Letters

Withdrawing life sustaining treatment and euthanasia debate

BMJ 2001; 323 doi: https://doi.org/10.1136/bmj.323.7323.1248 (Published 24 November 2001) Cite this as: BMJ 2001;323:1248

Euthanasia may be ethical, but it is not legal

  1. Tom Woodcock, consultant, critical care directorate (woodcock{at}intonet.co.uk)
  1. Southampton University Hospitals NHS Trust, Southampton General Hospital, Southampton SO16 6YD
  2. Sandringham Hospital, Sandringham, Victoria 3191, Australia
  3. University of Edinburgh, Edinburgh EH9 1UW
  4. General Infirmary, Leeds LS1 3EX
  5. Department of Anaesthesia, Royal Hospital for Sick Children, Edinburgh EH9 1LF

    EDITOR—Street and Henderson invite debate about an accepted medical practice (withdrawing life sustaining treatment under the influence of paralysing agents) that is approved by an authoritative ethical advisory committee and yet is of questionable legality.1 It should be no surprise that a course of action that is ethically justifiable may be illegal, for the law of England on care at the end of life is both morally and intellectually misshapen.2

    In their commentary Inwald and Vandyck submit that the advice of the ethical committee is not compatible with the common law of England, and that to cause respiratory muscle paralysis in a patient without providing ventilatory support is a form of euthanasia. I agree with their view, but I am not confident that their proposed solution of discontinuing the administration of the paralysing drug shortly before the abrupt discontinuation of ventilation, omitting to allow the drug to be eliminated or reversed, would be accepted by a court.

    Edwards tries to reconcile the practice of ventilator withdrawal under pharmacological paralysis with the legal doctrine of double effect, but she misses or avoids the point that we cannot claim that muscle relaxants are drugs necessary to alleviate suffering and primarily used for such palliation. Their lethal pharmacological effect on unventilated patients is therefore not secondary, and the practice constitutes euthanasia. Outside of its narrow legal standing, double effect is not universally accepted as a morally relevant concept. 3 4 In both these commentaries the only submitted justification for not waiting the hour or two it would take to clear the drug from the system (if it has been administered in a therapeutic dose) is to claim that the delay harms the patient who is lingering on a ventilator. Given that patients given curare ought normally to be sedated or anaesthetised during pharmacological paralysis, this alleged suffering cannot be given much weight. Moreover, Lord Goff specifically rejected the compassionate avoidance of lingering as a defence against mercy killing.2

    Although we can construct a strong case for the moral acceptability of euthanasia in such circumstances, it is unlikely that a court could be persuaded that the practice is legal according to England's current law. Edwards unsubstantiated statement that atracurium does not have problematic residual effects ought to be corrected.5

    References

    1. 1.
    2. 2.
    3. 3.
    4. 4.
    5. 5.

    Doctrine of double effect should be discarded

    1. Paul Biegler, emergency physician (pbiegler{at}netlink.com.au)
    1. Southampton University Hospitals NHS Trust, Southampton General Hospital, Southampton SO16 6YD
    2. Sandringham Hospital, Sandringham, Victoria 3191, Australia
    3. University of Edinburgh, Edinburgh EH9 1UW
    4. General Infirmary, Leeds LS1 3EX
    5. Department of Anaesthesia, Royal Hospital for Sick Children, Edinburgh EH9 1LF

      EDITOR—The debate about the moral culpability or otherwise of withholding life prolonging treatment in a child aged 2 years with meningococcal sepsis where the effects of neuromuscular blocking agents will undoubtedly hasten death perpetuates the irrationality of the doctrine of double effect.1

      The doctrine of double effect maintains that doctors are responsible for the intended effects of their actions but not for the unintended but foreseen side effects of the same actions. The doctrine thus seems to absolve doctors of responsibility in any situation where a reasonably foreseeable and preventable side effect intervenes to the detriment of the patient.

      To suggest that leading specialists in paediatric intensive care could not be fully aware that extubation in the presence of neuromuscular blockade will not lead to a rapid death is absurd. To suggest furthermore that by somehow intending to avoid imposing treatment that is not in the patient's best interests those doctors are not morally responsible for the other effect of the action—namely, death—is akin to suggesting that doctors who administer treatment with more than one potential effect are only responsible for one of those effects. I would be reluctant to attend a physician or surgeon who was so readily able to divest themselves of such responsibility.

      In the scenario presented by Street et al, it has been decided that on the basis of likely resultant quality of life, and the likely futility and burdensome nature of continued treatment, death is a better outcome than continued existence for the child. The medical profession, with the support of the law and the community, should recognise this and strive for the same degree of excellence in attaining death that it aims for in maintaining life. Death in the presence of neuromuscular blockade achieves that end better than if paralysing agents are reversed before extubation.

      References

      1. 1.

      Double effect is different from euthanasia

      1. Neil McIntosh, professor of child life and health (neil.mcintosh{at}ed.ac.uk)
      1. Southampton University Hospitals NHS Trust, Southampton General Hospital, Southampton SO16 6YD
      2. Sandringham Hospital, Sandringham, Victoria 3191, Australia
      3. University of Edinburgh, Edinburgh EH9 1UW
      4. General Infirmary, Leeds LS1 3EX
      5. Department of Anaesthesia, Royal Hospital for Sick Children, Edinburgh EH9 1LF

        EDITOR—Readers will not be surprised to learn that the topic of paralysing agents and euthanasia was discussed lengthily by both the working group and the ethics advisory committee of the Royal College of Paediatrics and Child Health before inclusion into their framework.1 There is always a fine line with the principle of double effect that demands integrity from the caregiver.

        The final wording by Inwald and Vandyck, that it is not necessary to withdraw the paralysing agent before the respiratory support is withdrawn, entails a misconception that the corollary is to continue the paralysing agent after respiratory support is withdrawn.2 The phrasing used more simply indicated that the agent should be withdrawn at the same time that the respiratory support is withdrawn—it would be euthanasia otherwise, which the working group unanimously rejected, as is stated quite clearly in the first sentence of this section in the framework. The working group accepted that the effects of the paralysing agent would continue after withdrawal from the ventilator, but withdrawal of the medicine before this point—if it were indeed required for optimal ventilation—would not be in the child's best interests. Life saving treatment is withdrawn at the point when the ventilator is switched off or the child is extubated. The paralysing agent until this point has also been a life saving treatment allowing successful ventilation.

        Although the BMA suggests that withdrawing respiratory support in these circumstances could be interpreted as intended killing, the working group considered this illogical.3 Although it has yet to be tested in law, it is useful to have Edwards coming to a similar conclusion.2 Critical to all of this is the perspective of the parents. There will always be guilt with the grief when they have been party to a decision about the withdrawal of life saving medical treatment. As members of the health care team our job is, firstly, to be honest from beginning to end, not just with the parents, but also with ourselves and, secondly, to support the parents through these events.

        References

        1. 1.
        2. 2.
        3. 3.

        Role of paralysis during withdrawal of care needs clarifying, not polarising

        1. M D D Bell, consultant in intensive care (dom{at}wybells.freeserve.co.uk)
        1. Southampton University Hospitals NHS Trust, Southampton General Hospital, Southampton SO16 6YD
        2. Sandringham Hospital, Sandringham, Victoria 3191, Australia
        3. University of Edinburgh, Edinburgh EH9 1UW
        4. General Infirmary, Leeds LS1 3EX
        5. Department of Anaesthesia, Royal Hospital for Sick Children, Edinburgh EH9 1LF

          EDITOR—By taking the simplistic view that muscle relaxants at the end of life accelerate death, Inwald and Vandyck have reached an inappropriately absolute stance on euthanasia and unlawfulness.1 Their suggestion that both current practice and guidelines cross the threshold for these criteria not only engenders uncertainty among the professional groups responsible for intensive care, but it leads to mistrust among patient's relatives, if not investigations by the General Medical Council, coroner, or police.

          Muscle relaxants should be prescribed only after failure of analgesic and sedative regimens to optimise ventilatory support or reduce oxygen consumption. If used appropriately in the first instance, relaxants should alter the manifestations of death rather than the cause or timing. Severe disruption of lung architecture, refractory myocardial failure, overwhelming brain injury, and gross metabolic disturbance are the usual causes of rapid death, as exemplified by the case in point. In conjunction with the degree of support before withdrawal, which can be manipulated, these pathologies dictate the timing of death, regardless of the administration of muscle relaxants.

          The associated analgesic and sedative regimens, by their impact on ventilatory drive and cardiovascular performance, are also relevant to the timing of death after withdrawal of support for either system, in the timescale hypothetically determined by relaxants alone. It could indeed be argued that struggling preterminal respiratory effort, rather than providing effective gas exchange, will accelerate hypoxia and death, generating the paradox of relaxants delaying the timing of death.

          Although sparing the family the distress of witnessing that struggle may be viewed as unfashionably paternalistic by those not responsible for care of this nature, the former arguments predicate against defining this process as euthanasia. If, however, owing to the idiosyncrasies of a particular case, paralysis were to be the main determinant of timing of death, the residual effects of a discontinued infusion would be identical with those of a continued infusion, rendering the distinction as to lawfulness between the two approaches illogical.

          I can also foresee the scenario whereby discontinuing relaxants before withdrawal of support, but not reversing the residual effect, could be considered unlawful, contrary to the authors' stance. In distinction to the above pathologies with the potential to cause rapid death, if the child had sustained a significant brain injury but retained ventilatory drive with little or no associated lung or cardiovascular impairment, the immediate cause of death would be muscle paralysis.

          Decision making about futility and techniques of withdrawal is difficult and subject to differing opinion. Not every decision or action may be defensible, warranting both guidelines and the scrutiny the review intended. It is unfortunate, however, that Inwald and Vandyck, in taking a polarised view of just one aspect of care, have potentially generated difficulties in an already problematic area rather than creating a helpful template defensible from a medical, ethical, and legal perspective.

          References

          1. 1.

          Neuromuscular blockade must be used with adequate sedation and analgesia

          1. Alasdair Waite, specialist registrar in anaesthesia (alasdairwaite{at}yahoo.com)
          1. Southampton University Hospitals NHS Trust, Southampton General Hospital, Southampton SO16 6YD
          2. Sandringham Hospital, Sandringham, Victoria 3191, Australia
          3. University of Edinburgh, Edinburgh EH9 1UW
          4. General Infirmary, Leeds LS1 3EX
          5. Department of Anaesthesia, Royal Hospital for Sick Children, Edinburgh EH9 1LF

            EDITOR—The debate on the withdrawal of life sustaining treatment under the influence of neuromuscular blockade was interesting.1 The end result of death was inevitable in this scenario, and the intent of this course of management was to relieve suffering. I was surprised that there was not more emphasis placed on the use of sedative and analgesic agents to ensure lack of awareness and comfort in the period after extubation.

            If one of the main aims of the continuation of the paralysing agents were to allow the patient a serene and dignified death, would it not be more appropriate to make use of the pharmacological actions of the numerous available sedatives and analgesics to achieve this? Paralysing agents in current use have no sedative or analgesic actions, although they may mimic this effect from the bedside. The continuation of paralysing agents may leave a doubt about awareness. The knowledge that these agents are no longer active, and the patient seems calm because of comfort and lack of awareness rather than neuromuscular blockade, must provide reassurance to family and staff alike.

            It is standard practice in anaesthesia to ensure that muscle relaxants are given in conjunction with sufficient doses of analgesic and sedative drugs to ensure that the patient is unaware of paralysis and other stimuli. Our primary duty of care is to the patient, and we must ensure that there is no patient awareness at this time. By ensuring adequate sedation and analgesia, with or without the use of neuromuscular blockade, our duty to remove suffering is fulfilled. When we achieve these aims, we automatically fulfil our secondary duty to relatives and carers who should be allowed the memory of a calm, comfortable death, free of suffering.

            References

            1. 1.
            View Abstract

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