It is not illegal or unethical for doctors to prescribe enough medication to relieve pain and other symptoms of dying patients where the intent is not to kill the patient but to relieve suffering. Taking meaningful steps to relieve pain is not murder. It is not "assisted suicide" and it is not "euthanasia."
Terminal sedation is available for patients whose pain or other symptoms cannot be relieved without sedation or, in some cases, for patients who simply do not want to experience the last days of their lives. Terminal sedation is a consciously induced coma during which feeding and nutrition are foregone by the patient. Ethicists and all of the major religions make a clear distinction between relieving pain and assisted suicide or euthanasia. Terminal sedation is perhaps the compromise alternative to physician-assisted suicide. It allows a suffering patient to sleep through the period until natural death occurs. It appears to be most frequently employed when patients suffer from uncontrollable apnea (air hunger), delirium or pain.
Ethical issues in terminal sedation center primarily on when it is appropriate. Need the patient, for example, be imminently dying? Is it appropriate to use terminal sedation to relieve "existential suffering" of the terminally ill? Drs. Timothy Quill and Ira Byock, both distinguished activists in the movement to improve medical care at end of life, have opined that the critical prerequisites for terminal sedation are (1) intractable suffering in the terminally ill and (2) informed consent of the patient or surrogate. This approach appears to focus on the imminence of death than the cause of suffering. (See: "Responding to Intractable Terminal Suffering: The Role of Terminal Sedation and Voluntary Refusal of Food and Fluids," Annals of Internal Medicine, Vol. 132, No. 5, March 2000).
Whatever the ethical issues, laws against assisted suicide or euthanasia are not called into play by terminal sedation. The practice was indirectly approved by several Supreme Court justices in the context of the court's decisions on physician-assisted suicide. It was painted as an explanation of why assisted suicide was not an essential component of the right of privacy. It also featured heavily in the court's questioning at oral argument of those cases, according to reports in the New England Journal of Medicine; see NEJM October 9, 1997, Vol. 337, No. 15. Although relegated to footnote 11, the majority opinion in Vacco v. Quill, 117 S.Ct. 2293 (1997), (by Chief Justice Renquist) specifically distinguished terminal sedation from physician-assisted suicide on the basis of the physician's intent. The concurring opinion of Justice O'Connor continues the distinction (no need to assert right to suicide since there is no barrier in the defendant states to pain relief even if it induces coma and courts death). There is no doubt that the Supreme Court accepted, in theory at least, the legality of terminal sedation. The minority view asserted that the distinction was without a difference and used the acceptance and prevalence of terminal sedation to support the challenged laws. See, e.g., Justice Stevens, dissenting. Opinions in the companion case, Gluckensberg v. Washington were similar.
Competent patients have a well-established constitutional right to give up painful or exhausting treatments, whether or not refusing treatment will hasten death. It is unethical for doctors to refuse such a request or to fail to refer the patient to another doctor who will. Most states have statutes that protect doctors against criminal actions when they respect a patient's request for comfort care only.
When a patient is unconscious or suffering from dementia, the family or the health care agent the patient has named in an advance directive can exercise the same rights for the patient under procedures established by state law. (In some states, guardians appointed by the court or through health care proxies cannot order withdrawal of artificial feeding and hydration.)
Even when a patient wants some treatments, he or she may always refuse any test or treatment that is too painful or too debilitating. Patients and their advocates should feel comfortable about asking a doctor why an invasive test is necessary. They should never hesitate to insist on an understandable explanation. Sometimes patients hesitate to request that a doctor explain his treatment choices. In that case he or she might ask a family member or friend to initiate the discussion. Nurses and hospital social workers can also help with explanations and communication. If the patient remains in pain, one approach is to ask for a palliative care consultation.
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