Opioid and sedative use are common ‘active’ practices in the provision of mainstream palliative care services, and are typically distinguished from euthanasia on the basis that they do not shorten survival time. Even supposing that they did, it is often argued that they are justified and distinguished from euthanasia via appeal to Aquinas’ Doctrine of Double Effect. In this essay, I will appraise the empirical evidence regarding opioid/sedative use and survival time, and argue for a position of agnosticism. I will (...) then argue that the Doctrine of Double Effect is a useful ethical tool but is ultimately not a sound ethical principle, and even if it were, it is unclear whether palliative opioid/sedative use satisfy its four criteria. Although this essay does not establish any definitive proofs, it aims to provide reasons to doubt—and therefore weaken—the often-claimed ethical distinction between euthanasia and palliative opioid/sedative use. (shrink)

Gilbertson et al should be commended for their insightful exploration of expanded terminal sedation (ETS)1; however, there are a number of concerns that I will address in this response. I will first better characterise the currently accepted and commonplace ‘standard’ TS (STS), and then argue that the advocated forms of ETS draw very close to—and at times clearly constitute a subtype of—euthanasia, as opposed to representing a similar but separate practice. I will then conclude with concerns regarding the inappropriate application (...) of ETS, particularly in the non-voluntary context. Gilbertson et al distinguish ‘gradual’ TS, which they state is the currently accepted form of TS, from ‘rapid’ TS, which is then argued to be a justifiable form of ETS. However, in my experience working in multiple large public teaching hospitals in New South Wales, Australia and consistent with local clinical practice guidelines,2 3 STS falls somewhere in the middle between ‘gradual’ and ‘rapid’ TS. STS explicitly aims to achieve permanent unconsciousness so as to eliminate the potential for (and therefore relieve) suffering; conversely, lighter or more intermittent forms of sedation, or administering sedatives with aims other than to achieve unconsciousness (eg, anxiolysis), do not constitute TS proper. STS uses doses proportionate to the extent of symptoms so as to avoid ‘overshooting’ and inadvertently administering excessive doses which actually hasten/cause death, in order to distinguish STS from euthanasia in this respect. This is achieved by gradually uptitrating doses when the patient appears distressed, and is therefore by definition …. (shrink)