© 2008 American Thoracic Society
Palliation or Euthanasia and End-of-Life Care: Is It in the Eye of the Beholder?From the Authors:We thank Drs. Rady, Verheijde, and McGregor for their letter referring to the American Thoracic Society (ATS) Official Clinical Policy Statement concerning palliative care for patients with respiratory diseases and critical illnesses (1). We appreciate their concerns that distinctions between palliative care and euthanasia may become blurred in clinical practice. The statement itself was written to make these distinctions clearer to health care providers, patients, and the public. Of particular concern to Dr. Rady and colleagues is that certain exigencies (e.g., those related to organ transplantation or terminal sedation) may lead to distortions in the application of the principle of double effect. According to the principle of double effect, under certain conditions, the intended good effect of a medical intervention (e.g., relief of pain or dyspnea by administration of sedatives or opioids) can justify an unintended but reasonably foreseen bad effect of the intervention (e.g., hastening the dying process) (2). Although the ATS statement supports the appropriate application of this principle, clinicians should be aware that published evidence does not support the commonly held belief that use of sedatives or opioids in palliative care at end of life actually hastens death (3–5). The misapplication of this principle may result in practices that generally lack moral standing and public acceptance in the United States—for example, physician-assisted suicide or euthanasia. It is important to appreciate that, despite the pressure to contain health care costs or the urgency of saving lives through organ transplantation, decisions of clinicians should be based on their primary obligation to promote their patient's welfare while adhering to ethically acceptable practices (i.e., in accord with the principle of beneficence). This new ATS statement does not take a specific position on the intentional hastening of the dying process, such as in physician-assisted suicide or euthanasia. However, a 1991 ATS statement clearly is in concert with Dr. Rady and colleagues' beliefs when it states that "Physician involvement in assisted suicide and active euthanasia, even if requested by the patient, is not endorsed by the ATS" (6). We appreciate the reminder by Dr. Rady and colleagues of the need to be vigilant and avoid promoting ethically unacceptable practices under the rubric of good medicine.
Johns Hopkins Hospital
University of Pennsylvania FOOTNOTES Conflict of Interest Statement: Neither author has a financial relationship with a commercial entity that has an interest in the subject of this manuscript. REFERENCES
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