Does Palliative Sedation Produce an Ethical Resolution to Avoid the Demand for Euthanasia in a Muslim Country?

CASE

According to the news published by Turkish newspapers in March 2016, Fatih was a 23-year-old young male with metastatic colorectal cancer. He had gone through several medical operations and chemotherapies, but his medical condition had only become increasingly worse. Ten days ago, Fatih refused to stay in the hospital and use any more medications. However, his pain was unbearable and he begged his father to kill him to relieve him from the intolerable pain. The father's psychological well-being had dramatically deteriorated due to his son's long-term futile treatment and suffering. He could not deny his son's last wish, and he shot his son and killed him. The lawyer defending the father claimed that this murder occurred due to the illegalization of euthanasia in Turkey; if euthanasia had been legalized, this heartbreaking incident would not have happened.[1] Is the lawyer right? Was there any other resolution to alleviate the patient's suffering? Can palliative sedation be a morally, legally, and religiously acceptable alternative to euthanasia?.

INTRODUCTION

One of the 20^thcentury's most influential politicians, preeminent civil rights activist, and world-famous Indian spiritual leader, Mohandas Karamchand Gandhi (1869-1947) says, “should my child be attacked by rabies and there was no hopeful remedy to relieve his agony, I should consider it my duty to take his life” (p.22).[23] In the scope of the concept of ahimsa (nonviolence), Gandhi renounces all forms of violence not only against human beings but against any beings; he justifies killing a person who suffers from an incurable disease through the sense of love and compassion toward the person.[245] The present case denotes a similar approach in respect to intentionally killing a person on the grounds of saving him from intolerable pain. Therefore, the increase in the number and prevalence of chronic diseases escalates patients' pain and suffering and prompts them to look for certain life-terminating interventions such as euthanasia and physician-assisted suicide (PAS).[6] Furthermore, some views opposing euthanasia and assisted suicide focus on palliative sedation as a morally justifiable method to alleviate terminally ill patients' suffering. In this context, the aim of this article is to analyze the present case to reach a conclusion on whether palliative sedation may be suggested, in a Muslim country, as an alternative to euthanasia.

EUTHANASIA AND PALLIATIVE SEDATION

Euthanasia is one of the most deliberated concepts in medical ethics attracting the attention of many ethicists, philosophers, and theologians. However, it does not mean that everyone addresses the same aspect when utilizing this word. The term euthanasia is a compound word consisting of eu (good) and thanatos (death), which originates from Greek.[7] In this sense, euthanasia literally means “good death,” while some define it as “mercy killing” in a euphemistic manner. However, some other views consider euthanasia to be suicide or even homicide. Moreover, medical, philosophical, and ethical discussions on the differences between “killing” and “letting die” illustrate conceptual distinctions between active or passive euthanasia and direct or indirect euthanasia. In addition, depending on the presence or absence of the patient's consent, other forms of euthanasia also become apparent: voluntary euthanasia, nonvoluntary euthanasia, or involuntary euthanasia.[891011]

The Netherlands, the first country to allow euthanasia, defines it as “administration of drugs with the explicit intention to end life at the explicit request of a patient” (p. 183).[712] Administering euthanasia in the Netherlands does not require the existence of a terminal illness, but the person's intolerable suffering.[13] In other words, in the Netherlands, the presence of unbearable suffering is a sufficient reason to demand euthanasia regardless of whether or not it stems from a terminal disease. Even the exhaustion of life without a physical and mental disease may be claimed as intolerable suffering for requesting euthanasia.[14] Bert Broeckaert describes euthanasia as “the administration of lethal drugs in order to painlessly terminate the life of a patient suffering from an incurable condition deemed unbearable by the patient, at this patient's request,” which limits euthanasia to incurable diseases (p.34).[15] The implementation of euthanasia in Belgium and Luxembourg largely matches Broeckaert's definition.[13]

Emanuel et al. emphasize the variety of definitions and different understanding of euthanasia and PAS in different countries. They describe euthanasia as the administration of a medication such as a sedative or neuromuscular relaxant, by a person, usually a physician, “to intentionally end a patient's life with the mentally competent patient's explicit request” (p. 80-81).[16] Furthermore, the American Medical Association (AMA) defines euthanasia as “the administration of a lethal agent by another person to a patient for the purpose of relieving the patient's intolerable and incurable suffering” (p. 8).[17] In this view, the definition of the AMA and the aforementioned other descriptions highlight the primary characteristic of euthanasia as administering certain medications to intentionally kill a person. However, in regard to the following issues, these definitions underline distinct conditions or they are silent in specifying their position:

• The person who is administering the medication; a physician, any health-care professional, or another party (excluding the person her/himself). If euthanasia is deemed to be a medical intervention, the medical intervention must be conducted by a medical professional

• Whether the person's explicit request for euthanasia is an obligatory condition (AMA's definition does not directly clarify this point). Some scholars think that if a morally acceptable form of euthanasia exists, it would be voluntary euthanasia demanded by a capable patient through an autonomous decision making process[1518]

• Under which conditions the demand for euthanasia may be acceptable and honored; whether in the case of a terminal disease, an incurable disease, the presence of intolerable suffering resulting from particular illnesses, or any suffering regardless of the existence of a physical and mental malady

• If the presence of a terminal or incurable disease is a precondition of euthanasia, whether a certain life expectancy should also be sought. For example, in Oregon's implementation of PAS (the Act uses the term death with dignity instead of assisted suicide to describe the life-terminating intervention), the life expectancy of the patient who requests assistance in her/his death must be <6 months.[19]

In light of all these considerations, without implying a moral judgement about the acceptability of euthanasia, this paper defines euthanasia as a physician's intentional action of administering lethal drugs to a dying patient, who explicitly requests the physician's action, due to her/his intolerable suffering from a terminal disease, to end the patient's life.

Like the definition of euthanasia, the conceptual notion of palliative sedation varies from one approach to another.[20] The National Hospice and Palliative Care Organization (NHPCO), which is the largest nonprofit organization to promote end-of-life care in the United States, introduces palliative sedation as a therapy in palliative care to mitigate resistant and unbearable pain and suffering by using medication to lower the patient's consciousness.[2122] The NHPCO declares three preconditions for palliative sedation: the patient must be terminally sick and imminently dying; the pain and suffering must be intolerable; and other palliative interventions must be ineffective to assuage the pain and suffering.[21] Bert Broeckaert defines palliative sedation as “the intentional administration of sedative drugs in dosages and combinations required to reduce the consciousness of a terminal patient as much as necessary to adequately relieve one or more refractory symptoms” (p.34).[15] The primary distinction between the NHPCO's approach and Broeckaert's definition is that even though the former expressly highlights the necessity of imminent death, the latter does not explicitly address such an obligation.

In general, palliative sedation is a component of palliative care. Relieving patients' pain and suffering, improving patients' quality of life, fulfilling a good death, and avoiding the demand for euthanasia are the four goals of palliative care.[23] Palliative sedation denotes the aggressive aspect of palliative care when dealing with intractable and intolerable suffering. From this perspective, some describe palliative sedation as the following: “a medical treatment,” “a treatment,” “a therapy,” or “a useful therapeutic procedure.”[20212425] Nevertheless, some others regard it as “slow euthanasia” due to certain similarities between palliative sedation and euthanasia, such as administering particular medications, as well as its possible effect on hastening death.[2627]

Relieving patients' pain and suffering has always been the fundamental goal of medicine. However, traditional palliative methods have become impotent in responding adequately to the suffering of aging populations with long-term chronic diseases.[27] This situation has prompted suffering patients/people to consider morally and religiously questionable solutions, such as euthanasia, in order to relieve their intolerable suffering. As Henk ten Have underlines, euthanasia arose as “an ultimate protest against medical power” which gives the opportunity for “biological existence” without providing the quality of life (p.507).[14] In this context, like the relationship between medical power and euthanasia, palliative sedation has a cause-and-effect relationship with euthanasia. In other words, palliative sedation, which was initially named terminal sedation and then controlled sedation in its short historical journey, is actually a protest against euthanasia and an alternative to euthanasia that seeks to alleviate patients' refractory symptoms-based intolerable suffering.[2528]

A study conducted by Maltoni et al. compared the overall survival of cancer patients who received palliative sedation with the overall survival of cancer patients who did not receive palliative sedation. The study shows that the survival of 90% of the patients who received palliative sedation was 10–14 days, whereas the survival of 90% of the patients who did not receive palliative sedation was 8–10 days. This data illustrates that palliative sedation does not have a life-shortening effect, and the survival of patients who need palliative sedation is not >2 weeks.[29] However, the NHPCO intentionally use the term imminent death, which is delineated as “a prognosis of death within 14 days,” in order to eliminate life-shortening-related concerns (p.916).[21] Furthermore, in describing palliative sedation, aside from the aforementioned points, underscoring the patient's request as well as the proportionality of reducing consciousness would ethically be more appropriate. In this view, this paper defines palliative sedation as intentionally and proportionately lowering an imminently dying patient's consciousness by administering sedative drugs at the patient's explicit request to relieve the patient's intractable and intolerable suffering resulting from a terminal disease.

SUFFERING AND COMPASSION

Alleviating patients' pain and suffering is a moral necessity of human beings as well as an essential duty of health-care professionals. Cassell distinguishes pain from suffering and claims that it is a primary obligation of physicians to assuage the suffering of patients even when it is impossible to mitigate the pain.[30] On the other hand, Thomasma and Kushner separates the term cure from heal and asserts that medicine can merely cure, but not heal.[31] He says that healing, which is associated with a person's suffering, requires compassion, which has the ability even to heal a patient who cannot be cured by medicine. All these statements indicate a conceptual complexity but also a close connection between compassion and pain and suffering.

Even though there is an association between pain and suffering, the two terms are not interchangeable. Suffering may stem from many sources, merely one of which is pain. Moreover, pain does not always cause suffering, or suffering does not always require pain; suffering can exist without pain and pain can exist without leading to suffering.[3032] Pain is largely about the physical body, while suffering is chiefly related to “a person's psychological or spiritual state” (p. 95).[33] Cassell explains suffering “as the state of severe distress associated with events that threaten intactness of (a) person” (p. 32).[30] According to Cassell, suffering may derive from an external source, such as an injury or illness, or it may come from the person's self as an internal distress. He also highlights that although relieving suffering is a crucial duty of health-care professionals, due to only focusing on external sources of suffering (injuries and diseases), rather than also considering internal sources of suffering, such as emotional, psychological, and spiritual distractions, they fail to achieve this duty.[30]

In regard to the relationship between suffering and compassion, Gelhaus stipulates the recognition of suffering as a required element of compassion, whereas Dougherty and Purtilo regard compassion as a necessary part of the patient–physician relationship.[3435] In this context, it is obvious that there is a substantial connection between compassion and suffering. Nevertheless, compassion is a contentious concept that needs to be clarified. The dictionary meaning of compassion is “a strong feeling of sympathy and sadness for the suffering or bad luck of others and a wish to help them.”[36] This definition contains three components: it is a feeling of sympathy; it is about the suffering of others; and it encompasses the wish to help. Andre Comte-Sponville analyzes compassion with a viewpoint similar to the lexical description. He stresses some characteristics of compassion as follows: It carries solely a positive connotation; it is universal because of directly aiming attention at suffering without morally judging the causes of the suffering; and it does not merely value the suffering of human beings, but of all beings, which makes compassion a universal virtue.[37]

Thomasma and Kushner also considers compassion a virtue, which “urges us forward from the feelings, prompting toward explicit activities of care, from kissing the child's cut to providing hospice care for the dying” (p. 416). Even though Thomasma and Kushner accepts the interconnection between compassion and feelings, he says that compassion transcends the existence of certain feelings by turning them into a readiness to help the sufferer.[31] Comte-Sponville reaches a parallel conclusion by evaluating the interaction between compassion and feelings. He articulates that “compassion allows us to pass from one realm to the other, from the emotional realm to the ethical realm, from what we feel to what we want, from what we are to what we must do” (p. 116).[37] In this sense, compassion is not only a feeling that pushes human beings to sympathize with the suffering of others but also an impulse to relieve that suffering.

As a feeling and virtue, compassion exhorts health-care professionals and others not to leave the patient with oppressive suffering. According to some, compassion is also a duty for health-care professionals to heal patients.[3135] However, the central debate is whether compassion can be an objective and morally acceptable ground to terminate a patient's life on the basis of relieving suffering; in other words, whether compassion may justify the killing of a patient. Gandhi gives an affirmative response to such a question. He argues that the idea of compassion legitimizes killing a person under three circumstances: The impossibility of cure, the failure of relieving suffering, and the absence of self-interest motivations. According to Gandhi's approach, it is even a duty to relieve suffering by the act of killing.[23]

CURRENT LEGAL SITUATION IN TURKEY

Turkey is constitutionally secular, but culturally a Sunni Muslim country. In Turkey, statutory regulations have not directly been codified in accordance with religious beliefs. However, the influence of the religion on the legislative structure may be inevitable. In addition, a harmony between the legal system and the society's religious faith could facilitate the social acceptance of legal regulations. For this reason, the case should be evaluated in the scope of this clarification to generate an accurate insight regarding the legal, religious, and social background of this case.

The Turkish Criminal Code (TCC) does not explicitly mention the prohibition of euthanasia. Nevertheless, article 84 criminalizes promoting suicide, encouraging a person to commit suicide, and helping the act of suicide in any manner whatsoever.[38] The last part of the provision, aiding the act of suicide, implicitly refers to euthanasia. Moreover, article 13 of the Regulations on Patient Rights (RPR) expressly forbids euthanasia by remarking that “on the grounds of medical requirements or any other reason, the right to life cannot be foregone. Even if a person or someone else requests it, the life of no one can be terminated.”[39] This means that the RPR considers the right to life an absolute right, in terms of euthanasia.

Palliative care services are in a very nascent stage in Turkey. The palliative care-related services were introduced for the first time in 2015. The relevant regulations do not encompass the phrase palliative sedation or imply anything which can be interpreted as palliative sedation.[40] Nevertheless, article 12 of the RPR says, “without the aim of diagnosis, treatment, or protection, anything which may cause death or risk of death or violate the integrity of the body or reduce mental or physical abilities cannot be done and cannot be requested.”[39] This provision prohibits causing death or risk of death as well as lowering a person's consciousness. However, the law grants certain exceptions: diagnosis, treatment, and protection purposes. The debate on whether palliative sedation is such an exemption depends on how palliative sedation is defined. Describing palliative sedation as a treatment and regarding any bad effect, such as reducing or terminating one's consciousness as the natural, side, or adverse effect of the treatment would legitimize the consequences of palliative sedation, in respect to the Turkish law. On the other hand, if it is not defined as a treatment, the aforementioned provision of the RPR would ban the implementation of palliative sedation because the consciousness lowering or terminating effect of sedation is indisputable.[2041]

RELIGIOUS ASPECT OF EUTHANASIA AND PALLIATIVE SEDATION

It is not surprising to state that the Islamic position on euthanasia is much clearer than its stance on palliative sedation (in this paper, the Islamic view refers to Sunni theology). According to Islam, humans are created by God, and the body is given to the human being as a “trust,” which means that the body is not the property of the human being; he/she is only the trustee of the body and must preserve the well-being and integrity of the body until God takes it back her/his death.[42] Muslims believe that God is the ultimate authority over human life, health, and death, but also they admit that in the case of the presence of any disease, they should utilize existing medical facilities to receive healing provided by God.[43] For this reason, paying attention to the wellness of human life is crucial in order to become a reliable trustee as well as to enable the practice of daily religious observances, such as five daily prayers.[44] In this sense, not merely the sanctity of life but also the quality of life matters in the Sunni theology. Nevertheless, in comparison with the quality of life, the sanctity of life has a higher priority.[42]

The substantive sources of the Sunni tradition (the Qur'an, Sunna, and ijma) do not explicitly indicate a position on euthanasia. Furthermore, unlike the Catholic tradition, the lack of an official authority to declare a religious view on bioethical matters and the shortage in today's academic studies on the Sunni bioethical perspective make it difficult to express a unanimously approved decision regarding the issues about which the scriptural sources do not disclose a certain stance.[4546] Nevertheless, euthanasia a relatively nonsophisticated subject to examine because of the definite viewpoint of Islam concerning the perception of life, death, and the hereafter.

Although not binding every Muslim, the Islamic Code of Medical Ethics, known as the Kuwait Document, may provide an insight into the general approach of Sunni theology on euthanasia. The document likens euthanasia to suicide and states “human life is sacred and should not be willfully taken…;” “a doctor shall not take away life even when motivated by mercy;” “in any case, the doctor shall not take a positive measure to terminate the patient's life;” and “the doctor shall do his best that what remains of the life of an incurable patient will be spent under good care, moral support, and freedom from pain and misery” (p. 64-68).[47] This approach regards life as sacred and refuses any medical intervention directly causing the patient's death. Moreover, the Sunni tradition chiefly focuses on accepting the destiny given by God, in the event of encountering incurable diseases with unbearable pain. According to al-Ghazali, believers must pay attention to three issues, one of which is to consent to the predestination and destiny given by God regardless of whether it is good or bad. In light of this perspective, inevitable medical conditions also come from God, and for the sake of God and His promise of the reward in the hereafter, the human being must endure the existing suffering until God bestows a natural death. In short, Islam supports mitigating the patient's suffering through religiously acceptable medical means and suggests spiritual and emotional care rather than euthanasia in the case of unavoidable pain and suffering.[48]

The Sunni tradition's noticeable emphasis on the hereafter is a substantial factor in the determination of it position on euthanasia. The perception of death is “as a transition to life after death, the suffering of this world is a reminder of the freedom from suffering in the world to come,” and euthanasia, which is considered “suicide would eliminate the reward for a lifetime of good deeds”(p. 176),[49] Therefore, according to the traditionalist Islamic view, the way individuals live or observe religious requirements is important, but the end-of-life is considerably more important. Even in the last seconds of life, any serious violation against religious commands, such as euthanasia, may erase all the good deeds the person has done throughout her/his lifetime.

In this view, it may be difficult to interpret the Islamic stance as being in favor of palliative sedation as well. All life-shortening medical interventions are outlawed by Islam. However, this point is not an issue because there is no reliable evidence that sedation hastens death. Nevertheless, intentionally lowering or ending a patient's consciousness, regardless of the patient's expected lifespan, is a serious concern. The Kuwait document accentuates the importance of relieving a patient's pain but does not explain whether there is a limitation on keeping the patient free from pain.[47] Furthermore, the Islamic perspective-reflecting literature in English does not provide sufficient evidence to declare a particular position on palliative sedation.[44]

According to al-Ghazali, protecting individuals' religion, life, reason, lineage, and property are five essential objectives of Islam. In accordance with al-Ghazali's view, reason refers to consciousness, and the prohibition of consuming alcohol or using intoxicating substances result from the significance of preserving consciousness.[50] Therefore, in general, reducing consciousness is not a permissible procedure. In regard to irreversibly ending consciousness at the end-of-life of a person, two fundamental challenges may emerge: eliminating the opportunity to worship as well as the chance to repent of her/his sins. Muslims are obliged to observe their religious practices until the time of death, as much as possible.[51] Inducing unconsciousness would prevent doing that. In addition, repentance is a crucial notion in Islam, and human beings have the opportunity to ask for forgiveness for all their wrongdoings until dying. According to the Hadith, “Allah (God) accepts the repentance of His (servant) so long as the death rattle has not yet reached his throat.”[52] In this context, intervening in a person's consciousness would deprive the patient of this possibility as well. However, it is important to note that temporarily lowering a patient's consciousness for curative reasons should be distinguished from permanently lowering or terminating consciousness in the scope of palliative sedation.

WHAT DOES THE CASE INDICATE?

The news in Turkish newspapers indicated that the patient's father killed his son at the patient's request and as the result of his love and compassion toward his son who was suffering from metastatic colorectal cancer.[1] Rather than providing a peaceful death, such as injecting a fatal medication, killing the patient by gunshot may be deemed a cruel way of terminating the patient's life. This method of killing denotes a serious ethical problem per se because fulfilling a good death or a peaceful death is the fundamental goal of palliative care as well as euthanasia, PAS, and palliative sedation.[2353] In other words, regardless of accepting or rejecting life-ending interventions, achieving a painless death, as much as possible, is a vital aim. However, the case clearly illustrates that the patient was slowly dying and intolerably suffering. Ignoring, overlooking, or bearing this scene of misery could be very difficult, especially for the father who was with his son throughout the process of the disease.

Gandhi says, “my idea of compassion makes this thing (allowing rabid dogs to die a slow death) impossible for me. I cannot for a moment bear to see a dog, or for that matter, any other living being, helplessly suffering the torture of a slow death” (p. 21-22).[2] According to Gandhi, a slow and painful death is a kind of torture and not taking action to relieve the pain is not congruent with compassion; if killing is the last resort to assuage the pain, it should be done. In this view, the father's action may be morally acceptable. Nevertheless, Gandhi stipulates three conditions in order to justify killing: the disease must be incurable, there must be no other way to relieve the suffering, and there must be no self-interest motivations behind the killing.[23] The patient's disease was incurable, hence the first requirement is satisfied, whereas the availability of the other two conditions is questionable.

Kelly also underlines the importance of pain management opportunities in the event of demanding euthanasia or PAS. Kelly denies the request for euthanasia or PAS under the availability of adequate pain management. Nevertheless, in the case of the lack of pain management facilities, he does not count the demand for these two life-terminating interferences as morally wrong.[9] In the assessment of both Gandhi and Kelly, the possibility of sufficient palliative care plays a pivotal role in appraising the morality of requesting death and honoring this demand by killing. In Turkey, palliative care-related regulations were introduced for the first time in 2015, and by this initiative, hospitals started establishing professional palliative care units.[40] Before 2015, the pertinent services were mostly provided under general medicine. In this context, the patient's treatment process coincided with instituting these new units. The case does not give adequate information as to whether the patient was offered sufficient and appropriate palliative care. However, the case shows that the patient experienced many unsuccessful curative attempts, which further increased the patient's suffering more and more.

The presence or absence of self-interest motivations is another key criterion to evaluate the moral status of the killing. According to the news in the Turkish daily newspaper Hurriyet on June 15, 2016, the court punished the father with imprisonment for 15 years. In his testimony, the father stated that on the day the incident occurred, he took his son to the hospital because of his intolerable pain, and after some pain-relieving treatment, they went back home. Upon returning back home, the patient again started vomiting with severe pain. Under unbearable pain, the patient screamed at his father and said, “what a fucking father you are, God damn you, either heal me or kill me!” The father said he could not endure his son's desperately suffering condition anymore and grabbed his gun and killed his son without telling him anything.[54] From this perspective, the case appears to indicate a murder. It may be difficult to be convinced that the patient mentioned and consented to such a killing. Moreover, it is doubtful that there was no self-interest in the father's motivation to kill the patient. The case demonstrates that the father was also suffering excessively; killing the patient did not merely end the patient's continuous suffering but also the father's suffering. This situation may to some extent indicate the existence of self-interest motivations.

Nevertheless, the self-interest-related suspicions chiefly stem from the second criterion, which requires adequate and appropriate palliative care. As Henk ten Have explains, palliative care aims to improve the patients' quality of life, implement effective pain management, facilitate a good death, and eliminate or at least reduce the demand for life-terminating interventions.[23] In addition, these services are not only supplied to patients but also their families. In many cases, the need of families for palliative care can be as imperative as for the patients. The present case proves that the lack of palliative care to the patient as well as his family caused a tragedy. For this reason, contrary to the lawyer's allegation that if euthanasia was legalized, this tragedy would not have occurred, the case explicitly reveals the urgency for well-organized, specialized, and professional palliative care rather than euthanasia.

Furthermore, as pinpointed in the previous sections, there are certain moral, legal, and religious concerns and difficulties when requesting euthanasia. In terms of the moral aspect, it should be remarked that relieving pain and suffering is a traditional and indispensable goal of medicine.[32] However, current medicine is impotent to completely alleviate all forms of pain and suffering. Some may accept the termination of a patient's life as a goal of medicine in light of the patient's autonomy, the intention of relieving uncontrollable suffering, and the idea of compassion.[14] However, some others argue that “death is itself not a good outcome,” and ending a patient's life means to perform a positive action to create an evil and harm that cannot be morally justified by the idea of relieving suffering (p. 153).[53] Medical ethics prevent health-care professionals from causing unnecessary harm. In addition, because of its subjectivity, compassion is an unreliable source to create a concrete moral foundation to justify terminating a life on the basis of relieving suffering. Moreover, compassion requests helping the sufferer, but killing is the destruction of human dignity and integrity, not help.

In regard to the legal viewpoint, the TCC implicitly and the RPR explicitly ban euthanasia. It is possible to modify statutory regulations and legalize or decriminalize euthanasia and similar interventions. Nevertheless, aside from moral hesitancies, the religious stance on these issues is a substantial barrier to radical changes. Under no circumstances does Islam allow medical intervention-based killing or hastening of death. Of course, “Islam does not exalt suffering,” but if suffering is incurable and inevitable, it urges the person to accept her/his destiny, which is given by God (p. 268).[4855] Moreover, pain and suffering in the world is viewed as redemption for the person's sins. In addition, Islam describes the human being as the combination of body and soul; the body represents the physical entity that is going to die, whereas the soul denotes the spiritual part of the human that is going to move to another realm.[55] The pain and suffering the patient faces are largely the pain and suffering of the physical body, but the pain and suffering at the time of dying are only pertinent to the soul. Al-Ghazali says that the suffering of dying is felt only by the soul; the physical body may not be able to reflect any reaction because the pain is so unbearable that the person gets tongue-tied.[56] This means that even if the body-related pain or suffering is eliminated by administering lethal drugs, the soul-related pain would not be alleviated by these medical interventions. The cure of the soul comes from the person's good deeds in the world.

To relieve intractable and intolerable pain and suffering, palliative sedation may be considered an alternative to euthanasia. In palliative sedation, the intention is to lower the patient's consciousness instead of fulfilling an imminent death. Furthermore, although in the past, there were some doubts about whether or not sedation hastens death, the studies have shown that palliative sedation does not have a life shortening effect.[202529] Moreover, the statistics of euthanasia and palliative sedation in the Netherlands exhibit that the demand for euthanasia has declined, while the demand for palliative sedation has risen. These findings are usually interpreted as evidence that palliative sedation can be an alternative to euthanasia.[27]

The availability of palliative sedation has the potential to decrease the request for euthanasia to some extent. However, this by itself does not prove that palliative sedation is an alternative to euthanasia. The opportunity to acquire sedation while actively dying may relieve patients' fears and anxieties; hence they could discontinue looking for euthanasia. Nevertheless, this situation cannot eliminate the demand for euthanasia. Palliative sedation is applied to patients who have a life expectancy of <2 weeks, whereas euthanasia can be requested during a longer life expectancy. For example, a patient who suffers from a terminal disease and has a 5-month life expectancy can demand euthanasia but cannot request palliative sedation. The difference in their coverage periods precludes these two interventions from becoming the alternative of each other. In short, palliative sedation can reduce the need for euthanasia but cannot replace euthanasia.

The present case does not provide any information about the patient's expected lifespan. For this reason, it is not possible to assume that the patient was eligible for palliative sedation. The religious approach is another obstacle when regarding palliative sedation as a possible option to relieve the patient's suffering. Protecting a person's consciousness is a central value in Islam.[50] Even though relieving unbearable pain and suffering is a valuable alibi, intentionally and irreversibly ending one's consciousness may lead to religious criticisms. The shortage of academic studies on this specific issue makes it difficult to reach an absolute conclusion, but it is doubtless that lowering or terminating a patient's consciousness is the critical element in the Islamic assessment of palliative sedation.

CONCLUSION

The case presents a tragic incident that occurred in Turkey. According to the lawyer defending the father, the criminalization of euthanasia caused this unfortunate consequence. Relieving intractable and intolerable suffering at the end-of-life is a primary argument to support euthanasia. Nevertheless, besides the legal hurdles, many ethical concerns and religious barriers preclude justifying euthanasia for this case. Palliative sedation may be considered a resolution to alleviate the patient's suffering. However, the limitation of palliative sedation to an expected lifespan of <2 weeks as well as the Islamic view on the importance of protecting consciousness makes it difficult to acknowledge palliative sedation as an alternative to euthanasia in this particular case. Nevertheless, the case indicates that not only the patient but also the patient's father was suffering desperately from the patient's long-term, fruitless, and aggressive treatment process. It is believed that the best option for the patient and the family was palliative care. If adequate and appropriate palliative care services were provided to the patient and family, the patient would have experienced a higher quality of life, a less painful end-of-life and a more peaceful death. In addition, these services would have helped the family in dealing with emotional, psychological, and spiritual difficulties during that hard time.