1. Define the specific ethical dilemma/s.
Several ethical dilemmas could be analyzed in the above-described clinical situation (e.g. proportionality of treatments, the role of the parents in decision-makings,
etc). Nevertheless, we shall focus our attention on the question whether it is ethically legitimate to deprive a patient of his consciousness at the end of life?
2. Refer to the ethical principles involved
The state of awareness is usually considered to be an objective good for the person, since consciousness is required for the exercise of a person’s
rational and relational capacities (including communication). Thus, intentionally depriving oneself, or another person, of consciousness is commonly regarded as morally wrong, as for instance in
the abuse of alcohol or drugs, etc. (non-malfeasance). Nevertheless, it is evident that in medical praxis the deprivation of a patient’s state of awareness is sometimes intentionally induced
(e.g. anesthesia, etc.). In such cases we do not even question its moral legitimacy (beneficence).
What is the difference? In anesthesia, or analgesia, the action is essentially oriented to beneficence and therefore morally justified by the therapeutic
principle. In such cases, while doing the good, the physician knows that some undesired effects cannot be avoided. Is it morally legitimate to perform actions that have (or may have) simultaneously
both good and bad results?
On the other hand, if respect for a patient’s autonomous decisions is an important ethical principle (autonomy), how could a physician justify the performance
of an act that intentionally deprives a patient of his capacity to exercise autonomy, specially if this happens at the end of life (i.e. at one of the most important moments)? Such an act couldn’t
be done without an extremely serious reason.
3. Collect and analyze ethically relevant clinical information.
Both the diagnosis and the resistance of the disease to the available treatments have been well documented in this case. The MRI showed that the cause of
this patient’s bad headache was the meningeal infiltration by tumor cells and the concomitant cerebral oedema. As the patient presented severe adverse effects in response to chemotherapy,
and since his brain had already been irradiated as part of the LLA treatment, an etiological treatment of the cause of his headache was not possible any more. The response of cerebral oedema to
corticosteroids was only partial and the patient’s pain was refractory to a progressive escalation of opioids. Thus, the need for strong opioids in high doses seems to be clinically justified
in spite of the above-mentioned associated problems.
4. Review alternative courses of action
Three alternative courses of action might be taken in this situation:
- To palliate this patient’s symptoms only to the extent that would allow us to preserve his full consciousness. This would practically result in an
awaken patient at the expense of an invalidating headache.
- To provide opioids in a dose needed to control this patient’s pain. This would practically mean to induce a state of permanent deep stupor at the
end of his life.
- To choose an intermediate level of treatment that would preserve a certain level of awareness sufficient to interact with his relatives. This would practically
mean incomplete pain management.
5. Suggest an ethical solution
The principle of double effect sheds light on the ethical dilemma related to this case, namely the need to undertake an action that will have well-known and
unavoidable bad effects as using opiates at the end of life, knowing that this may negatively affect the patient’s state of awareness, blood pressure and respiration. There are, indeed, many
situations in palliative medicine in which one cannot do good without also causing undesired bad effects. The principle of the double effect sets the ethical criteria for the legitimacy of actions
that have both good and bad effects:
a) The performed act has to be morally good (e.g. analgesia).
b) The good effect cannot be reached by means of the evil effect.
c) Only the good effects can be directly intended; the bad effects have to be only tolerated (as unavoidable) and never directly intended.
d) There needs to be a due proportion between the good and the bad effects.
The principle of double effect forbids the achievement of good ends by wrong means, according to the common saying 'the end does not justify the means'. In
our case study, the act of analgesia with high dose opiates is legitimized by the simultaneous fulfilment of the four conditions set by the principle of double effect. Indeed, the fulfilment of
four of these conditions are captured also in the traditional way of understanding the role of sedation in palliative care, as stated - for instance - in the Oxford Textbook of Palliative Medicine
(p. 407) - “The goal of palliative terminal sedation is to provide the dying patient relief of otherwise refractory, intolerable symptoms, and it is therefore firmly within the realm of good,
supportive palliative care and is not euthanasia.”
When used to alleviate refractory physical or psychological symptoms near to death, this praxis has been also called "palliative sedation", defined
as the deliberate administration of drugs in the dose and combination required to reduce a terminal patient’s consciousness to the extent needed to adequately alleviate one or more refractory
symptoms with the patient’s explicit, implicit or surrogate consent (Cf. SECPAL). Key aspects of this definition are the ideas that sedation is used 1) with a therapeutic intention, 2) as
a last resort, i.e., when all other alternatives have failed to provide adequate symptom control, 3) only to the extent it is strictly needed, and 4) after a process of ethically valid informed
consent. In other words, the definition stresses the importance of securing a due proportionality in the level to which a patient’s state of awareness is reduced. As long as the deprivation
of consciousness is tolerated only to the extent needed to control refractory symptoms the classical doctrine of double effect applies.
6. Consider the best way of implementing the suggested solution
If we are going to use high dose opiates, we would obviously need to simultaneously administrate laxatives. And, if we know that this kind of analgesia will
deprive the patient of his state of awareness, we will have to take care of his hydration and nutrition (adjusting it to the actual needs determined by his terminal condition). This would probably
require the concomitant installation of a urinary tube. Nevertheless, to completely withdraw hydration and nutrition may represent “euthanasia in disguise”, especially if it is done
with the intention to hasten his death. (Cf. Tannsjo T (ed): Terminal sedation: Euthanasia in Disguise? Kluwer, Dodrecht, 2004).
