From Cochrane to Aquinas: Euthanasia, palliative opioid use and palliative sedation

By Thomas David Riisfeldt

Having previously studied bioethics at university, I welcomed the recent opportunity to leave my comfortable philosopher’s armchair (albeit with some hesitation) and work as a junior doctor in a palliative care hospital.  My daily routine began with a ward round to check in on my patients.  In addition to exploring complex psychological, emotional and spiritual issues, the other main focus of the round was assessing my patients’ physical symptoms and how adequately they were being managed.  Subsequent medical decision making could then be divided into ‘passive’ practices (e.g. decisions to avoid artificial feeding and hydration by either removing or not inserting nasogastric feeding tubes or intravenous fluid drips), and ‘active’ practices.  The latter of these could be further divided into ‘non-pharmacological’ interventions (everything spanning from using fans to blow cool air over the faces of patients who were short of breath, to pet therapy with the local dog who visited on occasion—always a highlight of my day), and ‘pharmacological’ interventions.  These in turn commonly involved prescribing opioids such as morphine, and sedatives such as midazolam.

I often noticed that patients and their families (and secretly, me alongside them) would often ask “Will this medicine speed up the death of my loved one?”, sometimes concerned that it would, sometimes hopeful that it would.  The response from my senior colleagues was invariably “No, we have strong evidence that this medicine is effective in achieving pain relief (or sedation) without speeding up death”.  However, anecdotally and without any evidence to support my intuition, it did seem that after commencing continuous deep palliative sedation in particular, patients seemed to die shortly thereafter.  It also seemed to me that referring to this research evidence was used as a safeguard against the implicit (and sometimes explicit) suggestion that our actions were in any way affiliated with euthanasia.

This prompted me to investigate just how watertight this body of evidence was.  As I discuss in my essay, I arrived at the conclusion that it 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.

Given this agnosticism, if it turned out that palliative opioid and sedative use do actually shorten survival time, then they clearly share at least one important similarity with euthanasia, which also involves some active intervention, usually a medicine, used to bring about death.  In my experience, palliative care physicians are often (although not always) ethically opposed to euthanasia and assisted suicide, and commonly appeal Aquinas’ well-known Doctrine of Double Effect as a way to distinguish them from palliative opioid and sedative use.  In my essay I go on to explore the Doctrine, breaking it down into its component deontological and consequentialist roots, and then argue through thought experimentation that although it represents a genuine and valuable example of pluralistic ethics, it is not ultimately a sound or infallible ethical principle.  I also argue that there are strong reasons to doubt whether it actually applies to palliative opioid and sedative use to begin with.

By no means does my essay show that palliative opioid or sedative use shorten survival time, or that they are equivalent to euthanasia, or that their use should be limited.  However, it does challenge the ingrained belief that palliative opioid and sedative use are ethically shielded by the Doctrine of Double Effect against comparisons with euthanasia (and assisted suicide).

I hope that my essay encourages doctors, medical ethicists, and by extension patients and their families, to be aware of the lack of a definitive answer regarding whether palliative opioids and sedatives hasten death, and to think critically as to whether their use is really so separate to euthanasia as is commonly believed.  Although in honesty I am not completely decided on the matter myself, my essay could be used to support a model of integrated palliative care such as the one adopted in Belgium, where rather than being considered as ice and fire, euthanasia (and assisted suicide) are considered complementary to and are offered alongside other palliative care practices as alternative options at the end of life.

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

Author: Thomas David Riisfeldt

Affiliations: Department of Philosophy, University of New South Wales, Australia

Competing interests: None declared

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