临床研究与生物伦理学杂志

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Quality Palliative Care or Physician-assisted Death: A Comment on the French Perspective of End-of-life Care in Neurological Disorders

Mohamed Y. Rady, Joseph L. Verheijde and Michael Potts

Conflating physician-assisted death with palliative care is a growing concern in medicine. Palliative care is symptommanagement medical care without actively shortening the end-of-life trajectory of a terminal illness. Physician-assisted death intentionally shortens the dying process to bring about preplanned death as the means of relieving suffering. Physician-assisted death may be conflated with palliative care where this practice is illegal, eg, France. The Revised French Code of Medical Ethics states that when the decision to withdraw or withhold treatment is made in accordance with applicable law, and even if the patient has brain damage precluding an assessment of suffering, physicians must use the treatments, including analgesics and sedatives, to maximize the quality of end of life, safeguard the patient's dignity, and comfort relatives. This revision, which in France has the force of law, appears to uphold the Hippocratic Oath to alleviate suffering and deliver compassionate care. Additional analysis raises questions: (1) what type of treatment is being withdrawn or withheld? (2) What type of brain damage or neurological disability might preclude the assessment of suffering? (3) What type of suffering (eg, physical, psychosocial, existential, etc.) must be treated? (4) What measure of proportionality is applicable to ensure that sedatives and analgesics will not be the proximate causation of death? The legislation assumes potential suffering from treatment withdrawal which disrupts the current ethical paradigm on withdrawing versus withholding treatment. This legislation also applies to neurologically disabled patients incapable of requesting euthanasia but for whom a treatment limitation decision has been made. Re-evaluation of the double-effect principle, intention, and causation of death precludes using the term palliative care. The two-step process (ie, treatment withdrawal and administration of sedatives and analgesics) should be considered physician-assisted death in some neurologically disabled persons. The revision implicitly paves the way to organ donation euthanasia in neurological disorders.