Theoretical Medicine and Bioethics

, Volume 39, Issue 3, pp 233–263 | Cite as

The last low whispers of our dead: when is it ethically justifiable to render a patient unconscious until death?

  • Daniel P. SulmasyEmail author


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: (1) double-effect sedation, (2) parsimonious direct sedation, and (3) 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.


Palliative Sedation Euthanasia Double effect End-of-life Ethics 



I am grateful to several groups of colleagues who heard earlier versions of this paper over several years and gave constructive feedback—the Department of Palliative Care at the Massachusetts General Hospital in 2013, the Center for Bioethics and Medical Humanities at the Ohio State University in 2014, the Law and Ethics Seminar at the University of Chicago in 2015, the Program on Medicine and Religion at the University of Chicago (where the conference on which this special issue is based took place in 2016), and the Philosophy Department Colloquium of the Australian Catholic University in 2018. I am grateful to my colleague at Theoretical Medicine and Bioethics, Lynn Jansen, for functioning as editor for this paper and for her careful reading. I also thank the McDonald Agape Foundation for their generous support of the conference series, “Now and at the Hour of Our Death.”


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Copyright information

© Springer Nature B.V. 2018

Authors and Affiliations

  1. 1.The Pellegrino Center for Clinical Bioethics, The Kennedy Institute of Ethics, and the Departments of Medicine and PhilosophyGeorgetown UniversityWashingtonUSA

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