Autonomy and the possibility of perioperative euthanasia

Abstract

Editor—I was interested to read Knipe and Hardman’s1Knipe M Hardman G Past, present, and future of ‘Do not attempt resuscitation’ orders in the perioperative period.Br J Anaesth. 2013; 111: 861-863Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar editorial on the use of do not attempt resuscitation (DNAR) orders in the perioperative period. They make several important points, not least the central role of patient autonomy in modern medicolegal thinking.2Re T (Adult: Refusal of Treatment) [1993] Fam 95.Google Scholar They conclude that current guidance on cardiopulmonary resuscitation (CPR) in the perioperative period could be distilled to a binary patient choice of continuing or suspending a DNAR order. However, I am concerned that this over-simplifies what is in fact a highly nuanced problem and by having patient autonomy trump all other moral and legal factors limits consideration of these. To be truly autonomous, a full discussion with the patient or their representative would need to take place before their operation as to what they would or would not consent to. Despite this, the authors go on to state that ‘separate decisions will need to be made for each individual patient about what other treatment would be appropriate for them’. It is hard to reconcile these two viewpoints unless patient autonomy is held to be one factor out of many. The acknowledgement that there is much overlap between anaesthesia and CPR is the correct one and to then contend in the conclusion that they should be recognized as entirely separate concepts is not supported by logic or clinical experience.3McBrian M Heyburn G Do not attempt resuscitation orders in the peri-operative period.Anaesthesia. 2006; 61: 625-627Crossref PubMed Scopus (16) Google Scholar It is precisely for this reason that many more options exist than simply ‘continue’ or ‘suspend’. On the sliding scale of intervention, with CPR at one end, it makes no more sense to draw an arbitrary line at that point to stop life-sustaining treatment, while making every effort up until then, than it does at any other. The second area in which this new approach is fraught with both legal and ethical problems is with respect to euthanasia. This question raises an important issue in perioperative CPR, and while the authors acknowledge that inducing anaesthesia with no intention to treat an ensuing cardiac arrest could be seen as euthanasia, it is dismissed as requiring ‘no more thought’. While in palliative care, it is a well-established principle of law that the administration of analgesic and sedative drugs which may incidentally shorten life is lawful,4Airedale NHS Trust v Bland [1993] AC 789.Google Scholar this may not be the case in the perioperative period. This ‘doctrine of double effect’ relies upon knowledge of the primary intention of the treating doctor.5Douglas C Kerridge I Ankeny R Managing intentions: the end-of-life administration of analgesics and sedatives, and the possibility of slow euthanasia.Bioethics. 2008; 22: 388-396Crossref PubMed Scopus (61) Google Scholar This presents a fine line over which it is easy to conceive of anaesthesia with the primary intention of euthanasia rather than the absence of sensation and relief of pain. Although this is likely to be exceptionally rare, it merits more consideration in any proposed guideline. For these reasons, I would suggest that the current guideline6Association of Anaesthetists of Great Britain and IrelandDo Not Attempt Resuscitation (DNAR) Decisions in the Perioperative Period. 2009Google Scholar represents the correct approach, with a presumption in favour of suspending a DNAR order perioperatively. This would limit the prospect of any suggestion of euthanasia and allow for a more balanced view of patient autonomy than the black and white approach proposed. None declared.