Abstract
Among the oldest extant medical ethics, the Hippocratic Oath prohibits the giving of a deadly drug, regarding this act as an egregious violation of a medical ethic that is exclusively therapeutic. Proportionate palliative sedation involves the administration of a deadly drug. Hence it seems to violate the venerable Hippocratic promise associated with the dawn of Western medicine not to give a deadly drug. Relying on distinctions commonly employed in the analysis and evaluation of human actions, this article distinguishes physician-assisted suicide and euthanasia, as acts that necessarily violate the prohibition against giving a deadly drug, from proportionate palliative sedation, as an act that does not.
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Notes
In Aquinas’ words, “bonum est faciendum et prosequendum et malum vitandum” (Summa theologiae, I–II, q. 94, a. 2, in [1, p. 955]).
By proportionate palliative sedation, I refer to the (widely accepted) practice of administering a sedative to a patient at the end of life, with the consent of the patient and/or the patient’s family, in order to relieve distress and agitation in the face of otherwise intractable pain when so doing may also suppress or depress the patient’s breathing so as to result in the patient’s death. I concur with Farr Curlin [3], in an article also published in this special issue, in distinguishing palliative sedation to unconsciousness (PSU) from proportionate palliative sedation (PPS). PPS seeks to relieve distress at otherwise intractable pain. Hence, in PPS, the goal of relieving distress moderates the sedation. Accordingly, one aptly describes it as proportionate. In contrast to PPS (and as I use the phrase), PSU lacks this measuredness or moderation—being ordered toward unconsciousness regardless of the latter’s relation to agitation. Because “terminal sedation” does not clearly capture this important difference, I choose to use the term proportionate palliative sedation.
Of course, the intended is also voluntary. So the voluntary/intended distinction is that which contrasts what is voluntary but not intended (not deliberate) against what is voluntary and intended (deliberate). One could also aptly speak of this as a distinction between the simply voluntary and the intended. Or one could refer to it as the foreseen/intended distinction. This way of speaking, however, suggests a contrast between an epistemological attitude (foresight) and a volitional one (intention), while the contrast at issue concerns different volitional attitudes. Hence, I prefer to use voluntary/intended. Regardless of how one characterizes the distinction, it concerns a contrast within the voluntary.
Of course, as the voluntary/intended distinction proposes, an act can include voluntary badness—that is, be maleficent, literally producing badness—while the act does not incorporate intentional badness—that is, bad-will or malevolence, the pursuit of badness as an end or means. PPS is an instance of such an act. The question is whether this makes a moral difference in evaluating the act and in contrasting it with PAS and euthanasia.
Experiments repeatedly confirm the widespread intuition that the voluntary/intended distinction has moral relevance in act-evaluation. Subjects contrast consequentially similar acts in terms of this distinction. For an extensive treatment of the evidence, see, for example, John Mikhail [10].
References
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Cavanaugh, T.A. Proportionate palliative sedation and the giving of a deadly drug: the conundrum. Theor Med Bioeth 39, 221–231 (2018). https://doi.org/10.1007/s11017-018-9453-0
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DOI: https://doi.org/10.1007/s11017-018-9453-0