Tuesday, February 27, 2007

'Morphine cases'

'Morphine cases' are an established part of the philosophical debate on double effect. It is worth reminding ourselves that medical practice has moved on from the kind of case philosophers have in mind, which in described by the Rev Billings in the radio talk described below. Hat-tip to 'Care not Killing'.

The use of Morphine

"We remain deeply concerned that some media reports are giving the misleading impression that doctors are administering morphine to dying patients in the knowledge that it will kill them.

The latest of these came on Radio Four's 'Thought for Today' on 23 February, when the Rev Dr Alan Billings, Director of the Centre for Ethics and Religion at Lancaster University, addressed the case of Kelly Taylor, a 30 year old woman, who is currently seeking legal permission to be heavily sedated with morphine and then dehydrated until she dies.

In the broadcast, Rev Billings referred to the so-called 'double effect' of high doses of morphine – a misconception that has become pivotal in Kelly's case. He said, 'Every day we allow doctors to end the lives of some people by making a distinction between intention and outcome. A doctor increases the morphine of a terminally ill person in great pain to the point where they die. The morphine kills. That's the outcome, but the doctor is not thought culpable because his intention is the relief of pain, not the death of the patient.'

Rev Billings here was expressing two popular misconceptions about morphine: that it frequently ends the lives of terminally ill people, and that it causes sedation when given in doses necessary to relieve pain. We strongly refute the statement that doctors are ending lives by giving their patients large doses of morphine to control pain.

Morphine, if deliberately given in very high doses to people who are not in pain, does cause respiratory depression and death. It was indeed the drug used by Dr Shipman to kill his victims, and this has undoubtedly heightened public anxiety about its use. However, when correctly used to relieve pain in a patient who is terminally ill, morphine should never cause death. By contrast it usually lengthens life and improves its quality. This is because the therapeutic dose of morphine, which relieves pain, is virtually always well below the toxic dose which ends life and because the relief from pain which it brings removes stress factors in the patient's condition. In addition, toxic doses risk causing increased agitation in some patients- hardly what is intended by those advocating this approach. In modern medicine, and especially in palliative medicine, doctors can kill the pain without killing the patient.

So-called 'terminal sedation' is very rarely necessary; and when it is, it is used to control severe agitation, rather than physical pain, in patients whose conscious level is diminished by their illness. Even when used for the management of agitation, it is very seldom necessary to sedate any patient continuously until they die, but usually only for periods of 12 or 24 hours at a time. Whatever the circumstances, morphine is not the drug of choice used for this sedation since sedation wears off rapidly, which is good for patients taking it for pain relief, but it makes it a poor sedative."

The same mismatch between philosophical examples and medical practice applies to the 'craniotomy case': the procedure at issue (crushing the head of a baby during childbirth in order to remove it quickly from the birth canal) is simply no longer used. The really 'hard' cases often turn out to extremely rare. It is unclear, for example, whether a 'therapeutic' abortion would ever be needed to save the life of a mother.

Philosophers usually aren't medically qualified, and for us an imaginary situation is as good as a real one, for the purposes of testing intuitions and proposed policies. But perhaps we should be more careful about allowing pro-abortion medical myths publicity.

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