Medical Humanities Lexicon: Palliative Sedation

Today's entry in the Lexicon is palliative sedation.  I've been interested in the concept for some time, and "aeb" over at Women's Bioethics Blog put up an interesting post on the subject.

aeb writes at least in part from a nursing perspective, and she observes:

Nurses can struggle with palliative sedation because it can hasten death. The reason palliative sedation is ethically ok is due to the intent one has while administering it. The nurse must remember their intension is to promote comfort, but with that death may occur.

Erin Brender recently defined palliative sedation as "the use of sedative medications to relieve extreme suffering by making the patient unaware and unconscious (as in a deep sleep) while the disease takes its course, eventually leading to death. The sedative medication is gradually increased until the patient is comfortable and able to relax. Palliative sedation is not intended to cause death or shorten life."  294 JAMA 1850 (2005). 

An older common term for the same phenomenon is "terminal sedation," but a hospice physician informed me some time ago that the generally preferred current term, at least in my locale, is palliative sedation. 

I've mentioned on this blog before that one of my own academic interests is pain & pain management, and PS is obviously intricately connected to issues of pain management.

Here is the remainder of my comment in response to aeb's post, which will hopefully serve to explain briefly some of the important aspects of palliative sedation:

I think that a much better job needs to be done -- by the media, bioethicists, nurses, physicians, etc. -- of carefully disentangling notions of euthanasia from palliative sedation. The formal philosophical doctrine on which the distinction is based is, of course, the principle of double effect, and understanding it has helped me to gain some insight on the distinction.

The reason I think this is so important is because if one is able to explain why palliative sedation is utterly conventional (in terms of clinical practice, not conventional for the patients and families, of course!), one might be able to get somewhere in terms of pain management without invoking all of the understandable concerns about euthanasia (not saying these concerns aren't relevant, only that they are not equivalent to palliative sedation).

My understanding is that palliative sedation goes on every day in clinical settings all over the country, and I think the reason this is generally accepted, if not widely discussed, is because there is something of the principle of double effect that is kind of present in Western cultural heritage. That's not the only reason, but I find that most people I speak with about the principle seem to grasp it pretty quickly, and say that it tends to confirm their prior intuitions.

The principle of double effect in its modern sense is generally attributed to Aquinas.  Though the literature on the principle is explosive, the SCP explains:

"The conditions provided by Joseph Mangan include the explicit requirement that the bad effect not be intended:

A person may licitly perform an action that he foresees will produce a good effect and a bad effect provided that four conditions are verified at one and the same time:

1. that the action in itself from its very object be good or at least indifferent;
2. that the good effect and not the evil effect be intended;
3. that the good effect be not produced by means of the evil effect;
4. that there be a proportionately grave reason for permitting the evil effect” (1949, p. 43)."

Thus, in the context of opioid analgesia, a provider who administers high doses of a strong opioid with the intent of hastening the death of the patient cannot seek ethical sheter under the doctrine of double effect (because the "bad" effect is intended).  The provider who adminsters high doses of a strong opioid with the intent of ameliorating pain knowing that such high doses may hasten death, and who follows the other requirements and safeguards built into the doctrine of double effect, has acted (supposedly) in an ethically sound manner.  Under the latter, the death of the patient is literally the second (or double) effect.  See id.

Though I have no evidence for this claim, it is not inconceivable (especially insofar as the principle of double effect has deep roots in Western culture -- one ought not neglect the dialectical aspects of history, especially High Medieval history, where many aspects of the modern world can be traced, IMO) that there is some morally intuitionist appeal to the principle of double effect.  There may be some aspect of it that simply "feels" right to many Westerners.  I must hasten to add here that I am not advancing an entirely intuitionist platform for the principle, as that was most certainly not what Aquinas intended, nor am I prepared to commit to a wholly intuitionist approach (on the difficulties with moral intuitionism, see Levy, S.S., "A Limit on Intuitionistic Methods of Moral Reasoning," The Journal of Value Inquiry, Vol. 32, no. 4 (2006): 463-470).

But I do think there may be ethical content to intuitionism as a sign or a marker of something important (but obviously not as criterion of the good), and insofar as there is merit to that, the fact that many find the principle of double effect to be intuitivtely appealing may suggest something ethically worthwhile, if not dispositive about the view.  Finally, none of this should be taken as a knock-down, drag-out defense of the principle of double effect.  For an important critique of the doctrine and its application in clinical ethics, see T. Quill, R. Dresser, and D. Brock, "The Rule of Double Effect -- A Critique of Its Role in End-of-Life Decision-Making," N. Engl. J. Med. 337 (1997): 1768-1771.

(Those unaware of the strong historical and conceptual connections between Catholic traditions of medical ethics and early bioethics in the U.S. would be advised to read Al Jonsen's The Birth of Bioethics, and Jonsen & Stephen Toulmin's The Abuse of Casuistry).

The importance of palliative sedation is at least partly that its practice is so conventional, in hospitals all over the U.S. virtually every day.  It has become an accepted part of clinical practice, of end-of-life scenarios, as opposed to passive euthanasia (embodied in Oregon's Death with Dignity Act), and certainly in stark opposition to active euthanasia, the latter of which remains illegal in all fifty states and in most countries aside from the Netherlands.  While there are many difficult legal, ethical, and policy issues that attend inquiries into both passive and active euthanasia, palliative sedation seems easier to grapple with, if only by comparison.  Thus, even though one might well acknowledge the distinctions between palliative sedation, and passive and active euthanasia might, in certain cases, be fine, it does not follow that there exist no substantive differences between them.  The fact that many industrial societies have issued different legal and regulatory responses (i.e., different practices) with regards to each may itself mark the existence of such distinctions, even if teasing them out may be difficult.

Regardless of one's position, thinking through some of these issues is, I submit, an important part of thinking through some of the difficult problems that may arise in end-of-life scenarios.

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Bibliography

Albert R. Jonsen.  the birth of bioethics (Oxford: Oxford University Press, 1998).

Albert R. Jonsen, Mark Siegler, & William J. Winslade.  clinical ethics (6th ed. 2006).

Erin Brender, "Palliative Sedation," JAMA, Vol. 294, no. 14 (2005): 1850.

H. Ten Have, David Clark (eds.).  the ethics of palliative care: european perspectives (Buckingham, UK: Open University Press, 2002).

Joseph Boyle, "Medical Ethics and Double Effect: The Case of Terminal Sedation," Theoretical Medicine & Bioethics, Vol. 25, no. 1 (2004): 51-60.

Robert M. Baird, Stuart E. Rosenbaum (eds.).  caring for the dying: critical issues at the edge of life.  (Amherst, NY: Promethus Books, 2003).

T. Quill, R. Dresser, and D. Brock, "The Rule of Double Effect -- A Critique of Its Role in End-of-Life Decision-Making," N. Engl. J. Med. 337 (1997): 1768-1771.

Levy, S.S., "A Limit on Intuitionistic Methods of Moral Reasoning," The Journal of Value Inquiry, Vol. 32, no. 4 (2006): 463-470.

Shai J. Lavi.  the modern art of dying: a history of euthanasia in the united states.  (2005).  (Princeton: Princeton University Press).