Lars J. Materstvedt, Stein Kaasa “HELP IN DYING” VS. “HELPING THE DYING”: A PROPOSAL REGARDING CATEGORIZATION Lars J. Materstvedt, Stein Kaasa Unit for Applied Clinical Research, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway

“Help in dying” - HID: Examples of HID: Euthanasia (E) Physician-Assisted Suicide (PAS) HID = a “death promoting” intention

Euthanasia (E) What? How? A doctor’s intentionally killing a person who is suffering “unbearably” and “hopelessly” at the latter’s voluntary, explicit, repeated, well-considered and informed request How? Usually (but not exclusively) by administering intravenously a lethal dose of (different) quick-acting drugs/medication

Physician-Assisted Suicide (PAS) What? A doctor’s intentionally helping/assisting/co-operating in the suicide of a person who is suffering “unbearably” and “hopelessly” at the latter’s voluntary, explicit, and repeated, well-considered and informed request for the doctor's participation How? Usually (but not exclusively) by prescribing, preparing and giving a lethal dose of (different) drugs/medication to the person for self-administration

“Helping the dying” - HTD: HTD = optimal quality of life (QL) in the terminally ill, including submission to a palliative medicine unit symptomatic treatment social, psychological, religious and existential support HTD = a “life promoting” intention

The killing/letting die distinction Concerns the role of intention in medical practice (and in ethical theory) What is the physician’s intention in his treatment of the terminally ill? Is the intention HID or is it HTD?

The acts/omissions distinction The acts/omissions distinction is not always congruent with the killing/letting die distinction It is possible to kill someone by doing nothing at all (cf. omission) One can intentionally take another’s life both by acts and by omissions

Abstention from life-prolonging treatment - I Normally, acts of “letting die” in the terminally ill would be categorized as HTD acts These acts are not grouped together with HID acts such as E and PAS But is it more appropriate to label some instances of letting die as HID rather than HTD?

Abstention from life-prolonging treatment - II If you do not offer antibiotics to a patient with symptoms (pneumonia) and the patient dies soon with symptoms, you violate your duty to offer optimal symptom control. You may also cause an earlier death in the patient - i.e., earlier as compared with what would have happened if the patient received antibiotics. It might be said that in not treating the patient, you are “letting nature take its course” and so the patient dies “a natural death” due to his underlying disease. But if you refrain from offering treatment for the infection because you think that it is better for the patient to die, then arguably you are performing a HID act.

Abstention from life-prolonging treatment - III “The probability of chemotherapeutically halting a metastatic process may … be nil, … In [this circumstance], chemotherapy would be futile, as, even more obviously, would be resuscitation in the event of cardiac arrest in the terminal phase of the disease.” The EAPC stance on euthanasia, 1994 paper

Is the EAPC supporting HID? - I Is the quoted example of a DNR decision so “obvious” from a palliative care point of view? What is the meaning of “terminal phase”? The cardiac arrest patient might live for several more weeks or months, if adequate palliative care and treatment is provided after he has been resuscitated Hence he could, if resuscitated, perhaps have a relatively good QL

Is the EAPC supporting HID? - II In other words, by resuscitating the patient one would be performing a HTD act Letting him die (DNR) would deprive him of a potentially meaningful time left Accordingly, it would seem to amount to a HID act If palliative care is about QL at the end of life, then how do you justify DNR in the patient in question?

Terminal sedation (TS) Palliative care is about helping people have a better QL towards the end of life Arguably, a patient undergoing TS does not have a (real) life anymore In what sense, then, if in any, may TS be seen as contributing to the patient’s QL? Is TS a HTD act or a HID act?

Intending death The Dutch research on E and PAS: Alleviation of pain and symptoms with possible life-shortening effect. Partly with the intention of accelerating the dying process: 1990: 4 500 (3,5%) 1995: 4 100 (3%) Can one “partially” intend someone’s death? Is not this “slow euthanasia” = HID?

Intending vs. wishing What is the difference between intending and wishing? In the literature, the two are often used as synonymous Intentionally causing someone’s death in order to obtain a heart for transplant Wishing that someone dies in a car accident, so that a heart will be available for transplant

EAPC policy - I “It is essential to distinguish between: euthanasia; … and withholding or discontinuing life-prolonging treatments. One must never confuse these … different types of clinical judgements and activities.” The EAPC stance on euthanasia, 1994 paper

EAPC policy - II The distinction drawn in the quote is essential in the Dutch context as well - medically, ethically, and juridically But what if the physician intends the patient’s death through the withholding or discontinuing of life-prolonging treatment? Is he not then performing HID? This harks back to the point about intentionally killing through omission

Conclusions While E and PAS are necessarily HID acts, acts that would normally count as HTD acts may in certain instances be construed as HID acts Thus, HID may comprise both (medicalized) killing and letting die What characterisation of the physician’s acting at the end of a patient’s life is appropriate, depends upon: a) the physician’s intention in performing the act b) what steps are taken to realise the intended outcome Intending death is not the same as wishing that death comes sooner rather than later