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Palliative sedation, foregoing life-sustaining treatment, and aid-in-dying: what is the difference?

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Abstract

After a review of terminology, I identify—in addition to Margaret Battin’s list of five primary arguments for and against aid-in-dying—the argument from functional equivalence as another primary argument. I introduce a novel way to approach this argument based on Bernard Lonergan’s generalized empirical method (GEM). Then I proceed on the basis of GEM to distinguish palliative sedation, palliative sedation to unconsciousness when prognosis is less than two weeks, and foregoing life-sustaining treatment from aid-in-dying. I conclude (1) that aid-in-dying must be justified on its own merits and not on the basis of these well-established palliative care practices; and (2) that societies must decide, in weighing the merits of aid-in-dying, whether or not to make the judgment that no life is better than life-like-this (however this is specified) part of their operative value structure.

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Notes

  1. At present, the following professional organizations do not support legalization of aid-in-dying: National Hospice and Palliative Care Organization [4], Hospice and Palliative Nurses Association [5], American Nurses Association [6], American Medical Association [7].

  2. Both cases—VSED and refusal of ANH—call for good palliative supportive care [11]. This includes assessing whether the patient’s decision is complicated by depression or some other potentially correctable factor. If this is the case, attending to the decisional process may resolve the issue of eating and drinking in VSED, but not in refusal of ANH without also attending to the details of resuming ANH.

  3. However, see Morita el al. [23] and Claessens et al. [24] for studies of palliative sedation that specify such measures.

  4. Corresponding to -4 (no response to voice, but any movement in response to physical stimulation) or -5 (no response to voice or physical stimulation) on the Richmond Agitation-Sedation Scale [27].

  5. Besides Rachels [29], among many others who rely on the argument from functional equivalence, see Brock [30, 31] and Kamm [32].

  6. Data of sense include colors, odors, sounds, and so forth; data of consciousness include acts of seeing, smelling, hearing, perceiving, inquiring, understanding, reflecting, judging, and so forth [33, p. 299].

  7. “The anticipation of a constant system to be discovered grounds classical method; the anticipation of an intelligibly related sequence of systems grounds genetic method; the anticipation that data will not conform to system grounds statistical method; and the anticipation that the relations between the successive stages of changing system will not be directly intelligible grounds dialectical method. But data must either conform or not conform to system, and successive systems must be either related or not related in a directly intelligible manner. Accordingly, taken together, the four methods are relevant to any field of data; they do not dictate what data must be; they are able to cope with data no matter what they may prove to be” [33, pp. 509–510].

  8. Like the x in algebra, heuristic definition anticipates an answer to a question or a problem; value is what one expects to determine in making choices about what to do.

  9. For Lonergan, our acts of experiencing feelings in a particular situation, understanding the situation and its ramifications, sorting out what is really going on and what is best to do, and deciding to act accordingly—all of this—is integrated both on the side of the situation under consideration (the object) and on the side of the person performing these acts (the subject) [33, pp. 349–352]. Intentionality refers to the object-relatedness of all conscious acts; it includes but extends beyond the meaning of intention as the object of feeling (motive) and as the object of choice (goal or value).

  10. It often helps loved ones to sort out their intentions in making end-of-life decisions with potentially bad effects for the patient to ask: would I be satisfied with the outcome of this decision if the bad effect does not occur?

  11. According to this study, the median Glasgow Coma Score dropped from 12 or better a week before death to 9 on day of death (with 8 being the cutoff for coma).

  12. This should not mean short-circuiting the spiritual, social, and emotional dimensions of hospice care, neither for the patient prior to deep sedation nor for the patient’s loved ones throughout the dying and grieving process [20]; but see [49] regarding these very factors contributing to nurses’ distress around the practice of palliative sedation.

  13. In this case, nurses usually administer the medication(s) which hasten death, albeit with physician’s orders. With PAD, a patient self-administers the medication in question; with VE, a physician administers it [12].

  14. These same two questions play a prominent role in H. Richard Niebuhr’s account of an ethics of responsibility in The Responsible Self [53]. To my knowledge, Lonergan and Niebuhr worked independently of one another, although both developed their ideas within a context of concern for authenticity following the Second World War.

  15. Calling both practices by the same name, palliative sedation to unconsciousness, obscures this difference. They should be named differently; for instance, rapid deep sedation of the imminently dying and continuous deep sedation for existential suffering.

  16. Coordinating VSED with PSU amounts to aid-in-dying, both factually and intentionally. However, when a patient chooses VSED independent of a decision to employ PSU, then a physician need not be complicit in hastening death by continuing to attend to the patient’s psychosocial-spiritual needs, as well as to symptoms such as pain or dyspnea. This situation may involve a significant difference in perspective for patient and physician regarding the particular circumstances and ultimate value of the patient’s life. I deal with this further in the next section of this paper.

  17. The claim that PSU is equivalent to aid-in-dying because permanent loss of consciousness amounts to brain death requires a separate analysis [56], which I defer since the end-of-life situations in which contested definitions of brain death are pivotal do not involve patients who are aware of distressing symptoms—as is the case with PSU.

  18. He states candidly and omnisciently that both Smith and Jones enter a bathroom with the same intent to kill a young boy and that both continue to act on this basis despite different circumstances until each boy is dead. This singular intent is the very basis on which each man is considered responsible for the death of the boy in question.

  19. The same considerations apply to the patient with a potentially favorable prognosis who voluntarily stops eating and drinking, although in this case, as indicated earlier, eating and drinking do not constitute a treatment.

  20. Duffy [66] describes a change in attitude toward aid-in-dying as it has affected his practice in ways that would be hard to quantify on a slippery slope metric.

  21. In comparison to Daniel Sulmasy [68], as I mentioned above, Lonergan identifies goods of order intermediate between the empirical and transcendental orders of value. Fred Lawrence puts Lonergan’s tripartite structure of value and the human good in historical perspective: “Aristotle defined the good as the object of appetite…. Thomas [Aquinas] made explicit a more intellectual dimension of the good as good of order…. [Lonergan] goes beyond this to specify more clearly the notion of the good as what is intended in questions for deliberation” [69, p. 141]. We are originators of value in being able to ask and answer questions concerning the worth of what we do. In this sense, we condition the possibility of value judgments and are ourselves of transcendental value.

  22. Henk ten Have and Jos Welie [65, p. 175] come to this conclusion in their analysis of the practice of aid-in-dying in the Netherlands: “The practice of euthanasia … is justified by physicians and in terms of medical criteria.… The Dutch euthanasia movement started as a protest against medical power, emphasizing patient autonomy as a counterbalance. But after 30 years of debate, the power of medicine appears only to have increased because physicians decide whether patients’ suffering is so unbearable that euthanasia is indicated”.

  23. On February 6, 2015, the Supreme Court of Canada published its decision to remove Canada’s prohibition on physician-assisted dying to worldwide notice. The justices were explicit about arguing from self-determination, but deemed it unnecessary to unpack the disvalued quality of life judgment implicit in their decision relative to equal treatment for persons with disabilities [70].

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Acknowledgments

Earlier versions of this paper were presented at the West Coast Methods Institute in Los Angeles in April 2014 and at the Lonergan Workshop in Boston in June 2014. I would like to thank David Ndegwah for challenging me to recognize that different viewpoints set the conditions for better understanding, especially during times of rapid historical change.

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    Patrick Daly

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Daly, P. Palliative sedation, foregoing life-sustaining treatment, and aid-in-dying: what is the difference?. Theor Med Bioeth 36, 197–213 (2015). https://doi.org/10.1007/s11017-015-9329-5

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