Palliative Care and the "Double Effect"

Palliative care is treatment which is aimed at the relief of suffering but which cannot cure.

When a terminally ill person is in great pain, large doses of drugs may be given to alleviate their suffering and these drugs may also hasten the time of death. This practice is usually legal, yet some people argue it is a form of euthanasia and that it is hypocritical to forbid other ways of easing a terminally ill person's suffering by assisting them to die.

Put simply, the law accepts that the doctor may give analgesics (i.e. drugs which remove or relieve pain) that hasten the patient's death, and foresee that they will do so, but he or she must intend only to relieve pain, not to kill the patient, even if the patient has asked for help to die. This is known as the principle of double effect.

The principle of double effect has extended to include, since about 1988, the deliberate sedation of patients to deep unconsciousness for the purpose of relieving suffering. This is called terminal sedation and undoubtedly can hasten death. Whilst they are sedated they receive no food or fluid and it is anticipated that they will die. No attempt is made to prolong life, nor, it is said, to hasten death, although this is clearly foreseen.

Also entering the discussion on end-of-life care is the advice to patients to refuse food and fluids as a supposedly reasonable alternative to a request for medical assistance in suicide; it is categorized as being without the higher degree of moral questioning as medically assisted dying.

Professor Erich Loewy discusses succinctly the hypocrisy of terminal sedation and describes the suggestion to cease eating and drinking as "not an ethically legitimate, or even minimally acceptable, option". (See reference next column).

Many of the articles and books you will find cited on this web site discuss 'double effect'. Here are just a few of them:

• Should Palliative Care Allow Deliberate Hastening of Death?, by Rodney Syme, FRCS, paper delivered to Palliative Care Victoria Conference, 18 March, 2002
• Terminal Sedation, Self-Starvation, and Orchestrating the End of Life by Erich Loewy, Archives of Internal Medicine, 12 Feb, 2001, Vol. 161, 329-332
• Sedation in Terminally Ill Patients by Janet Hardy, The Lancet, Vol.356, 2000 (p.1866)
• Seven Legal Barriers to End-of-Life Care by Alan Meisel et al, Journal of the American Medical Association, Vol.284, 2000 (p.2495)
• Origins of the Desire for Euthanasia and Assisted Suicide in People with HIV/AIDS by J.V.Lavery et al, The Lancet, Vol.358, 2001 (p.362)
• Desire for Physician-Assisted Suicide - Requests for a Better Death? A.L.Back and Robert Pearlman, Editorial - The Lancet, Vol. 358, 2001 (p. 344)
• A Tale of Two Deaths, by Rodney Syme, FRACS, March 1997
• Euthanasia: a Pyrrhic Victory, by David Kelly, former Chairman, Victorian Law Reform Commission, and Loane Skene, Associate Professor of Law, Melbourne University, The Age (26 March 1997)
• The Rule of Double Effect - A Critique of Its Role in End-of-Life Decisions, New England Journal of Medicine, Vol.337, No.24, 11 December 1997
• Palliative Options of Last Resort, Timothy Quill MD, Bernard Lo MD, Dan Brock PhD, Journal of the American Medical Association, 17 December 1997, Vol.278, No.23
• More openness needed in palliative care, by Jessica Corner, Director and Deputy Dean (Nursing), Centre for Cancer and Palliative Care Studies, Institute of Cancer Research/Royal Marsden NHS Trust, London, British Medical Journal, Vol.315, 8 November 1997
• The Limits of Palliative Care, by Dr Roger Hunt, 10 October 1996
• The Intent to Kill, by Kay Koetsier,DWDV REPORT,November 1999