The principle of double effect

After my last blog, I thought I might make sure that some of the confusing terms surrounding physician-assisted suicide are explained. The following table puts terms into brief, but clear, relationships.

Common terms

Term	Intent	Procedure	Outcome
Palliative sedation	To relieve suffering	Titration of medication until sedation	Unconsciousness or minimally aroused
Euthanasia	To cause death	Administer a lethal dose of medication	Immediate death
Physician-assisted suicide	To cause death	Patient self-administers a prescribed lethal dose of medication	Immediate death
Voluntary refusal of food and fluid	To cause death	Patient refuses to eat or drink	Death in days to few weeks

Of these, palliative sedation is an option for providers of dying patients. It is a controversial procedure to manage severe, refractory symptoms despite “optimal” medical management. Palliative sedation may shorten the time necessary to provide relief of suffering; is effective regardless of etiology of suffering; does not necessarily hasten death if used in those not eating and drinking already; leads to a relatively peaceful death; provides some control over timing; and is flexible enough to allow sedation of varying degrees, depending on the symptoms and patient preference.

On the other hand, providers must first address concerns about nutrition and hydration; the depth and duration of sedation; and the difficulty in assessing ongoing symptoms. Further it requires IV access; is a more active role for providers, which increases the emotional and cognitive burden on physicians, nurses and allied professionals; and it requires some quantification of the degree of suffering for a particular patient. In practice, palliative sedation is rarely used but often discussed. A recent discussion of this topic and its ethical implications can be found here.

As an oncology and palliative care physician, I have received requests for palliative sedation, physician-assisted suicide and euthanasia. A common scenario for a euthanasia request occurs at the bedside of a dying patient who is lingering beyond our expectations. The family begins to struggle and suffer as they watch their loved one slowly die. They want the “fight” to be over faster and perceive their loved one as suffering. Then they ask if there is anything I can do to “speed this up?” I stand on ethically solid ground when I tell patients and families that I will be as aggressive as it takes to control symptoms but will never administer medications with the intent of ending life. The slippery slope of these terms all boils down to intent: the state of mind with which an act is done. If one’s intent is to relieve suffering (beneficence) and the unintended (though predictable) consequence of that action is that a patient dies sooner than they may have otherwise, the provider can be confident that they acted ethically. You can find more information on the Principle of Double Effect here.