June 19, 2012 | Posted By Michael Brannigan, PhD

Does the case for terminal sedation actually weaken the case against physician-assisted suicide?

Terminal sedation, more clinically referred to as "palliative sedation," is a legally sanctioned alternative to physician-assisted suicide, a last resort in palliative treatment. It involves inducing and maintaining unconsciousness in a terminally ill patient until the patient dies, and is often accompanied by withholding or withdrawing medical feeding and hydration.

For example, if, in my advanced cancer, I experience intolerable pain, delirium, dyspnea or distress, to alleviate these unmanageable symptoms I let my physician sedate me into unconsciousness until I die. Sort of like undergoing anesthesia before surgery, without waking up.

In its landmark 1997 case against physician-assisted suicide, Washington vs. Glucksberg, the Supreme Court endorsed terminal sedation. Justice Stephen Breyer, concurring with Justice Sandra Day O'Connor's rejection of any prevailing right to die, noted that patients in intolerable pain and suffering could always resort to "sedation which can end in a coma."

Though legal, terminal sedation is still controversial. Supporters regard it as an indispensable component in palliative care; critics view it as "slow euthanasia." More to the point, does it affect the logic in arguments against assisted suicide?

First, does terminal sedation hasten death? Bear in mind that the American Academy of Hospice and Palliative Medicine endorses "the use of sedating medicines ... to decrease a patient's level of consciousness to mitigate the experience of suffering, but not to hasten the end of his or her life." Dartmouth Medical School's Ira Byock insists that terminal sedation does not hasten death, since death is imminent by the time terminal sedation is applied, and medical feeding at that point no longer prolongs life.

Nonetheless, the jury is still out. Hastening death naturally evokes questions regarding cause and intent — two major philosophical thorns in the case against assisted suicide (and active euthanasia). Namely, in physician-assisted suicide, the physician participates in causing and intending the patient's death.

Does terminal sedation involve causing and intending death? If so, isn't there a double standard in banning assisted suicide while permitting terminal sedation?

Consider cause. It is one thing to induce unconsciousness to relieve intractable pain. The sticking point lies in the total package — sedation combined with withholding medical feeding.

For critics, withholding feeding serves to bring about the patient's death. According to Indiana University health law scholar David Orentlicher, "the patient dies from the intentionally induced stupor or coma. It is the physician-created state of diminished consciousness that renders the patient unable to eat, not the natural progression of the patient's underlying disease."

Yet cause is a slippery notion. What kind of cause? For instance, in the legally sanctioned withdrawing of a ventilator, would not the physical act of turning it off, resulting in a patient's death, contribute to bringing about that death?

Here's where intent enters, but intent is equally problematic.

How do we sufficiently determine intent when the outcome is usually the patient's death? One way is to apply the double-effect principle, distinguishing between the primary intent (e.g., relieving suffering) and its foreseen, unintended consequence (e.g. death). With terminal sedation, when all else has failed, a physician induces unconsciousness intending to relieve suffering, without intending death. So also, in assisted suicide, by providing a patient with lethal medication, a physician may primarily intend to relieve the patient's anguish, without intending death.

We've come full circle. No easy answers here, just tough, necessary questions, all of which broaden the painful complexity of end-of-life decisions.

What does all this mean? As a start, let's be especially prudent regarding terms like cause and intent. Without carefully unpacking their meanings, we can use them inconsistently.

Does the case for terminal sedation weaken the case against assisted suicide? Unless we honestly untangle our line-drawing, our line-drawing is in the sand.

To see more of Dr. Brannigan's work, go to http://www.timesunion.com/brannigan.

The Alden March Bioethics Institute offers graduate online masters in bioethics programs. For more information on the AMBI master of bioethics online program, please visit the AMBI site.

1 comments | Topics: Bioethics and the Law , Doctor-Patient Relationships , End of Life Care , Ethics and Morality , Patient Autonomy , Physician Assisted Suicide


Mary Mills

Mary Mills wrote on 09/16/12 10:09 AM

This happened to my Mother on 8/17/2012 by a Hospice Care Facility in Jacksonville Florida. My Mother succumbed to Palliative Sedation. She arrived on 8/13/2012 Monday Evening and died Friday 8/17/2012 at 1pm in a Coma induced Stupor. She was sent there for Assessment and to "stabilize" her condition. I was not aware of what was happening until it was too late. I am against this type of Palliative Care unless there is Explicit Informed Consent by the Patient or the Family. I was even told by the Doctor he would not reverse the medications given. I had legal Power Of Attorney and also was her Health Care Surrogate. I am appalled at the carelessness of the Supreme Court and State Constitutions that are allowing this type of Medical Care to occur without there being a formal outlined procedure for Explicit Informed Consent and Patient Education. My Mother would not have chosen this for herself. After reviewing the Medical Records requested from Hospice I was assured that there was No Informed Consent signed by my Mother and the only Informed Consent I signed was in the Hospital prior to her Admittance into the Care Facility and this Informed Consent was vague to say the least and only authorized the Facility to perform Palliative Care but not Palliative Sedation resulting in Death. I believe that the way this legislation has been completely left to interpretation that it opens the door to Civil Rights Violations. In our case and cases like ours, it has violated our Civil Rights, not only my Mother's but mine as well. It is putting too much power in the hands of the Doctors who enforce this treatment upon unassuming patients. I no longer have respect for the Hospice Entity and have lost respect for the Doctors who treat the terminally ill patient with this treatment without first discussing and receiving Explicit Informed Consent. We live in a Country that fights for Civil Rights, a Country where one person can take prayer out of School, and now a Country where Euthanasia is disguised behind the fallacy of Terminal Sedation. Call it what it is (terminal sedation) and make sure the Patient and Family are well aware of what is happening. Unless there is a change in legislation to protect the rights given to all Citizens of the United States of America we will undermine the very fabric our Country is made of and the foundation the Constitution of America and the Declaration of Independence was founded upon will permanently be compromised. This foundation is based on the idea that every person is created equal and that they are endowed by their Creator with certain unalienable rights to Life, Liberty, and the pursuit of Happiness and these rights should be protected by the Constitution of the United States of America. I think there should be formal legislation enacted to protect these rights from the hands of Doctors who assume they know what is best for the patient without even discussing this plan of treatment with the patient or the family.

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