Patients who are imminently dying sometimes experience symptoms refractory to traditional palliative interventions, and in rare cases, continuous sedation is offered. Samuel H. LiPuma, in a recent article in this Journal, argues that continuous sedation until death is equivalent to physician-assisted suicide/euthanasia based on a higher brain neocortical definition of death. We contest his position that continuous sedation involves killing and offer four objections to the equivalency thesis. First, sedation practices are proportional in a way that physician-assisted suicide/euthanasia is not. (...) Second, continuous sedation may not entirely abolish consciousness. Third, LiPuma’s particular version of higher brain neocortical death relies on an implausibly weak construal of irreversibility—a position that is especially problematic in the case of continuous sedation. Finally, we explain why continuous sedation until death is not functionally equivalent to neocortical death and, hence, physician-assisted suicide/euthanasia. Concluding remarks review the differences between these two end-of-life practices. (shrink)

The American Journal of Bioethics, Volume 11, Issue 6, Page 62-64, June 2011.

The use of terminal sedation to control theintense discomfort of dying patients appearsboth to be an established practice inpalliative care and to run counter to the moraland legal norm that forbids health careprofessionals from intentionally killingpatients. This raises the worry that therequirements of established palliative care areincompatible with moral and legal opposition toeuthanasia. This paper explains how thedoctrine of double effect can be relied on todistinguish terminal sedation from euthanasia. The doctrine of double effect is rooted inCatholic moral casuistry, but (...) its applicationin law and morality need not depend on theparticular framework in which it was developed. The paper further explains how the moral weightof the distinction between intended harms andmerely foreseen harms in the doctrine of doubleeffect can be justified by appeal to alimitation on the human capacity to pursue good. (shrink)

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

In its October 2001 issue, this journal published a series of articles questioning the Whole-Brain-based definition of death. Much of the concern focused on whether somatic integration - a commonly understood basis for the whole-brain death view - can survive the brain's death. The present article accepts that there are insurmountable problems with whole-brain death views, but challenges the assumption that loss of somatic integration is the proper basis for pronouncing death. It examines three major themes. First, it accepts the (...) claim of the "disaggregators" that some behaviors traditionally associated with death can be unbundled, but argues that other behaviors (including organ procurement) must continue to be associated. Second, it rejects the claims of the "somaticists," that the integration of the body is critical, arguing instead for equating death with the irreversible loss of "embodied consciousness," that is, the loss of integration of bodily and mental function. Third, it defends higher-brain views against the charge that they are necessarily "mentalist," that is, that they equate death with losing some mental function such as consciousness or personhood. It argues, instead, for the integration of bodily and mental function as the critical feature of human life and that its irreversible loss constitutes death. (shrink)

Susan D. McCammon and Nicole M. Piemonte offer a thoughtful and thorough commentary on our manuscript entitled “Expanding the use of Continuous Sedation Until Death.” In this reply we attempt to clarify and further defend our position. We show how continuous sedation until death is not a “first resort” but rather a legitimate option among many that should available to terminally ill patients whose life expectancy is less than six months. We also attempt to show that we do not equivocate (...) the meaning of palliative care as the commentators suggested. We argue that the traditional notion of palliative care should move beyond relief of “experienced suffering” to relief of potential suffering for those whose life expectancy is less than six months. Lastly, we challenge the commentator’s position that the realm of ordinary medicine” should be the guide to care, by showing how the notion of ordinary medicine has been successfully challenged in both bioethical scholarship and the courts in a way that shows ordinary medicine to be an evolving concept rather than a static, universal guide. (shrink)

The relatively new practice of continuous sedation at the end of life (CS) is increasingly being debated in the clinical and ethical literature. This practice received much attention when a U.S. Supreme Court ruling noted that the availability of CS made legalization of physician-assisted suicide (PAS) unnecessary, as CS could alleviate even the most severe suffering. This view has been widely adopted. In this article, we perform an in-depth analysis of four versions of this ?argument of preferable alternative.? Our goal (...) is to determine the extent to which CS can be considered to be an alternative to PAS and to identify the grounds, if any, on which CS may be ethically preferable to PAS. (shrink)

The American Journal of Bioethics, Volume 11, Issue 6, Page 43-44, June 2011.

Recently both whole brain death (WBD) and higher brain death (HBD) have come under attack. These attacks, we argue, are successful, leaving supporters of both views without a firm foundation. This state of affairs has been described as “the death of brain death.” Returning to a cardiopulmonary definition presents problems we also find unacceptable. Instead, we attempt to revive brain death by offering a novel and more coherent standard of death based on the permanent cessation of mental processing. This approach (...) works, we claim, by being functionalist instead of being based in biology, consciousness, or personhood. We begin by explaining why an objective biological determination of death fails. We continue by similarly rejecting current arguments offered in support of HBD, which rely on consciousness and/or personhood. In the final section, we explain and defend our functionalist view of death. Our definition centers on mental processing, both conscious and preconscious or unconscious. This view provides the philosophical basis of a functional definition that most accurately reflects the original spirit of brain death when first proposed in the Harvard criteria of 1968. (shrink)

As currently practiced, the use of continuous sedation until death (CSD) is controlled by clinicians in a way that may deny patients a key choice in controlling their dying process. Ethical guidelines from the American Medical Association and the American Academy of Pain Medicine describe CSD as a “last resort,” and a position statement from the American Academy of Hospice and Palliative Medicine describe it as “an intervention reserved for extreme situations.” Accordingly, patients must progress to unremitting pain and suffering (...) and reach a last-resort stage before the option to pursue CSD is considered. Alternatively, we present and defend a new guideline in which decisionally capable, terminally ill patients who have a life expectancy of less than six months may request CSD before being subjected to the refractory suffering of a treatment of “last resort.”. (shrink)