Ethics Page – Palliative Sedation

ETHICAL CASE ANALYSIS: PALLIATIVE SEDATION

Paulina Taboada, MD, PhD

CASE HISTORY

An 18 year old man with acute lymphoid leukemia (ALL) had a partial response to first line chemotherapy. Complete remission was reached after second line therapy. However, during the consolidation phase, he developed intense headache, associated with nausea and vomiting. Evaluation revealed CNS tumor involvement. Salvage chemotherapy, along with corticosteroids to reduce cerebral edema, did not affect the disease or provide symptom relief.

High dose parenteral opioids were not successful in relieving his severe headache and caused a number of unpleasant side effects. Mild sedation was proposed to the patient and his parents to treat the refractory headache. The patient accepted, but the parents hesitated. They did not like the idea of inducing a state of unconsciousness that would prevent them from communicating with their son during his last days of life. Further ground for their doubts was the eventual need for tube-feeding and a urinary tube and the eventual respiratory problems associated with the state of reduced awareness.

ETHICAL ANALYSIS

Several ethical issues could be analyzed in the above-described clinical situation (e.g. the role of parents in decision-making, proportionality of treatment, etc). Nevertheless, I shall focus my attention on the question whether it is ethically legitimate to deprive a patient from consciousness at the end of life.

Intentionally depriving oneself or another person from consciousness is commonly regarded as morally wrong (e.g., alcoholism or drug-addiction), because awareness is a necessary condition for exercising important human goods (like rationality, freedom, affectivity, communication, etc.). Would it be morally legitimate to intentionally deprive a patient from his ability to exercise autonomy, rationality, communication, etc., especially at the end of life?

In the above described clinical case, the direct goal of therapy is not necessarily to deprive the patient from the use of his ‘mental properties’, but rather to alleviate a severe and refractory symptom (tumor related headache). Hence, if we would have an alternative to alleviate the patient’s headache without inducing unconsciousness, we would certainly choose it. Nevertheless, therapeutic options were exhausted in this case. Hence, we have to deal with a refractory, severe symptom, for which palliative sedation is indicated. IS it ethically right to use therapies that may have simultaneously good and bad effects (in this case, relief of severe, refractory symptoms vs. deprivation of ‘mental properties’)?

Traditionally, the ethical principle of double effect (PDE) has been applied to analyze whether actions that have (or may have) simultaneously both good and bad effects can be ethically justified. This principle states these sorts of actions can be ethically legitimate if the following conditions are simultaneously fulfilled:

1. The action in itself is morally right.
2. The good effects are not caused by the evil effects.
3. Only the good effects are directly intended; the bad effects are not intended but only indirectly tolerated (as unavoidable).
4. There is an adequate proportion between good and bad effects.

In other words, the PDE states that it is ethically wrong to pursue good ends through bad means. Hence, it forbids doctors, for instance, to relieve the distress of dying patients by killing them. But it allows the use of drugs to relieve severe and refractory symptoms, even if this therapy may indirectly produce undesired bad effects, like the deprivation of ‘mental properties’ or the eventual hastening of death.

Applying the requirements of PDE to palliative sedation in the above described clinical situation, we come to the conclusion that it can be actually morally justified. Indeed, the act itself is morally right, as it can be best described as the palliation of severe, refractory symptoms. In other words, the direct intention of this action is to relieve otherwise refractory pain. Thus, sedation is induced here to reduce the patient’s perception of pain and not primarily to deprive him from the exercise of ‘mental properties’. In fact, the loss of ´mental properties’ is tolerated as the necessary effect of a last resort therapeutic tool for pain management. Hence, if there would be another therapeutic option to relieve pain that would preserve consciousness, we would certainly prefer it. But, unfortunately, there is none. Thus, palliative sedation is used here as a last resort pain management therapy and can be therefore justified both from a technical and an ethical point of view.

As concluding remarks, I would like to stress the idea that the use of sedatives and other drugs that negatively affect a patient’s awareness (e.g. opiates) often raise ethical questions among patients, relatives and health care professionals. Indeed, they fear that the occurrence of adverse effects (e.g. respiratory depression, hypotension, unconsciousness, etc.) may hasten the patient’s death. Nevertheless, it is important to remember that an adequate use of sedatives and opiates is usually not associated with respiratory depression and the hastening of death. But even if undesired effects would appear, the indication of these therapies can have a moral foundation if all the conditions of the PDE are simultaneously fulfilled.

PaulinaTaboada,MD,PhD
Director - Center for Bioethics
Pontificia Universidad Catolica de Chile Santiago, Chile