The relationship between voluntary assisted dying and mainstream palliative care
An article written by Thomas David Riisfeldt
As voluntary assisted dying becomes legalised in an increasing number of jurisdictions both nationally and globally, an evaluation of its relationship with current mainstream palliative care practices becomes paramount. I have attempted to explore this relationship in some of my recent research. The first step in this process, actually defining the terms euthanasia and assisted suicide, posed a very unexpected challenge, and any evaluation of the relationship they might have with other end-of-life practices was not possible without a foundation of clear terminology. The first part of my process was therefore to explore the contentious aspects of the definitions of euthanasia and assisted suicide, in contradistinction to other end-of-life practices. [1] This led to the identification of six disputed definitional factors, based on distinctions between (1) killing vs. letting die, (2) fully intended vs. partially intended vs. merely foreseen deaths, (3) voluntary vs. nonvoluntary vs. involuntary decisions, (4) terminally ill vs. not terminally ill patients, (5) patients who are fully conscious vs. those in permanent comas or persistent vegetative states, and (6) patients who are suffering vs. those who are not. I explored these factors in-depth and used them as building blocks in an attempt to delineate all of the different possible end-of-life practices, which were then tabulated to form a taxonomy.
Now being able to use this clear terminology as a platform for further evaluation, I proceeded to assess whether euthanasia/assisted suicide should be deemed as complementary or contradictory to currently mainstream palliative care practices. [2] Following an exploration of the aims of each of these practices, the role of the doctor as a healer, and the concept of patient abandonment, I reached the conclusion that euthanasia/assisted suicide are compatible with mainstream palliative care practices. I then evaluated whether mainstream palliative care practices make euthanasia/assisted suicide unnecessary nonetheless, and reached the conclusion that this is not the case, and therefore argued that euthanasia/assisted suicide should be considered as complementary to rather than mutually exclusive with mainstream palliative care practices.
A further piece of my recent work responds to Gilbertson et al. in their article on expanded terminal sedation, within which they advocate for broadening the scope of currently accepted terminal sedation to include terminal sedation which is commenced ‘rapidly’ at high doses, terminal sedation for patients who do not have non-refractory suffering, and terminal sedation for patients who are not imminently dying. [3,4] They then posit that this expanded terminal sedation is an alternative to assisted dying, which could therefore accommodate patients in jurisdictions where assisted dying is illegal, and also accommodate patients who lack decision-making capacity, motivated by the utilitarian grounds of reducing the suffering that these patients may otherwise experience. My response to Gilbertson et al. is aided by the taxonomy developed in my earlier work; I argue that their proposed expanded terminal sedation draws very close to and in some instances actually constitutes a subtype of euthanasia, rather than being an alternative practice altogether. I then argue that it is essential that this is recognised, so that this form of euthanasia (masquerading as expanded terminal sedation) is not inappropriately implemented, particularly in the nonvoluntary context.
This all amounts to a recognition that voluntary assisted dying is coming, and the relationship that it shares with mainstream palliative care is therefore becoming increasingly relevant. I hope that I have helped characterise the key aspects of euthanasia/assisted suicide and other end-of-life care practices through the definitional taxonomy developed, along with offering some reasons as to why euthanasia/assisted suicide should be considered as complementary to mainstream palliative care practices and offering some insights on the dangers of expanded terminal sedation when masquerading as an alternative to assisted dying.
References
- Riisfeldt TD. Overcoming Conflicting Definitions of "Euthanasia," and of "Assisted Suicide," Through a Value-Neutral Taxonomy of "End-Of-Life Practices". J Bioeth Inq. 2023 Feb 2. doi: 10.1007/s11673-023-10230-1. Epub ahead of print.
- Riisfeldt TD. Euthanasia and Assisted Suicide Are Compatible with Palliative Care and Are Not Rendered Redundant by It. Camb Q Healthc Ethics. 2023 Jan 25:1-9. doi: 10.1017/S0963180122000706. Epub ahead of print.
- Riisfeldt TD. Expanded terminal sedation: dangerous waters. J Med Ethics. 2023 Mar 9:jme-2023-109021. doi: 10.1136/jme-2023-109021. Epub ahead of print.
- Gilbertson L, Savulescu J, Oakley J, Wilkinson D. Expanded terminal sedation in end-of-life care. J Med Ethics. 2022 Dec 21:jme-2022-108511. doi: 10.1136/jme-2022-108511. Epub ahead of print.
Thomas David Riisfeldt
BMed MD BA BASS (Hons I)
Neurology Advanced Trainee registrar
NSW Health