A recent administrative law decision in Victoria, Australia, applied double effect reasoning in a novel way. Double effect reasoning has hitherto been used to legitimate treatments which may shorten life but where the intent of treatment is pain relief. The situation reviewed by the Victorian tribunal went further, supporting actions where a doctor agrees to provide pentobarbitone to a patient at some time in the future if the patient feels at that time that his pain is unbearable and he wants (...) to end his life. The offer to provide the drug was described as a palliative treatment in that it gave reassurance and comfort to the patient. Double effect reasoning was extended in this instance to encompass potentially facilitating a patient’s death. This extension further muddies the murky double effect reasoning waters and creates another challenge to this concept. (shrink)

ZusammenfassungDie von einem multiprofessionellen Behandlungsteam durchgeführte Symptombehandlung bei inkurablen Patienten am Lebensende erweist sich als hoch effektiv und verschafft den meisten Patienten eine ausreichende Linderung. Dennoch verbleibt ein Patientenanteil, bei dem auch unter Berücksichtigung physischer, psychischer, sozialer und spiritueller Bedürfnisse kein erträglicher Zustand erreicht werden kann. In diesen Extremfällen können Sedierungsmaßnahmen zur Linderung eingesetzt werden. Der Begriff und das Angebot der terminalen Sedierung sind in vielerlei Hinsicht umstritten. Eine Kasuistik soll die Problemstellung veranschaulichen und zeigen, wie die terminale Sedierung von (...) erfahrenen Behandlern als ergänzendes Instrument der Symptombehandlung eingesetzt werden kann, auch wenn sie keine perfekte Antwort auf unerträgliches Leiden in der Sterbesituation darstellt. Im Literaturvergleich werden aktuelle medizinische, rechtliche und psychosoziale Fragen diskutiert. (shrink)

Despite advances in palliative care, some patients still suffer significantly at the end of life. Terminal Sedation (TS) refers to the use of sedatives in dying patients until the point of death. The following limits are commonly applied: (1) symptoms should be refractory, (2) sedatives should be administered proportionally to symptoms and (3) the patient should be imminently dying. The term ‘Expanded TS’ (ETS) can be used to describe the use of sedation at the end of life outside one or (...) more of these limits.In this paper, we explore and defend ETS, focusing on jurisdictions where assisted dying is lawful. We argue that ETS is morally permissible: (1) in cases of non-refractory suffering where earlier treatments are likely to fail, (2) where gradual sedation is likely to be ineffective or where unconsciousness is a clinically desirable outcome, (3) where the patient meets all criteria for assisted dying or (4) where the patient has greater than 2 weeks to live, is suffering intolerably, and sedation is considered to be the next best treatment option for their suffering.While remaining two distinct practices, there is scope for some convergence between the criteria for assisted dying and the criteria for ETS. Dying patients who are currently ineligible for TS, or even assisted dying, should not be left to suffer. ETS provides one means to bridge this gap. (shrink)

Trolley dilemmas have been tested cross-culturally, but only recently have researchers begun to assess the effect of responding to such dilemmas in a foreign language. Previous studies have found a Moral Foreign Language Effect in trolley dilemmas, whereby subjects who respond to these dilemmas in a foreign language, tend to offer more utilitarian responses. The present study seeks to test whether the MFLE holds amongst native speakers of Arabic. Additionally, the present study seeks to test whether the use of visual (...) images has any effect on responses. For such purposes, four groups were compared: 1) participants responding to trolley dilemmas in English without visual images; 2) participants responding to trolley dilemmas in Arabic without visual images; 3) participants responding to trolley dilemmas in English with visual images; 4) participants responding to trolley dilemmas in Arabic with visual images. (shrink)

When a severely suffering dying patient is deeply sedated, and this sedated condition is meant to continue until his death, the doctor involved often decides to abstain from artificially administering fluids. For this dual procedure almost all guidelines require that the patient should not have a life expectancy beyond a stipulated maximum of days (4–14). The reason obviously is that in case of a longer life-expectancy the patient may die from dehydration rather than from his lethal illness. But no guideline (...) tells us how we should describe the dual procedure in case of a longer life-expectancy. Many arguments have been advanced why we should not consider it to be a form of homicide, that is, ending the life of the patient (with or without his request). I argue that none of these arguments, taken separately or jointly, is persuasive. When a commission, even one that is not itself life-shortening, foreseeably renders a person unable to undo the life-shortening effects of another, simultaneous omission, the commission and the omission together should be acknowledged to kill her. I discuss the legal and ethical implications of this conclusion. (shrink)

To fulfill their crucial duty of relieving suffering in their patients, physicians may have to administer palliative sedation when they implement treatment-limitation decisions such as the withdrawal of life-supporting interventions in patients with poor prognosis chronic severe brain injury. The issue of palliative sedation deserves particular attention in adults with serious brain injuries and in neonates with severe and irreversible brain lesions, who are unable to express pain or to state their wishes. In France, treatment limitation decisions for these patients (...) are left to the physicians. Treatment-limitation decisions are made collegially, based on the presence of irreversible brain lesions responsible for chronic severe disorders of consciousness. Before these decisions are implemented, they are communicated to the relatives. Because the presence and severity of pain cannot be assessed in these patients, palliative analgesia and/or sedation should be administered. However, palliative sedation is a complex strategy that requires safeguards to prevent a drift toward hastening death or performing covert euthanasia. In addition to the law on patients' rights at the end of life passed in France on April 22, 2005, a recent revision of Article 37 of the French code of medical ethics both acknowledges that treatment-limitation decisions and palliative sedation may be required in patients with severe brain injuries and provides legal and ethical safeguards against a shift towards euthanasia. This legislation may hold value as a model for other countries where euthanasia is illegal and for countries such as Belgium and Netherlands where euthanasia is legal but not allowed in patients incapable of asking for euthanasia but in whom a treatment limitation decision has been made. (shrink)

A distinction is commonly drawn between continuous sedation until death and physician-assisted suicide/euthanasia. Only the latter is found to involve killing, whereas the former eludes such characterization. I argue that continuous sedation until death is equivalent to physician-assisted suicide/euthanasia in that both involve killing. This is established by first defining and clarifying palliative sedation therapies in general and continuous sedation until death in particular. A case study analysis and a look at current practices are provided. This is followed by a (...) defense of arguments in favor of definitions of death centering on higher brain (neocortical) functioning rather than on whole brain or cardiopulmonary functioning. It is then shown that continuous sedation until death simulates higher brain definitions of death by eliminating consciousness. Appeals to reversibility and double effect fail to establish any distinguishing characteristics between the simulation of death that occurs in continuous sedation until death and the death that occurs as a result of physician-assisted suicide/euthanasia. Concluding remarks clarify the moral ramifications of these findings. (shrink)

It is often claimed that the intentions of physicians are multiple, ambiguous, and uncertain—at least with respect to end-of-life care. This claim provides support for the conclusion that the principle of double effect is of little or no value as a guide to end-of-life pain management. This paper critically discusses this claim. It argues that proponents of the claim fail to distinguish two different senses of “intention,” and that, as a result, they are led to exaggerate the extent to which (...) clinical intentions in end-of-life contexts are ambiguous and uncertain. It argues further that physicians, like others who make life and death decisions, have a duty to get clear on what their intentions are. Finally, it argues that even if the principle of double effect should be rejected, clinical intentions remain ethically significant because they condition the meaning of extraordinary clinical interventions, such as that of palliative sedation. (shrink)

The controversy over the equivalence of continuous sedation until death (CSD) and physician-assisted suicide/euthanasia (PAS/E) provides an opportunity to focus on a significant extended use of CSD. This extension, suggested by the equivalence of PAS/E and CSD, is designed to promote additional patient autonomy at the end-of-life. Samuel LiPuma, in his article, “Continuous Sedation Until Death as Physician-Assisted Suicide/Euthanasia: A Conceptual Analysis” claims equivalence between CSD and death; his paper is seminal in the equivalency debate. Critics contend that sedation follows (...) proportionality protocols for which LiPuma’s thesis does not adequately account. Furthermore, sedation may not eliminate consciousness, and as such LiPuma’s contention that CSD is equivalent to neocortical death is suspect. We not only defend the equivalence thesis, but also expand it to include additional moral considerations. First, we explain the equivalence thesis. This is followed by a defense of the thesis against five criticisms. The third section critiques the current use of CSD. Finally, we offer two proposals that, if adopted, would broaden the use of PAS/E and CSD and thereby expand options at the end-of-life. (shrink)

Gegenwärtig gibt es eine intensive internationale Diskussion zum Stellenwert der Sedierungsbehandlung am Lebensende. Auch in Deutschland sind der grundsätzliche Status und die medizinethische Bewertung palliativer bzw. terminaler Sedierung noch nicht ausreichend geklärt. Der vorliegende Beitrag stellt anhand der Analyse sechs möglicher klinischer Szenarien differenzierte Beispiele für die Situation von Patienten vor einer Sedierungsbehandlung dar. Dazu wird ein Vergleich mit Standardsituationen der Sterbehilfe vorgenommen. Für die moralische Bewertung werden Aktionen und Intentionen der Sedierungsformen unter besonderer Berücksichtigung von Aufklärung und Autonomie diskutiert. (...) Aus Perspektive einer klinisch orientierten Ethik sind eine differenzierte Entscheidungsanalyse, die Form informierter Zustimmung sowie der Ablauf der Sedierungs- und Ernährungsbehandlung von Bedeutung. Eine kritische Debatte zur moralischen Legitimität der Sedierung am Lebensende ist notwendig für die medizinethische Kultur ärztlicher Praxis. (shrink)

While the developers of the “Ixtlan Basic Kit” promise a curative treatment taking advantage of increased neuroplasticity for targeting the underlying neurological causes of Alzheimer's disease and...

The articles in this issue of the Journal of Medicine and Philosophy explore emerging technologies, medical innovations, and shifting moral norms, expanding present discussions around topics in bioethics both old and new. Some question whether novel definitions of death and harm change the moral permissibility of killing, particularly at the hands of a physician. Others question how increased or decreased abilities affect responsibility and achievement. Another illustrates how rhetorical appeals to character have been used to justify otherwise morally illicit actions (...) within the clinic. Together, these articles shed new light on topics in the field of bioethics. (shrink)

In The Abuse of Casuistry Jonsen and Toulmin describe one view of moral reasoning as follows:Those who take a rhetorical view of moral reasoning… do not assume that moral reasoning relies for its force on single chains of unbreakable deductions which link present cases back to some common starting point. Rather, this strength comes from accumulating many parallel, complementary considerations, which have to do with the current circumstances of the human individuals and communities involved and lend strength to our conclusions, (...) not like links to a chain but like strands to a rope or roots to a tree.Whether or not all moral reasoning resembles “strands to a rope,” bioethics testimony certainly does. Bioethics testimony is eclectic, a composite of many loosely woven strands. Rarely, if ever, is bioethics testimony “a chain of unbreakable deductions.” Rarely is it “pure” ethics, much less pure normative ethics. (shrink)

It has long been thought that by using morphine to alleviate the pain of a dying patient, a doctor runs the risk of causing his death. In all countries this kind of killing is explicitly or silently permitted by the law. That permission is usually explained by appealing to the doctrine of double effect: If the use of morphine shortens life, that is only an unintended side effect. The paper evaluates this view, finding it flawed beyond repair and proposing an (...) alternative explanation. It is not the intention of the doctor that counts, but the availability of an “objective” palliative justification. (shrink)

The “doctrine of double effect” has a pleasing ring to it. It is regarded by some as the cornerstone of any sound approach to end-of-life issues and by others as religious mumbo jumbo. Discussions about “the doctrine” often generate more heat than light. They are often conducted at cross-purposes and laced with footnotes from Leviticus.

Die Medikalisierung des Sterbens hat dazu geführt, dass ein „guter Tod“ zunehmend auch von medizinischen Interventionen erwartet wird. Die Möglichkeiten einer „terminalen Sedierung“ bis zum Tode werden von vielen als Ausweg angesehen, wenn bei unerträglichem Leid und aussichtsloser Prognose der Wunsch nach aktiver Sterbehilfe angesprochen wird. Durch eine Sedierung können zwar bei schwerstkranken Patienten schwerste therapierefraktäre Leidenszustände effektiv gelindert werden. Diese Therapieoption kann aber auch in der Absicht angewendet werden, den Todeseintritt medizinisch zu beschleunigen, so dass im Zusammenhang mit der (...) Euthanasiedebatte auch das Thema der terminalen Sedierung kontrovers diskutiert wird. Richtlinien zu Indikation, Technik und Dokumentation sind notwendig, um Stellenwert und Grenzen der terminalen Sedierung im Rahmen der palliativen Betreuung am Lebensende zu verdeutlichen und durch Transparenz Fehlentwicklungen zu vermeiden. (shrink)

The American Journal of Bioethics, Volume 11, Issue 6, Page 48-49, June 2011.

The American Journal of Bioethics, Volume 11, Issue 6, Page 49-51, June 2011.