In the preceding article I raised the question whether in an Orthodox Christian perspective there could ever be a morally acceptable way to care for a dying person, consumed by uncontrollable pain and suffering, even if the protocol had the effect of hastening the patient’s death. Fortunately, such cases today are rare. Palliative care and medications for pain management have been developed to the point that “terminal anguish” can usually be mitigated to an acceptable degree. But not always.
The question arose because at the time my aged and infirm mother was dying. Her final days were marked by organ failure and acute respiratory distress. The hospice team did all it could to provide her relief and facilitate her struggle. But her struggle continued, and we had no doubt that her suffering was real. Now she has passed on, and we are still grieving; grieving both her loss and the fact that for days she was consumed with the physiological process of having her life painfully ebb away. We knew that for months she had longed to die. Seeing her lying on her deathbed, gasping for breath and in obvious distress, I couldn’t keep from mulling over what I had always taken to be a forbidden, even unthinkable question. Is it ever appropriate – that is, in conformity with the will of God – to intervene in the dying process in such a way as to facilitate the passage from a life that is no longer a life, into the blessedness of life beyond? And if so, just what are the limits that must be set on such intervention?
These are questions we Orthodox have difficulty raising, much less discussing with others, including priests and theologians. When it is a matter of euthanasia and the circumstances that might lead a person to opt for it, we rightly insist that “there are better ways.” Hospice care can work wonders, as can proper pain management and palliative care in general. And the slippery slope engaged in taking a person’s life, even if they desire it, presents a very real and present danger. Proper care, when a cure is not possible, is the most appropriate response we can make, the most precious gift we can offer, when a person becomes irreversibly “terminal,” that is, when death is imminent.
The question we need to address is whether under certain very specific circumstances that care can include a form of medical intervention that might accelerate the dying process as the cost, the unwanted and unintended byproduct, of alleviating the person’s otherwise unmanageable suffering. To answer the question, one point needs to be made clear: there is no moral or spiritual obligation to bear physical anguish until the bitter end, as if suffering were punishment for our sins or a precondition for our redemption. It is neither. God does not inflict suffering as a penalty; and Christ alone has wrought our redemption through His own suffering on the Cross.
There is a specific procedure that has raised severe opposition in certain sectors of our society that nevertheless merits our consideration and, I would say, our approval. I’m referring to the practice known as “palliative sedation,” also called by the unfortunate name “terminal sedation.” (The expression “terminal,” by the way, is normally used to indicate that the patient, because of some illness or accident, has less than six months to live. Used this way, the term is virtually meaningless. No prognosis, especially regarding death, is dependable over such a long period. By “terminal,” we should mean rather that the person has “entered the dying process,” and, barring divine intervention, will die within a matter of days.)
Palliative sedation involves providing the patient with medication to induce various levels of unconsciousness, from a light sleep to a non-lethal coma. Only in the most extreme cases of intractable pain and suffering should the medical team consider rendering the patient comatose (and such cases, again, are very rare). It is a relatively simple matter to titrate the dosages so that the patient finds relief without the danger that the medication will bring on premature death. Yet even if the procedure to sedate does to some degree hasten death (by a matter of hours or days at most), is it not permissible to have recourse to the principle of double effect? That principle states that an action may not be evil in itself, and that whatever evil effects might arise from it may not be willfully sought as the objective of the action. In other words, the ends do not justify the means. But if an unintended harm comes incidentally and proportionately from a basically good action, then that carries no moral culpability. With regard to terminal illness, this means that within carefully prescribed limits it should be morally permissible to administer sedating medication, even if the unintended consequence is to shorten very slightly the patient’s lifespan. The operative language here, of course, is “very slightly.” This can vary from case to case, but its determination can only apply when death is truly imminent.
The principle of double effect, often criticized by ethicists as either too rigid or too lax, allows removing a terminally ill patient from mechanical life-support, if the patient or their proxy so desires. It should also allow a protocol that effectively diminishes acute pain as a patient draws near to death, even if that protocol inadvertently hastens the final moment. Determining just what limits should be placed on the protocol to insure against a “hidden” or “crypto-euthanasia” is a matter that must be decided among the patient, family members, the medical team and spiritual advisors.
Insofar as possible, a dying patient should be maintained in a state of consciousness, to benefit from the sacraments of confession and communion, to say good-bye to loved ones, and to pray. If pain and anguish are so great, however, that these gestures are impossible, then consideration should be given to relieving that distress by means of sedation. This is no more a protocol for euthanasia than is refusing to administer CPR to a reluctant octogenarian, or withholding or removing a ventilator from a person who has requested that a DNR (“do not resuscitate”) order be writ large on his or her chart. Even if a particular procedure slightly hastens death, if it is performed with the purpose of helping the patient achieve a “painless, blameless and peaceful ending” to their life, it is not euthanasia. It is simply what each of us would normally desire: compassionate care.
Because of widespread confusion over the issue of palliative sedation, some readers of these reflections will likely condemn them and me for heresy, insensitivity, or wanton neglect of dying patients. They may feel that they only advance the perverse aims of the “euthanasia movement,” and therefore it is “unorthodox” even to voice (or to think) them. But if any of those readers have found themselves raising similar questions as they watched a loved one die in pain and distress, yet as Orthodox Christians they felt compelled to keep such questions to themselves, then perhaps it is worthwhile discussing this issue publicly. Perhaps by openly confronting difficult and even offensive questions – especially those we dare not raise out of the misguided fear that they are forbidden or definitively resolved – we might allow and even encourage our faithful to voice the cares and concerns they have about their own lives and personal experiences. We might convey the important message that life is made up of difficult questions and hard choices, and that we have not only the moral right, but the pastoral obligation to address those questions and make those choices as faithfully as we can.
In the final analysis, we are asking not “what is morally acceptable?” or “what course of action is licit?” We are asking rather, “What is God calling us to do in this particular situation, given these particular circumstances, in order to fulfill His will and remain faithful to His ultimate purpose?”