Monday, August 27, 2012

Politics & the Meaning of Intent

The prime minister of New Zealand equates aggressive pain treatment for the terminally ill with euthanasia. Is he correct?

He also says euthanasia, currently illegal in New Zealand, is a common practice in hospitals there. The relative truth in that statement probably depends whether one agrees with him that euthanasia and palliative sedation are essentially the same thing.

But they are not. The New Zealand palliative care community calls the prime minister’s comments "misguided," and I agree.

The ethics of care at the end of life is central to much of the work of the Community Ethics Committee of Boston. As a member, I recently participated in the study of the Death With Dignity Act, on the Massachusetts ballot in November (see our White Paper and Executive Summary). This, in part, is why I was drawn to the story out of New Zealand.

Earlier, we produced a report about the practice we came to know as Continuous Deep Sedation as Comfort Care Until  Death -- in other words, palliative sedation for the imminently terminal. But we went with the longer title in part because we wanted to be as clear as possible about what we were endorsing.

And we did endorse. In calling Continuous Deep Sedation not only ethical, but an important treatment option in compassionate care for the dying, we felt it important to clearly understand distinctions among the end-of-life practices.

Relatively speaking (and by comparison with the Death With Dignity study), it was easy for us to come to consensus in support of Continuous Deep Sedation. For me, crucial to endorsing CDS was this fact: while CDS can hasten death for a terminal patient, it also can have the opposite effect. That is, the control of intractable pain in some cases allows the patient's organs to resume function, and actually prolong life. With CDS, the intent is to treat pain, and the cause of death truly is the underlying illness, not the treatment.

Were CDS the same as euthanasia, this would not be true. The euthanized patient dies from the treatment. Death is the point. It is the intended outcome.

John Key, the New Zealand prime minister, doesn't make this distinction. The New Zealand Herald reports that Key, a supporter of legalizing euthanasia in New Zealand, said if he was hospitalized, terminally ill and in pain, "if they just effectively wanted to off the switch and legalise that by legalising euthanasia, I'd want that. I look at a situation where I think there's a lot of euthanasia that effectively happens in our hospitals."

Palliative care is misunderstood by many to be exclusively end-of-life care, and ghettoized into the second half of a sentence that begins, "There's nothing more we can do ..." And yet studies show palliative care to both extend life and improve quality of life. And so the prime minister's comments indicate a self-serving opinion that does harm to compassionate care for the terminally ill and others.

"His personal opinion given as Prime Minister has serious negative consequences in the trust people have in hospital care of the seriously ill," Sinead Donnelly, New Zealand chairwoman of the Australian and New Zealand Society of Palliative Medicine, told the New Zealand Herald.

Donnelly distinguished euthanasia from a patient's right to refuse treatment or hastening death as an unintended consequence. She said the society agreed with the country’s medical association that doctor-assisted suicide and euthanasia are unethical -- and would be regardless of a change in legality.

Hospice NZ Medical Adviser Sandy MacLeod said stopping treatment that was no longer effective was not euthanasia, and conversely that prolonging such treatment could increase suffering and distress.

"It appears the prime minister has confused the ceasing of curative treatments with ending a person's life,” MacLeod said. “In situations like this people are in fact dying from an advanced disease, not from the withdrawal of the treatment."

NOTE: Through research for this blog, I've discovered a number of impressive reporters internationally covering end of life issues. Add to that list Claire Trevett of the New Zealand Herald.

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