The principle of double effect in palliative sedation

Abstract

Clinical advancements in the use of opioid analgesia regimens have proven to be successful for the management of pain in most terminally ill patients. Clinicians however claim that there is still a small percentage of palliative patients who suffer intractable pain at the end stages of life. It is believed that these exceptional cases of pain would benefit from palliative sedation. While palliative sedation is indeed effective to manage intractable pain, bioethicists have pointed out that sedation poses a threat to the patient with qualities akin to ‘slow euthanasia’ and ‘physician assisted death’. Furthermore, the Principle of Double Effect has been the primary lens through which the practice of terminal sedation has been evaluated, and whilst some believe that the practice can be justified by this Principle, many bioethicists believe that this is not possible. Using a deductive and critical approach, literature on the application of the principle of double effect in palliative sedation has been appraised. From this appraisal, two fundamental problems have been unearthed. First there is the difficulty of determining clinician’s intention in the ‘foreseen but not intended’ quality of the Double Effect. This is a problem in the application of the principle even beyond its application to palliative sedation. Secondly, there is a problem in the sequencing of cause and effect, as several invasive clinical actions in palliative sedation can be construed as ‘causing harm’ a priori the positive effect of pain relief and the foreseen but not intended possibility of death. This sequencing of evil actions preceding any good and bad effects is not ethically justified by the Doctrine. Nevertheless, ethicists do not preclude the use of palliative sedation for rare and extreme cases of intractable pain. Alternative moral principles have been explored in support of palliative sedation for when there are no alternatives, and a proportionally grave need for this resolve.