Sedation Archives - Protection of Conscience Project Library

(Editorial) A right to be unconscious

Julian Savulescu, Janet Radcliffe-Richards

Extract
[Referring to Sinmyee et al] This seems to us to be an important, landmark paper. This is because the issues it addresses are important in their own right: how to ensure death without suffering in jurisdictions where assisted dying (including assisted suicide or euthanasia) is allowed, and also, because the technicalities are the same, in cases of capital punishment by lethal injection. Moreover, the paper shows the potential for the use of anaesthesia in contexts beyond surgery. Anaesthesia in its ordinary uses is intended to facilitate surgery designed to restore a patient to improved health and functioning. In assisted dying, however, there is no question of restoring health. The proposition is to use anaesthesia primarily to prevent suffering in a patient who is about to die and, in this sense, places anaesthesia on a new footing as a primary medical intervention, serving a purpose in its own right. . .

Savulescu J, Radcliffe-Richards J. A right to be unconscious. Anaesthesia. 2019 May; 74(5): 557-559

Weakening the ethical distinction between euthanasia, palliative opioid use and palliative sedation

Thomas David Riisfeldt

Abstract
Opioid and sedative use are common ‘active’ practices in the provision of mainstream palliative care services, and are typically distinguished from euthanasia on the basis that they do not shorten survival time. Even supposing that they did, it is often argued that they are justified and distinguished from euthanasia via appeal to Aquinas’ Doctrine of Double Effect. In this essay, I will appraise the empirical evidence regarding opioid/sedative use and survival time, and argue for a position of agnosticism. I will then argue that the Doctrine of Double Effect is a useful ethical tool but is ultimately not a sound ethical principle, and even if it were, it is unclear whether palliative opioid/sedative use satisfy its four criteria. Although this essay does not establish any definitive proofs, it aims to provide reasons to doubt—and therefore weaken—the often-claimed ethical distinction between euthanasia and palliative opioid/sedative use.

Riisfeldt TD. Weakening the ethical distinction between euthanasia, palliative opioid use and palliative sedation. J Med Ethics 2019;45:125-130.

Euthanasia and Palliative Sedation in Belgium

Raphael Cohen-Almagor, E Wesley Ely

Abstract
The aim of this article is to use data from Belgium to analyse distinctions between palliative sedation and euthanasia. There is a need to reduce confusion and improve communication related to patient management at the end of life specifically regarding the rapidly expanding area of patient care that incorporates a spectrum of nuanced yet overlapping terms such as palliative care, sedation, palliative sedation, continued sedation, continued sedation until death, terminal sedation, voluntary euthanasia and involuntary euthanasia. Some physicians and nurses mistakenly think that relieving suffering at the end of life by heavily sedating patients is a form of euthanasia, when indeed it is merely responding to the ordinary and proportionate needs of the patient. Concerns are raised about abuse in the form of deliberate involuntary euthanasia, obfuscation and disregard for the processes sustaining the management of refractory suffering at the end of life. Some suggestions designed to improve patient management and prevent potential abuse are offered.

Cohen-Almagor R, Ely EW. Euthanasia and Palliative Sedation in Belgium. BMJ Supportive Palliative Care. 2018 Jan 04;8(3):307-313.

To Die, to Sleep: US Physicians’ Religious and Other Objections to Physician-Assisted Suicide, Terminal Sedation, and Withdrawal of Life Support

Farr A Curlin, Chinyere Nwodim, Jennifer L Vance, Marshall H Chin, John D Lantos

American Journal of Hospice and Palliative Care

Abstract
This study analyzes data from a national survey to estimate the proportion of physicians who currently object to physician-assisted suicide (PAS), terminal sedation (TS), and withdrawal of artificial life support (WLS), and to examine associations between such objections and physician ethnicity, religious characteristics, and experience caring for dying patients. Overall, 69% of the US physicians object to PAS, 18% to TS, and 5% to WLS. Highly religious physicians are more likely than those with low religiosity to object to both PAS (84% vs 55%, P < .001) and TS (25% vs 12%, P < .001). Objection to PAS or TS is also associated with being of Asian ethnicity, of Hindu religious affiliation, and having more experience caring for dying patients. These findings suggest that, with respect to morally contested interventions at the end of life, the medical care patients receive will vary based on their physicians’ religious characteristics, ethnicity, and experience caring for dying patients.

Curlin FA, Nwodim C, Vance JL, Chin MH, Lantos JD. To Die, to Sleep: US Physicians’ Religious and Other Objections to Physician-Assisted Suicide, Terminal Sedation, and Withdrawal of Life Support. American J Hospice & Pall Care. 2008;25(12):112-120.

The Proper Place of Values in the Delivery of Medicine (Conscience in Medicine)

Julian Savulescu

Extract
Physicians who fail to act in their patient’s interests breach the fundamental duty of care of a physician. It is negligent to deny a person who would benefit a blood transfusion, a vaccination, an abortion, intensive care or sedation at the end of their life. Physicians should not play God. If they morally disagree with some medical treatment, they can give their reasons to their patients and they can take that debate to the level of law and professional bodies. But in a liberal society they should not inflict their judgments on their patients. Physicians can disagree, but they should not dictate.

Savulescu J. The Proper Place of Values in the Delivery of Medicine (Conscience in Medicine). Am J Bioeth. 2007 Dec 19;21-22.

Palliative Care and Euthanasia: Belgian and Dutch Perspectives

Bert Broeckaert, Rien Janssens

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In the first part of this article the input of palliative care organisations in the Dutch euthanasia debate is described and explained by situating it in its broader context. First opinions on euthanasia of a variety of palliative care organisations are described. Secondly the Dutch debate on palliative care and euthanasia is analysed and evaluated. In a second part of this article a brief introduction to Belgian palliative care is given. This introduction is followed by an overview of the way organised palliative care has been active in the Belgian euthanasia debate. Attention too is given to the Belgian discussion on palliative sedation, sedation being presented by some as the palliative alternative to euthanasia but seen by others as nothing but euthanasia in disguise

Broeckaert B, Janssens R. Palliative Care and Euthanasia: Belgian and Dutch Perspectives. Ethical Perspectives 9(2-3); 2002 Feb 01, 156-175

Conscience clause: moral compromise

Chris Thatcher

Extract
Ask your pharmacist: It’s the ubiquitous slogan of the past decade, underscoring the campaigns of most national and provincial pharmacy organizations as they promote the value of pharmacy services. But what if the question is about RU-486, the abortion drug, or Preven, the morning-after-pill? What if the question is from a physician seeking information on terminal sedation or assisted suicide?

Such questions push, and often breach, an ethical boundary for some pharmacists, who find their desire to help the patient in conflict with their moral convictions. And the ethical quagmire is likely to get deeper as advocacy groups press the federal government to allow physician-assisted suicide and various health organizations promote greater access to emergency postcoital contraception.

If these practices compromise your moral convictions, could you be fired by your employer for refusing to fill a prescription? More specifically, is there a point at which your personal beliefs supersede your obligation to the patient? That’s the difficult question posed by an Alberta-based group called Concerned Pharmacists for Conscience, which has suggested a conscience clause to protect pharmacists in such situations.

Thatcher C. Conscience clause: moral compromise. Can Pharm J. 1999;132(7):10-11

The Nurse’s Appeal to Conscience

Ellen W Bemal, Patricia S Hoover

Abstract
A case is presented in which a registered nurse caring for a 63-year-old patient in severe pain from terminal cancer disagrees with the attending physician’s order of morphine for fear that it will hasten the patient’s death. The nurse finds herself on duty alone one night when the patient and her daughter request more morphine. Bernal and Hoover contend that, because the nurse apparently took no prior action to explore alternative courses of pain relief for the patient or to make other arrangements for care, her duty of care overrides her appeal to conscience in the immediate situation. Aroskar believes that the nurse in this situation must give the injection, find someone else who can, or contact the physician. She holds, however, that nurses should be allowed to refuse to carry out particular procedures based on an appeal to personal conscience if the decision is founded on accurate information, acceptance of consequences, and advance planning.

Bemal EW, Hoover PS. The Nurse’s Appeal to Conscience. Hastings Cent Rep. 1987;25-26. Available from: