Ethical Framework of Palliative Sedation: The Principle of Double Effect
The ethical rationale for the use of palliative sedation derives from the
principles of double effect, informed consent, and autonomy, although double
effect is by no means necessary to endorse appropriate and proportionate sedation
to alleviate refractory suffering.
Principle of Double Effect
The doctrine of double effect was developed
by the Roman Catholic church (Quill
1997) and dates back to the Salmanticenses theologians of the 16th and
17th centuries (Walton
2002). However, the greatest credit in modern times for the thorough exposition
of this principle as a norm applicable to the whole field of moral theology
is owed to the Jesuit theologian Jean Pierre Gury.
The principle of double effect is a rule of conduct frequently used to
determine when a person may lawfully and ethically perform an action from
which two effects will follow, one bad, and the other good.
It is applied to situations in which it is impossible to avoid all harmful
actions, helping clinicians decide whether one potentially harmful action is
preferable to another. In fact, double effect was utilized by the Attorney
General of New York in the Vacco v Quill Supreme Court case to support the
state's distinction between assisted suicide and what was then referred to
as terminal sedation (Vacco
v Quill 1997,
Gauthier 2001).
Four Basic Components of the Principle of Double Effect
The nature of the act must be good or morally neutral and not in a category
that is absolutely prohibited or intrinsically wrong.
The intent of the healthcare provider must be good, and while the good
effect and not the bad effect must be intended, the bad effect can before
seen, tolerated, and permitted.
A distinction between means and effects must be envisioned, in that death
must not be the means to the good effect. In other words, the
good effect must be produced directly by the action, not by the bad
effect. Otherwise, the agent would be using a bad means to a good end,
which is never allowed
A proportionality between the good and bad effects must be substantiated
by reason, in that the good effect must exceed or balance the bad effect
(Rousseau
2000, Quill 1997) i.e. the good effect must be sufficiently desirable
to compensate for the allowing of the bad effect.
The principled and ethical use of palliative sedation incorporates the four
conditions that constitute the doctrine of double effect, although some argue
that at times the beneficial intent of the clinician may be unclear and that
whether death is intended or merely foreseen is ambiguous and less clear (Stone
1997).
Factors to be Considered before Instituting Palliative Sedation
Clinician intent
There is a perceived ambiguity of clinicians intent of sedation. Palliative
sedation is appropriate only in situations when the 4 basic conditions
of the “double effect” principle are satisfied (as described
above).
Informed consent
There is a distinct possibility that sedation can also be initiated without
explicit consent of the patient or surrogate: Palliative sedation should
not be instituted without the explicit informed consent of the terminally
ill patient (who is suffering from refractory symptoms) or surrogate. Such
a practice is legally, ethically and morally wrong.
Patient intent
The intent of the patient, like that of the clinician, must also be considered.
Ethical and moral dilemmas may arise when a patient furtively desires a
quick death by requesting palliative sedation; if the patient's intent
is known or suspected, ethical and psychiatric consultations are obligatory
(Rousseau 2000).
Autonomy
Finally, autonomy and informed consent are closely intertwined with double
effect. They allow a reasonable person to make self-directed and personal
treatment choices based upon a truthful and understandable presentation
of information, and they are unquestionably mandatory prior to initiation
of palliative sedation (Rousseau 2000). Both autonomy and informed consent require the patient or surrogate
to have decision making capacity, defined as the ability to receive and
understand information, to deliberate and choose between alternatives,
and to communicate wishes. However, clinicians should be mindful of the
fact that decision making capacity may fluctuate and vary from time to
time, thus encouraging frequent reassessment. Also, decision making capacity
is different than the legally determined attribute of competency (Cowan
2002), and the two terms should not be used interchangeably.
