Double Effect and Terminal Sedation

When someone is suffering from the effects of a terminal illness, a doctor can use sedatives and painkillers (like diamorphine) to “lessen the pain and/or distress”. Officially, a palliative care doctor will prescribe these drugs in dosages which are necessary to keep the patient symptom-free. But, a more compassionate doctor, who knows that their patient wants their life to end, can give increasing amounts of such drugs, privately knowing that the intention is to shorten the patient’s life.

An example of double effect was demonstrated in the High Court case (in London) of Annie Lindsell in 1997. She had motor neuron disease, and had written a living will refusing tube feeding, if this became necessary to keep her alive. In 1997, she sought a court declaration that her GP could administer enough diamorphine to render her unconscious when her ability to swallow food normally became affected. In the High Court, her doctor stated that “I believe in the forthright and unhesitating relief of distress and pain, with no half measures…I am going to treat Annie when she develops symptoms which prevent her from eating and drinking. This will allow her to sleep. There will be no eating and drinking. The decline into death is quite predictable”. The High Court confirmed this approach.

It is difficult to know how prevalent this, and related practices are. A survey by Professor Clive Seale, of London University was reported in the January 2006 issue of Palliative Medicine, in which he estimated that one-sixth of all the deaths in this country were actually hastened by the intended, compassionate use of the “double effect”. Further, he believed that there were also one thousand cases of voluntary euthanasia and two thousand deaths, due to non-voluntary euthanasia, occurring annually. Similar results were also obtained by Professor Seale in a follow-up study reported in Palliative Medicine in 2009: then, he noted that “continuous deep sedation is relatively common in UK medical practice, particularly in hospitals and home care settings”. More recently in June 2016, Baroness Molly Meacher, the chairman of Dignity in Dying, claimed “Thousands of Doctors are helping people to die every year“.

Advantages:

  • The patient does not experience further pain or suffering.

Disadvantages and Limitations:

  • In the UK the practice is unregulated and secretive. Doctors are not free to discuss the options openly, (especially with their patients), as they are in fear of accusations that they are breaking the law. From the patient’s point of view it is very difficult to choose a doctor who is more likely to provide this end of life treatment, if that is what they wish for. It is a lottery. Instead, we need an open, legalised, process with checks and balances to ensure that patients wishes are respected and doctors are protected and acting legally when they compassionately act in the best interests of their patients – even when that includes knowingly hastening their death.
  • If a person no longer wants to stay alive, being sedated while they starve to death may seem to them (and others) unnecessary and inhumane. Instead, some people would prefer to be given lethal drugs, as death will come quicker which is likely to be beneficial for friends and family they leave behind. Also, if they found themselves in that situation, some people would not want to waste medical resources being kept unconscious while they starve to death, rather than to have lethal medication which will achieve the same result more quickly.