When Comfort Hastens Death: Rethinking the Line Between Palliative Care and Euthanasia for Dying Children

A child is dying. She is in pain that the team cannot relieve at doses of opioid low enough to let her keep breathing comfortably. Her parents have agreed, with us, that the goal of care is now her comfort. We give her the medication she needs. She is calm. Her breathing slows. She dies sooner than she would have without it.

What was that? Palliative care? Euthanasia? Something in between?

For most of my career as a pediatrician and bioethicist, the official answer has been clear: palliative care and euthanasia are categorically different. Palliative care relieves suffering; euthanasia ends life. The leading professional bodies — the International Association for Hospice and Palliative Care, the International Children's Palliative Care Network — have insisted that the two should never be considered alternatives, and that good palliative care cannot include hastening death.

In a Viewpoint published this week in The Lancet Child & Adolescent Health, Chantal Joren, Eduard Verhagen, and I argue that this framing, however well-intentioned, gets in the way of clear thinking — and sometimes in the way of good care.

The conceptual machinery is straining

The conventional account leans heavily on the doctrine of double effect: a treatment that foreseeably hastens death can still be ethical, as long as the intent is to relieve suffering rather than to cause death. The other workhorse is proportionality: when the burdens of life-prolonging treatment outweigh the benefits, it is permissible to withdraw it, even if death follows.

These ideas work well most of the time. But they strain at the edges. Consider a comatose child who is not actively dying but is sustained by medications and artificial nutrition. The team and the parents agree to withdraw those interventions and to provide sedation to ensure she does not suffer. Is death caused by her underlying disease, or by what we have done? The honest answer, in many such cases, is: both.

When clinicians give analgesics or sedatives in doses high enough to predictably suppress breathing — and continue to do so — and call the result palliative care, we are sometimes sustaining a comforting fiction. The medications relieve suffering. They also hasten death. The intent is often genuinely mixed, even within the same clinician at the same bedside.

Naming matters

We do not argue that euthanasia should be legal for all children everywhere. Different societies should reach different conclusions, weighing autonomy, best interests, and concerns about protecting vulnerable patients. Some jurisdictions — Belgium, the Netherlands, Colombia — permit pediatric euthanasia under strict conditions. Most do not. These divergent policies reflect different judgments about how to balance the same competing values.

We do argue that paediatric palliative care and paediatric euthanasia are not moral opposites. They are points on a continuum of compassionate responses to suffering at the end of life. Withholding treatment, palliative sedation, and active euthanasia differ in important ways — in intention, in the clinician's role, in the legal status they have in different jurisdictions. But they share an underlying ethical commitment: that some forms of suffering should not be left unaddressed, and that a proportionate response to such suffering is part of what good care for dying children looks like.

When we pretend otherwise — when we administer high doses of sedatives with the half-acknowledged intention of hastening death and call it palliation — we don't preserve the ethical clarity of palliative care. We erode it. The double standard inhibits meaningful conversation, limits oversight, and leaves clinicians and families to navigate the hardest decisions of their lives in a fog of euphemism.

The objections, briefly

The slippery-slope worry — that recognizing euthanasia as ethically continuous with palliative care will normalize life-ending acts — is empirically testable, and the data so far do not bear it out. In the Netherlands, where neonatal euthanasia has been legal under strict conditions for two decades, there have been three reported cases. Three.

The professional-identity worry — that intentional life-ending is incompatible with the physician's role — is harder to address because it is partly about how we understand ourselves. But clinicians already participate in decisions that foreseeably hasten death every day. The question is not whether we are sometimes implicated in a patient's death. We are. The question is under what conditions our involvement is ethically justified, and whether we have the language and the institutional support to think honestly about it.

What I want clinicians to take from this

I have spent decades thinking about pediatric end-of-life decisions. A few things have become clearer with time. One, families do not want philosophical discourse; they want to take care of their child. Two, clinicians at the bedside often understand the continuum intuitively, even when our official frameworks deny it. Three, transparency about what we are doing — and why — is the foundation of trust, oversight, ethical reflection, and the ability to collectively learn from experience.

The disagreement among countries about pediatric euthanasia is real, serious, and not going to be resolved by any single paper. But the disagreement is about means, not ends. Everyone believes that dying children should have access to excellent palliative care. Nobody thinks a child should suffer when suffering can be relieved. If we can hold onto that common ground — and stop pretending that very similar acts are categorically different because we use different words for them — we will be in a better position to do right by the children we cannot save.

The Viewpoint is available at The Lancet Child & Adolescent Health: https://www.thelancet.com/journals/lanchi/article/PIIS2352-4642(26)00070-2/abstract.