Author: Charles F. von Gunten, MD

Question : What is the distinction between the use of morphine at the end of life to control symptoms and euthanasia/assisted suicide?

Case Scenario: An 83 year old former industrial worker has been hospitalized because of severe pain. He has pancreatic cancer with metastases to liver and lung. He has severe abdominal pain.

Many physicians inaccurately believe that morphine has an unusually or unacceptably high risk
of an adverse event that may cause death, particularly when the patient is frail or close to the
end of his or her life. In fact, morphine-related toxicity will be evident in sequential development of drowsiness, confusion and loss of consciousness before his respiratory drive is significantly compromised.

Many physicians inappropriately call this risk of a potentially adverse event, a double effect, when it is in fact a secondary, unintended consequence. The principle of double effect refers to the ethical construct where a physician uses a treatment, or gives medication, for an ethical intended effect where the potential outcome is good (eg, relief of a symptom), knowing that
there will certainly bean undesired secondary effect (such as death). An example might be the separation of Siamese twins knowing that one twin will die so that the other will live. Although this principle of “double effect” is commonly cited with morphine, in fact, it does not apply,
as the secondary adverse consequences are unlikely.

When offering a therapy, it is the intent in offering a treatment that dictates whether it is ethical medical practice:

if the intent in offering a treatment is desirable or helpful to the patient and the potential outcome good (such as relief of pain), but a potentially adverse secondary effect is undesired and the potential outcome bad (such as death), then the treatment is considered ethical

If the intent is not desirable or will harm the patient and the potential outcome bad, the treatment is considered unethical

All medical treatments have both intended effects and the risk of unintended, potentially adverse, secondary consequences, including death. Some examples are TPN, chemotherapy, surgery, amiodarone, etc.

Assisted suicide and Euthanasia are not examples of “double effect.” The intent in offering the treatment is to end the patient’s life.

If the intent in morphine in the scenario is to relieve pain and not to cause death, and accepted dosing guidelines are followed:

the treatment is considered ethical, the risk of a potentially dangerous adverse secondary effects is minimal, and the risk of respiratory depression is vastly over-estimated.

Related Links:

Reference: Emanuel LL, von Gunten CF, Ferris FD. (1999) The Education for Physicians on End-of-Life Care (EPEC) curriculum. American Medical Association, Chicago.

Medical College of Wisconsin Palliative Care Center:   www.mcw.edu/palliativecare.htm

Hospice and Palliative Nurses Association:   www.hpna.org

National Hospice and Palliative Care Organization:   www.nhpco.org