Euthanasia, Palliative Sedation and Assisted Suicide

Introduction

A number of moral questions have been raised regarding Euthanasia, assisted Suicide, and palliative sedation. The ethical issues regarding these three revolve around patients’ autonomy and the desire to relieve pain and suffering, as major motivations. Another pressing ethical concern regards the power and the role of medical practitioners, as well as the availability of euthanasia options that limit occurrence of good death (¹, p.505). Euthanasia is the termination of the life of a patient with the request of the patient to elude suffering. Palliative sedation is taking the patient to an unconscious condition to relieve them of unbearable pain and aid the treatment of an illness or a physical condition. Assisted suicide is where somebody assists another one in terminating life, where the one being killed is in complete control of the process of killing (², p. 100).

Euthanasia

History

The moral debate regarding dying started during the bio-ethics era, with criticism being focused on medical interventions of ‘death and dying’ process. There is proof that ‘death and dying’ has been on focus for a very long period of time (³, p.1). Critics argued that medicine was leading to the alienation of persons from their own dying. In addition, the criticisms were focused on medical interventions at the end of life, with the view that human beings were not being allowed to control their final stages in life. There has been an increased interest in moral concerns regarding euthanasia over years, with the focus being turned on the justification of euthanasia, whether euthanasia is an issue for medical professionals to carry out or not, and the relationship between euthanasia and physician-assisted suicide.

Medical and Moral Arguments

Euthanasia is yet to be clearly defined within legal frameworks and medical practice. It has been allowed in many countries and states, just as assisted suicide. According to Hamji, the issue of euthanasia will continue to raise moral and medical concerns despite its allowance by several states (⁴, p. 465). There is debate whether euthanasia should be accepted as a morally upright way of undertaking a good death or not. Euthanasia is mainly requested under various motivations including terminal cancer, as well as other motivations such as hopelessness, dependency, dyspnoea, and pain (⁵, p. 268).

Some moral debate on euthanasia revolves around the autonomy of the patient, i.e. his/her intention to terminate his/her own life, as well as the need for respect of patient’s autonomy in ending his/her own life. Euthanasia is justified with respect to one’s autonomy of controlling life. There must be a request from the patient for a medical practitioner to aid termination of his life, and that the medical practitioners should be limited in their power to decide to terminate life, according to Jojanneke and colleagues (p. 260). This is necessary because sometimes, medical practitioners have considered other issues such as the need to save money and relief family members of the stress, while their patient is undergoing treatment, and decided to terminate life. For instance, out of the 57000 cases of decision-making regarding patient death recorded in the Netherlands (⁶, p.273) in 1995, 900 cases involved the termination of the patient’s life without the request of the patient. These reasons must be considered unacceptable since any medication or effort should be geared towards saving the patient, and not the family members or technology investments on the patient. Another issue is that physician-assisted suicide requires that the patient is in control of the whole process of dying and has to perform the act of suicide. Active euthanasia is where the patient requests the doctor to terminate his/her life. It has been argued that legalizing euthanasia may lead to narrowing the gap between euthanasia and assisted suicide (⁷, p.272).

However, another moral concern regarding the autonomy of the patient to end his/her own life, regards the limits to be allowed on the autonomy. Whether there should be a justifiable reason for an individual to terminate his/her own life and the use of this justifiable reason to decide whether the autonomy must be granted, or not, is a major moral concern.

Nevertheless, an individual should be left to determine his/her own autonomy even though some people observe that there must be some limitations to the level of autonomy. According to opponents of the idea of patient autonomy, patients cannot be allowed to just take their lives without any justifiable reason. In addition, there is an argument that heteronymous conditions surround the value of life, such as the attachment with family members, which limits the complete autonomy of patients in making an individual decision to terminate life, according to Henk Jos (p. 300).

Physician-Assisted Suicide

As defined earlier on, PAS refers to a situation where one decides to terminate his or her own life, and is assisted to do so (⁸, p.277). This means that the patient takes a lethal dose by himself to end his life according to Dees and colleagues. However, the role of the medical practitioner may include prescribing the drugs to the patient in order to terminate his own life.

PAS and the Moral Dilemmas

The moral implications of PAS are not different from those existing in euthanasia. The role of patient in commission of suicide is clear in PAS as is the role of the medical practitioner in euthanasia. Many patients may terminate their lives even without requesting for doctors’ prescription, and even in secret, while some do it in secret, according to Henk and Jos (⁹). The patient must be held guilty of homicide. Some countries, however, consider that PAS is not a crime and have legalized it. The legal frameworks allowing PAS require to be very carefully drafted in order to allow only some situations and conditions surrounding PAS. This is so as to prevent other forms of suicide. The doctor cannot be held responsible for the patient’s death when it is found that the patient has played a role to request, accept and take the drugs themselves. The role of the medical practitioner is only regarded as “mere”, and according to Henk and Jos, this does not mean that euthanasia is regarded more serious than PAS. For those countries where PAS and euthanasia are not legalized, the responsibility of committing suicide through both determines how heavy the punishment is. Euthanasia may be punished heavily with more years of jail than PAS (p. 299). However, several moral questions have been raised on the exact role of the patient in the latter’s death. Sometimes doctors commit PAS and regard it as euthanasia, and there are many gaps allowing this. For instance, it may not be clear whether the doctor who injects lethal dose on the patient has actually committed PAS or other forms of suicide (see Henk and Jos, p. 289). It may be unclear if the doctor commits PAS or not, if he/she places it on the lips of a patient who is unable to move his/her own limbs.

Effects of PAS

Legalizing or illegalizing PAS affects the society in many ways. Recognition and legalization of individual autonomy in choosing to terminate their lives and control the process through PAS may be regarded as an inadequate argument, because it may increase chances of self-abuse (¹⁰, p.276). This is the case when individuals make choice of PAS for other reasons than intense suffering. There is evident that intense suffering so as to lead a patient to choosing PAS or euthanasia is yet to be clearly defined, meaning that the society may abuse rights for PAS, where it has been legalized. Some countries with legal frameworks allowing PAS require that patients choosing PAS must have conditions of intolerable suffering, as posited by Rietjens and colleagues (p. 280). Some contend that there must be no other solutions to his/her problem, or the other solutions must be exhausted. Some countries have recorded decreased deaths with introduction of palliative sedation, meaning that the slippery slope argument that PAS allows one’s autonomy to directing their lives, must be rejected altogether. Proponents see PAS as a threat to the society because it may lead to abuses, and sometimes patients may even ignore prescription advises or fail to do everything possible to save their own lives. In addition, legalizing PAS may increase chances of negligence of duty on the part of medical practitioners since there are available options to a prolonged illness or terminal illness (¹¹, p.280). It may lead to negligence of the society taking responsibility (under all circumstances) to save individuals from suffering through a reversible means.

PAS in relation to Euthanasia

One moral concern regarding euthanasia and assisted death is whether the person who has already made an autonomous decision to terminate his life should be assisted to do so, and who should assist them. It has been considered that medical professionals should be appropriate to get involved in terminating lives, in this respect. Patients who attempt to terminate their lives secretly without assistance from the doctor should be held responsible and punished. The laws allowing PAS must differentiate these conditions of occurrence of PAS. The requirement that the patient must be in control means that patients who are emotionally and intellectually or physically capable of controlling the process of taking their own lives cannot be regarded to have committed PAS according to Henk and Jos (p. 311). Doctors in these scenarios should be held responsible for euthanasia if they provided medical assistance such as to cause the death of the patient.

Nevertheless, other solutions to alleviating the patient from suffering should be made available in order to turn away many people who are seeking PAS, even considering the fact that patients are under an autonomous control of their own lives (¹², p.1165). In fact, it may be argued that many seek PAS since there are no fit medical interventions available, or that they are not well informed about the options they can take. Complete autonomy requires that no one should prescribe to patients who should take their lives and therefore, restricting PAS to doctors as the only ones to take the “mere” role in assisting patients to terminate their lives is unjustifiable.

Sometimes medical practitioners provide large doses of pain killers, which result to death of the patient and this is illegal. This is so, sometimes, when the patient has not requested that his/her life be terminated. Yet, these practitioners regard themselves as undertaking euthanasia, according to Henk and Jos (p. 201). In other cases, some medication may be targeted at terminating patients’ life, a situation known as physician-assisted suicide (¹³, p.283) It must also be considered that it is illegal for patients to forego medications, even when they have made up their minds to die. However, moral judgment regarding euthanasia or physically-assisted suicide must revolve around whether the patient had made the autonomous decision to die. In addition, other measures such as those intended to prolong life at the end-of-life, pain alleviation medication and active termination of patient’s life must be differentiated from physically-assisted suicide (¹⁴, p.275).

Moral issues of euthanasia and PAS also focus on the question whether both are methods of relieving suffering or not. While some patients may refuse to take medication in order to die because they regard that they would better be dead than undergoing the unbearable suffering, it may be argued that the choice for death is an irreversible solution to their suffering, especially considering if they would have wanted the reversal of the decision. Choice of death may therefore, be regarded as a means of relieving one from excessive suffering.

There must be a control to the choice of the method of relieving a patient from suffering, whether the choice is undertaken by the doctor or patient (¹⁵, p. 341). This is especially so, when there is an alternative such as provision of palliative sedation. Sometimes, court decisions have ruled in favor of people who request for euthanasia under claim that their living has unbearable suffering, or that they are tired of living. This raises serious questions whether the medical practitioners should, therefore, be free to determine to terminate life or not, when they judge that the patient has unbearable suffering. This is an important matter for determination if these patients have not requested euthanasia, or are not in a position to do so, according to Dees and colleagues (p. 344). Moral justification for the latter, however, must be attached to other issues such as whether the physician has exhaustively explored other alternatives such as use of palliative care or not. This is important in order to reduce what has been regarded as medical subjectivity.

Palliative Sedation

Some have argued out that people should be allowed to cope with pain and face finiteness and death without medical interventions (¹⁶, p. 318). Clearly, this is one of the moral concerns that explain the difference between assisted suicide and palliative sedation. Moral questions arise whether letting patients to die by neglecting medication, through exaggerated palliative care provision and by withdrawing medication is morally upright or quickening their death are acceptable. It is considered morally upright when a medical practitioner offers medication in order to prevent death or even quicken death.

Moral Justification of Palliative Sedation

There has been an interest to provide care and social support to patients at the end-of-life stages, so as to alleviate their suffering and prolong their lives (¹⁷, p.45). This is not contentious in as far as the choice of the patient is a longer life, and that the patient is not in unbearable suffering. In fact, palliative care must be considered as an option before medical practitioner offers to choose to terminate the life of a person. Netherlands has, for instance, recorded a decrease in the number of patients who requested euthanasia after intensive intervention strategy in palliative care was put in place. Hence, negligence of medical practitioners to providing medical interventions such as to assist the patient to avoid quick death must be taken seriously and morally unacceptable.

One moral issue revolving around palliative sedation focuses on provision of medication, with a view that a patient would be negatively affected to end to dying. In fact, this sedation interferes with peaceful dying process, and reduces the wellbeing and proper functioning of the patient’s body. The negative impacts would increase as the patient approached end-of-life (¹⁸, p. 321). However, Pittureri has concluded that palliative sedation does not lead to hastened death, according to some people (¹⁹, p. 1166). Therefore, it is a viable solution to those undergoing excessive pain. This is in consideration that the patient would have persisted or born the illness altogether, such that his/her death would be quickened.

The choice of palliative care for those with terminal illnesses is at least so as to prolong their lives. This includes incurable illnesses like cancer, kidney and heart failures, brain failure and serious accidental injuries. Palliative sedation is applied so as to make the patients unconscious and relieve them of unbearable suffering (²⁰, p.1164). Such medication may be beneficial in hopeless situations. The level of sedation is a very serious moral issue in palliative sedation. Some treatments require that a person is under sedation so as to treat and, therefore, sedation is important.

Usually, patients with incurable terminal illnesses or serious physical implications undergo a lot of pain and are exposed to further illnesses, loss of appetite and social exclusion since they must spend the rest of their lives mostly in bed (²¹, p.68). These situations have psychological and emotional costs, as well as economic costs to patients and their family members. Some of these situations include other risks such as fracture of lungs and liver failure. The situation is worse where medical regulations require that patients at the end of life spend their lives at home. No wonder, observes that these treatments present no expected benefits and must be abolished. They are strenuous because medical practitioners feel guilty when they can’t deliver cure and governments feel condemned when they can’t offer a solution.

Storey is of the opinion that these patients should be allowed to die with the dignity they deserve (p. 66). In fact, it may be considered morally unacceptable when families dedicate all they had in order to prolong the life of a patient under these circumstances, only to end up with him/her dying. This is different from a situation where a patient hopes to recover completely. It may be morally acceptable to dedicate whatever one has, in order to save his life in the latter case. Although it may be justifiable to give patients euthanasia under these conditions of terminal illness, this argument may be unacceptable where the patients choose these medications and are ready to undertake them in order to prolong their life. Indeed, as earlier stated, making of the decision regarding termination of a patient’s life under the terminal illness condition appear to be safe when it is left to the patient. It is morally acceptable that the suffering of these terminally ill patients be alleviated through use of sedation – although it has negative impact on their survival, since they would eventually die (²², p. 68).

Differences between Euthanasia, Palliative Sedation and Assisted-Suicide

One of the eminent differences between euthanasia and assisted suicide is that the former requires the patient not to perform the act of suicide, while in the latter, the patient is in control of the act of dying (²³, p.279). Request of termination of life has to be there for it to be considered euthanasia. Both of them are connected in that there has to be a request from the patient for some kind of assistance. Some people request euthanasia under such severe conditions when they regard that it is better to die than suffer (²⁴, p. 351, yet their lives would have been saved through efficient palliative care or sedation. It has been argued that choosing to kill oneself is much more difficult than letting someone to do it on one’s behalf, since several patients choose euthanasia than PAS.

The choice of patient is recognized in PAS and euthanasia, and the intention is for terminating the life of the patient. This is different with palliative sedation, which aims to save the life of the patient. This is through the application of pain control, as well as emotional and social support for patients (²⁵, p. 92). Unfortunately, pain control has either been misused such as to result to death or underutilized. For instance, many countries are yet to incorporate it into their heath care policies. In addition, palliative care must be considered as a human right (²⁶, p. 768). Sedative application of pain medication interventions is attached to patient’s emotional, psychological, spiritual, and physiological torture and the relative desire to become well again. Thus, death or worse conditions resulting from palliative condition would manifest with the initial intention of the medical practitioner being to save life and not terminate it.

Medical professionals may be at liberty to use pain medications and sedation, because their whole intention of bringing patients to normal is considered morally upright, if it is meant to alleviate pain and suffering. This is the case even when it leads to death, unintentionally. Furthermore, according to Sauders (²⁷, p. 8), still some people would have chosen euthanasia if they were in a position to do so before they died. Pain – regarded as anything which would cause a person to be distressed or suffer – may become unbearable to the point of requiring that one involves interventions to alleviate it. This would be in an attempt to avoid other problems caused by physical pain, such as emotional, psychological, spiritual and physiological pain. In addition, life must be protected since it is considered a gift from God.

Euthanasia and PAS have irreversible consequences on the victim since they result to direct death. This is not the case with sedative treatments. Pain relieve through sedative treatments may lead to cognitive impairment, as well as hasten death, but this is not direct death. Nevertheless, this moral debate about administering of pain relief medication should be focused upon how safe it should be administered, since it is not obvious that pain relief leads to cognitive impairment or hasten death.

Like in euthanasia and PAS cases, it has been argued that pain medication must be limited to the decision of the patient, where the patient can make a decision to undertake it or not. It can be acceptable where patients cannot make these decisions, but it is important to consider that the intention should be to alleviate pain (²⁸, p. 267). Whether pain is to be acceptable or not is a moral concern in religious settings. Sometimes, spiritual teaching allow pain and suffering such as Catholic Church teachings. It is important for people to be allowed to suffer according to their faith they held and face death where necessary. Again, it may be argued that prolonging life is unacceptable when God decides to terminate it and where the missions of his /her life are interfered with (²⁹, p. 161).

The power and the role of medical practitioners in the life of the patient also play a role in differentiating the three. Evidently, medical practitioners are, by a large extent, allowed to make decisions on whether to provide palliative sedation to avoid death or to quicken death of the patient (³⁰, p. 201). However, such power and authority may be limited in PAS. Euthanasia sometimes allows medical practitioners to terminate the life of the patient if they regard that the patient would be better if relieved from the current suffering. However, unclear definition of what morally constitutes euthanasia has caused different practice in euthanasia, allowing much power on the medical practitioners’ side. In other words, unclear definition of what constitutes euthanasia has partly allowed increased medical practitioners’ power to make choices regarding whether to undertake it or not (³¹, p. 256). Passive euthanasia has been disregarded as euthanasia, although some debate regards it as a category of euthanasia. The inclusion of passive euthanasia as a form of euthanasia may imply that doctors can neglect provision of medical intervention to the extent that the patient dies.

Conclusion

In conclusion, there are many moral questions arising in the areas of palliative sedation, euthanasia and assisted suicide. Definition of euthanasia is yet to be made clear according to Hamji (p. 465). Therefore, many doctors questionably continue with assisted suicide and other forms of euthanasia which have been doubted. Assisted suicide and euthanasia are connected and there are several moral questions which show differences between the two. For instance, PAS requires that the patient has a complete control of his dying while in euthanasia the doctor takes the role of terminating the patient’s life, according to Rizzo (p. 282). The two are differentiated by consideration of who takes the responsibility of terminating life. Euthanasia is sometimes regarded as supposed to occur when a patient requests for it but is sometimes undertaken under assumptions without the patients’ request. Medical professionals must wait for such a request from the patient. Palliative sedation differ from PAS and euthanasia in that it is undertaken to save the life and does not directly lead to direct death of the patient. Assisted suicide and euthanasia both raise ethical questions whether they must be taken as means of a good death or not. Together with palliative sedation, they raise moral questions whether the medical practitioner has the power to decide over the fate of the patient, especially when medication or withdrawal of the same would cut short the life of the patient, as posited by O’ rourke (p. 159), Henk and Jos (p. 321). Palliative care is necessary, but when a patient is taken to sedation to treat the illness, moral questions must be raised because literature supports the fact that sedation may shorten life, although Pittureri (p. 1166) has doubted this position. Sometimes, this palliative sedation goes on without the request of the patient.

Bibliography

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Footnotes

1. Hamj Have, “Euthanasia: moral paradoxes”. Palliative Medicine 15 (2003) : 505-511.
2. Henk, Have and Jos, Welie. Death and medical power. An ethical analysis of the Dutch euthanasia practice. London: Open University Press, 1999.
3. Kübler-Ross Elisabeth, On death and dying. (Toronto: Macmillan, 1969).
4. Ibid¹.
5. Jojanneke Gé and Richard Marquet, “Requests for euthanasia in general practice before and after implementation of the Dutch Euthanasia Act”. British Journal of General Practice 60 (2010): 263-267.
6. Rietjens, Judith, Paul, Maas, Bregje, Onwuteaka, Johannes, Delden and Agnes, Heide. “Two decades of research on euthanasia from the Netherlands. What have we learned and what questions remain?” Bioethical Inquiry 6 (2009) : 271-283.
7. Henk, Have and Jos, Welie. Death and medical power. An ethical analysis of the Dutch euthanasia practice. London: Open University Press, 1999.
8. Rizzo, Robert. “Physician-assisted suicide in the United States: the underlying factors in technology, health care, and palliative medicine.” Theor Med 21 (2000): 277–89.
9. Henk, Have and Jos, Welie. Death and medical power. An ethical analysis of the Dutch euthanasia practice. London: Open University Press, 1999.
10. Rietjens, Judith, Paul, Maas, Bregje, Onwuteaka, Johannes, Delden and Agnes, Heide. “Two decades of research on euthanasia from the Netherlands. What have we learnt and what questions remain?” Bioethical Inquiry 6 (2009) : 271-283.
11. Rizzo, Robert. “Physician-assisted suicide in the United States: the underlying factors in technology, health care and palliative medicine.” Theor Med 21 (2000) : 277–89.
12. Pittureri, Maltoni. “Palliative sedation therapy does not hasten death: Results from a prospective multicenter study.” Annels of Ontology 20 (2009) : 1163-1169.
13. Rizzo Robert, “Physician-assisted suicide in the United States: the underlying factors in technology, health care and palliative medicine.” Theor Med 21 (2000) : 277–89.
14. Rietjens Judith and Paul Maas, Bregje Onwuteaka, Johannes Delden and Agnes Heide, “Two decades of research on euthanasia from the Netherlands. What have we learnt and what questions remain?” Bioethical Inquiry 6 (2009) : 271-283.
15. Dees, Marianne, Myrra, Vernooij-Dassen, Wim, Dekkers and Chris, Weel. “Unbearable suffering of patients with a request for euthanasia or physician-assisted suicide: An integrative review.” Psycho-Oncology 19 (2010) : 339–352.
16. Claessens Pattricia, Johan Menten, Paul Schotsmans and Bert Broeckaert, “Palliative Sedation: A Review of the Research Literature.” Journal of Pain and Symptom Management 36, no 3 (2008) : 310-333.
17.  Clark, David, Jane, Seymour. Reflections on palliative care. Buckingham: Open University Press, 1999.
18. Claessens Pattricia, Johan Menten, Paul Schotsmans and Bert Broeckaert, “Palliative Sedation: A Review of the Research Literature.” Journal of Pain and Symptom Management 36, no 3 (2008) : 310-333.
19. Pittureri Maltoni, “Palliative sedation therapy does not hasten death: Results from a prospective multicenter study.” Annels of Ontology 20 (2009) : 1163-1169.
20. Pittureri, Maltoni. “Palliative sedation therapy does not hasten death: Results from a prospective multicenter study.” Annels of Ontology 20 (2009) : 1163-1169.
21. Storey Porter, “Birth, suffering and death: Catholic perspectives of the edges of life.” Philosophy and Medicine 41 (1992) : 67-75.
22. Storey, Porter. “Birth, suffering and death: Catholic perspectives of the edges of life.” Philosophy and Medicine 41 (1992) : 67-75.
23. Rizzo, Robert. “Physician-assisted suicide in the United States: the underlying factors in technology, health care and palliative medicine.” Theor Med 21 (2000) : 277–89
24. Dees Marianne, Myrra Vernooij-Dassen, Wim Dekkers and Chris Weel, “Unbearable suffering of patients with a request for euthanasia or physician-assisted suicide: An integrative review.” Psycho-Oncology 19 (2010) : 339–352.
25. Sepulveda Cecilia, Amanda Marlin, Tokuo Yoshida and Andreas Ullrich, “Palliative care: The world health organization’s global perspective.” Journal of Pain and Symptom Management 24, no 2 (2002) : 91-96. See also Clark, David Jane and Seymour, Reflections on palliative care. (Buckingham: Open University Press, 1999) for Palliative care literature.
26. Gwyther Liz, Frank Brennan and Richard Harding, “Advancing Palliative Care as a Human Right.” Journal of Pain and Symptom Management 38, no 5 (2009) : 767-774.
27. Sauders Cicely, “The evolution of palliative care.” Patient Education and Counselling 41 (2000) : 7-1.
28. Hamj, Have. “Euthanasia: moral paradoxes”. Palliative Medicine 15 (2001) : 505-511.
29. O’ rourke Kevin, “Pain relief: Ethical issues and catholic teaching.” Philosophy and Medicine 41 (1992) : 157-169.
30. Henk, Have and Jos, Welie. Death and medical power. An ethical analysis of the Dutch euthanasia practice. London: Open University Press, 1999.
31. Henk, Have and Jos, Welie. Death and medical power. An ethical analysis of the Dutch euthanasia practice. London: Open University Press, 1999.