Terminal sedation is stealthy euthanasia

Protesters holding signs saying “Bring relief, but do not kill” and “No to euthanasia” earlier this year as France debated a Bill calling for the “deep and continued sedation” of the terminally ill. While some may feel the approach is more natural as death takes several days, the writer says it is still euthanasia.
PHOTO: Terminal sedation is stealthy euthanasia

THERE is a new favourite in the euthanasia movement called "terminal sedation".

It was legalised in France last month. Said to be less drastic than euthanasia, it was already legal in France's neighbours, Belgium and the Netherlands.

This end-of-life procedure involves the use of narcotics to cause deep, continuous sedation of the terminally ill. The idea is to relieve not only intractable pain but also shortness of breath, delirium, uncontrolled vomiting and the anguish of facing death.

What could be kinder than helping the dying "go gentle into that good night"? Yet, from its name, one would not have known that what ends life is not the sedation but the fact that fluids are concurrently and totally discontinued for the unconscious patient. Such dehydration leads inevitably to death within one or two weeks, even for healthy persons. By contrast, starvation alone, where fluids are not restricted, takes weeks or even months to bring on death. So it is dehydration that kills the patient - unless the disease takes him first.

The idea is to make a patient, who is dying with intractable suffering that cannot be alleviated despite optimal treatment, go into deep sleep but avoid using so much sedative that he stops breathing. This is an ever-present concern since narcotics can suppress the brain centre that controls our automatic breathing. Thus, sedation may hasten death unintentionally, which would still be euthanasia.

However, if there is no overdose, then death is not caused by the narcotics, which the doctor actively administers. Instead, it is the dehydration that brings on death, which proponents say is medically justified: As the body's systems begin shutting down with approaching death, the kidneys can no longer excrete the additional fluid that a continuous drip delivers. That fluid could pool in the lungs, causing the patient difficulty in breathing. However, if fluids are withheld, this will not happen.

To reassure family members that withholding fluids will not cause the patient extreme thirst, it is pointed out that in hospices where the terminally ill are cared for until death, patients who can no longer drink or eat are routinely not rehydrated or fed. The hospice experience is that such patients do not die in discomfort, proponents claim.

There is, however, no medical consensus yet on the benefits or harm of rehydration in this situation. Perhaps this hospice practice needs serious debate for it is hard to believe that such patients are not thirsty. Perhaps, being unconscious, they just cannot tell anyone that they are thirsty.

Most family members are told that applying lubricant to the unconscious patient's lips and wetting them with ice chips regularly throughout the day will suffice. But it seems more prudent to assume the patient does experience thirst - unless disease has destroyed the brain centre for thirst.

How do proponents justify this procedure ethically? Most resort to the doctrine of double effect, originally developed in Roman Catholic theology in the Middle Ages. This holds that an action is morally permissible even if it leads to serious harm, like death, so long as it brings about a lot of good as well.

The doctrine also stresses that, in such scenarios, it is the doer's intention that matters: An act is permissible as long as the doctor, say, does not intend for his actions to cause his patient to die. But it is hard to know or prove a doctor's intention.

In fact, in a 2003 study, Dutch doctors confessed that in 20 per cent of all cases of terminal sedation with the withholding of fluids, they intended to hasten the patient's death.

Under this doctrine, deep sedation is ethically permissible since the delirious are routinely sedated to stop their restlessness, so the patient is more comfortable. As long as the doctor does not intend it, even if the sedative does happen to stop breathing, sedation remains morally permissible.

But is the critical step of dehydration also morally justifiable? Proponents say that though feeding and hydration by drip may seem indicated when the dying person can no longer eat and drink, the drip is wrong as it only prolongs his intolerable suffering and lengthens the dying process.

Also, a drip may cause fluids to accumulate in the lungs. Moreover, if the patient has elected while conscious and rational to have hydration withheld once he is rendered deeply unconscious, doing so only respects his right to be master of his own life and death. So, withholding fluids is morally permissible though it leads to death, it is argued.

Given all these considerations, proponents say, this procedure is not conflicted by the moral doubts that beset patient-requested physician-assisted suicide (passive euthanasia) and mercy killing (active euthanasia).

But I find it morally ambiguous, straddling active and passive euthanasia, at best.

Take the dehydration. To bring about one's own death by refusing fluids is called passive euthanasia in every instance it has been done without deep sedation. Proponents say withholding hydration is a passive act of omission, not an active act of commission. Yet refusing hydration is a decision that one must take actively: If the patient drinks, he will not die, so refusing fluids is a proactive decision and an active act.

Likewise, in concurring with the patient's decision, the physician's decision to withhold hydration is also one that he has to actively make.

Now consider the sedation. Its main aim is to relieve pain and suffering caused by the terminal disease and so that the patient may not feel thirsty, it is said. But once the sedation is deep enough, it causes something else not directly intended: the patient can no longer drink. That is, dehydration becomes an unintended consequence of sedation. This means that with deep enough sedation, because hydration is withheld when the patient can no longer choose to drink, death becomes unavoidable.

It is passive euthanasia where a person is starved of food and deprived of water unto death. The only difference now is that it is preceded by the patient being rendered unconscious and kept so until he dies. Thus, the withholding of hydration here is euthanasia by stealth, with deep sedation providing it some political cover.

As death takes several days, this approach may feel safer and more natural to the patient and his kin. It may also feel more ethical to the physician - though it still ends in death.

This is why it is now the new favourite in the euthanasia movement.

Proponents increasingly prefer the terminology of "palliative sedation" to terminal sedation in the hope that conflating it with palliative care might render it acceptable politically.

However, it quacks and waddles so much like the proverbial duck that I feel it is still the duck called euthanasia - by any other name.

andyho@sph.com.sg


This article was first published on Apr 4, 2015.
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