In the realm of terminal care, when a doctor performs palliative care to prevent a patient suffering pain, the question “isn’t that euthanasia” is sometimes raised by the patient’s family.

By definition, euthanasia is an act that has a positive intention to shorten the life of the patient, such as the administration of a lethal dose of medication. On the other hand, palliative care is treatment which is intended to reduce the patient’s pain, so the purpose and substance of palliative care is entirely different from euthanasia.

However, like other forms of treatment, the use of medication may have a negative effect on the patient’s prognosis, and in the unfortunate case that it results in the patient’s death, it sometimes appears from an outsider’s view that the treatment followed the same process as euthanasia.

Generally, the distinction between palliative care and euthanasia is said to lie in the degree of awareness that the treatment will hasten the patient’s death. In other words, the distinction can be made by considering, from a clinical point of view, the percentage likelihood that the patient’s death could be hastened by administrating medication to relieve the patient from pain.

It is difficult to unequivocally identify this percentage, but for example, if it is determined that there is a “high probability”, then there is a possibility that it will be classified as euthanasia.

However, even if it can be said to be euthanasia, whether this is equivalent to murder under the criminal law requires separate consideration; euthanasia is categorized as “proactive euthanasia” (e.g. injecting a lethal dose of medication), “passive euthanasia” (e.g. ceasing life-prolonging treatment) and “indirect euthanasia” (e.g. in circumstances where eliminating or reducing the patient’s pain was certain to result in hastening their death) and debated as to whether it satisfies the elements of murder.

Putting aside “proactive euthanasia”, it is extremely difficult to specifically quantify the effect that an act of treatment will have on the patient’s prognosis at the front line of clinical care, so it could be argued that the categories of “passive euthanasia” and “indirect euthanasia” are concepts that were forcibly created so that lawyers who are not medically trained are able to explain them.

To avoid these indiscreet categories (concepts) getting out of control at the front line of clinical care, it is necessary to be aware of the issue of “how should this be explained to the patient’s family”, in order to avoid treatment being misunderstood as euthanasia.

For example, the administration of palliative medication sometimes drastically reduces the patient’s awareness level, so that they cannot properly communicate with their family and eventually die in that state. In such cases, the family may have doubts or remorse such as “did that hasten the patient’s death?” or “did it result in euthanasia?”.

All medications have side effects, so there are times where negative effects on the patient’s prognosis cannot be avoided in not only palliative care but in general medical treatment too. But particularly in the case of terminal care, where the patient’s death is approaching, it is essential that the patient’s family sufficiently understands in detail the degree of effect that palliative care had on the patient’s prognosis.

In other words, it is vital that prior to commencing palliative care, the treating staff carefully explains the patient’s current overall condition, not with an abstract explanation but using detailed evaluation scores and clinically predicted prognosis for each factor, and that palliative care is intended only to relieve the patient’s pain and is not linked to shortening the patient’s life. In particular, it is necessary to have a process for obtaining consent to treatment, in which it is explained openly to the patient’s family that, depending upon the patient’s symptoms, the selection of sedative or analgesic medication is not always backed by sufficient literary support.

Regarding this point, in addition to the Ministry of Health, Labour and Welfare’s “Guideline Regarding the Decision-Making Process for Treatment and Care at the Final Stage of Life” (March 2018 edition) that I introduced in my previous column, hospitals should also refer to the Japanese Society for Palliative Medicine’s “Clinical Guidelines for Palliative Sedation Therapy” and the Japan Medical Association’s “Palliative Cancer Treatment Guidebook” when establishing a palliative care system that is in line with the hospital’s circumstances.

(Translated from the original Japanese)