Is there a difference between palliative sedation and euthanasia?

BioEdge

Xavier Symons

One common argument in favour of legalising euthanasia is that several accepted medical practices already involve hastening the death of patients. Some ethicists claim, for example, that we are already hastening patients’ deaths in palliative care contexts through the administration of toxic levels of opioids and sedatives to patients. In palliative sedation — a relatively common procedure in end of life scenarios — doctors administer strong doses of drugs such as midazolam to sedate a patient. Ostensibly this is done to relieve refractory symptoms, yet some suggest that doctors are fully aware that the drugs may bring about a quicker death. In light of this, some ethicists argue that we need not be so concerned about hastening death through euthanasia — this is a mere extension of the already existing practices in palliative care.

There are two common rejoinders to this argument. The first is that palliative sedation does not even hasten death — in fact, studies show that it actually may prolong life. Thus, there is no causal link between the administration of analgesics and barbiturates and the death of the patient.

The second is that the practice of palliative sedation is defensible on the basis of double effect reasoning. The doctrine of double effect is quite difficult to summarise in a sentence, but essentially the claim is that doctors do not intend for the patient’s death to be hastened, even though they foresee that this may be the case.

A new article in the Journal of Medical Ethics attempts to critique these two responses. Doctor Thomas David Riisfeldt of the University of New South Wales argues that empirical evidence on palliative sedation does not in fact provide a reliable indication of whether or not palliative sedation hastens death. In a blog post summarising the article, Riisfeldt writes:

“[the claim that pain killers and sedatives do not hasten death] is not watertight at all.  This is mainly owing to the ethical limitations (more so, the ethical impossibility) of conducting high-quality randomised controlled trials to definitively compare survival times in patients receiving or not receiving palliative opioids and sedatives, along with a number of other practical difficulties.  I conclude that adopting a position of agnosticism on the matter is appropriate”.

In the article, Riisfeldt also suggests that the doctrine of double effect is indefensible, and argues that — in the case of palliative sedation — there is no meaningful distinction between the direct effect of the action (pain relief) and the unintended consequence (death).

So, does Riisfeldt’s critique itself hold water? He makes a series of controversial claims regarding the nature of palliative sedation, and whether it violates the sanctity of life principle (he believes that it does). It seems to this author that his essay would be befitting a robust response from someone familiar with the literature on palliative sedation and also the across the ethics of double effect.


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Weakening the ethical distinction between euthanasia, palliative opioid use and palliative sedation

Thomas David Riisfeldt

Journal of Medical Ethics

Abstract

Opioid and sedative use are common ‘active’ practices in the provision of mainstream palliative care services, and are typically distinguished from euthanasia on the basis that they do not shorten survival time. Even supposing that they did, it is often argued that they are justified and distinguished from euthanasia via appeal to Aquinas’ Doctrine of Double Effect. In this essay, I will appraise the empirical evidence regarding opioid/sedative use and survival time, and argue for a position of agnosticism. I will then argue that the Doctrine of Double Effect is a useful ethical tool but is ultimately not a sound ethical principle, and even if it were, it is unclear whether palliative opioid/sedative use satisfy its four criteria. Although this essay does not establish any definitive proofs, it aims to provide reasons to doubt—and therefore weaken—the often-claimed ethical distinction between euthanasia and palliative opioid/sedative use.


Riisfeldt TD. Weakening the ethical distinction between euthanasia, palliative opioid use and palliative sedation. J Med Ethics 2019;45:125-130.

Redefining the Practice of Medicine- Euthanasia in Quebec, Part 2: ARELC in Detail


Abstract

An Act Respecting End-of-Life Care (“ARELC”) is intended to legalize euthanasia by physicians in the province of Quebec.  It replaces the original Bill 52, the subject of a previous commentary by the Project. ARELC purports to establish a right to euthanasia for a certain class of patients by including it under the umbrella of “end-of-life care.”  ALERC calls euthanasia for competent patients “medical aid in dying” (MAD).  ALERC provides for but does not  identify euthanasia for incompetent patients, called here Euthanasia Below the Radar (EBTR).
 
ARELC’s definition of palliative care clearly distinguishes palliative care from MAD.  In defining MAD, the statute does not say “kill,”  but employs a euphemism: “hastening death.”  Nonetheless, it is obvious that ARELC authorizes a physician to kill patients.

The MAD guidelines for euthanasia restrict it to legally competent persons at least 18 years old who are insured under the provincial Health Insurance Act.  Beyond age, legal competence and residency/insurance, someone seeking euthanasia must be at “the end of life,” suffering from an incurable serious illness, in an advanced state of irreversible decline and suffering from constant and unbearable physical or psychological pain.  The patient need not be terminally ill and is free to refuse effective palliative treatments.

A qualifying patient must personally make a written request for MAD “in a free and informed manner.” It must be signed in the presence of professional, who must also sign the request. The attending physician must confirm the eligibility of the patient and the free and informed nature of the request. He must verify the persistence of suffering and a continuing desire for euthanasia, speak to other members of the health care team and see that the patient is able to discuss the decision with others. However, the physician cannot advise family members unless the patient so wishes. Thus, a physician may kill a patient without the knowledge of the family. Finally, the attending physician must obtain a written opinion of an independent physician confirming eligibility for euthanasia.

Only physicians may administer the lethal drugs or substances, and, having done so, must remain with a patient until he dies. Physicians who provide MAD must report the fact to institutional authorities or the College of Physicians, as well as the Commission on End-of-Life Care.

A central role in the provision of euthanasia is assigned to institutional councils of physicians, dentists and pharmacists (or, in their absence, institutional directors of care).  They are to adopt MAD guidelines, and then review reports from physicians who have provided the procedures to “assess the quality of the care provided.” The Collège des médecins is also to receive such reports from physicians and, apparently, to establish or at least recognize “clinical standards” relative to the procedures.

In addition to the MAD protocol, ARELC permits a substitute decision-maker to order that an incompetent patient be starved and dehydrated to death.  This provides an alternative form of euthanasia subject to none of the restrictions or conditions imposed by MAD guidelines: hence the term used here – “Euthanasia Below the Radar” (EBTR).  Since death by starvation and dehydration would be a painful process, it is likely that, in such circumstances, continous palliative sedation (CPS) would be used to anesthetize the patient. This may lead to the under-reporting of the actual number of euthanasia cases and further confusion about continuous palliative sedation.

Canadian criminal law is not affected by ARELCA physician who does what ARELC requires in the MAD protocol will have provided excellent evidence that the killing was intentional, planned and deliberate. Conforming to the Act Respecting End-of-Life Care would seem to increase the likelihood that a physician – and anyone counselling, aiding, abetting his act – could be charged and convicted for first degree murder, for which the punishment is life imprisonment without parole for 25 years. [Full Text]