Continuous sedation until death is an increasingly common practice in end-of-life care. However, it raises numerous medical, ethical, emotional and legal concerns, such as the reducing or removing of consciousness, the withholding of artificial nutrition and hydration, the proportionality of the sedation to the symptoms, its adequacy in actually relieving symptoms rather than simply giving onlookers the impression that the patient is undergoing a painless 'natural' death, and the perception that it may be functionally equivalent to euthanasia. This book brings (...) together contributions from clinicians, ethicists, lawyers and social scientists, and discusses guidelines as well as clinical, emotional and legal aspects of the practice. The chapters shine a critical spotlight on areas of concern and on the validity of the justifications given for the practice, including in particular the doctrine of double effect. (shrink)

Continuous sedation until death (CSD), the act of reducing or removing the consciousness of an incurably ill patient until death, often provokes medical-ethical discussions in the opinion sections of medical and nursing journals. A content analysis of opinion pieces in medical and nursing literature was conducted to examine how clinicians define and describe CSD, and how they justify this practice morally. Most publications were written by physicians and published in palliative or general medicine journals. Terminal Sedation and Palliative Sedation are (...) the most frequently used terms to describe CSD. Seventeen definitions with varying content were identified. CSD was found to be morally justified in 73 % of the publications using justifications such as Last Resort, Doctrine of Double Effect, Sanctity of Life, Autonomy, and Proportionality. The debate over CSD in the opinion sections of medical and nursing journals lacks uniform terms and definitions, and is profoundly marked by ‘charged language’, aiming at realizing agreement in attitude towards CSD. Not all of the moral justifications found are equally straightforward. To enable a more effective debate, the terms, definitions and justifications for CSD need to be further clarified. (shrink)

After a review of terminology, I identify—in addition to Margaret Battin’s list of five primary arguments for and against aid-in-dying—the argument from functional equivalence as another primary argument. I introduce a novel way to approach this argument based on Bernard Lonergan’s generalized empirical method. Then I proceed on the basis of GEM to distinguish palliative sedation, palliative sedation to unconsciousness when prognosis is less than two weeks, and foregoing life-sustaining treatment from aid-in-dying. I conclude that aid-in-dying must be justified on (...) its own merits and not on the basis of these well-established palliative care practices; and that societies must decide, in weighing the merits of aid-in-dying, whether or not to make the judgment that no life is better than life-like-this part of their operative value structure. (shrink)

In this book, James Dunson explores end-of-life ethics including physician-assisted suicide and continuous sedation. He argues that ethical debates currently ignore the experience of the dying patient in an effort to focus on policy creation, and proposes that the dying experience should instead be prioritized and used to inform policy development.

The book's main contribution is its interdisciplinary approach to the issue of sedation at the end-of-life. Because it occurs at the end of life, palliative sedation raises a number of important ethical and legal questions, including whether it is a covert form of euthanasia and for what purposes it may legally be used. Many of the book chapters address the first question and almost all deal with a specific form of the second: whether palliative sedation should be used for those (...) experiencing "existential suffering"? This raises the question of what existential suffering is, a topic that is also discussed in the book. The different chapters address these issues from the perspectives of the relevant disciplines: Palliative Medicine, Bioethics, Law and Theology. Hence, helpful accounts of the clinical and historical background for this issue are provided and the importance of drawing accurate ethical and legal distinctions is stressed throughout the whole book. So the volume represents a valuable contribution to the emerging literature on this topic and should be helpful across a broad spectrum of readers: philosophers, theologians and physicians. (shrink)

“Terminal sedation” refers to the use of sedation as palliation in dying patients with a terminal diagnosis. Although terminal sedation has received widespread legal and ethical justification, the practice remains ethically contentious, particularly as some hold that it foreseeably hastens death. It has been proposed that empirical studies show that terminal sedation does not hasten death, or that even if it may hasten death it does not do so in a foreseeable way. Nonetheless, it is clear that providing terminal sedation (...) in combination with the withholding or withdrawing of life-prolonging treatments such as fluid and nutrition can foreseeably hasten death significantly—what is here called early terminal sedation . There are ethical justifications for the use of sedation in palliative care and thus it would seem that ETS is an ethically and legally acceptable practice. However, what emerges from the literature is the repeated assertion that terminal sedation must be restricted to use in imminently dying patients—the “imminence condition”—and that therefore ETS is unacceptable. This restriction has taken on greater significance with the trend of palliative care to include the care of patients who are not imminently dying. This paper proposes to show that although there is widespread intuitive support for the imminence condition, it does not follow from the justifications for sedation as palliation, and that explicit arguments for the imminence condition are needed. (shrink)

Slow euthanasia or a good palliative intervention?There are many ways in which doctors influence the circumstances and/or the timing of a patient’s death. Some of these are accepted as normal medical practice—for instance, when a disproportional treatment is forgone, others are considered tolerable only under strict conditions or even intolerable, such as non-voluntary active euthanasia. A relatively new phenomenon in the ethical discussion on end-of-life decisions is terminal sedation. Terminal sedation is used in patients with terminal illnesses where normal medical (...) treatments cannot relieve severe symptoms such as pain and agitation, and no option is left but to take away the perception of these symptoms. Often, the decision to start terminal sedation is accompanied by the decision to forgo the provision of artificial nutrition and hydration in these patients. In The Netherlands, terminal sedation was estimated to be applied in 4–10% of all deaths in 2001.1 The combination of these two decisions have made the moral status of terminal sedation the subject of fierce ethical debates. Is it slow euthanasia2,3 or is it a good palliative intervention that should be sharply distinguished from euthanasia?4,5 One of the characteristics of this debate is that it is a very confused one: people disagree about the meaning of the term, the appropriateness of it and, of course, about the conditions under which it would be morally justified. As a matter of fact, these three discussions are deeply connected: as is often the case, a discussion about terms is a discussion about norms in disguise.The first observation to be made is that many seemingly descriptive definitions of terminal sedation contain normative claims. Examples of this are definitions of terminal sedation in which only …. (shrink)

A distinction is commonly drawn between continuous sedation until death and physician-assisted suicide/euthanasia. Only the latter is found to involve killing, whereas the former eludes such characterization. I argue that continuous sedation until death is equivalent to physician-assisted suicide/euthanasia in that both involve killing. This is established by first defining and clarifying palliative sedation therapies in general and continuous sedation until death in particular. A case study analysis and a look at current practices are provided. This is followed by a (...) defense of arguments in favor of definitions of death centering on higher brain (neocortical) functioning rather than on whole brain or cardiopulmonary functioning. It is then shown that continuous sedation until death simulates higher brain definitions of death by eliminating consciousness. Appeals to reversibility and double effect fail to establish any distinguishing characteristics between the simulation of death that occurs in continuous sedation until death and the death that occurs as a result of physician-assisted suicide/euthanasia. Concluding remarks clarify the moral ramifications of these findings. (shrink)

The main premise of the Royal Dutch Medical Association's (RDMA) guideline on palliative sedation is that palliative sedation, contrary to euthanasia, is normal medical practice. Although we do not deny the ethical distinctions between euthanasia and palliative sedation, we will critically analyse the guideline's argumentation strategy with which euthanasia is demarcated from palliative sedation. First, we will analyse the guideline's main premise, which entails that palliative sedation is normal medical treatment. After this, we will critically discuss three crucial propositions of (...) the guideline that are used to support this premise: (1) the patient's life expectancy should not exceed 2 weeks; (2) the aim of the physician should be to relieve suffering and (3) expert consultation is optional. We will conclude that, if inherent problematic aspects of palliative sedation are taken seriously, palliative sedation is less normal than it is now depicted in the guideline. (shrink)

Practitioners of palliative medicine frequently encounter patients suffering distress caused by uncontrolled pain or other symptoms. To relieve such distress, palliative medicine clinicians often use measures that result in sedation of the patient. Often such sedation is experienced as a loss by patients and their family members, but sometimes such sedation is sought as the desired outcome. Peace is wanted. Comfort is needed. Sedation appears to bring both. Yet to be sedated is to be cut off existentially from human experience, (...) to be made incapable of engaging self-consciously in any human action. To that extent, it seems that to lose consciousness is to lose something of real value. In this paper, I describe how sedation and the question of intentionally bringing about sedation arise in the care of patients with advanced illness, and I propose heuristics to guide physicians, including Christian physicians, who seek to relieve suffering without contradicting their profession to heal. (shrink)

In a substantial number of cases, dying patients are brought into a state of lowered consciousness and kept in it until they die in order to prevent or stop severe suffering. Many guidelines and position statements have been published in recent years on sedation until death, as I will call this policy. Some have been published by professional organisations and are meant to be binding for their members, others are the work of task forces and merely aim at providing medical, (...) moral, and legal guidance.1 These guidelines all take the following positions: the patient’s consciousness should not be lowered more than is necessary for preventing her from suffering; it must be impossible to alleviate the suffering in any... (shrink)

This special issue of Theoretical Medicine and Bioethics takes up the question of palliative sedation as a source of potential concern or controversy among Christian clinicians and thinkers. Christianity affirms a duty to relieve unnecessary suffering yet also proscribes euthanasia. Accordingly, the question arises as to whether it is ever morally permissible to render dying patients unconscious in order to relieve their suffering. If so, under what conditions? Is this practice genuinely morally distinguishable from euthanasia? Can one ever aim directly (...) at making a dying person unconscious, or is it only permissible to tolerate unconsciousness as an unintended side effect of treating specific symptoms? What role does the rule of double effect play in making such decisions? Does spiritual or psychological suffering ever justify sedation to unconsciousness? What are the theological and spiritual aspects of such care? This introduction describes how the authors in this special issue wrestle with such questions and shows how each essay relates to the author’s individual position on palliative sedation, as developed in greater detail within his contribution. (shrink)

This paper is concerned with the moral justification for palliative sedation until death. Palliative sedation involves the intentional lowering of consciousness for the relief of untreatable symptoms. The paper focuses on the moral problems surrounding the intentional lowering of consciousness until death itself, rather than possible adjacent life-shortening effects. Starting from a Kantian perspective on virtue, it is shown that continuous deep sedation until death (CDS) does not conflict with the perfect duty of moral self-preservation because CDS does not destroy (...) capacities for agency. In addition, it is argued that CDS can frustrate the imperfect duty of self-cultivation by reducing consciousness permanently. Nevertheless, there are cases where CDS is morally acceptable, namely, cases where the agent has already permanently lost the possibility for free action in advance of sedation—for example, due to excruciating and ongoing pain. Because the latter can be difficult to diagnose properly, safeguards may be needed in order to prevent the application of CDS for the wrong reasons. (shrink)

Not everyone finds a in suffering. Indeed, even those who do subscribe to this interpretation recognize the responsibility of each individual to show not only sensitivity and compassion but render assistance to those in distress. Pharmacologic hypnosis, morphine intoxication, and terminal sedation provide their own type of medical to the terminally ill patient suffering unremitting pain. More and more states are enacting legislation that recognizes this need of the dying to receive relief through regulated administration of controlled substances. Wider legislative (...) recognition of this need would go far toward allowing physicians, in the exercise of their reasonable medical judgment, to administer a range of narcotics and barbiturates to the terminally ill without fear of legal sanctions. Sadly, social attitudes and governmental concerns about the spread of drug addiction provide an undeniable policy nexus that impedes unduly a rational approach or exception for the treatment of pain experienced by the dying. (shrink)

This article discusses the place of sedation in the care of the terminally ill, as used in the practice of palliative care using case studies, clinical pragmatism forms the theoretical framework from which to elucidate the varying part that sedation plays in the overall management of a person facing the end of life. We contend that when used appropriately, sedation is an ethical and legitimate intervention that enhances comfort at the end of life and ought not sedate the person onto (...) “oblivion”. (shrink)

ABSTRACTThere has been much discussion regarding the acceptable use of sedation for palliation. A particularly contentious practice concerns deep, continuous sedation given to patients who are not imminently dying and given without provision of hydration or nutrition, with the end result that death is hastened. This has been called ‘early terminal sedation’. Early terminal sedation is a practice composed of two legally and ethically accepted treatment options. Under certain conditions, patients have the right to reject hydration and nutrition, even if (...) these are life‐sustaining. Patients are also entitled to sedation as palliation for intolerable, intractable suffering. Though early terminal sedation is thought to be rare at present, the changing nature of palliative medicine suggests its use will increase.Arguments regarding early terminal sedation have failed to recognize early terminal sedation as a distinct legal and ethical entity. It can be seen as both the simple sum of treatment refusal and sedation for palliation, analogous to terminal sedation. It can also be seen as an indivisible palliative treatment, more analogous to assisted suicide or euthanasia. But ultimately, it is wholly analogous neither to terminal sedation given when death is imminent, nor to assisted suicide or euthanasia. This paper contends that early terminal sedation should be considered as a distinct entity. Such a reconception promises to provide a way forward in the debate, practice and policy regarding this contentious area of palliative medicine. (shrink)

Continuous sedation is increasingly used as a way to relieve symptoms at the end of life. Current research indicates that some physicians, nurses, and relatives involved in this practice experience emotional and/or moral distress. This study aims to provide insight into what may influence how professional and/or family carers cope with such distress.

This article focuses on the ethical aspects of medically-induced sedation and pain relief in intensive care medicine. The study results reported are part of a larger investigation of patients’ experiences of being sedated and receiving pain relief, and also families’ experiences of having a close relative under controlled sedation in an intensive care unit. The study is based on qualitative in-depth interviews with nine nurses and six doctors working in intensive care and surgical units in a major Norwegian hospital. The (...) textual data are interpreted according to Kvale’s method for analyzing qualitative data. There are ethical problems regarding how to achieve an acceptable balance between a patient’s subjective well-being and the medical need for reduced sedation. The authors discuss whether some medical reasons for reduced sedation are ethically justifiable, given the actual medical knowledge available. The study also addresses the ethical consequences of reducing medically-induced sedation and the demands it puts on interdisciplinary co-operation and communication, as well as the importance of improving the quality of medical and nursing care. (shrink)

A patient with end-stage motor neurone disease was admitted for hospice care with worsening bulbar symptoms. Although he initially walked onto the ward he became very distressed and asked for sedation. After much discussion, this man was deeply sedated, and after some harrowing days, died. Was it right to provide terminal sedation? What should the threshold be for such treatment? How should our personal reservations affect how we approach the distressed patient in an end-of-life situation?

Continuous deep sedation at the end of life is a practice that has been the topic of considerable ethical debate, for example surrounding its perceived similarity or dissimilarity with physician-assisted dying...

William L. Rowe poses a dilemma between God’s freedom and essential moral goodness by arguing that God cannot satisfy the arguably accepted condition for libertarian freedom, namely, ability to do otherwise. Accordingly, if God does a morally good action A freely, then there is at least a possible world in which God refrains from doing A and thereby does the morally wrong action. And if God does a morally wrong action in one of the possible worlds, he ceases to be (...) essentially morally perfect. I will argue that Rowe’s conclusion is based on a specific possible world semantics, and we might avoid Rowe’s conclusion with an alternative understanding of modality. In doing so, I will examine the conception of modality proposed by al-Ghaza ̄l ̄ı in which the possibility of a state of affairs does not entail its actuality in at least one possible world. (shrink)

The relatively new practice of continuous sedation at the end of life (CS) is increasingly being debated in the clinical and ethical literature. This practice received much attention when a U.S. Supreme Court ruling noted that the availability of CS made legalization of physician-assisted suicide (PAS) unnecessary, as CS could alleviate even the most severe suffering. This view has been widely adopted. In this article, we perform an in-depth analysis of four versions of this ?argument of preferable alternative.? Our goal (...) is to determine the extent to which CS can be considered to be an alternative to PAS and to identify the grounds, if any, on which CS may be ethically preferable to PAS. (shrink)

The American Journal of Bioethics, Volume 11, Issue 6, Page 41-42, June 2011.

The American Journal of Bioethics, Volume 11, Issue 6, Page 62-64, June 2011.

Terminale Sedierung ist unter bestimmten Umständen ethisch rechtfertigbar: Mit dem Wissen um die Begrenztheit des eigenen Lebens ist auch der Sterbeprozess ein bewusst zu gestaltender, dem eigenen Willen unterworfener Bestandteil des Lebens. Das schließt auch die (paradoxe) Möglichkeit ein, bewusst auf das Bewusstsein beim eigenen Sterben zu verzichten. Anhand eigener Studien kann der Autor zeigen, dass sich der Wunsch nach Sterbehilfe bei terminal kranken Menschen als die Folge einer konsequenten Einordnung in das System der Medizin deuten lässt. Infolgedessen begreifen Patienten (...) auch das Sterben als eine Aufgabe des Medizinsystems, so dass sie ärztliche Sterbehilfe als Ausdruck für ein menschenwürdiges Sterben, paradoxerweise sogar als natürlichen Tod auffassen können. In dieser Situation ermöglicht die terminale Sedierung einen Fortschritt: Das Medizinsystem kann der von ihm erwarteten Zuständigkeit für den Prozess des Sterbens nachkommen, ohne direkt und intentional zu töten. Trotzdem bleiben bezüglich der Missbrauchsmöglichkeiten, der Rollenkonfusion der Ärzte und der Grenzen menschlicher Handlungsräume Zweifel. Vor der „Illusion der glatten Lösungen“ (H. Thielicke) wird gewarnt und für den Versuch geworben, das jeweils Beste für die einzelnen Betroffenen zu erreichen. (shrink)

Surveys in different countries (e.g. the UK, Belgium and The Netherlands) show a marked recent increase in the incidence of continuous deep sedation at the end of life (CDS). Several hypotheses can be formulated to explain the increasing performance of this practice. In this paper we focus on what we call the ‘natural death’ hypothesis, i.e. the hypothesis that acceptance of CDS has spread rapidly because death after CDS can be perceived as a ‘natural’ death by medical practitioners, patients' relatives (...) and patients.We attempt to show that the label ‘natural’ cannot be unproblematically applied to the nature of this end-of-life practice. We argue that the labeling of death following CDS as ‘natural’ death is related to a complex set of mechanisms which facilitate the use of this practice. However, our criticism does not preclude the view that CDS may be clinically and ethically justified in many cases. (shrink)

İdrak ve niteliği felsefenin en önemli problemlerinden biridir. İbn Sînâ hissî, hayalî, vehmî ve aklî olmak üzere dört farklı idrak mertebesi dillendirir. Buna göre insan nefsi nesnelerin suretlerini duyu yetileriyle algılar. Daha sonra bu suretleri hayal yetisine teslim eder. Akabinde akıl bu sureti barındırdığı maddî eklentilerden arındırarak aklî suretlerin oluşumu için gerekli zeminleri hazırlar. Daha sonra faal akıl insan nefsine aklî suretleri verir. İnsan zihninde duyularla algılanan bu kavramlardan başka kavramlar da vardır. Bu küllî kavramların yeri nesnel âlem değil öznel (...) âlemdir. İslam felsefesi geleneğinde Fârâbî ilk defa bu ayırımı yapar ve ma‘kūlleri birinci ve ikinci ma‘kūller diye iki kısma ayırır. İbn Sînâ da bu sınıflandırmayı benimser ve konu hakkında yeni açıklamalar getirir. İbn Sînâ, ikinci ma‘kūllerin sonraki dönemlerde yapılan felsefî ve mantıkî ayırımını her ne kadar dillendirmese de eserlerinden bu iki ma‘kūl türünün farklılığına teveccüh eder. Bu çalışmada İbn Sînâ felsefesinde idrak olgusunun gerçekleşme niteliği ele alınacak ve daha sonraki dönemlerde dillendirilen ikinci felsefî ma‘kūl anlamların İbn Sînâ felsefesindeki yeri açıklanacaktır. (shrink)

ZusammenfassungWährend die terminale Sedierung neueren niederländischen Erhebungen zufolge bereits in mehr als 5% aller Sterbefälle zur Leidensminderung am Lebensende angewandt wird, sind viele der durch dieses Verfahren aufgeworfenen begrifflichen und ethischen Fragen weiterhin offen. Kontrovers ist insbesondere die begriffliche Einordnung der Kombination von terminaler Sedierung und Behandlungsabbruch sowie die Frage nach den dafür einschlägigen ethischen Kriterien. Ausgehend von einer Analyse von drei Szenarien mit unterschiedlicher kausaler Rollenverteilung argumentiere ich dafür, den Standardfall der Kombination von terminaler Sedierung und Behandlungsabbruch unter die (...) Kategorie der „passiven Sterbehilfe“ zu subsumieren und für sie dieselben ethischen Kriterien wie für den Behandlungsabbruch allein gelten zu lassen. Eine tentative vergleichende Bewertung ergibt, dass die terminale Sedierung als ultima ratio der Leidensminderung am Lebensende gegenüber der Alternative des assistierten Suizids insgesamt als ethisch vorzugswürdig gelten sollte, ohne jedoch die Alternative des assistierten Suizids als in toto unzulässig erscheinen zu lassen. (shrink)