Euthanasia, palliative opioid use and palliative sedation: A rejoinder

By Thomas David Riisfeldt.

One of my recent essays has generated a considerable amount of critique which I was fortunate to be able to explore in my essay ‘A response to critics: Weakening the ethical distinction between euthanasia, palliative opioid use and palliative sedation’. I will briefly comment on some of these points here.

I can clearly recall from my medical student days being constantly taught (and reassured) that opioids and sedatives, when appropriately used in the palliative care setting, do not hasten death, and that they are therefore far removed from euthanasia. In my original essay I conducted a literature search which found that there is not a strong body of evidence supporting this claim, suggesting that we should adopt a position of agnosticism on the matter. Schofield et al. correctly acknowledge that there is a wealth of information showing that opioid and sedative use is safe in other settings outside of palliative care, and then argue that I have introduced a cherry-picking bias by focusing solely on the palliative care population. They also argue that continuous deep palliative sedation (CDPS), a subset of palliative sedation, falls beyond the scope of routine palliative care, and that my research will contribute to opiophobia and be deleterious to the provision of palliative care globally, and therefore be harmful to patients, their families and health professionals.

However, it is well known that one drug can have varying effects when used in different clinical settings, and I argue that the paucity of evidence regarding opioid and sedative safety in the specific palliative care population is highly relevant and problematic. Based on the current level of information available, a position of agnosticism regarding whether they hasten death in this setting is still appropriate. Furthermore, in my personal clinical experience, CDPS does not fall beyond the scope of routine palliative care, and this is supported by the European Association for Palliative Care’s framework on palliative sedation which was introduced by Schofield et al. The Australian and New Zealand Society of Palliative Medicine also aligns itself with this policy.

I would also like to emphasise that I wholly and passionately advocate for the use of opioids and sedatives in the palliative care setting. I have treated many dying patients in both general hospitals and hospices, and know how essential they are in achieving adequate pain and other symptom relief.  By arguing that there may not be an ethically-significant difference between palliative opioid and sedative use and euthanasia, I have been attempting to advance the case for the latter rather than hinder the case for the former. I therefore do not think that my research ought to contribute to opiophobia or have harmful real-world consequences.

Materstvedt then argues that euthanasia ‘ends’ rather than ‘relieves’ suffering, and by virtue of this it does not constitute a treatment per se, rendering my original arguments a non-starter.  I think that this is in all likelihood splitting hairs, and doubt whether this linguistic difference represents a true, substantive difference. I also doubt whether this difference, even if substantive, has any ethical relevance, and certainly do not think that it precludes any comparison between euthanasia and palliative opioid and sedative use from being performed.

Symons and Giebel then turn to my discussion of the Doctrine of Double Effect (DDE). I acknowledge that my deontological and consequentialist interpretation of the DDE through a Kantian/Millian framework is anachronistic, and that a contemporaneous interpretation from Aquinas’ perspective is more historically appropriate.  Having studied both Kant and Mill, their ethical systems do seem to have immediate relevance to the DDE, and I thought that they would be an interesting and potentially insightful way to deconstruct and analyse the DDE. I also believe that we have the academic liberty to stand on the shoulders of these giants and appraise the DDE through them, despite this anachronism. I do not think that one interpretation is ‘better’ than the other; rather, each should be appraised according to its own merits.

Symons and Giebel subsequently argue that the DDE is a sound ethical principle when interpreted from Aquinas’ perspective. Giebel also argues that palliative opioid and sedative use do meet the DDE’s four criteria when interpreted from this perspective, and that it does not contravene the Doctrine of the Sanctity of Human Life (DSHL) either. Conversely, I think that these two interpretations of the DDE are actually very similar. I therefore argue, on the same grounds as for the Kantian/Millian interpretation, that even on the interpretation from Aquinas’ perspective the DDE is unsound, palliative opioid and sedative use do not meet its four criteria, and it still contradicts the DSHL.

The arguments that I have made are ultimately intended to strengthen the case for euthanasia, given its similarity to palliative opioid and sedative use, which are themselves clearly acceptable ethical practices. My research could therefore be used to support a model of integrated palliative care such as the one adopted in some European countries, where rather than being considered as ice and fire, euthanasia is considered complementary to and is offered alongside other palliative care practices as alternative options at the end of life.


Paper title: A response to critics: Weakening the ethical distinction between euthanasia, palliative opioid use and palliative sedation

Author: Dr Thomas David Riisfeldt

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

Competing interests: None declared

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