Proposals for Treatment of Dying Stir Ethics Dispute

Ethics guidelines that permit a doctor to administer potentially fatal narcotics doses to a terminal patient--standards that could be seen as strikingly close to euthanasia--were to be proposed today by one of the nation’s most respected think tanks.

While the new guidelines would permit the use of narcotics in amounts strong enough to kill a patient who has consented to the treatment, the authors of the new report insisted that the proposal maintains a distinction between legitimate care of the terminally ill and mercy killing.

Dissenting Opinion Included

But some members of the 20-person committee that drew up the guidelines conceded that, in some respects, the standards could be construed as closely approaching, or even crossing, the line between active and passive euthanasia.

The blurring of the distinction prompted one committee member, Los Angeles ethicist Leslie Stephen Rothenberg, to insist on publication of a dissent at the conclusion of the 153-page report.

The new ethics standards also take sharp issue with the concept of treating older patients less aggressively or comprehensively than younger ones--a practice thought to be widespread in medicine and often justified on grounds that there is a difference in the potential for “quality of life” for the young and the very old.

The guidelines, produced by the Hastings Center, an internationally known ethics think tank headquartered in Briarcliff Manor, N.Y., are the first specific standards drawn up since a presidential ethics commission published a major report in 1983.

Broad Base of Consultants

While not representing the official position of any organized medical group, the report was the result of a 2 1/2-year project that included among its consultants top officials of the American Medical Assn., the American College of Surgeons, the American Hospital Assn., the American Geriatrics Society, the American Nurses Assn., the Catholic Health Assn., the National Council on Aging and the Health Insurance Assn. of America.

“There has been a clear groping for appropriate policy in this area,” said project director Susan Wolf, “and, I think, a real need for these guidelines. (This is) a group of experts sitting down and really getting down to brass tacks--going beyond the rhetoric and reports of the last decade.”

Active euthanasia--socially countenanced now in only one country, the Netherlands--permits a physician to deliberately end the life of a consenting terminally ill patient. So-called passive euthanasia involves taking steps nominally intended to relieve pain and suffering but which may also hasten death.

On the issue of “quality of life,” the report argues that adding a year to the life of an 85-year-old is not necessarily different from extending, by the same 12 months, the longevity of a patient who is 55, or even 25.

“Some view the term ‘quality of life’ as a euphemism for the judgment that certain individuals who are in very poor condition are valueless to society and ought to be allowed to die,” the report concluded. “That kind of judgment would be unethical and we reject it.”

But for a patient who has decided in advance, documented the decision carefully and perhaps also appointed a surrogate decision-maker to oversee the health care, the Hastings Center standards would approve the administering of massive amounts of pain relievers regardless of the effects.

“There is some belief that providing narcotics to dying patients might constitute a form of wrongful killing, since it can lead to respiratory depression and hasten death,” the report concluded. “Providing large quantities of (narcotics) does not constitute wrongful killing when the purpose is not to shorten the lives of these patients, but to alleviate their pain and suffering.

“Some patients near death do not receive adequate pain medication and end their lives in great suffering. This relief may foreseeably lead to an earlier death. Yet it may still be morally and legally acceptable, if the intention is not to kill but to relieve the suffering.”

The new guidelines, however, specifically reject euthanasia as an acceptable medical practice, arguing that “even when a medical intervention hastens death, the means used are those ordinarily used in treatment--analgesics, sedatives or anesthetics--not those associated with criminals--poisons, guns or knives.”

In all, said Bruce Jennings, associate project director, “there was a general agreement among us that there is such a line (between ethically permissible treatment of the terminally ill and deliberate mercy killing) and it is important, but it is hard to draw it or locate it precisely.

“I think it’s fair to say (that we are very) close to that line between active and passive euthanasia because the side effect of the medication (the narcotics) can be to retard respiration and to perhaps bring about the onset of death earlier than it would otherwise have occurred.”

Jennings said the Hastings Center panel struggled with the possible conflict just as American society will have to struggle with it as the health care delivery system becomes ever more adept at postponing death.

Dan Brock, the staff philosopher for the presidential ethics commission and one of three from the earlier study to serve on the Hastings Center committee, said the guidelines could be read to “blur” the distinction between active killing of the terminally ill and merely hastening an imminent death in the guise of pain relief.

Morphine as a Poison

“The difficulty here,” Brock, a professor of philosophy and human values in medicine at Brown University in Rhode Island, said, “(is that) in one respect morphine could be understood as a poison in these circumstances. But what are medically appropriate means?”

The distinction was at least partially lost on Rothenberg, one of two committee members who insisted on publication of the dissent at the back of the report. Rothenberg objected that the distinction between “terminating treatment” and “terminating life” was not drawn specifically and forcefully enough to avoid an inevitable social struggle with the so-called “slippery slope” of progressively legitimizing the taking of life.

Brock said that, societally, the United States must also come to grips with the challenge of setting national priorities for care people may receive. Some of the guidelines, he and Jennings said, could legitimately include age limits above which a particular treatment might not be offered.

On other issues, the Hastings Center guidelines concluded that:

--It is not ethical for doctors and health workers to remove a person from a breathing machine with the stated purpose of weaning the victim from dependence on the machine when the real reason is to hasten death in a hopeless case. It is also not ethical for health workers to respond slowly to an emergency in a terminal patient if the patient or legally designated guardian has elected to have all available life-saving means used.

--There should not be two classes of treatment called “ordinary” and “extraordinary,” because the two terms imply that one type of treatment--extraordinary--may be reserved for use only in selected cases.