When reflecting on the dilemma facing Dr Cox, the key question surely is: is it ever necessary to kill a dying patient in order to kill the pain? If the answer is no, then clearly any doctor who does cannot plead necessity (force majeure). In other words, if suffering can be relieved within the law, a doctor cannot justify stepping outside it.
It is important, however, not to oversimplify the doctor's dilemma. Doctors have two general responsibilities, namely, to preserve life and to relieve suffering - and inevitably there will be times when the two seem to be in conflict.
When a terminally ill patient is close to death, preserving life becomes increasingly meaningless and the emphasis on relieving suffering becomes paramount. Even here, however, the doctor is obliged to achieve his object with minimum risk to the patient's life. This means that treatment to relieve pain and suffering which coincidentally brings forward the moment of death by a few hours or days is acceptable (the principle of double-effect) but administering a drug such as potassium chloride or curare, whose primary action is to cause death, is not acceptable. As Lord Justice Devlin stated in the late 1950s:
`A doctor who is aiding the dying does not have to calculate in minutes, or even in hours, and perhaps not in days or weeks, the effects upon a patient's life of the medicines he administers or else be in peril of a charge of murder.'
So what more could Dr Cox have done to ease his patient's pain and suffering? The answer is: quite a lot. What he should have done, however, depends on the diagnosis:
- was he giving doses of diamorphine which were too small?
- was he endeavouring to relieve pain which was poorly responsive to opioids with diamorphine alone?
- was he dealing with a case of `paradoxical pain', as described recently by Morley and associates?
- was he dealing with `terminal anguish' and relying on diazepam alone to control this?
It is possible that Dr Cox simply failed to increase the dose of diamorphine high enough and fast enough. However, to rely on diamorphine alone to control movement-related pain, particularly in someone with arthritis, is a fundamental mistake -- but one still commonly made. In this circumstance, a nonsteroidal anti-inflammatory drug and a strong opioid should be prescribed concurrently. Thus, ideally, the patient should have been persuaded to continue any long-standing arthritic analgesic medication. She had a gastric ulcer: did that mean she had stopped taking a NSAID? With the various gastro-protective agents on the market, a gastric ulcer is not an absolute contra-indication to the continued use of NSAID.[2,3]
Moreover, several NSAID can be given by suppository or injection/continuous subcutaneous (SC) infusion in patients who are too ill to swallow. If asked, my advice would have been to give diamorphine and NSAID together by SC infusion, using a portable syringe driver.
The question of paradoxical pain is clearly important. Paradoxical pain refers to a rare syndrome in which more morphine or diamorphine causes more rather than less pain. It appears to be caused by a genetic inability to convert morphine to morphine-6-glucuronide (a highly potent morphine metabolite) so that only morphine-3-glucuronide (normally an inactive metabolite) is formed. It is suggested that, at very high concentrations, morphine-3-glucuronide has a non-specific stimulant effect on the central nervous system and, via this or other mechanism, antagonises the analgesic effect of morphine itself.
I do not think, however, that this was a case of paradoxical pain. Reliable reports of this rare condition link it with high dose intrathecal morphine or diamorphine. Less reliable anecdotal reports have suggested that it may also be seen with multi-gramme doses of IV morphine/diamorphine, ie doses much greater than those quoted by the press. But supposing it was paradoxical pain, what could Dr Cox have done? After taking advice from a palliative medicine or pain relief clinic colleague he could have changed to fentanyl or methadone - both of which are readily available in parenteral forms. And if his colleagues were unaware of the paradoxical pain syndrome, he would undoubtedly have been advised to render the patient unconscious until her imminent death ensued.
What about restlessness in the dying? As with other symptoms, careful evaluation is important. A full bladder or rectum may be the cause. However, assuming there is no readily correctible cause, an anxiolytic-sedative should be given -as happened in the case in question. But, although diazepam is often a good drug in this situation, it is not always so. Many patients need a neuroleptic such as haloperidol or chlopromazine. Indeed, a combination of a benzodiazepine and a neuroleptic may well be needed.
In a few patients, however, mild sedation serves only to make matters worse as the patient panics in response to the drug-induced drowsiness. This condition, which may or may not be associated with a confusional state, has been aptly called `terminal anguish'. Possibly, this is what Dr Cox was faced with. Not only is it distressing for all concerned, it only responds to heavy sedation with diazepam/midazolam and haloperidol/chlorpromazine/methotrimeprazine, or chlormethiazole, or phenobarbitone/amylobarbitone/thiopentone.
The dose of benzodiazepine and neuroleptic is arbitrary; it depends on what has previously been used and failed (ie even larger doses). That of IV chlormethiazole follows the recommendations of the British National Formulary for use in status epilepticus. The dose of SC phenobarbitone also varies: possibly 200 mg stat and 600-1200 mg by SC infusion over 24 hours. Guidelines for IV amylobarbitone and thiopentone are available. The aim with all of these manoeuvres is to render the patient unconscious - until death ensues.
What is the difference between what I am recommending and what Dr Cox did? After all, both result in the patient's death. The difference is that the former is both ethical and legal, whereas the latter is not. And as already noted, if a doctor can achieve his goal within the law, he cannot claim necessity as a reason for breaking the law. So should the law be changed? After all, IV potassium chloride is quicker, easier and cheaper than the cocktails referred to above. In my opinion the answer to that is an emphatic no! Deliberate death acceleration (`euthanasia') would take the medical profession and society over a dividing line, which, however thin it may become on rare occasions, they cross at their peril. The experience in The Netherlands demonstrates beyond reasonable doubt that abuse follows use of euthanasia as an instrument to relieve terminal pain and distress.[6,7]
The dividing line is based on intent. With one path of action, the primary intent is to relieve suffering while respecting an ultimate prohibition on the taking of life. With the other, the primary intent is to take life in order to relieve suffering. And, to quote from a recent Report from the World Health Organisation:
'Now that a practicable alternative to death in pain exists, there should be concentrated efforts to implement programmes of palliative care, rather than a yielding to pressure for legal euthanasia.'