Double effect, and
Rule of Double Effect -- A Critique of Its Role in End-of-Life Decision
Making." The New England Journal of Medicine
-- December 11, 1997 -- Vol. 337, No. 24, by
Timothy E. Quill, M.D., Rebecca Dresser, J.D., and Dan W. Brock.
sedation usually refers to when a consenting patient is sedated to the point
of unconsciousness to relieve otherwise untreatable pain and suffering, and
is then allowed to die of dehydration or other intervening complications.
The goal of administering the sedative, to relieve otherwise unrelievable
suffering, is good. Whether death is intended or merely foreseen is less clear.
Unlike the use of high-dose opioids to relieve pain, with death as a possible
but undesired side effect, terminal sedation inevitably causes death, which
in many cases is what the patient desires. It is for this reason that terminal
sedation has sometimes been called "slow euthanasia." Although the
overall expressed goal of terminal sedation is to relieve otherwise uncontrollable
suffering, life-prolonging therapies are withdrawn with the intent of hastening
to Timothy Quill, terminal sedation would thus not be permitted under the
rule of double effect, even though it is usually considered acceptable according
to current legal and medical ethical standards.
recently has been proposed as an alternative to physician-assisted suicide
persons whose suffering cannot be addressed by standard pain management and
cessation of life support (1-9). In the United States, for
example, the practice of terminal sedation does not require changes in the
law (1-4). The patient is sedated to unconsciousness to
relieve severe physical suffering and is then allowed to die of dehydration
or some other intervening complication. Terminal sedation is ethically considered
to be a combination of aggressive symptom management (sedatives to treat unbearable
symptoms) and withdrawal of life-sustaining therapy (fluids, nutrition, and
other treatments). When considered as an aggregate act, terminal sedation
may be more morally complex and ambiguous than is generally acknowledged (1,
8-10), but many persons who adamantly oppose physician-assisted suicide
find this practice acceptable (11-12 ). The practice differs
from euthanasia in that the dose of medication is maintained but not increased
once sedation is achieved and no subsequent intervention to accelerate death,
such as the introduction of a muscle-paralyzing agent, is given.
Quill TE, Lo B, Brock DW. Palliative options of last resort:
a comparison of voluntarily stopping eating and drinking, terminal sedation,
physician-assisted suicide, and voluntary active euthanasia. JAMA. 1997;278:2099-104.
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care of the terminally ill. N Engl J Med. 1991;327:1678-82.
Cherny NI, Portenoy RK. Sedation in the management of refractory
symptoms: guidelines for evaluation and treatment. J Palliat Care. 1994;10:31-8.
Ventifridda V, Riptamonti C, De Conno F, Tamburini M, Cassileth BR.
Symptom prevalence and control during cancer patients' last days of life.
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Bernat JL, Gert B, Mogielnicki RP. Patient refusal of hydration
and nutrition. An alternative to physician-assisted suicide or voluntary
active euthanasia. Arch Intern Med. 1993;153:2723-8. |
Printz LA. Terminal dehydration, a compassionate treatment. Arch
Intern Med. 1992;152:697-700. | PubMed
7. Miller FG, Meier DE.
Voluntary death: A comparison of terminal dehydration and physician-assisted
suicide. Ann Intern Med. 1998;128:559-62. | PubMed
8. Quill TE. The ambiguity
of clinical intentions. N Engl J Med. 1993;329:1039-40. |
Quill TE, Dresser R, Brock DW. The rule of double effecta critique
of its role in end-of-life decision making. N Engl J Med. 1997;337:1768-71.
10. Billings JA, Block SD.
Slow euthanasia. J Palliat Care. 1996;12:21-30. |
Byock IR. Consciously walking the fine line: thoughts on a hospice
response to assisted suicide and euthanasia. J Palliat Care. 1993;9:25-8.
12. Lynn J, Cohn F, Pickering JH,
Smith J, Stoeppelwerth AM. American Geriatrics Society on physician-assisted
suicide: brief to the United States Supreme Court. J Am Geriatr Soc. 1997;45:489-99.