Intended for healthcare professionals

Education And Debate Ethical debate

The distinction between withdrawing life sustaining treatment under the influence of paralysing agents and euthanasiaAre we treading a fine line?Paralysing agents may be given up to but not at or beyond the point of extubationThe parents' perspective on withdrawing treatmentThe doctrine of double effect is difficult but not impossible to apply

BMJ 2001; 323 doi: (Published 18 August 2001) Cite this as: BMJ 2001;323:388

The distinction between withdrawing life sustaining treatment under the influence of paralysing agents and euthanasia

Although it is lawful to withdraw life sustaining treatment in a child provided it is within that child's best interests, the timing of discontinuation of paralysing agents with the withdrawal of ventilatory support raises ethical issues. Here several commentators consider the ethical, legal, clinical, and personal implications of a fictitious case study.

Are we treading a fine line?

  1. K Street, paediatric specialist registrar (,
  2. J Henderson, senior lecturer
  1. Institute of Child Health, Bristol Royal Hospital for Sick Children, Bristol BS2 8BJ
  2. a Portex Department of Anaesthesia, Intensive Therapy and Respiratory Medicine, Institute of Child Health, London WC1N 1EH
  3. b Crown Office Chambers, One Paper Buildings, Temple, London EC4Y 7EP
  4. 32 Littleheath, Charlton, London SE7 8HU
  5. Centre for Ethics in Medicine, University of Bristol, Bristol BS2 8BH
  1. Correspondence to: Dr K Street, Knapp Cottage, Knapp Road East, Thornbury, South Gloucester BS35 2HJ

    [The purpose of medicine is] to do away with the sufferings of the sick, to lessen the violence of disease and to refuse to treat those who are overmastered by their disease


    The ability to treat disease and sustain life by artificial means is continually advancing. At the same time there is a need to acknowledge when limits have been reached in a patient and continued treatment is no longer in his or her best interests.

    In September 1997 the Royal College of Paediatrics and Child Health concluded a two year period of consultation with professional and patients' interest groups with the publication of the document Withholding or Withdrawing Life Saving Treatment in Children: a Framework for Practice.2

    One of the many issues discussed in this document are the pharmacological agents often used in life sustaining situations and the distinction from euthanasia. The document states that while “it is unlawful to give a medicine with the primary intent of hastening death … giving a medicine to relieve suffering which may, as a side effect, hasten death is lawful and can be appropriate.” Paralysing agents are often used in ventilated patients. Withdrawal of ventilatory support while the paralysing agents are effective inevitably leads to death. Although the royal college does not support euthanasia, the guidelines state that “when the decision is made to withdraw treatment, it is not necessary to withdraw the paralysing agent before respiratory support is withdrawn.”

    But are we treading a fine …

    Correspondence to: D Inwald

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