A response to critics: weakening the ethical distinction between euthanasia, palliative opioid use and palliative sedation

2019 ◽  
Vol 46 (1) ◽  
pp. 59-62 ◽  
Author(s):  
Thomas D Riisfeldt
Keyword(s):  
Palliative Care ◽  
Human Life ◽  
Double Effect ◽  
Palliative Sedation ◽  
Care Provision ◽  
Doctrine Of Double Effect ◽  
Opioid Use ◽  
Category Mistake ◽  
Original Argument ◽  
Cherry Picking

My essay ‘Weakening the ethical distinction between euthanasia, palliative opioid use and palliative sedation’ has recently generated some critique which I will attempt to address in this response. Regarding the empirical question of whether palliative opioid and sedative use shorten survival time, Schofield et al raise the three concerns that my literature review contains a cherry-picking bias through focusing solely on the palliative care population, that continuous deep palliative sedation falls beyond the scope of routine palliative care, and that my research may contribute to opiophobia and be harmful to palliative care provision globally. Materstvedt argues that euthanasia ‘ends’ rather than ‘relieves’ suffering and is not a treatment, and that the arguments in my essay are therefore predicated on a ‘category mistake’ and are a non-starter. Symons and Giebel both raise the concern that my Kantian and Millian interpretation of the Doctrine of Double Effect is anachronistic, and that when interpreted from the contemporaneous perspective of Aquinas it is a sound ethical principle. Giebel also argues that palliative opioid and sedative use do meet the Doctrine of Double Effect’s four criteria on this Thomistic account, and that it does not contradict the Doctrine of the Sanctity of Human Life. In this response I will explore and defend against most of these claims, in doing so clarifying my original argument that the empirical and ethical differences between palliative opioid/sedative use and euthanasia may not be as significant as often believed, thereby advancing the case for euthanasia.

Weakening the ethical distinction between euthanasia, palliative opioid use and palliative sedation

2018 ◽  
Vol 45 (2) ◽  
pp. 125-130 ◽  
Author(s):  
Thomas David Riisfeldt
Keyword(s):  
Palliative Care ◽  
Survival Time ◽  
Empirical Evidence ◽  
Double Effect ◽  
Palliative Sedation ◽  
Ethical Principle ◽  
Doctrine Of Double Effect ◽  
Opioid Use ◽  
Care Services ◽  
Palliative Care Services

Opioid and sedative use are common ‘active’ practices in the provision of mainstream palliative care services, and are typically distinguished from euthanasia on the basis that they do not shorten survival time. Even supposing that they did, it is often argued that they are justified and distinguished from euthanasia via appeal to Aquinas’ Doctrine of Double Effect. In this essay, I will appraise the empirical evidence regarding opioid/sedative use and survival time, and argue for a position of agnosticism. I will then argue that the Doctrine of Double Effect is a useful ethical tool but is ultimately not a sound ethical principle, and even if it were, it is unclear whether palliative opioid/sedative use satisfy its four criteria. Although this essay does not establish any definitive proofs, it aims to provide reasons to doubt—and therefore weaken—the often-claimed ethical distinction between euthanasia and palliative opioid/sedative use.

Ethical end-of-life palliative care: response to Riisfeldt

2019 ◽  
Vol 46 (1) ◽  
pp. 51-52 ◽  
Author(s):  
Heidi Giebel
Keyword(s):  
Palliative Care ◽  
End Of Life ◽  
End Of Life Care ◽  
Human Life ◽  
Double Effect ◽  
Palliative Sedation ◽  
Life Care ◽  
Intrinsic Properties ◽  
Principle Of Double Effect ◽  
Care Response

In a recent article, 1 Riisfeldt attempts to show that the principle of double effect (PDE) is unsound as an ethical principle and problematic in its application to palliative opioid and sedative use in end-of-life care. Specifically, he claims that (1) routine, non-lethal opioid and sedative administration may be “intrinsically bad” by PDE’s standards, (2) continuous deep palliative sedation (or “terminal sedation”) should be treated as a bad effect akin to death for purposes of PDE, (3) PDE cannot coherently be applied in cases where death “indirectly” furthers an agent’s intended end of pain relief via medically appropriate palliative care, and (4) application of PDE requires sacrificing common beliefs about the sanctity of human life. I respond by showing that Riisfeldt’s understanding of PDE is seriously mistaken: he misattributes Kantian and Millian reasoning to the principle and conflates acts’ intrinsic properties with their effects. Further, a corrected understanding of PDE can address Riisfeldt’s case-specific objections.

scholarly journals Palliative opioid use, palliative sedation and euthanasia: reaffirming the distinction

2019 ◽  
Vol 46 (1) ◽  
pp. 48-50 ◽  
Author(s):  
Guy Schofield ◽  
Idris Baker ◽  
Rachel Bullock ◽  
Hannah Clare ◽  
Paul Clark ◽  
...  
Keyword(s):  
Palliative Care ◽  
Real World ◽  
Symptom Control ◽  
Evidence Base ◽  
Routine Care ◽  
Palliative Sedation ◽  
Routine Practice ◽  
Opioid Use ◽  
Important Distinction ◽  
Opioid Prescribing

We read with interest the extended essay published from Riisfeldt and are encouraged by an empirical ethics article which attempts to ground theory and its claims in the real world. However, such attempts also have real-world consequences. We are concerned to read the paper’s conclusion that clinical evidence weakens the distinction between euthanasia and normal palliative care prescribing. This is important. Globally, the most significant barrier to adequate symptom control in people with life-limiting illness is poor access to opioid analgesia. Opiophobia makes clinicians reluctant to prescribe and their patients reluctant to take opioids that might provide significant improvements in quality of life. We argue that the evidence base for the safety of opioid prescribing is broader than that presented, restricting the search to palliative care literature produces significant bias as safety experience and literature for opioids and sedatives exists in many fields. This is not acknowledged in the synthesis presented. By considering additional evidence, we reject the need for agnosticism and reaffirm that palliative opioid prescribing is safe. Second, palliative sedation in a clinical context is a poorly defined concept covering multiple interventions and treatment intentions. We detail these and show that continuous deep palliative sedation (CDPS) is a specific practice that remains controversial globally and is not considered routine practice. Rejecting agnosticism towards opioids and excluding CDPS from the definition of routine care allows the rejection of Riisfeldt’s headline conclusion. On these grounds, we reaffirm the important distinction between palliative care prescribing and euthanasia in practice.

scholarly journals La sedazione palliativa tra etica e diritto: la situazione italiana

2013 ◽  
Vol 62 (1) ◽  
Author(s):  
Fabio Persano
Keyword(s):  
Palliative Care ◽  
Pain Therapy ◽  
Ethical Issues ◽  
Double Effect ◽  
Palliative Sedation ◽  
University Hospital ◽  
Allo Scopo ◽  
Traditional Concept ◽  
Principle Of Double Effect ◽  
The University

In materia di Legge 38/2010 sulle cure palliative e la terapia del dolore, va segnalato il fatto che il legislatore non ha preso esplicitamente posizione riguardo alla sedazione terminale. Questa pratica (che consiste nella riduzione intenzionale della vigilanza con mezzi farmacologici, fino alla perdita della coscienza, allo scopo di ridurre o abolire la percezione di un sintomo – altrimenti intollerabile per il paziente – nonostante siano stati messi in opera i mezzi più adeguati per il controllo del sintomo, che risulta, quindi, refrattario) presenta due importanti problemi etici, consistenti nella necessaria soppressione della coscienza e nel possibile abbreviamento della vita del malato. La soluzione proposta dalla bioetica personalista (l’applicazione del principio del duplice effetto, per il quale un atto è etico anche se da esso ne consegue pure un male non voluto, a determinate condizioni) viene qui riproposta ed eletta a soluzione plausibile anche sul piano giuridico, attraverso una correzione del tradizionale concetto penalistico di dolo. L’articolo è arricchito da ampi riferimenti alle linee guida della Società Italiana di Cure Palliative e contiene le raccomandazioni per la pratica clinica della sedazione terminale elaborate dal Policlinico Gemelli di Roma. ---------- With reference to the Law 38/2010 on palliative care and pain therapy, it should be noted that the legislature has not adopted a position about the palliative sedation. This practice (which consists of the intentional reduction of vigilance up to unconsciousness by pharmacological means, to reduce or abolish the perception of a symptom – otherwise intolerable for the patient – even though the most appropriate means have used for the control of the symptom, which is, therefore, refractory) raises two important ethical issues, that concern the necessary suppression of consciousness and the abbreviation of life. The solution of the Personalistic Bioethics (the application of the principle of double effect, for which an act is ethical even if it causes unintended evils, under certain conditions) is here reproposed, presenting it as plausible solution also for the legal level, through a correction of the traditional concept of malice. Furthermore, the article includes extensive references to the guidelines of the Italian Society of Palliative Care as well as to recommendations of the University Hospital “A. Gemelli” of Rome on terminal sedation

scholarly journals Impact of legalization of Medical Assistance in Dying on the Use of Palliative Sedation in a Tertiary Care Hospital: A Retrospective Chart Review

2021 ◽  
pp. 104990912110304
Author(s):  
Amy Nolen ◽  
Rawaa Olwi ◽  
Selby Debbie
Keyword(s):  
Palliative Care ◽  
Acute Care ◽  
Tertiary Care Hospital ◽  
Tertiary Care ◽  
Palliative Sedation ◽  
Palliative Care Unit ◽  
Care Hospital ◽  
Medical Assistance ◽  
Medical Assistance In Dying ◽  
Before And After

Background: Patients approaching end of life may experience intractable symptoms managed with palliative sedation. The legalization of Medical Assistance in Dying (MAiD) in Canada in 2016 offers a new option for relief of intolerable suffering, and there is limited evidence examining how the use of palliative sedation has evolved with the introduction of MAiD. Objectives: To compare rates of palliative sedation at a tertiary care hospital before and after the legalization of MAiD. Methods: This study is a retrospective chart analysis of all deaths of patients followed by the palliative care consult team in acute care, or admitted to the palliative care unit. We compared the use of palliative sedation during 1-year periods before and after the legalization of MAiD, and screened charts for MAiD requests during the second time period. Results: 4.7% (n = 25) of patients who died in the palliative care unit pre-legalization of MAiD received palliative sedation compared to 14.6% (n = 82) post-MAiD, with no change in acute care. Post-MAiD, 4.1% of deaths were medically-assisted deaths in the palliative care unit (n = 23) and acute care (n = 14). For patients who requested MAiD but instead received palliative sedation, the primary reason was loss of decisional capacity to consent for MAiD. Conclusion: We believe that the mainstream presence of MAiD has resulted in an increased recognition of MAiD and palliative sedation as distinct entities, and rates of palliative sedation increased post-MAiD due to greater awareness about patient choice and increased comfort with end-of-life options.

scholarly journals Consensus-based approach to managing opioids, including opioid misuse and opioid use disorder, in patients with serious illness: protocol for a modified Delphi process

BMJ Open ◽  
2021 ◽  
Vol 11 (5) ◽  
pp. e045402
Author(s):  
Caroline King ◽  
Robert Arnold ◽  
Emily Dao ◽  
Jennifer Kapo ◽  
Jane Liebschutz ◽  
...  
Keyword(s):  
Palliative Care ◽  
Opioid Therapy ◽  
Opioid Use Disorder ◽  
Opioid Misuse ◽  
Opioid Use ◽  
Serious Illness ◽  
Modified Delphi ◽  
Delphi Approach ◽  
Institutional Review ◽  
Management Guidance

IntroductionManagement of opioid misuse and opioid use disorder (OUD) among individuals with serious illness is an important yet understudied issue. Palliative care clinicians caring for individuals with serious illness, many of whom may live for months or years, describe a complex tension between weighing the benefits of opioids, which are considered a cornerstone of pain management in serious illness, and serious opioid-related harms like opioid misuse and OUD. And yet, little literature exists to inform the management of opioid misuse and OUDs among individuals with serious illness. Our objective is to provide evidence-based management guidance to clinicians caring for individuals with serious illness who develop opioid misuse or OUD.Methods and analysisWe chose a modified Delphi approach, which is appropriate when empirical evidence is lacking and expert input must be used to shape clinical guidance. We sought to recruit 60 clinicians with expertise in palliative care, addiction or both to participate in this study. We created seven patient cases that capture important management challenges in individuals with serious illness prescribed opioid therapy. We used ExpertLens, an online platform for conducting modified Delphi panels. Participants completed three rounds of data collection. In round 1, they rated and commented on the appropriateness of management choices for cases. In round 2, participants reviewed and discussed their own and other participants’ round 1 numerical responses and comments. In round 3 (currently ongoing), participants again reviewed rounds 1 and 2, and are allowed to change their final numerical responses. We used ExpertLens to automatically identify whether there is consensus, or disagreement, among responses in panels. Only round 3 responses will be used to assess final consensus and disagreement.Ethics and disseminationThis project received ethical approval from the University of Pittsburgh’s Institutional Review Board (study 19110301) and the RAND Institutional Research Board (study 2020-0142). Guidance from this work will be disseminated through national stakeholder networks to gain buy-in and endorsement. This study will also form the basis of an implementation toolkit for clinicians caring for individuals with serious illness who are at risk of opioid misuse or OUD.

Double Effect Donation

2021 ◽  
Vol 88 (2) ◽  
pp. 149-162
Author(s):  
Charles C. Camosy ◽  
Joseph Vukov
Keyword(s):  
Brain Death ◽  
Organ Donation ◽  
Human Life ◽  
Double Effect ◽  
Natural Death

Double Effect Donation claims it is permissible for a person meeting brain death criteria to donate vital organs, even though such a person may be alive. The reason this act is permissible is that it does not aim at one’s own death but rather at saving the lives of others and because saving the lives of others constitutes a proportionately serious reason for engaging in a behavior in which one foresees one’s death as the outcome. Double Effect Donation, we argue, opens a novel position in debates surrounding brain death and organ donation and does so without compromising the sacredness and fundamental equality of human life. Summary: Recent cases and discussion have raised questions about whether brain death criteria successfully capture natural death. These questions are especially troubling since vital organs are often retrieved from individuals declared dead by brain death criteria. We therefore seem to be left with a choice: either salvage brain death criteria or else abandon current organ donation practices. In this article, we present a different way forward. In particular, we defend a view we call Double Effect Donation, according to which it is permissible for a person meeting brain death criteria to donate vital organs, even though such a person may be alive. Double Effect Donation, we argue, is not merely compatible with but grows out of a view that acknowledges the sacredness and fundamental equality of human life.

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