Daunting questions on our fate
by Michael Brannigan
Published Thursday, May 31, 2012 in the Albany NY Times Union
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.