Is Continuous Sedation at the End of Life an Ethically Preferable Alternative to Physician-Assisted Suicide?

Abstract

The relatively new practice of continuous sedation at the end of life (CS) is increasingly being debated in the clinical and ethical literature. This practice received much attention when a U.S. Supreme Court ruling noted that the availability of CS made legalization of physician-assisted suicide (PAS) unnecessary, as CS could alleviate even the most severe suffering. This view has been widely adopted. In this article, we perform an in-depth analysis of four versions of this “argument of preferable alternative.” Our goal is to determine the extent to which CS can be considered to be an alternative to PAS and to identify the grounds, if any, on which CS may be ethically preferable to PAS.

Keywords:

• continuous deep sedation
• physician-assisted suicide
• ethics
• end-of-life decision making

Acknowledgments

The research on which this article is based is linked to a larger project, the ‘UNBIASED’ study (UK – Netherlands – Belgium International SEDation study) which is a collaboration between research teams in UK, Belgium and the Netherlands with funding from the Economic and Social Research Council (UK) (grant no: RES-062–23-2078), Research Foundation Flanders (BE), the Flemish Cancer Association (BE), the Special Research Funds of the University of Ghent (BE), Netherlands Organisation for Scientific Research (NL) and the Netherlands Organisation for Health Research and Development (NL). For information, contact Professor Jane Seymour, [email protected].

Notes

Admittedly, the practice of euthanasia, which is not the subject of this paper, is even more controversial.

Vacco, Attorney General of New York, et al. v. Quil et al., 521 U.S. 793, (S.C., 1997).

Washington et al. v. Glucksberg et al., 521 U.S. 702 (S.C., 1997).

Wet toetsing levensbeëindiging op verzoek en hulp bij zelfdoding. Staatsblad [Official Journal of The Netherlands]194, (2001) (effective 1 April 2002, Staatsblad 165, 2002).

Loi du 16 mars 2009 sur l’euthanasie et l’assistance au suicide—A-N°46. Journal Officiel du Grand-Duché de Luxembourg, (2009), available at http://www.legilux.public.lu/leg/a/archives/2009/0046/a046.pdf

Wet van 28 mei 2002 betreffende de euthanasie. Belgisch Staatsblad [Official Journal of Belgium] (22 June 2002), effective 22 September 2002. Unofficial English translation available at http://www.kuleuven.be/cbmer/viewpic.php?LAN=E&TABLE =DOCS&ID=23

The modification of Art. 115 is currently a topic of heated debate in Switzerland. In October 2009 the Federal Council submitted two possible scenarios for consultation: (1) specifying strict duties of care to be respected by organizations that provide assistance, or (2) banning organized (as opposed to “private”—see later discussion) assisted suicide altogether. In the fall of 2010 the government will present the results of the consultation process and decide on further steps.

Swiss Academy of Medical Sciences (SAMS), Revised guidelines on care of patients at the end of life (2004). Presentation by Dr. Margrit Leuthold, Member of the Swiss National Advisory Commission on Biomedical Ethics, at the 8th Global Summit of National Bioethics Advisory Bodies, Singapore, 26–27 July 2010.

Swiss Academy of Medical Sciences (SAMS), Revised guidelines on care of patients at the end of life (2004). SAMS does specify the following conditions for such “private” assisted suicides: The patient must be approaching the end of life; alternative ways of providing assistance must have been discussed and, if desired, implemented; and the patient must be a competent person expressing a persisting wish that has been carefully considered without external pressure.

Given that administering food and fluids to imminently dying patients can cause further medical problems, it seems unusual that this should be required.

This claim is intensely debated, but we cannot go into that debate in this paper.

We use the term C(D)S when a reference to continuous sedation at the end of life could apply to continuous sedation in general as well as to continuous deep sedation.

Even though the research reports combined data for euthanasia and PAS, we consider that there is likely to be little difference in the patient profile for PAS and euthanasia in the Netherlands and Belgium.

Data from the Netherlands and Oregon show a slightly different picture. The official Oregon reports show that the practice mainly involves patients aged 65 to 85, while the majority of Dutch patients receiving euthanasia/PAS are younger than 65 (van der Heide et al. 2007).

See Table 1 of the official Oregon State report on the use of PAS, 2009 Summary of Oregon's Death with Dignity Act, available at http://www.oregon.gov/DHS/ph/pas/docs/yr12-tbl-1.pdf (accessed June 6, 2010).

See, for example, Table 1 of the official Oregon State report on the use of PAS. See also Rietjens et al. (2006).

See Table 1 of the official Oregon State report on the use of PAS.

It needs to be emphasized that, according to available research, requests for CDS rarely occur (e.g., Chambaere et al. 2010; Rietjens et al. 2004).

Research by Norwood and colleagues (2009) paints an image of the euthanasia practice in the Netherlands that does not indicate slippery slope risks. As regards the indications of a slippery slope (with regard to the performance of euthanasia) in the Netherlands, Rietjens and colleagues (2009) have undertaken an extensive analysis of the data that is currently available. Their findings sketch an image of euthanasia that is more nuanced than the one usually drawn by those who posit a slippery slope.

In this article we cannot undertake a critical normative assessment of these guidelines, so by “abuse” we mean here “failure to comply with the guidelines” rather than abuse in a purely ethical sense.

Note here that it is to be expected that legalizing euthanasia would pose a greater risk of undermining patients’ trust in their doctor than legalizing PAS, for in the case of euthanasia the doctor and not the patient performs the life-ending act.