Terminal sedation vs. PAS: Difference just semantics?
Ethicist says it’s a touchy subject
Physician-assisted suicide (PAS) in the United States is legal only in Oregon, but the palliative care practice of terminal sedation is viewed by some as accomplishing the same thing as PAS, only without the stigma and illegality associated with intentional euthanasia.
Terminal sedation involves using sedatives in dying patients to lessen pain that is not responsive to other treatments. The practice sedates a patient into unconsciousness, which may lead to coma and death. Hastened death is a recognized risk factor, but the objective of terminal sedation is not to hasten or cause death.
Intent is the bright line differentiating terminal sedation from PAS; because death may be viewed as a desirable, if not intentional, outcome for dying patients in extreme pain, physicians are careful to make that distinction, according to Rosamond Rhodes, PhD, an ethicist and professor at Mount Sinai School of Medicine in New York City. The "double effect" concept often enters the discussion.
The double effect is derived from Roman Catholic doctrine that permits certain acts of abortion when mothers’ lives are in danger. The principle distinguishes between the intent of an action and the consequences; for example, if drugs are administered with the intent of relieving pain, but death occurs as an unintended consequence of the drugs, the administration of the drugs is not considered euthanasia — even if death was an expected result.
"In my experience, physicians don’t like to talk about a number of things, and one of those is doctor participation in physician-assisted suicide," says Rhodes. "So the framework of the double effect gets incorporated into palliative care."
She says in patients in the end stages of terminal illness whose pain cannot be ameliorated by standard techniques, the only way to reduce their pain is through sedation.
"The patient is suffering so much that they and their family want the pain to end, and doctors will go along with terminal sedation," Rhodes says. "Everyone sees it as letting the patient die, and they will say that the person died as a result of their disease."
Doctors favor terminal sedation, not PAS
Two recent studies conducted at the University of Iowa and Yale University, one involving internal medicine physicians1 and one focusing on internal medicine residents2, indicated that a strong majority of those surveyed (78% of physicians and 66% of residents) supported the use of terminal sedation.
But two-thirds of those in each study who said they support terminal sedation said they oppose PAS. One-third of participants in the studies said they considered PAS, in theory, to be "ethically appropriate" in certain circumstances.
The American Medical Association’s Code of Medical Ethics is silent on the topics of the double effect and terminal sedation.
Rhodes speculates that in some cases, not all, the difference between PAS and terminal sedation is simply one of semantics.
"Is there a morally significant difference in ending a life quickly with a cocktail [of medications used in PAS] and a terminal sedation?" she asks. "I would say not, but there is a psychological difference.
"The language of the double effect has allowed doctors to be much more comfortable in upping the dose of pain medications to a level you know is likely to suppress respiration. Philosophically, there’s no difference, but psychologically and in the language, it allows people to be more comfortable."
The intent of terminal sedation is not to cause death, but the doctrine of the double effect, Rhodes says, allows doctors who use terminal sedation in patients for whom death is going to be a certain side effect "to be comforted by thinking, I didn’t do it. The underlying disease is killing the patient.’"
The U.S. Supreme Court ruled in 1997 that Americans do not have a constitutional right to PAS, and left it to the states to decide. The court has not directly addressed terminal sedation, but in decisions in PAS and euthanasia cases, some of the court’s language and opinions have led most experts to conclude that terminal sedation is legally acceptable as a means of palliative care in patients near death and in extreme pain. Yet those decisions have not caused physicians to be any more comfortable with discussing hastening death through terminal sedation, Rhodes says.
Experience, religion shape opinions
In the universities’ studies, physicians’ and residents’ attitudes correlated with the frequency with which they attended religious services and with their experience in caring for terminally ill patients, according to the author of both studies.
Lauris Kaldjian, MD, a former Yale faculty member who is now assistant professor of internal medicine at University of Iowa College of Medicine and a member of the college’s Program in Biomedical Ethics and Medical Humanities, says the studies reflect that physicians surveyed were more likely to support terminal sedation but oppose PAS if they had significant experience with terminally ill patients or if they attended religious services frequently.
The more experience physicians had in treating terminally ill patients, the more they were opposed to PAS, Kaldjian says. Sixty-eight percent of doctors who had cared for 50 or more terminally ill patients in the year preceding the study opposed PAS. He adds that among doctors more experienced in caring for terminally ill patients, there was a greater emphasis on rigorous end-of-life care, along with a greater reluctance to intentionally cause death.
The study of internal medicine physicians indicates that the more often a doctor attends religious services, the more likely he or she is to disagree with PAS. Thirty percent of those who said they do not attend religious services at all report they disagree with PAS, compared to 76% of those who attend weekly religious services.
A recently published study of the attitudes of physicians in the Netherlands toward terminal sedation3 reports that most only used terminal sedation when their patients were actively dying and, therefore, almost 75% reported they were confident that sedation did not appreciably shorten life. Forty percent reported that sedation did not shorten life; 33% estimated that terminal sedation shortened life by less than a week.
"If your ethics are based on a series of rules, and one is don’t kill,’ then your attitudes toward terminal sedation and PAS will be very different," says Rhodes. "But if your ethics are about figuring out what to do in this situation, and recognizing when features of a situation justify violating a standard principle, it won’t matter what name is hung on it."
References
- Kaldjian LC, Jekel JF, Bernene JL, et al. Internists’ attitudes towards terminal sedation in end of life care. J Med Ethics 2004; 30:499-503.
- Kaldjian LC, Wu BJ, Kirkpatrick JN, et al. Medical house officers’ attitudes toward vigorous analgesia, terminal sedation, and physician-assisted suicide. Am J Hosp Palliat Care 2004; 21:381-387.
- Rietjens JA, van der Heide A, Vrakking AM, et al. Physician reports of terminal sedation without hydration or nutrition for patients nearing death in the Netherlands. Ann Intern Med 2004; 141:178-185.
Sources
- Lauris Kaldjian, MD, Department of Internal Medicine, University of Iowa Carver College of Medicine, 200 Hawkins Drive, Iowa City, IA 52242. E-mail: [email protected].
- Rosamond Rhodes, PhD, Professor, Medical Education, Mount Sinai School of Medicine, New York, NY 10029. Phone: (212) 241-3757. E-mail: [email protected].
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