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”)

Abstract

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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Notes

  1. 1.

    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part of a team that has jointly come to the therapeutic decision and the team is acting as one person, or, on an outdated hierarchical model of the physician–nurse relationship, is an extension of the physician’s agency.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.

References

  1. 1.

    Papavasiliou, Evangelia S., Sarah G. Brearley, Jane E. Seymour, Jayne Brown, and Sheila A. Payne. 2013. From sedation to continuous sedation until death: How has the conceptual basis of sedation in end-of-life care changed over time? Journal of Pain and Symptom Management 46: 691–706.

    Article  Google Scholar 

  2. 2.

    Saunders, Cicely M. 1989. Pain and impending death. In Textbook of pain, 2nd ed, ed. Patrick D. Wall and Ronald Melzack, 624–631. New York: Churchill Livingstone.

    Google Scholar 

  3. 3.

    Saunders, Cicely M. 2006. Cicely Saunders: Selected writings 19582004. ed. David Clark. New York: Oxford University Press.

  4. 4.

    Saunders, Cicely M., and Mary Baines. 1983. Living with dying: The management of terminal disease. New York: Oxford University Press.

    Google Scholar 

  5. 5.

    Ventafridda, Vittorio, Carla Ripamonti, Franco De Conno, Marcello Tamburini, and Barrie R. Cassileth. 1990. Symptom prevalence and control during cancer patients’ last days of life. Journal of Palliative Care 6: 7–11.

    Google Scholar 

  6. 6.

    Jonsen, Albert R., Mark Siegler, and William J. Winslade. 1982. Clinical ethics: A practical approach to ethical decisions in clinical medicine. New York: MacMillan.

    Google Scholar 

  7. 7.

    Pellegrino, Edmund D. 1998. Emerging ethical issues in palliative care. Journal of the American Medical Association 279: 1521–1522.

    Article  Google Scholar 

  8. 8.

    Greene, William R., and William H. Davis. 1991. Titrated intravenous barbiturates in the control of symptoms in patients with terminal cancer. Southern Medical Journal 84: 332–337.

    Article  Google Scholar 

  9. 9.

    Enck, Robert E. 1991. Drug-induced terminal sedation for symptom control. American Journal of Hospice and Palliative Medicine 8: 3–5.

    Google Scholar 

  10. 10.

    Quill, Timothy E., Rebecca Dresser, and Dan W. Brock. 1997. The rule of double effect—a critique of its role in end-of-life decision making. New England Journal of Medicine 337: 1768–1771.

    Article  Google Scholar 

  11. 11.

    Billings, J. Andrew, and Susan D. Block. 1996. Slow euthanasia. Journal of Palliative Care 12: 21–30.

    Google Scholar 

  12. 12.

    Washington v. Glucksberg, 117 S. Ct. 2258 (1997).

  13. 13.

    Vacco v. Quill, 117 S. Ct. 2293 (1997).

  14. 14.

    Orentlicher, David. 1997. The Supreme Court and physician-assisted suicide—rejecting assisted suicide but embracing euthanasia. New England Journal of Medicine 337: 1236–1239.

    Article  Google Scholar 

  15. 15.

    Cherny, Nathan I., and Russell K. Portenoy. 1994. Sedation in the management of refractory symptoms: Guidelines for evaluation and treatment. Journal of Palliative Care 10: 31–38.

    Google Scholar 

  16. 16.

    Wein, Simon. 2000. Sedation in the imminently dying patient. Oncology (Williston Park) 14: 585–592.

    Google Scholar 

  17. 17.

    Quill, Timothy E., Barbara Coombs Lee, and Sally Nunn. 2000. Palliative treatments of last resort: Choosing the least harmful alternative. Annals of Internal Medicine 132: 488–493.

    Article  Google Scholar 

  18. 18.

    Rousseau, Paul. 2001. Existential suffering and palliative sedation: A brief commentary with a proposal for clinical guidelines. American Journal of Hospice and Palliative Medicine 18: 151–153.

    Article  Google Scholar 

  19. 19.

    Rousseau, Paul. 2000. The ethical validity and clinical experience of palliative sedation. Mayo Clinical Proceedings 75: 1064–1069.

    Article  Google Scholar 

  20. 20.

    Quill, Timothy E., Bernard Lo, Dan W. Brock, and Alan Meisel. 2009. Last-resort options for palliative sedation. Annals of Internal Medicine 151: 421–424.

    Article  Google Scholar 

  21. 21.

    Elsayem, Ahmed, Eardie Curry III, Jeanette Boohene, Mark F. Munsell, Bianca Calderon, Frank Hung, and Eduardo Bruera. 2009. Use of palliative sedation for intractable symptoms in the palliative care unit of a comprehensive cancer center. Supportive Care in Cancer 17: 53–59.

    Article  Google Scholar 

  22. 22.

    Cowan, John D., Libby Clemens, and Teresa Palmer. 2006. Palliative sedation in a southern Appalachian community. American Journal of Hospice and Palliative Medicine 23: 360–368.

    Article  Google Scholar 

  23. 23.

    Miccinesi, Guido, Judith A.C. Rietjens, Luc Deliens, Eugenio Paci, Georg Bosshard, Tore Nilstun, Michael Norup, and Gerrit van der Wal. 2006. Continuous deep sedation: Physicians’ experiences in six European countries. Journal of Pain and Symptom Management 31: 122–129.

    Article  Google Scholar 

  24. 24.

    American Academy of Hospice and Palliative Care Medicine. 2014. Statement on palliative sedation, December 5. http://www.aahpm.org/positions/palliative-sedation.

  25. 25.

    National Ethics Committee and Veterans Health Administration. 2006. The ethics of palliative sedation as a therapy of last resort. American Journal of Hospice and Palliative Medicine 23: 483–491.

    Article  Google Scholar 

  26. 26.

    Kirk, Timothy W., and Margaret M. Mahon. 2010. National Hospice and Palliative Care Organization (NHPCO) position statement and commentary on the use of palliative sedation in imminently dying terminally ill patients. Journal of Pain and Symptom Management 39: 914–923.

    Article  Google Scholar 

  27. 27.

    Sulmasy, Daniel P., and Nessa Coyle. 2012. Palliative sedation and the rule of double effect. In End-of-life ethics: A case study approach, ed. Kenneth J. Doka, Amy S. Tucci, Charles A. Corr, and Bruce Jennings, 109–125. Washington, DC: Hospice Foundation of America.

    Google Scholar 

  28. 28.

    Berlinger, Nancy, Bruce Jennings, and Susan M. Wolf. 2013. The Hastings Center guidelines for decisions on life-sustaining treatment and care near the end of life, 2nd ed. New York: Oxford University Press.

    Google Scholar 

  29. 29.

    Jonas, Hans. 2001. The phenomenon of life: Toward a philosophical biology. Evanston, IL: Northwestern University Press.

    Google Scholar 

  30. 30.

    Sulmasy, Daniel P. 2008. Dignity and bioethics: History, theory, and selected applications. In Human dignity and bioethics: Essays commissioned by the President’s Council on Bioethics, ed. Edmund D. Pellegrino, 469–501. Washington, DC: President’s Council on Bioethics.

    Google Scholar 

  31. 31.

    Jansen, Lynn A., and Daniel P. Sulmasy. 2002. Proportionality, terminal suffering and the restorative goals of medicine. Theoretical Medicine and Bioethics 23: 321–337.

    Article  Google Scholar 

  32. 32.

    Waters, Flavie, and Romola S. Bucks. 2011. Neuropsychological effects of sleep loss: Implication for neuropsychologists. Journal of the International Neuropsychological Society 17: 571–586.

    Article  Google Scholar 

  33. 33.

    Byock, Ira. 1997. Dying well: Peace and possibilities at the end of life. New York: Riverhead.

    Google Scholar 

  34. 34.

    Sulmasy, Daniel P. 2006. Spiritual issues in the care of dying patients: “…It’s okay between me and God.” Journal of the American Medical Association 296: 1385–1392.

    Article  Google Scholar 

  35. 35.

    Kuhl, David. 2002. What dying people want: Practical wisdom for the end of life. New York: PublicAffairs.

    Google Scholar 

  36. 36.

    Sulmasy, Daniel P. 2006. Healing the dying. In The rebirth of the clinic: An introduction to spirituality in health care, 197–212. Washington, DC: Georgetown University Press.

  37. 37.

    Thomasma, David C. 1986. Philosophical reflections on a rational treatment plan. Journal of Medicine and Philosophy 11: 157–165.

    Article  Google Scholar 

  38. 38.

    Johnstone, Brian V. 1985. The meaning of proportionate reason in contemporary moral theology. Thomist 49: 223–247.

    Article  Google Scholar 

  39. 39.

    Jackson, Vicki C. 2004. Being proportional about proportionality: The ultimate rule of law. Constitutional Commentary 21: 803–859.

    Google Scholar 

  40. 40.

    Pellegrino, Edmund D., and David C. Thomasma. 1981. A philosophical basis of medical practice: Towards a philosophy and ethic of the healing professions. New York: Oxford University Press.

    Google Scholar 

  41. 41.

    Paracelsus. 1941. Seven defensiones: The reply to certain calumniations of his enemies. In Four treatises of Theophrastus von Hohenheim called Paracelsus, ed. Henry E. Sigerist, 1–41. Trans. C. Lilian Temkin. Baltimore: Johns Hopkins Press.

    Google Scholar 

  42. 42.

    Cannon, Walter B. 1932. The wisdom of the body. New York: W.W. Norton.

    Google Scholar 

  43. 43.

    Mahony, John. 1975. Ethical aspects of donor consent in transplantation. Journal of Medical Ethics 1: 67–70.

    Article  Google Scholar 

  44. 44.

    Guevin, Benedict M. 1996. The principles of informed (proxy) consent and totality in the reputable practice of medicine. American Journal of Jurisprudence 41: 189–202.

    Article  Google Scholar 

  45. 45.

    Campbell, Courtney S. 1990. Religion and moral meaning in bioethics. Hastings Center Report 20: S4–S10.

    Article  Google Scholar 

  46. 46.

    Sachs, M. 2003. Das Steinschnittverbot im hippokratischen Eid: medizinhistorische und ethische Betrachtungen zur Geschichte der Chirurgie. Zentralblatt für Chirurgie 128: 341–347.

    Article  Google Scholar 

  47. 47.

    Prioreschi, P. 1995. The Hippocratic Oath: A code for physicians, not a Pythagorean manifesto. Medical Hypotheses 44: 447–462.

    Article  Google Scholar 

  48. 48.

    Anscombe, G.E.M. 1957. Intention. Oxford: Blackwell.

    Google Scholar 

  49. 49.

    Searle, John R. 1983. Intentionality: An essay in the philosophy of mind. Cambridge: Cambridge University Press.

    Google Scholar 

  50. 50.

    Bratman, Michael E. 1987. Intention, plans, and practical reason. Cambridge: Harvard University Press.

    Google Scholar 

  51. 51.

    Donagan, Alan. 1987. Choice: The essential element in human action. Abingdon: Routledge and Kegan Paul.

    Google Scholar 

  52. 52.

    Sulmasy, Daniel P. 2007. ‘Re-inventing’ the rule of double effect. In The Oxford handbook of bioethics, ed. Bonnie Steinbock, 114–149. Oxford: Oxford University Press.

    Google Scholar 

  53. 53.

    Jensen, Steven J. 2010. Good and evil actions: A journey through Saint Thomas Aquinas. Washington, DC: Catholic University of America Press.

    Google Scholar 

  54. 54.

    Cavanaugh, T.A. 2006. Double-effect reasoning: Doing good and avoiding evil. Oxford: Oxford University Press.

    Google Scholar 

  55. 55.

    Bennett, Jonathan. 1966. Whatever the consequences. Analysis 26: 83–102.

    Article  Google Scholar 

  56. 56.

    Davis, Nancy. 1984. The doctrine of double effect: Problems of interpretation. Pacific Philosophical Quarterly 65: 107–123.

    Article  Google Scholar 

  57. 57.

    Boyle, Joseph. 1991. Who is entitled to double effect? Journal of Medicine and Philosophy 16: 475–494.

    Article  Google Scholar 

  58. 58.

    Quinn, Warren S. 1989. Actions, intentions, and consequences: The doctrine of double effect. Philosophy & Public Affairs 18: 334–351.

    Google Scholar 

  59. 59.

    Chappell, Timothy. 2001. Two distinctions that do make a difference: The action/omission distinction and the principle of double effect. Philosophy 77: 211–233.

    Google Scholar 

  60. 60.

    Hills, Alison. 2007. Intentions, foreseen consequences and the doctrine of double effect. Philosophical Studies 133: 257–283.

    Article  Google Scholar 

  61. 61.

    Masek, Lawrence. 2010. Intentions, motives and the doctrine of double effect. Philosophical Quarterly 60: 567–585.

    Article  Google Scholar 

  62. 62.

    Sulmasy, Daniel P., and Edmund D. Pellegrino. 1999. The rule of double-effect: Clearing up the double talk. Archives of Internal Medicine 159: 545–550.

    Article  Google Scholar 

  63. 63.

    Cherny, Nathan I., Nessa Coyle, and Kathleen M. Foley. 1994. Suffering in the advanced cancer patient: A definition and taxonomy. Journal of Palliative Care 10: 57–70.

    Google Scholar 

  64. 64.

    World Health Organization. 2002. National cancer control programmes: Policies and managerial guidelines, 2nd ed. Geneva: World Health Organization.

    Google Scholar 

  65. 65.

    Ferrell, Betty, and Nessa Coyle. 2008. The nature of suffering and the goals of nursing. New York: Oxford University Press.

    Google Scholar 

  66. 66.

    Barnard, David. 2006. The skull at the banquet. In Death in the clinic, ed. Lynn A. Jansen, 66–80. Lanham, MD: Rowman and Littlefield.

    Google Scholar 

  67. 67.

    Sulmasy, Daniel P., Farr Curlin, Gerard S. Brungardt, and Thomas Cavanaugh. 2010. Justifying different levels of palliative sedation. Annals of Internal Medicine 152: 332–333.

    Article  Google Scholar 

  68. 68.

    Cherny, Nathan I. 2006. Sedation for the care of patients with advanced cancer. Nature Clinical Practice Oncology 3: 492–500.

    Article  Google Scholar 

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Acknowledgements

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). https://doi.org/10.1007/s11017-018-9459-7

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Keywords

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