Mr. Oltzik received what some doctors call palliative sedation and others less euphemistically call terminal sedation. While the national health coverage debate has been roiled by questions of whether the government should be paying for end-of-life counseling, physicians like Dr. Halbridge, in consultations with patients or their families, are routinely making tough decisions about the best way to die.
Among those choices is terminal sedation, a treatment that is already widely used, even as it vexes families and a profession whose paramount rule is to do no harm.
Doctors who perform it say it is based on carefully thought-out ethical principles in which the goal is never to end someone’s life, but only to make the patient more comfortable.
But the possibility that the process might speed death has some experts contending that the practice is, in the words of one much-debated paper, a form of “slow euthanasia,” and that doctors who say otherwise are fooling themselves and their patients.
My grandfather died of cancer. He was sent home and he was allowed to medicate for pain relief as needed…which he did. When he was in less pain, he used less pain reliever. When he was in more pain, he used more of the drugs. Toward the end, he was in a lot of pain and the dosages used to actually grant relief from pain grew larger and larger until at some point they crossed over what was survivable and God took him home. (This happened in 1987 and it is still very painful and brings tears to my eyes as I write this.)
The difference was, and this is an important difference from euthenasia, he was medicating to bear the pain, not to commit suicide. His death was the byproduct of compassionate and humane medicine that was attempting to provide him with the best possible quality of life. The euthenasia crowd have a very different goal. They have determined that the quality of life of a particular patient is no longer worth living (based on what ever) and have made a conscious decision to deliberately end life.
Even if the exact same medications are used, the difference of intent remains and it is an gulf that divides the culture of life from the culture of death. No one murdered my grandfather and he did not commit suicide. He died as a side effect of his pain relief medication.
That makes all the difference.
The article correctly takes note of the principle of “double effect,” which is a standard tool in theological and philosophical ethics. There is a difference between using increased medication to control pain, which may have the unintended consequence of the hastening of an already inevitable death, and the use of medication with the specific intent of hastening or causing death. They are not the same.
My Advance Directive (supplemental to my durable power of attorney for health care) requires that if I’m unable to make decisions for myself and if my body is likely (in the opinion of two independent specialists) to die within a certain time frame, that my body is to be denied all nutrition or liquids until the body is dead, with the proviso that “all distressing symptoms are to be fully controlled by means of appropriate drug therapy, even if such therapy should shorten my life.” I read a copy of the document to my doctor before having it inserted in my file and said with a smile, “You know what that means?” He replied, “Of course.” I’d rather my family just call the veterinarian and do it cheaply but one must stay within the parameters of the law. I’m one of those people of the fundamentalist variety who believes that *any* human intervention is playing God, from taking an aspirin for a headache to in vitro fertilization to euthanasia. However, I’m fine with it all, including euthanasia, so long as it’s completely and utterly and provably voluntary and provably so directed by the person in question, though euthanasia should never be used unless and until the body is actually in the final dying process. As a long-time priest I can say unequivocally that it is perfectly clear when a person’s body is in the final dying process and when it is not. Making sure that people are responsible about its practice is the problem, and therefore the thought of legalizing the practice of euthanasia gives me pause.
William Witt is undoubtedly both more intelligent and far better educated than I am, no doubt, but when he writes “There is a difference between using increased medication to control pain, which may have the unintended consequence of the hastening of an already inevitable death, and the use of medication with the specific intent of hastening or causing death. They are not the same.” I must disagree. C’mon we *all* know that by administering a lethal dose of morphine, for example, that the person will die. It will, of course, fully and completely control the pain (and the more visible distressing symptoms of the dying process). I can think of five physicians and three nurses who have independently have told me that most terminal drug therapy is done for the sake of onlooking relations and friends, who get upset by seeing someone they love’s body die. I only wish we could administer heroin, like they do in England, since it doesn’t as cloud the mind as morphine. To me the worst and most objectionable part of terminal drug therapy/euthanasia is that it obscures the consciousness at a time when, as the Church has *always* taught, the last moments of one’s earthly existence are so important.
To believe that because there is no “real” difference in the outcome between double effect vs. terminal sedation; there should be no difference in how they are ethically evaluated by Christians is to dismiss one of the basic guides – what is the intent or “will” – to determining whether any thought, word, or deed is sinful and therefore in need of repentance.
Fr. Carl Eyberg
In my experience, terminal sedation is thankfully extremely rarely applied and is only used when extreme symptoms are uncontrolled by the most aggressive efforts. These patients should be managed by physicians trained in palliative medicine. I can understand the concern that this model of care might be misused.
It is NOT true that a so-called “lethal” dose of morphine will automatically lead to death. As the writer in #1 wrote, there are times when medicating to relieve pain (and in this case it was apparently intractable, chronic, and acute) actually brings about the result of relieving pain–and of also enhancing the quality of life of a person dying in the midst of such pain. It’s called Palliative Care and its goal is to improve the quality of one’s life, whether one is dying or not.
Aren’t we called to act compassionately? I don’t believe hastening death by purposely overdosing is compassionate but I DO believe alleviating pain in any way possible is.
It’s such a difficult situation. I once worked with hospice when I was younger and thought that program had all of the best answers but, now that I’m older, I am encountering situations that don’t fit the mold.
I had a call from my godmother over the weekend. She’s 88 and has been in poor health for quite a few years now but she’s always had a plucky spirit. Not now. In addition to very slowly progressing leukemia, severe spine problems and arthritis, she has now totally lost her vision. She cried a lot during our conversation and I can’t even imagine how awful it would feel to be alone, sick, and now blind on top of it all.
All of her friends are now deceased and her last sister passed away a few months ago. She has a niece who looks in on her, but that’s it. Her daughter lives far away and insists that her mum can’t go to a nursing home because she’d have to sell her home and the daughter wants the home.
My godmother says she’s waiting to die so she can join her husband, sisters, parents and all of her friends, and she is begging God to know why He won’t take her home. What do you SAY to that? I had no idea so I didn’t say anything at all, just listened. I would gladly have her come to live here with me but I live very far away, too, and she won’t hear of it. I’ve brought it up before. Can’t blame her, really. All she’s ever known is there and she’d want to be buried with the rest of her family. Not a time to go to a new place to live.
I don’t believe in euthanasia but situations like this really do make you cry out to Heaven. I have no idea what the answers are.
#8 Teatime,
Listening is a good start. Prayers for your godmother are coming. Is there a church with a Stephen’s ministry around?
I am not knowledgeable in regards to the medical details of this issue, but I can add another anecdote: My grandmother, who has since gone to be with the Lord, suffered a fall a number of years ago, broke her hip, and was placed in a long-term care facility. For 2-3 years after that, her mind slowly deteriorated; names and memories began to fade and she became less and less alert. Then, due to a medical emergency, the medication she had been placed on had to be temporarily halted, and within days she was herself again and all the stories and memories came back! I do not know all the specifics of her case, but I was pretty mad that it was simply assumed by the doctors that her memory loss was caused by her condition and old age and did not even think to scale back on the medication. Not long after that, she led me–at the age of 96–on a tour of the local cemetery where she spent an hour recounting stories about just about every family plot represented there.
It’s a deeply personal issue and difficult to look at in a way that is isolated from our own, often painful, experiences. However, the moral issues have been well defined for some time. To quote: Pius XII affirmed that it is licit to relieve pain by narcotics, even when the result is decreased consciousness and a shortening of life, “if no other means exist, and if, in the given circumstances, this does not prevent the carrying out of other religious and moral duties.” But we should not forget that this issue exists on a continuim of respect for the dignity of all human life. To quote: The Second Vatican Council, in a passage which retains all its relevance today, forcefully condemned a number of crimes and attacks against human life:
“Whatever is opposed to life itself, such as any type of murder, genocide, abortion, euthanasia, or willful self-destruction, whatever violates the integrity of the human person, such as mutilation, torments inflicted on body or mind, attempts to coerce the will itself; whatever insults human dignity, such as subhuman living conditions, arbitrary imprisonment, deportation, slavery, prostitution, the selling of women and children; as well as disgraceful working conditions, where people are treated as mere instruments of gain rather than as free and responsible persons; all these things and others like them are infamies indeed.
“They poison human society, and they do more harm to those who practice them than to those who suffer from the injury. Moreover, they are a supreme dishonor to the Creator.”
Senior Priest,
There is a huge difference between primary and secondary effects. It is morally permitted to medicate someone when the goal is to alleviate pain – even if the dosage necessary to alleviate the pain is close to leathal or even leathal. It is not morally permitted to medicate someone over that dosage to hasten or cause death. The first has the primary goal of stopping pain. The second has the primary goal of killing someone. The frist is medicine; the second is murder (morally).
Now, the problem comes in when we or a person we love is in the throes of terminal pain. Our desires and our loves can confuse our motives and we all know that we are masters at self deception. This is why medication should only be used under a doctor’s orders. We may not know our own motivations (or we may convince ourselves that we don’t know them). But God does know our motivations. He knows our hearts better than we know them ourselves.
This is why prayer and the aid of a Chaplain trained in Palliative Care is important to the end of live issues.
YBIC,
Phil Snyder
To my mind, Philip, you are of course perfectly correct in terms of reasoning, and what you write is undoubtedly undergirded by traditional theology. However, I find myself constrained to suggest that such a line of thought is merely that and no more than that. It is a bunch of human conceptions tied up with a handsome bow which is best used as part of a methodology for salving a conscience troubled by the suffering of a loved one. At least we are more forthright when dealing with the suffering of our family pets.
When my mother was in the process of dying at the hospital her breathing was very labored and you could hear the fluid rattling in her lungs with every breath. I asked the attending nurse if there was anything that could be done to make her more comfortable. I will never forget his answer – “I can give her more medication, but it probably will depress her respiration. Is that what you want me to do?” I stopped and looked at him for a few seconds and then said, “Are you asking me to have you give her enough drugs to kill her?” He stared at me for a second and then turned and walked away. She passed away several hours later. That exchange with the nurse still haunts me.
Earlier this year my father-in-law was in hospice care for advanced cancer. I noted that they kept him heavily sedated and really made no attempt to give him food or water. He lasted for almost seven days with no food or water. For the last two days he seemd completely unaware and barely conscious. I still don’t know how I feel about withholding food and water to hasten death.
As I put it in my comment above, that’s why this is in my Advance Directive, “all distressing symptoms are to be fully controlled by means of appropriate drug therapy, even if such therapy should shorten my life.â€
I can say from an experience a friend’s mother had just four weeks ago that hospice overdosing happens perhaps more often than we’d like to admit. My friend’s mother will die sometime in the near future, of cancer. She is not in any particular pain at this time. When a local hospice organization took over her case, she was heavily medicated and nearly died within six days. Her daughter took her to the hospital for pneumonia treatment, and the mother survived to see her son when he arrived from overseas and is still living and comfortable at home today. I was really shaken by this, having always heard good things about hospice care. They seemed to assume severe pain without investigating to confirm it before medicating.
#9 Underground Pewster,
Thank you for your prayers! She is a Catholic. I asked about spiritual care and she said someone comes to bring her Communion once per month. That’s about all the RCs have, from personal experience. Their parishes are very large. I wish I had some Episcopal ties there but I don’t. It would be such a blessing if people would visit her once per week. She’s a wonderful woman and it wouldn’t be a chore.
Just because one “looks” at though they are sleeping, it was my experience
that there can be terrible suffering and pain. Following surgery I was given
morphine, only to be too drugged to express my severe pain and nausea. More needs to be said about pain within the drugged state. Do WE simply not wish to see the pain of our loved ones? What if the pain is merely masked and they are suffering helplessly?
For those interested, the cancer my grandfather suffered from was a rapid growing melanoma on top of his head that had gotten through his skull and into his brain before they caught it. His condition was terminal. Until the very end, according to my father, he was not in too much pain. He did not use the powerful drugs given him until they were very necessary and he did not anticipate the end; rather, he reacted appropriately to the pain he was in and gradually increased his dosages to mitigate the pain…not to kill himself as some seem to have suggested.