Several years ago, bureaucrats at the United Kingdom's National Health Service-a socialized system in which hospitals are funded and operated by the state-reacted to legitimate and widespread complaints from family members that their loved ones were dying in agony in NHS hospitals. In response, well-meaning pain-control experts created a protocol-known as the Liverpool Care Pathway-which, among other provisions, informed doc-tors when to apply a legitimate medical palliative intervention known as palliative sedation. The protocol was recommended for adoption by the Na-tional Institute on Clinical Excellence (NICE)-the NHS's rationing and quality oversight board-and there you go; problem solved.1
Except it wasn't. Indeed, as so often happens in centralized systems, the bureaucratic remedy for one problem led to even worse trouble down the line. The LCP's palliative sedation protocol has, in practice, too often been applied as "terminal sedation"-a form of backdoor euthanasia. Understand-ing how and why that happened serves as an important cautionary tale about potent dangers of centralized healthcare.
"Palliative" Versus "Terminal" Sedation
In order to understand what went so badly wrong in the implementation of the LCP-and why it is important-we must first detail the crucial moral and factual distinctions between the legitimate pain-controlling medical treat-ment known as palliative sedation (PS) and a slow-motion method of eutha-nasia sometimes called "terminal sedation" (TS). The two are too often conflated, particularly by euthanasia advocates seeking to blur moral dis-tinctions and definitions.
A very good article published in the Journal of Pain & Palliative Care Pharmacotherapy clearly distinguishes between sedation applied to control pain and sedation used as a method of killing.2 First, author Michael P. Hahn, a respiratory therapist with Loma Linda University, notes that palliative se-dation applies the least amount of sedative to obtain the needed relief:
Ideally, the level of palliative sedation is provided in a fashion that is titrated to a minimal level that permits the patient to tolerate unbearable symptoms, yet the patient can continue to periodically communicate.3
PS employs varying degrees of sedation and time under that sedation level, depending on the circumstances:
The three most common levels of providing PS include mild, intermediate, and deep. When mild sedation is used, the patient is awake and the level of consciousness is lowered to a somnolent state, with verbal or nonverbal communication still possible. With intermediate sedation, the patient is asleep or stuporous and can still be awakened to communicate briefly. The third level is deep sedation, which refers to the patient being near or in complete unconsciousness and does not communicate verbally or nonverbally. Besides regulating the degree of sedation, palliative sedation may also be provided intermittently or continuously.4
In other words, palliative sedation is a medical treatment applied when necessary to relieve intense suffering; it offers individualized relief from pain and suffering (caused by conditions such as severe agitation) as the situation may warrant. It is not directed at ending the patient's life. Death is not the goal. If the patient dies, it is usually from the underlying condition or as an unwanted side effect, which can happen with any medical treatment. In other words, PS is no more euthanasia if a patient dies from complications than if a patient dies during heart surgery.
In contrast, terminal sedation intends to kill by putting the person into a permanent artificial coma and withholding food and fluids. TS-caused deaths usually are caused by dehydration over a period of about two weeks. In this sense, Hahn notes, palliative sedation and terminal sedation are mirror opposites (my emphasis below):
Palliative sedation is not a euphemism that is morally equivalent to euthanasia, nor is it "slow euthanasia" [e. …