In this paper it is argued that physicians’ restrictive attitudes in offering abortions during 1946–1965 in Sweden were due to their private values. The values, however, were rarely presented openly. Instead physicians’ values influenced their assessment of the facts presented—that is, the women's’ trustworthiness. In this manner the physicians were able to conceal their private values and impede the women from getting what they wanted and needed. The practice was concealed from both patients and physicians and never publicly discussed. It (...) is also argued that a similar tacit practice could currently be applied by palliative care physicians. Such practice might allow palliative care physicians to be restrictive when offering sedation therapy without appearing paternalistic or declaring conscientious objections. However, the practice runs counter to patients’ right to participate in making decisions. The women seeking abortion began to oppose the situation and eventually a new abortion law was introduced 1975. Patients at the end of life will never be able to protest against palliative care physicians’ restrictive attitudes. This is a vulnerable and weak group, unable to lodge complaints after the treatment. In order to respect patients’ autonomy, even suffering patients at the end of their lives, it is suggested that physicians should openly declare their values when it comes to providing treatments that might shorten life. Such transparency might facilitate more genuine shared decision-making and accordingly less suboptimal end-of-life care. (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)

In 2016, France passed a major law that is unique in giving terminally ill and suffering patients the right to the controversial procedure of continuous deep sedation until death (CDS). In so doing, the law identifies CDS as a sui generis clinical practice, distinct from other forms of palliative sedation therapy, as well as from euthanasia. As such, it reconfigures the ethical debate over CDS in interesting ways. This paper addresses one aspect of this reconfiguration and its (...) implications for the intentions at work in this complex time at the end of life. The concept of intention is often considered central to the ethics of end-of-life care, but its role is recognized to be problematic, with charges of elusiveness and ambiguity. I aim to show that consideration of the French law affords a new understanding of the intentionality of CDS, and that in addition to the obvious importance of this for clarifying the ethics of the practice, it may suggest new ways of addressing the wider problem of ambiguous clinical intentions at end of life. (shrink)

Bu kitap değerlendirmesinde, Orna Donath’ın annelikten pişman olma durumunu nasıl ele aldığına değinilecek, kitabın güçlü ve zayıf yönleri üzerinde durulacaktır.

Results of a comprehensive simulation study are reported investigating the effects of sample size, test length, number of attributes and base rate of mastery on item parameter recovery and classification accuracy of four DCMs. Effects were evaluated using bias and RMSE computed between true parameters and estimated parameters. Effects of simulated factors on attribute assignment were also evaluated using the percentage of classification accuracy. More precise estimates of item parameters were obtained with larger sample size and longer test length. Recovery (...) of item parameters decreased as the number of attributes increased from three to five but base rate of mastery had a varying effect on the item recovery. Item parameter and classification accuracy were higher for DINA and DINO models. (shrink)

Kant’s general taxonomy of duties includes substantial claims that normatively and theoretically differentiates it from other moral theories. Basing his moral theory on a conception of Right, he also made a general classification of several duties with their corresponding moral worth. The general aim of this study is to identify the basic principles and criteria that determine Kant’s classification of duties. Another aim is to trace some implications and effects of Kant’s conception of duties in the contemporary discussion of social (...) and economic rights. We argue that the normative basis of the argument against social and economic rights is very similar to that of the principles Kant uses in his classification of duties. However, from the responsibility of the state, Kant imposes legitimate obligations over individuals, albeit indirectly. (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)

The Rule of Double Effect (RDE) holds that it may be permissible to harm an individual while acting for the sake of a proportionate good, given that the harm is not an intended means to the good but merely a foreseen side-effect. Although frequently used in medical ethical reasoning, the rule has been repeatedly questioned in the past few decades. However, Daniel Sulmasy, a proponent who has done a lot of work lately defending the RDE, has recently presented a reformulated (...) and more detailed version of the rule. Thanks to its greater precision, this reinvented RDE avoids several problems thought to plague the traditional RDE. Although an improvement compared with the traditional version, we argue that Sulmasy's reinvented RDE will not stand closer scrutiny. Not only has the range of proper applicability narrowed significantly, but, more importantly, Sulmasy fails to establish that there is a morally relevant distinction between intended and foreseen effects. In particular, he fails to establish that there is any distinction that can account for the alleged moral difference between sedation therapy and euthanasia. (shrink)

To the Editor: It was with great interest that our Canadian Palliative Sedation Therapy Guideline working group read Jeffrey Berger's recent article ("Rethinking Guidelines for the Use of Palliative Sedation," May-June 2010). Given our own group's efforts to develop national guidelines, we have rethought the issue of palliative sedation therapy several times over the past year.The use of clear and concise definitions is fundamental to the development of any consensus guidelines on this topic. In the (...) article, the term "palliative sedation to unconsciousness," or PSU, implies the concerning assumption that sedation will knowingly be to unconsciousness in the palliative case under consideration. This conflicts with .. (shrink)

Effective palliative care that rests on a sound ethical foundation requires ongoing discussions about patient and family values and preferences. This is especially important when addressing care at end-of-life including artificial nutrition and hydration, withdrawal of life-sustaining therapies and palliative sedation as well as requests for assistance in hastening death. The eighth volume in the HPNA Palliative Nursing Manuals series, Legal and Ethical Aspects of Palliative Care, provides an overview of critical communication skills and formal organizational mechanisms, such as (...) ethics committees and interdisciplinary rounds, required for decisions in ethical dilemmas which respect diversity in the views of colleagues, as well as patients. The content of the concise, clinically focused volumes in the HPNA Palliative Nursing Manuals series is one resource for nurses preparing for specialty certification exams and provides a quick-reference in daily practice. (shrink)

A number of practices at the end of life can causally contribute to diminished consciousness in dying patients. Despite overlapping meanings and a confusing plethora of names in the published literature, this article distinguishes three types of clinically and ethically distinct practices: double-effect sedation, parsimonious direct sedation, and sedation to unconsciousness and death. After exploring the concept of suffering, the value of consciousness, the philosophy of therapy, the ethical importance of intention, and the rule of double (...) effect, these three practices are defined clearly and evaluated ethically. It is concluded that, if one is opposed to euthanasia and assisted suicide, double-effect sedation can frequently be ethically justified, that parsimonious direct sedation can be ethically justified only in extremely rare circumstances in which symptoms have already completely consumed the patient’s consciousness, and that sedation to unconsciousness and death is never justifiable. The special case of sedation for existential suffering is also considered and rejected. (shrink)

Palliative care and hospice should be the standards of care for all terminally ill patients. The first place for clinicians to go when responding to a request for assisted death is to ensure the adequacy of palliative interventions. Although such interventions are generally effective, a small percentage of patients will suffer intolerably despite receiving state-of-the-art palliative care, and a few of these patients will request a physician-assisted death. Five potential “last resort” interventions are available under these circumstances: (1) accelerating opioids (...) for pain or dyspnea; (2) stopping potentially life-prolonging therapies; (3) voluntarily stopping eating and drinking; (4) palliative sedation (potentially to unconsciousness); and (5) physician-assisted death. Patient, family, and clinicians should search for the least harmful way to respond to intolerable end-of-life suffering in ways that are effective and also respect the values of the major participants. A system that allows an open response to such cases ultimately protects patients by ensuring a full clinical evaluation and search for alternative responses, while reinforcing the need to be responsive and to not abandon. (shrink)

Rapidly advancing technologies in the field of extracorporeal cardiopulmonary resuscitation (ECPR) have presented a new challenge in accurate neuroprognostication following cardiac arrest. Determination of brain state informs the prognostic picture and allows providers to begin effective communication regarding likelihood of meaningful neurological recovery as defined by patients or family members. The evolving role of sedation during ECPR and its impacts on ethical tension in decision-making is reviewed. Work surrounding the advancing field of neuroprognostication after cardiac arrest and hypothermia is (...) summarized and implications of premature withdrawal of life-sustaining treatments are discussed. Advances that improve predictive value for neurological recovery are utilized in affirming and discussing the implications for end-of-life wishes of individuals in the setting of intensive resuscitative therapies. (shrink)

The current Ebola virus epidemic in Western Africa appears to be spiraling out of control. The worst-case projections suggested that the unchecked spread could result in almost 1.4 million cases by the end of January 2015 with a case fatality rate of at least 50%. The United States and European nations have begun to respond in earnest with promises of supplies, isolation beds, and trained health care personnel in an effort to contain the epidemic and care for the sick. However, (...) there is neither a vaccine nor specific treatment for Ebola infection, and therapy is ideally centered on supportive care. I have previously argued that the provision of palliative care is obligatory during an overwhelming health catastrophe, notably pandemic influenza. Since affected Ebola patients have best outcomes with technologically advanced intensive care—resources in scarce supply in the area—I suggest that the only acceptable approach to large numbers of very sick, dying, and suffering Ebola patients who overwhelm the reso.. (shrink)

The current Ebola virus epidemic in Western Africa appears to be spiraling out of control. The worst-case projections suggested that the unchecked spread could result in almost 1.4 million cases by the end of January 2015 with a case fatality rate of at least 50%. The United States and European nations have begun to respond in earnest with promises of supplies, isolation beds, and trained health care personnel in an effort to contain the epidemic and care for the sick. However, (...) there is neither a vaccine nor specific treatment for Ebola infection, and therapy is ideally centered on supportive care. I have previously argued that the provision of palliative care is obligatory during an overwhelming health catastrophe, notably pandemic influenza. Since affected Ebola patients have best outcomes with technologically advanced intensive care—resources in scarce supply in the area—I suggest that the only acceptable approach to large numbers of very sick, dying, and suffering Ebola patients who overwhelm the resources available to successfully manage them is effective palliative care. However, this could hasten death in this vulnerable population and hence, while ethically and medically justifiable, is not without social risk. (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)

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)

“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)

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)

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)

A lesson from cognitive behavior therapy (CBT) is that it is possible for people to change their beliefs and attitudes in ways that enhance mood. This chapter discusses mainly how the ideas from positive psychology combined with the therapeutic methods developed in CBT might provide ways of helping individuals to enhance their mood and increase happiness. The best single perspective from which to gain an understanding of positive psychology is that of evolutionary psychology, even though it is underdeveloped and (...) contentious. Evolutionary psychology bridges the gap between individual history and the general features of the human condition that helps to explain both our capacity for happiness and some of the barriers to achieving it. The modern general evolutionary view of emotions is that they help animals in regulating their effort: how they behave at any one time and how they apportion their time and energy between different types of behavior. (shrink)

Background: In the last two decades, nursing authors have published ethical analyses of palliative sedation—an end-of-life care practice that also receives significant attention in the broader medical and bioethics literature. This nursing literature is important, because it contributes to disciplinary understandings about nursing values and responsibilities in end-of-life care. Research aim: The purpose of this project is to review existing nursing ethics literature about palliative sedation, and to analyze how nurses’ moral identities are portrayed within this literature. Research (...) design: We reviewed discussion papers, written by nurses about the ethics of palliative sedation, which were cited in MEDLINE, CINAHL, Nursing and Allied Health, or Philosopher’s Index (search date March 2018). Twenty-one papers met selection criteria. We performed a comprehensive review and analysis (using the Qualitative Analysis Guide of Leuven), of the values, responsibilities, and relationships reflected in authors’ portrayal of the nursing role. Findings: Two different tones are apparent in the extant nursing ethics literature. One is educational, while the other is critically reflective. Irrespective of tone, all authors agree on the alleviation of suffering as a fundamental nursing responsibility. However, they differ in their analysis of this responsibility in relation to other values in end-of-life care, including those that depend on consciousness. Finally, authors emphasize the importance of subjective and experience-based understandings of palliative sedation, which they argue as depending on nurses’ proximity to patients and families in end-of-life care. Discussion and conclusion: Based on our findings, we develop three recommendations for future writing by nurses about palliative sedation. These relate to the responsibility of recognizing how consciousness might matter in (some) peoples’ moral experiences of death and dying, to the importance of moral reflectiveness in nursing practice, and to the value of a relational approach in conceptualizing the nursing ethics of palliative sedation. (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)

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)

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)

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)

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)

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)