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Wednesday, 25 March 2015

Guest Blogger on Palliative Sedation Danger

from a reader in medicine...

Final Penitence and Palliative Sedation.

Palliative sedation has been in the news quite recently, well the French news, as the French government has recently voted and approved of its use. This has the prolife community up in arms because of the loose wording that allows one to use it as direct euthanasia.

What is palliative sedation? It is an end of life medical treatment where in the patient, who is in great pain that is beyond the comfort of palliative analgesia or painkillers. The patient is placed under deep, continuous sedation either for short periods to allow for concurrent treatment to take effect, or until death is reached.

The example on Wikipedia is that of a patient with end-stage oesophageal cancer wherein the tumour has become so enlarged that it compresses the trachea. The typical treatment for that is intubation, or a tracheostomy, where one opens the trachea from the neck to insert a tube in order to allow ventilation. These procedures in themselves are uncomfortable and the patient may refuse, and thus desire palliative sedation to avoid the conscious discomfort and pain of death by suffocation.

However, what the French has voted on its on is different from this, it is clearly euthanasia. Their bill involves those who are ‘deeply handicapped or ill persons who judge that any treatment they are receiving is “uselessly prolonging life,” either because they are “disproportionately heavy” or have lasted “too long.”’ And the withdrawal of feeding and hydration tubes while putting the patient into a deep continuous sedation until death. You can read more here:

The argument for the permissibility of palliative sedation in moral philosophy would be through the Principle of Double Effect. It is similar to the one for the use of palliative analgesiacs which suppress the respiratory system such as morphine. The argument of the latter being that it is good to relieve the pain and make the terminal patient comfortable, and this good outweights the consequential evil that death maybe hastened by respiratory suppression, however it can be tolerated because the patient is comfortable. This is not euthanasia because the intent and act are for pain relief and not death.

In palliative sedation, the arguemnt is similar except that it involves placing the patient into deep sedation to prevent the conscious sensation of pain. Also, palliative physicians ensure that respiratory suppression does not occur by titrating the drugs accurately, thus death will occur according to the underlying cause.  It is important to note the difference here as compared to the recent French ruling, is that feeding and hydration of the patient, as well as other life support interventions are continued during this sedation.

I must digress here and note that in certain cases, it is medically justifiable to withdraw hydration and feeding tubes from a dying patient in order to increase their comfort. In the case of dying by congestive cardiac disease where in the lungs are filled with fluid, the constant hydration by IV fluids may make it difficult for the patient to breath. Hence, removal is for comfort. However, this is only done in the final hours of life.

Thus, it would seem that palliative sedation on its own is morally justifiable,  and a good thing to give a patient in desperate pain. Ah, but up to this point we have not considered it from the viewpoint of moral theology.

One of the things the Christian prays for is the provision of a good death and the grace of final repentance. All repentence is through the grace of God, and without which, we fallen sons of Adam would be unable to seek reconcilliation and forgiveness for our sins. Final repentence is for the final conversion of the soul upon her deathbed. Conversion requires an act of  will to love God and to abandon and hate one’s sins.

The will, as St Thomas teaches, is in one of the higher facultives of the soul and is through we derive our volition. Furthermore, it can only express itself when a person is conscious. This is why, St Thomas teaches that the things we are not culpable for the things we dream about since we are not conscious during that time, unless of course, we arise halfway and persist in those sinful thoughts. Thus, in order for conversion or repentence to occur, one must be conscious to will it.

Secondly, we are rational animals, and because of that we are moral creatures. Thus, the Church teaches that anything that detracts from the dignity that comes from that gift of rationality is sinful. This is why impairing our congnitive facultives through excess drinking or the use of recreational drugs is a grave sin. We detract from the dignity that God gave us to take that of animals, which are below us. Hence, palliative sediation tows a fine line from begin necessary to unneccessary, and thus sinful. It would certainly be a grave sin to put oneself in such a state consciously knowing that it dulls the cognitive faculties and prevents the opportunity for the grace of final repentance. It would be a denial of the hope of God Himself.

That said, not all sedation is deep continuous sedation. There are legitamate uses of shallow sedation, such as when one is placed intubated and placed on a ventilated in cases of respiratory distress. The sedation is necessary to prevent the patient from taking out the tube himself thus injurying his vocal cords in the process and denying his body much needed oxygen. However, it is noted that in such a case, the patient is conscious. Another instance would be where one is overly anxious or excited and is a harm to oneself or others in the case of a behaviour altering brain tumour or dementia.

Thirdly, under such deep sedation where one is unconscious, there would be no merit for the sufferings that one undergoes. These may be from God as necessary mortification for our salvation. They may even be from God as penance for the salvation of others.

In conclusion, the moral aspects of palliative sedation must be studied from the lens of moral theology. Clearly, there are many issues that need to be discussed and clarified.  Sadly, there haven’t been any great moral theologians in this era, and most of these life issues, even in Catholic circles, are discussed only from the limited lens of moral philosophy. One wonders how many Catholics, outside of easy topics like abortion and contraception, actually understand the theological reasoning behind the other issues?