Despite advances in palliative care, some patients still suffer significantly at the end of life. Terminal Sedation (TS) refers to the use of sedatives in dying patients until the point of death. The following limits are commonly applied: (1) symptoms should be refractory, (2) sedatives should be administered proportionally to symptoms and (3) the patient should be imminently dying. The term ‘Expanded TS’ (ETS) can be used to describe the use of sedation at the end of life outside one or (...) more of these limits.In this paper, we explore and defend ETS, focusing on jurisdictions where assisted dying is lawful. We argue that ETS is morally permissible: (1) in cases of non-refractory suffering where earlier treatments are likely to fail, (2) where gradual sedation is likely to be ineffective or where unconsciousness is a clinically desirable outcome, (3) where the patient meets all criteria for assisted dying or (4) where the patient has greater than 2 weeks to live, is suffering intolerably, and sedation is considered to be the next best treatment option for their suffering.While remaining two distinct practices, there is scope for some convergence between the criteria for assisted dying and the criteria for ETS. Dying patients who are currently ineligible for TS, or even assisted dying, should not be left to suffer. ETS provides one means to bridge this gap. (shrink)

In developing their policy on paediatric medical assistance in dying (MAID), DeMichelis, Shaul and Rapoport decide to treat euthanasia and physician-assisted suicide as ethically and practically equivalent to other end-of-life interventions, particularly palliative sedation and withdrawal of care (WOC). We highlight several flaws in the authors’ reasoning. Their argument depends on too cursory a dismissal of intention, which remains fundamental to medical ethics and law. Furthermore, they have not fairly presented the ethical analyses justifying other end-of-life decisions, analyses and decisions (...) that were generally accepted long before MAID was legal or considered ethical. Forgetting or misunderstanding the analyses would naturally lead one to think MAID and other end-of-life decisions are morally equivalent. Yet as we recall these well-developed analyses, it becomes clear that approving of some forms of sedation and WOC does not commit one to MAID. Paediatric patients and their families can rationally and coherently reject MAID while choosing palliative care and WOC. Finally, the authors do not substantiate their claim that MAID is like palliative care in that it alleviates suffering. It is thus unreasonable to use this supposition as a warrant for their proposed policy. (shrink)

A key question has been underexplored in the literature on conscientious objection: if a physician is required to perform ‘medical activities,’ what is a medical activity? This paper explores the question by employing a teleological evaluation of medicine and examining the analogy of military conscripts, commonly cited in the conscientious objection debate. It argues that physicians (and other healthcare professionals) can only be expected to perform and support medical acts – acts directed towards their patients’ health. That is, physicians cannot (...) be forced to provide or support services that are not medical in nature, even if such activities support other socially desirable pursuits. This does not necessarily mean that medical professionals cannot or should not provide non-medical services, but only that they are under no obligation to provide them. (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)