Annie (not her real name) was, as my children would put it, really "freaking out". She was only in her 30s when it was discovered that she had rapidly advancing terminal cancer. Unfortunately, she had stopped taking her medication for her schizophrenia and her behavior deteriorated rapidly.
The decision was made to give her sedatives by intravenous drip for a short time and then stabilize her on her usual medication. Within a couple of days, the continuous sedative drip was slowly stopped and we were all relieved that Annie was now able to understand and deal with her terminal diagnosis.
This incident happened almost 20 years ago. Today, we have a much different scenario involving sedation and the end of life.
This year, Assembly woman Patty Berg, a California lawmaker who has repeatedly tried to legalize assisted suicide, sponsored the "Right to Know End-of-Life Options Act" (AB 2747), a bill that would require doctors to discuss such options as "palliative sedation" and "voluntary stopping of eating and drinking" with terminally ill patients. Not surprisingly, Compassion and Choices (the former Hemlock Society) is an enthusiastic supporter of this measure.
As I wrote in 2002,1 supporters define terminal sedation as the deliberate "termination of awareness" for "relief of intractable pain when specific pain relieving protocols or interventions are ineffective" and/or "relief of intractable emotional or spiritual anguish (existential suffering, psychological distress, emotional exhaustion)."2 Since such sedation continues until death, there is usually the withdrawal of all treatment, including even food and water, so that death occurs as quickly as possible. No matter how long it takes until death occurs, supporters of terminal sedation insist that the cause of death is the underlying illness rather than suppression of breathing, dehydration or the removal of essential drugs such as insulin or heart medications. It is unfortunate that supporters of terminal sedation now frequently change the term to the more benign-sounding "palliative sedation". True palliative sedation such as Annie's is not the same as this terminal sedation.
Paradoxically, despite the mainstream media's fascination with "right-to-die" issues, I have only recently seen any mainstream media source even start to look at the issue of sedating people to death.
In March 2008, Time magazine published an article, "When is Sedation Really Euthanasia?"3, in which Kathleen Kingsbury, the author, readily admits "terminal sedation -- often goes hand-in-hand with cutting off other medications or removing a patient's feeding tubes" and that terminal sedation is beginning to supplant lethal overdoses in the Netherlands as the preferred death procedure. In the end, however, the author appears to agree with Dr. Ira Byock, a palliative care specialist and active promoter of terminal sedation, who maintains that such sedation is a legal, "end-of-life" option that is sometimes abused by being done "too early", without the person's consent or "to sidestep legal requirements to perform euthanasia".
Miss Kingsbury also quotes Dr. Porter Storey, executive vice-president of the American Academy of Hospice and Palliative Medicine, as saying, "the option to sedate can be a tremendous liberation", relieving patients of their "fear of dying or not getting adequate help at the end of life". Dr. Storey maintains "Good doctors don't intentionally shorten life."4 Of course, a good doctor would not intentionally shorten life but sedating someone into unconsciousness and deliberately depriving him or her of food and water will in fact end life if it goes on long enough, regardless of the stated intention of the alleged good doctor.
While controversial public cases like Terri Schiavo's involved removing food and water from so-called "vegetative" people without "living wills" or other documents, California's "Right to Know End-of-Life Options Act"5 would allow a fully conscious, terminally ill person to intentionally stop eating and drinking while being sedated until death. However, causing or hastening death to relieve suffering is euthanasia no matter what procedure is being used and regardless of whether a person consents. And, of course, it is a very small step from allowing terminal sedation to actually allowing a faster lethal overdose.
The centerpiece of the California bill was a menu of "end-of-life" options including palliative (terminal) sedation and "voluntary stopping of eating and drinking" for people expected to die within a year. California health care providers who had ethical or medical objections to such palliative sedation were legally required to transfer the patient to a provider with no such scruples. Given the current "right-to-die" mindset in much of medical education, this does not bode well for developing future ethical health care providers when the bill stated "Every medical school in California is required to include end-of-life care issues in its curriculum and every physician in California is required to complete continuing education courses in end-of-life care."
When pro-life, disability, and other groups of concerned citizens mounted a campaign against AB 2747, the sponsors of the bill started removing some parts of the bill to get it passed, but, as of August 2008, the bill has not passed and the opposition to it continues.
As assisted suicide bills have regularly failed in state legislatures in the years since Oregon passed its assisted suicide law, euthanasia supporters have had to change tactics, although not their ultimate goal of choosing death as a constitutional right. The outreach to medical groups like hospice and palliative care organizations is particularly disturbing.
Euthanasia supporters have been successful in getting some medical and nursing groups to change their official positions from opposition to assisted suicide/euthanasia to neutrality on the issue. And now, almost all of the mainstream media accepts death by withdrawal of treatment as humane and legal for the severely brain-injured. It was just a matter of time before that vulnerable group of people expanded to include people with lesser disabilities and now even the fully conscious but terminally or "hopelessly" ill person.
But as everyone really knows, it is virtually impossible to starve and dehydrate to death painlessly. The idea of terminal sedation to make such a death possible thus becomes essential to the process.
Bills like California's are not only incremental steps to the goal of legalizing euthanasia. They are also a crucial part of the effort of "right-to-die" groups to reeducate the public, especially doctors and nurses. This is why bills like California's are so insidious. When an induced coma with self-starvation and dehydration is seen as proper medical treatment for anyone, the whole rationale of ethical health care is turned on its head.
When medically vulnerable people are given the option of a legal, doctor-assisted premature death, can we be surprised when we discover that none of us is permanently safe from the same fate?
3 "When Is Sedation Really Euthanasia?" by Kathleen Kingsbury. Time, March 21, 2008. Available online at: http://www.time.com/time/health/article/0,8599,1724911,00.html. [Back]
5 The amended text of AB 2747 is available online at: http://www.leginfo.ca.gov/pub/07-08/bill/asm/ab_2701-2750/ab_2747_bill_ 20080702_amended_ sen_v94.html. [Back]