By Hitoshi Arima

Today, many people spend their final days in a medically induced sleep. According to a survey conducted in Japan, just under 20 percent of people who die from cancer receive some form of sedation.

Patients approaching death may experience extremely severe suffering. For example, a cancerous tumor may invade areas dense with nerves, causing intense pain. Declining lung function can lead to severe shortness of breath. Some patients suffer relentless nausea or violent convulsions, known as myoclonus, as side effects of treatment.

Sedation allows even such patients to become drowsy or to fall into a deeper sleep, easing or eliminating their suffering.

While the relief of suffering is clearly a good thing, a reduction in consciousness is not usually regarded as desirable. Even at the very end of life, diminished consciousness may mean losing the opportunity to speak one last time with loved ones. Things one had hoped for, events one wished to see, and matters one wanted to settle may all become impossible.

Moreover, sedation may not only reduce consciousness but can also eliminate it entirely. Some patients lose consciousness completely and die in that state. These cases are known as continuous deep sedation until death (CDSUD).

Death is often likened to sleep. We speak of dying as falling peacefully asleep or sleeping forever. If one were to fall into a deep sleep without even dreams and never awaken again, that state might, at least from the person’s own perspective, not differ very much from death.

Beyond metaphor, it has also been argued that sedation can in fact bring about death. Sedative drugs such as benzodiazepines and barbiturates, when administered in high doses, can act on the brain’s respiratory center, suppress breathing, and thereby carry a risk of shortening life.

For these reasons, the ethical permissibility of sedation has become a subject of debate. Because sedation can render a person completely unconscious and may even hasten death, some have claimed that the difference between sedation and euthanasia is unclear.

Since the beginning of this century, a growing number of countries and regions have legalized euthanasia. Euthanasia is an act that causes a patient’s death in order to relieve severe suffering, typically in the context of terminal illness. A common method involves administering drugs such as rocuronium—muscle relaxants that eliminate muscular tension and ultimately stop the heart.

One might think that when sedation serves the patient’s interests and accords with the patient’s wishes, there is no reason to prohibit it. However, this line of thought can lead one to think that euthanasia should also be permissible in at least some cases in which sedation is allowed. That conclusion is particularly tempting when a patient’s distress can be relieved only by CDSUD. If completely eliminating the patient’s consciousness through CDSUD can be said to serve the patient’s interests, then euthanasia may likewise appear to do so. Patients who prefer this form of sedation may also see euthanasia as an acceptable alternative.

The same point has been made regarding the relationship between euthanasia and the withholding or withdrawing of life-sustaining treatment. If one thinks that withholding or withdrawing treatment is always permissible whenever it fits with the patient’s wishes and interests, then one is hard pressed to deny that euthanasia can sometimes be justified. In some cases, a patient’s symptoms are so severe that stopping life-sustaining treatment is in the patient’s interests. In such cases, euthanasia may be judged to better serve the patient’s interests, since it brings a painful life to an end more quickly than simply discontinuing treatment. Under these conditions, some patients would also be likely to seek euthanasia.

In short, if respect for patient autonomy and patient benefit were all that mattered, we would be led to permit not only sedation and the withholding or withdrawing of treatment, but euthanasia as well.

In practice, sedation and the withholding or withdrawing of treatment are widely practiced around the world, while euthanasia remains prohibited in many countries. This difference in practice is often regarded as ethically justifiable. Yet citing only the principles of respect for autonomy and beneficence is not sufficient to defend this view. Some other moral principle is needed.

Recently, I published a paper on the ethics of sedation. In that paper, I examined the extent to which sedation can be justified under a moral rule known as the doctrine of double effect (DDE).

The DDE says that we should not intend to cause someone’s death. But it also allows us to do things that we know will cause someone’s death, as long as causing the death is not among our intentions.

The DDE has long been seen as especially valuable in discussions of end-of-life ethics, because it is thought to justify allowing some forms of sedation and the withholding or withdrawing of life-sustaining treatment, while still categorically prohibiting euthanasia.

Sedation, foregoing treatment, and euthanasia all carry a risk of shortening a patient’s life in exchange for stopping suffering. Still, these practices are commonly understood to differ in important ways. In the case of sedation or withholding treatment, doctors are generally taken—and usually take themselves—to be aiming only to relieve suffering, with any shortening of life seen as a side effect. By contrast, doctors who perform euthanasia are almost always understood, and would typically acknowledge, that they aim to shorten a person’s life.

The DDE distinguishes between actions in which one intends to cause a person’s death and actions in which death occurs without being intended. The former are prohibited, whereas the latter may sometimes be permitted. Accordingly, if it is correct that death is not intended in cases of sedation or the withholding or withdrawal of treatment, but is intended in cases of euthanasia, then the DDE allows us to reject euthanasia outright while still allowing some cases of sedation and the withholding or withdrawal of treatment.

Although more and more countries have legalized euthanasia in recent years, most countries still prohibit it. Many people want to clarify how far sedation and the withholding or withdrawal of treatment can be allowed while holding on to the view that euthanasia should never be permitted. People with this concern will naturally be interested in whether the DDE is sound and in what it implies in practice. I am one of them.

My paper concluded that one form of sedation practice, which I called double-effect sedation, often fails to be justified under the DDE, despite being widely regarded as permissible. This paper forms part of my broader personal research agenda, in which I apply the DDE to a range of end-of-life issues. In an earlier paper, I made a similar argument about a different form of sedation practice, which I called gradual CDS (continuous deep sedation). Although it too is widely regarded as justifiable under the DDE, I argued that it is unjustifiable in most cases. Furthermore, in a very recent paper published in another journal, I applied the DDE to the withholding and withdrawal of treatment. There, despite objections from some critics, I concluded that withholding and withdrawing treatment can be justified under the DDE across a fairly wide range of cases.

These conclusions may be disappointing to those who accept the current widespread use of sedation. However, the conclusions should be understood as the result of an attempt to develop a consistent and plausible way of thinking about the ethics of euthanasia, withholding or withdrawing treatment, and sedation together. I believe that if we continue to maintain a categorical prohibition of euthanasia, we must also conclude that some forms of sedation currently in practice cannot be justified.

Author: Hitoshi Arima

Affiliation: Yokohama City University

Competing Interests: None to Declare