{"id":3462,"date":"2018-12-23T21:58:09","date_gmt":"2018-12-23T20:58:09","guid":{"rendered":"https:\/\/blogs.bmj.com\/medical-ethics\/?p=3462"},"modified":"2018-12-23T22:01:35","modified_gmt":"2018-12-23T21:01:35","slug":"from-cochrane-to-aquinas-euthanasia-palliative-opioid-use-and-palliative-sedation","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/medical-ethics\/2018\/12\/23\/from-cochrane-to-aquinas-euthanasia-palliative-opioid-use-and-palliative-sedation\/","title":{"rendered":"From Cochrane to Aquinas: Euthanasia, palliative opioid use and palliative sedation"},"content":{"rendered":"

By Thomas David Riisfeldt<\/p>\n

Having previously studied bioethics at university, I welcomed the recent opportunity to leave my comfortable philosopher\u2019s armchair (albeit with some hesitation) and work as a junior doctor in a palliative care hospital.\u00a0 My daily routine began with a ward round to check in on my patients.\u00a0 In addition to exploring complex psychological, emotional and spiritual issues, the other main focus of the round was assessing my patients\u2019 physical symptoms and how adequately they were being managed.\u00a0 Subsequent medical decision making could then be divided into \u2018passive\u2019 practices (e.g.<\/em> decisions to avoid artificial feeding and hydration by either removing or not inserting nasogastric feeding tubes or intravenous fluid drips), and \u2018active\u2019 practices.\u00a0 The latter of these could be further divided into \u2018non-pharmacological\u2019 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\u2014always a highlight of my day), and \u2018pharmacological\u2019 interventions.\u00a0 These in turn commonly involved prescribing opioids such as morphine, and sedatives such as midazolam.<\/p>\n

I often noticed that patients and their families (and secretly, me alongside them) would often ask \u201cWill this medicine speed up the death of my loved one?\u201d, sometimes concerned that it would, sometimes hopeful that it would.\u00a0 The response from my senior colleagues was invariably \u201cNo, we have strong evidence that this medicine is effective in achieving pain relief (or sedation) without speeding up death\u201d.\u00a0 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.\u00a0 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.<\/p>\n

This prompted me to investigate just how watertight this body of evidence was.\u00a0 As I discuss in my essay, I arrived at the conclusion that it is not watertight at all.\u00a0 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.\u00a0 I conclude that adopting a position of agnosticism on the matter is appropriate.<\/p>\n

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.\u00a0 In my experience, palliative care physicians are often (although not always) ethically opposed to euthanasia and assisted suicide, and commonly appeal Aquinas\u2019 well-known Doctrine of Double Effect as a way to distinguish them from palliative opioid and sedative use.\u00a0 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.\u00a0 I also argue that there are strong reasons to doubt whether it actually applies to palliative opioid and sedative use to begin with.<\/p>\n

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.\u00a0 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).<\/p>\n

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.\u00a0 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.<\/p>\n

Paper title: <\/strong>Weakening the ethical distinction between euthanasia, palliative opioid use and palliative sedation<\/a><\/p>\n

Author:<\/strong> Thomas David Riisfeldt<\/p>\n

Affiliations:<\/strong> Department of Philosophy, University of New South Wales, Australia<\/p>\n

Competing interests:<\/strong> None declared<\/p>\n

Social media accounts of post author: <\/strong>PhilPeople,\u00a0<\/a>LinkedIn<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"

By Thomas David Riisfeldt Having previously studied bioethics at university, I welcomed the recent opportunity to leave my comfortable philosopher\u2019s armchair (albeit with some hesitation) and work as a junior doctor in a palliative care hospital.\u00a0 My daily routine began with a ward round to check in on my patients.\u00a0 In addition to exploring complex […]<\/p>\n

Read More…<\/a><\/p>\n","protected":false},"author":353,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1],"tags":[],"class_list":["post-3462","post","type-post","status-publish","format-standard","hentry","category-uncategorized"],"yoast_head":"\nFrom Cochrane to Aquinas: Euthanasia, palliative opioid use and palliative sedation - Journal of Medical Ethics blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/blogs.bmj.com\/medical-ethics\/2018\/12\/23\/from-cochrane-to-aquinas-euthanasia-palliative-opioid-use-and-palliative-sedation\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"From Cochrane to Aquinas: Euthanasia, palliative opioid use and palliative sedation - 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