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

The last low whispers of our dead.

Are burdened with His Name.

—John Greenleaf Whittier, “Immortal Love” (“Our Master”)


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.

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    Note that a nurse carrying out a physician’s order would not be considered an intervening agent for the purposes of this analysis, since the nurse is ideally part of a team that has jointly come to the therapeutic decision and the team is acting as one person, or, on an outdated hierarchical model of the physician–nurse relationship, is an extension of the physician’s agency. By an intervening moral agent, I mean someone who makes an independent moral decision, as when a physician purposefully leaves a supply of opioids available for a nurse’s aide to steal in order to treat her uninsured mother’s back pain. The proper category of ethical analysis in such cases is moral complicity, not double effect.


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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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Correspondence to Daniel P. Sulmasy.

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Sulmasy, D.P. The last low whispers of our dead: when is it ethically justifiable to render a patient unconscious until death?. Theor Med Bioeth 39, 233–263 (2018).

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  • Palliative
  • Sedation
  • Euthanasia
  • Double effect
  • End-of-life
  • Ethics