Is there a difference between palliative sedation and euthanasia?

Xavier Symons
January 19, 2019
Reproduced with Permission

One common argument in favour of legalising euthanasia is that several accepted medical practices already involve hastening the death of patients. Some ethicists claim, for example, that we are already hastening patients' deaths in palliative care contexts through the administration of toxic levels of opioids and sedatives to patients. In palliative sedation -- a relatively common procedure in end of life scenarios -- doctors administer strong doses of drugs such as midazolam to sedate a patient. Ostensibly this is done to relieve refractory symptoms, yet some suggest that doctors are fully aware that the drugs may bring about a quicker death. In light of this, some ethicists argue that we need not be so concerned about hastening death through euthanasia -- this is a mere extension of the already existing practices in palliative care.

There are two common rejoinders to this argument. The first is that palliative sedation does not even hasten death -- in fact, studies show that it actually may prolong life. Thus, there is no causal link between the administration of analgesics and barbiturates and the death of the patient.

The second is that the practice of palliative sedation is defensible on the basis of double effect reasoning. The doctrine of double effect is quite difficult to summarise in a sentence, but essentially the claim is that doctors do not intend for the patient's death to be hastened, even though they foresee that this may be the case.

A new article in the Journal of Medical Ethics attempts to critique these two responses. Doctor Thomas David Riisfeldt of the University of New South Wales argues that empirical evidence on palliative sedation does not in fact provide a reliable indication of whether or not palliative sedation hastens death. In a blog post summarising the article, Riisfeldt writes:

"[the claim that pain killers and sedatives do not hasten death] is not watertight at all. This is mainly owing to the ethical limitations (more so, the ethical impossibility) of conducting high-quality randomised controlled trials to definitively compare survival times in patients receiving or not receiving palliative opioids and sedatives, along with a number of other practical difficulties. I conclude that adopting a position of agnosticism on the matter is appropriate".

In the article, Riisfeldt also suggests that the doctrine of double effect is indefensible, and argues that -- in the case of palliative sedation -- there is no meaningful distinction between the direct effect of the action (pain relief) and the unintended consequence (death).

So, does Riisfeldt's critique itself hold water? He makes a series of controversial claims regarding the nature of palliative sedation, and whether it violates the sanctity of life principle (he believes that it does). It seems to this author that his essay would be befitting a robust response from someone familiar with the literature on palliative sedation and also the across the ethics of double effect.