker objections to BD/DNC * Ethical considerations associated with BD/DNC determination in a pregnant person  * Enhancing public trust in BD/DNC The new position statement is intended to complement recommendations in the AAN/AAP/CNS/SCCM 2023 “Pediatric and Adult Brain Death/Death by Neurologic Criteria Consensus Guideline” as well as the 2021 AAN Code of Professional Conduct. It replaces the 2019 AAN position statement, “Brain death, the determination of brain death, and member guidance for brain death accommodation requests.”

The next World Federation of Right To Die Societies conference will be in Tokyo in November 2026.   The WFRTD meets every two years to exchange news and views, to elect Directors and Officers of the Federation, and to conduct other business. It was a pleasure to present in both Toronto (2022) and Dublin (2024).  I look forward to engaging with WFRTD participants in Tokyo in one year.   

Earlier this week, the U.S. Court of Appeals for the Fifth Circuit heard oral arguments in Hickson v. Saint David's Healthcare Partnership (No. 24-50956). Plaintiffs are suing for disability discrimination, alleging that the treating clinician determined that the patient had no quality of life because he was quadriplegic. The patient's guardian agreed to withhold and withdraw life-sustaining treatment. So, this was not a case of unilateral withholding/withdrawing. Clinicians had the authorized decision maker's consent.   But plaintiffs allege that the presence of consent is not dispositive. The informed consent discussion was "slanted" rather than "balanced." In other words, the clinician steered the guardian to hospice by presenting that as the only legitimate option. No real choice was presented. If the Fifth Circuit rules for the plaintiffs, they can proceed to litigate their federal disability discrimination claim in the district court.

Some religiously affiliated ethicists have addressed "The Role of the Physician in Caring for Patients Pursuing VSED: Challenging the Conventional Approach" in the Journal of the American Geriatrics Society. Here is their abstract:   The conventional approach to caring for patients pursuing voluntarily stopping of eating and drinking (VSED) allows physicians to disagree with the patient's decisions to pursue VSED, but it assumes clinicians should accept the patient's choice and provide all aspects of supportive care after the patient has autonomously elected to pursue VSED.  We argue this conventional approach problematically ignores the problem of complicity with what some physicians take to be an unethical action. We propose an alternative approach that makes space for clinicians opposed to VSED to advise against this course of action, and to provide palliative medicine while resisting interventions that facilitate VSED. Remarkably, the authors concede that VSED has meaningful clinical, ethical, and legal status. They focus on how objecting clinicians can limit their participation. This is acceptable. Clinicians can generally refuse participation with healthcare (WLST, MAID...) to which they object on conscience grounds. Ben Frush

I am delighted to deliver the 2025 Annual Krug Lecture in Biomedical Ethics at 6:00PM ET on Wednesday, November 12, 2025, at Oakland University William Beaumont School of Medicine. A remote option is available here.  Here is the description for VSED Increasingly Common among End-of-Life Options: Top 10 Things You Need to Know. Suppose you were just diagnosed with early-stage dementia. You can enjoy your life now and for the next few years. But you are determined to avoid living into late-stage dementia under conditions that you judge intolerable. Unfortunately, traditional end-of-life options may be unable to accomplish your goal. While you have the right to refuse life-sustaining treatments, you may never depend on such treatments. Even if medical aid in dying was available in your jurisdiction, you would not qualify. The long progressive nature of dementia means that you lack the requisite six-month prognosis. In response to these limitations, increasingly, patients are voluntarily stopping eating and drinking (VSED) to avoid living with late-stage dementia and other conditions they determine to be unbearable and unendurable. These patients of VSED die a peaceful, comfortable death from dehydration in 8 to 14 days. This presentation reviews the clinical, ethical, and legal status of VSED, and concludes by highlighting obstacles to wider access and implementation.

The North Carolina Court of Appeals has just finished briefing in a case where clinicians wrote a DNR order without proper authorization and contrary to the patient's expressed wishes. That DNR order led to withholding of CPR. (Wyer v. Alamance Regional Medical Center).   In 2021, the trial court dismissed the case because plaintiffs failed to include expert evidence. But in 2022, the court of appeals held that the plaintiffs could proceed on res ipsa loquitor. In 2025, the trial court granted summary judgment to defendants on that claim. Now the parties are back in the court of appeal to litigate the scope of the res ipsa loquitor doctrine. The plaintiff argues that the doctrine fits. An unauthorized DNR order entered into a patient’s chart—contrary to existing, valid directives and family statements—does not ordinarily occur in the absence of negligence. The electronic medical record was within the exclusive control of defendant and its providers. So, it must have been their negligence. 

Earlier this week, the U.S. Court of Appeals for the Fifth Circuit heard oral arguments in Hickson v. Saint David's Healthcare Partnership (No. 24-50956). Plaintiffs are suing for disability discrimination, alleging that the treating clinician determined that the patient had no quality of life because he was quadriplegic. The patient's guardian agreed to withhold and withdraw life-sustaining treatment. So, this was not a case of unilateral withholding/withdrawing. Clinicians had the authorized decision maker's consent.   But plaintiffs allege that the presence of consent is not dispositive. The informed consent discussion was "slanted" rather than "balanced." In other words, the clinician steered the guardian to hospice by presenting that as the only legitimate option. No real choice was presented. If the Fifth Circuit rules for the plaintiffs, they can proceed to litigate their federal disability discrimination claim in the district court.

I am delighted to deliver the 2025 Annual Krug Lecture in Biomedical Ethics at 6:00PM ET on Wednesday, November 12, 2025, at Oakland University William Beaumont School of Medicine. A remote option is available here.  Here is the description for VSED Increasingly Common among End-of-Life Options: Top 10 Things You Need to Know. Suppose you were just diagnosed with early-stage dementia. You can enjoy your life now and for the next few years. But you are determined to avoid living into late-stage dementia under conditions that you judge intolerable. Unfortunately, traditional end-of-life options may be unable to accomplish your goal. While you have the right to refuse life-sustaining treatments, you may never depend on such treatments. Even if medical aid in dying was available in your jurisdiction, you would not qualify. The long progressive nature of dementia means that you lack the requisite six-month prognosis. In response to these limitations, increasingly, patients are voluntarily stopping eating and drinking (VSED) to avoid living with late-stage dementia and other conditions they determine to be unbearable and unendurable. These patients of VSED die a peaceful, comfortable death from dehydration in 8 to 14 days. This presentation reviews the clinical, ethical, and legal status of VSED, and concludes by highlighting obstacles to wider access and implementation.

Consider contributing to this special issue of BIOETHICS by July 20, 2026.    ‘Voluntary Assisted Dying’ (VAD) legislation permits physicians to prescribe lethal substances to eligible patients, enabling those patients to end their lives at a time of their choosing. VAD (known also as Physician Assisted Suicide and Medical Assistance in Dying) is available in a growing number of jurisdictions, for example, Belgium, Canada, Germany, Luxembourg, the Netherlands, New Zealand, all six Australian States, and is expected to be made available soon in the United Kingdom. Different jurisdictions have developed a variety of regulations about eligibility for VAD. While some jurisdictions restrict eligibility to state residents who are expected to die within six months, others have adopted – or are considering adopting – far more permissive frameworks. The landscape of VAD legislation and practice is evolving rapidly and is the subject of much dispute.  This special issue addresses a core normative question: Under what circumstances should Voluntary Assisted Dying be permitted? Some argue that anyone who autonomously expresses a wish to end their own life ought to be entitled to the assistance of a trained healthcare provider. Others argue that healthcare providers should never be permitted to assist patients who wish to commit suicide. Between these two poles there is much middle ground to be staked out and a robust debate to be had which we aim to promote. We welcome contributions that engage with core normative issues regarding the circumstances under which Voluntary Assisted Dying ought to be permitted. Examples of such issues include but are not limited to: * The normative significance of autonomy in VAD decision making. This topic includes discussions of the appropriate role autonomy should play in VAD, what counts as autonomous decision making in this context, and whether only those who experience unbearable suffering and/or terminal illness should be entitled to autonomously access VAD. * Whether VAD should be available to people living with some forms of mental disability and/or illness; and if so, which forms and under what conditions? * The question of how to respond to concerns about coercive influences that may shape the preferences of people who express a wish to die. Examples here are considerations of what constitutes coercion, when coercion is problematic, and how can individuals be protected from coercive influences? * Whether an assisted suicide is compatible with the maintenance of human dignity. We welcome consideration of the role human dignity should play in VAD discourse and legislation (if any), and what it means to respect human dignity when a person expresses a wish to die? * Philosophical, ethical and practical difficulties with the notion of ‘eligibility’ for VAD. Prospective contributors are encouraged to email Steve (stclarke@csu.edu.au), Tessa (tholzman@csu.edu.au), or Xavier Symons (xavier.symons@acu.edu.au) to discuss potential submissions.

The American Academy of Neurology has just released a new position statement: "Brain Death/Death by Neurologic Criteria Guidance on Communication, Objections, Pregnancy, and Public Trust."   It provides updated member guidance regarding: * Communication with surrogate decision makers about brain death/death by neurologic criteria (BD/DNC) * Management of surrogate decision-maker objections to BD/DNC * Ethical considerations associated with BD/DNC determination in a pregnant person  * Enhancing public trust in BD/DNC The new position statement is intended to complement recommendations in the AAN/AAP/CNS/SCCM 2023 “Pediatric and Adult Brain Death/Death by Neurologic Criteria Consensus Guideline” as well as the 2021 AAN Code of Professional Conduct. It replaces the 2019 AAN position statement, “Brain death, the determination of brain death, and member guidance for brain death accommodation requests.”

The North Carolina Court of Appeals has just finished briefing in a case where clinicians wrote a DNR order without proper authorization and contrary to the patient's expressed wishes. That DNR order led to withholding of CPR. (Wyer v. Alamance Regional Medical Center).   In 2021, the trial court dismissed the case because plaintiffs failed to include expert evidence. But in 2022, the court of appeals held that the plaintiffs could proceed on res ipsa loquitor. In 2025, the trial court granted summary judgment to defendants on that claim. Now the parties are back in the court of appeal to litigate the scope of the res ipsa loquitor doctrine. The plaintiff argues that the doctrine fits. An unauthorized DNR order entered into a patient’s chart—contrary to existing, valid directives and family statements—does not ordinarily occur in the absence of negligence. The electronic medical record was within the exclusive control of defendant and its providers. So, it must have been their negligence. 

Some religiously affiliated ethicists have addressed "The Role of the Physician in Caring for Patients Pursuing VSED: Challenging the Conventional Approach" in the Journal of the American Geriatrics Society. Here is their abstract:   The conventional approach to caring for patients pursuing voluntarily stopping of eating and drinking (VSED) allows physicians to disagree with the patient's decisions to pursue VSED, but it assumes clinicians should accept the patient's choice and provide all aspects of supportive care after the patient has autonomously elected to pursue VSED.  We argue this conventional approach problematically ignores the problem of complicity with what some physicians take to be an unethical action. We propose an alternative approach that makes space for clinicians opposed to VSED to advise against this course of action, and to provide palliative medicine while resisting interventions that facilitate VSED. Remarkably, the authors concede that VSED has meaningful clinical, ethical, and legal status. They focus on how objecting clinicians can limit their participation. This is acceptable. Clinicians can generally refuse participation with healthcare (WLST, MAID...) to which they object on conscience grounds. Ben Frush