By Tim Waggoner

SACRAMENTO, May 29, 2008 ( – An assisted-suicide bill that allows doctors and nurses to suggest death by unconscious dehydration has barely passed the California State Assembly.

AB 2747 would authorize total sedation without nutrition and hydration for depressed and confused patients, whether or not their natural death was imminent. The bill would also allow family members to order the death of a mentally disabled person when a nurse opines they have less than a year to live, similar to Terry Schindler Schiavo’s death at the hands of her husband.

AB 2747 passed the Democrat-controlled Assembly Wednesday afternoon on a 41-32 vote, a one-vote margin of victory in the 80-member lower house. The vote was virtually party line, Democrats for, Republicans against. AB 2747 is authored by the same Democrats who unsuccessfully carried physician-assisted suicide bills for the last three years.

“This deceptive bill will cause death and shorten life, despite its claims,” said Randy Thomasson, president of Campaign for Children and Families, a leading California-based pro-life, pro-family organization. “Drying up and shriveling to death through dehydration is a fate worse than lethal injection. By transforming palliative sedation into a vehicle for assisted suicide, AB 2747 would transform doctors and nurses from healers and comforters into killers like Dr. Jack Kevorkian.”

AB 2747 would allow a doctor or a nurse to opine that a patient has “less than one year to live,” and then ask depressed patients if they would like to be totally sedated into unconsciousness. Total sedation is usually an irreversible procedure that does not include nutrition and hydration. If patients or decision-making family members fall prey to suggestions of total sedation, death from dehydration will usually occur within five days.

This is the fourth time that the assisted suicide bill has been pushed by Assembly Democrats Patty Berg and Lloyd Levine. But this year, instead of proposing to have doctors administer lethal injections, AB 2747 aims to produce death by sedation abuse, a clear violation of life-affirming medical ethics. Until now, total sedation has been used only when death was imminent – within hours or days – and when strong pain medication was not enough. Medical ethics require that food and water (nutrition and hydration) not be removed when sleep-inducing drugs are used, since doing so would cause unnatural, as opposed to natural, death. Yet AB 2747 pushes total sedation even if patients have not rejected food and water.

“Just as the assisted-suicide bills of the last three years have been rejected, so should the California Legislature reject AB 2747,” said Thomasson. “Assisted suicide by total sedation ignores the sanctity of human life and violates life-affirming medical ethics. People who are ill need support, spiritual care, and counseling if they’re depressed. But AB 2747 would ensure the death of innocent Californians at the hands of an increasingly unscrupulous insurance industry that regards people cheaper dead than alive.”

Dr. Howard M. Ducharme is past chair of the philosophy department at the University of Akron. On January 24, 2002, Dr. Ducharme participated in “The Debate over Total/Terminal/Palliative Sedation,” sponsored by The Center for Bioethics and Human Dignity (, where he detailed how total sedation prematurely kills people:

Total sedation (TS)—called by some “terminal sedation,” “palliative sedation,” or “slow euthanasia”—is a protocol recently added to the lexicon of contemporary medical interventions and is a construct actively promulgated by the National Hospice and Palliative Care Organization (NHPCO). It is defined as “the application of pharmacotherapy to induce a state of decreased or absent awareness (unconsciousness) in order to relieve the burden of otherwise intractable suffering.” With only this much said, there may seem to be no ethical objection to TS—a patient who is terminally ill, imminently dying, and suffering overwhelming physical pain may simply request temporary TS to get some sleep today with the hope that the pain will be endurable tomorrow. However, any quick acceptance of TS would be ill-advised because of the many “devils in the details.”

TS is not limited to patients with terminal illness who are imminently dying. The NHPCO’s policy explains that TS can be used “in the last day or two of life,” but it can also be used “at multiple points” in a “patient’s trajectory toward death,” when the patient is not imminently dying. Thus, TS is not limited by standard clinical criteria as put forth in the AMA’s policy on forgoing life-sustaining treatment (FLST)—i.e., that the patient be terminally ill and imminently dying.

TS protocol allows that the sedation may be “partial or complete,” and that it can be initiated as a temporary and reversible sedation. There is no problem with this application of sedation; however, TS policy does not limit the time frame, or require reversibility, of sedation. Though the NHPCO states that “[TS] need not be considered irreversible,” TS can be titrated to produce a “complete unresponsiveness of patients” with the “intent” to provide “deep sedation until death occurs, without concern for reversibility.” When a permanent TS treatment is administered upon the patient’s directive, it cannot be revoked; no totally unconscious patient will ever have the opportunity to reverse her directive, say, to look at the face of a loved one just one last time. By contrast, when a DNR order is in effect, it can be revoked by the patient at any time. Absolute final farewells must precede permanent TS—just as in an act of euthanasia.

TS protocol also allows that any concomitant therapies may be added to the TS patient’s protocol, each “based on their own merits.” Thus, a terminally ill patient (e.g., an HIV+ or early-stage ALS patient) who is not imminently dying can be given TS concomitant with a decision to forego (withhold or withdraw) life-sustaining treatment (FLST). When the patient’s life does depend upon the continuation of life-sustaining treatment, the cause of his death may be ambiguous. Would the immediate cause be regarded as FLST and not at all dependent upon the active interventions of TS policy? What if such a patient refuses to forego life-sustaining treatment without first undergoing TS? In such a scenario, TS is necessarily implicated in the immediate cause of the death of the patient. Such a context carries TS into the frontiers of euthanasia. Furthermore, TS plus concomitant patient decisions can place TS squarely in the arena of euthanasia, e.g., when a TS patient elects to have her organs harvested per the Non-Heart-Beating Cadaver Donor Protocol. Here the result is an act, elsewhere argued, of “thrift-euthanasia.”

Another troubling aspect of TS is that strict respect for patient autonomy is compromised on several fronts.

According to the NHPCO, “When patients do not have [autonomous] capacity, their designated decision-makers may make the decision on their behalf.” This element of TS policy dissolves two fundamental boundaries set up to protect patients. When irreversible TS is deemed appropriate by family members (third-party, outside observers) of a non-competent patient, TS is then administered as non-voluntary or involuntary TS—on a parallel with non-voluntary and involuntary euthanasia. Additionally, TS decisions made by substituted decision-makers will not be based on first-hand descriptions of the level of suffering experienced by the patient. Rather, they will be mere inferences based on observations and value-laden evaluations of onlookers—who may have low pain thresholds and/or high sensitivity to the perceived suffering of others. Family members may (or may not) have the best of intentions, but they are nonetheless incapable of knowing for certain whether or not the patient has crossed over from tolerable to intolerable distress, the supposed symptom required for TS.

The ugly reality is that irreversible TS may too often be treatment given to a patient for the comfort of the family.

If the patient does want to die, then TS will be readily accepted. If she does not want to die, then simply being approached to consider TS will communicate to her that she must be a burden on others and/or that her life just cannot be worth living any longer. Such reflections by the patient may be exactly enough to shift an individual’s suffering from bearable to unbearable.

The psychological distress added to the patient’s life by others initiating this conversation may be the existential push that takes them over the TS cliff. Furthermore, when TS becomes hospice and hospital policy, it will be incumbent on the agency to inform all patients of their TS options at admission. Therefore TS policy adds significantly to the so-called “culture of death” mentality already inundating society.

Lastly, given the details unpacked above, a health care team can initiate the discussion of TS of an incompetent patient with family members and carry it out all without any patient involvement. This is a dire and shadowy way to end the lives of others via paternalistic, non-voluntary, existential euthanasia.