John Heng, left, and Dr. Bill Sullivan Photos by Michael Swan

Palliative sedation opens whole new ethical can of worms

  • December 1, 2012

Midazolam, administered under the tongue, can put a stop to seizures. It also puts a stop to thinking, awareness, all perception of self, the world, pain, anguish and fear.

Does that make it the perfect solution to the horrors of people dying in pain and spiritual desolation?

Continuous palliative sedation therapy — the practice of administering drugs which reduce consciousness until a terminally ill patient dies — opens up whole new ethical questions, according to Dr. Bill Sullivan, a family physician and bioethicist, and University of Western Ontario philosopher John Heng.

“It’s not an intent to kill the person, but in the cognitive sense it is the end of that person’s life,” Sullivan told a Canadian Catholic Bioethics Institute seminar sponsored by the Order of Malta in October. Sullivan has worked on the 2012 statement of the International Association of Catholic Bioethicists on continuous palliative sedation.

“Reduction of consciousness is a direct effect of the drugs. So you’re harming a natural human good — consciousness,” said Heng.

Palliative sedation should not be confused with euthanasia. The intention is not to kill the patient. But perhaps the ambitions of palliative care should be set a little higher than not killing patients, Heng suggested.

“We must think about what this is doing to the practice of medicine. The hospice movement began as a holistic approach.”

Drugs which keep patients quiet and manageable would seem to create a shortcut to an unobtrusive death. Not only that, managing a sedated patient is relatively cheap. So, Heng asks in whose interest is palliative sedation?

“Life is finite. In this finitude, our goal is to find meaning and hope even at the end of life,” said Sullivan.

Medicine should help patients in their quest for meaning and their sense of connection with others, rather than cutting them off from the world, said Sullivan.

“We are relational beings.”

Of course, unmanaged pain can also cut patients off from everything except the pain. But it’s not always easy to distinguish between physical pain and psychological anguish, and drugs certainly don’t make the distinction.
“Existential suffering is a concern,” Sullivan said. “A pill is just not the proper response.”

The Canadian Society for Palliative Care Physicians adopted a framework for continuous palliative sedation therapy earlier this year.

“The aim or intention of CPST should be the relief of suffering due to refractory and intolerable symptoms and not the sedation itself,” reads the framework published in the Journal of Palliative Medicine. “There should be no intention to shorten life and no intention to bring about complete loss of consciousness, although the latter may sometimes be necessary.”

The Catholic take on this begins with the inherent dignity of human existence, said Heng.

“The intrinsic dignity of people with reduced consciousness is always to be respected,” he said.

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