Palliative Care

The main causes to request physician assisted suicide among terminally ill patients according to cohort study conducted in Switzerland, were 56.7% cancer, nervous system causes 20.6%, and mood disorder (mental or behavioral disorder) 2.8%, among terminally ill patient who aged (25-64 years), compared with terminally ill patients who aged (65-94 years) cancer 40.8%, circulatory 15.2%, and nervous system causes 11.3% [7]. The Hippocratic Oath includes the unambiguous statement “I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan” [8]. An argumentative assay is a writing method, challenging communication task that calls upon sophisticated cognitive and linguistic abilities, where the writer takes a position and tries to convince the reader to perform an action or to adopt a point of view regarding a controversial issue [9]. Therefore, the aim of this paper is to create an argumentative essay to argue the use of physician assisted suicide for terminally ill patients as a last resort to end their suffer and end their life, while taking the legal and ethical points of view of opponents and proponents into consideration.Palliative Care And Assisted Suicide Essay

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Physician assisted suicide defines as “knowingly and intentionally providing a person with the knowledge or means or both required to commit suicide, including counseling about lethal doses of drugs, prescribing such lethal doses or supplying the drugs” [10]. Physician assisted suicide is considered the most controversial end of life practice according to its ethical acceptability and the desirability of legalization [11]. Netherlands’s physicians have applied physician assisted suicide since 1977, then it has done legally since 1992 [12]. Also, Oregon legalized physician assisted suicide in 1997 [13]. According to Oregon’s Death with Dignity Act, the patient who request physician assisted suicide should be; an adult with 18 years old or more, capable to make and communicate the health decision, diagnosed with terminal illness that will lead to death within six months, and an Oregon resident [14]. The purpose of this literature review is to discuss the opponent’s and proponent’s points of view related to physician assisted suicide, from the legal and ethical sides.Palliative Care And Assisted Suicide Essay

Legal Arguments
Opponents

Physician assisted suicide is illegal in china under Article 232 “whoever intentionally commits homicide shall be sentenced to death, life imprisonment or fixed term imprisonment of not less than 10 years; if the circumstances are relatively minor, he shall be sentenced to fixed-term imprisonment of not less than 3 years but not more than 10 years”, and Article 233 “whoever negligently causes death to another person shall be sentenced to fixed-term imprisonment of not less than 3 years but not more than 7 years; if the circumstances are relatively minor, he shall be sentenced to fixed-term imprisonment of not more than 3 years, except as otherwise specifically provided in this Law” of the Criminal Law of People’s Republic of China [15].Palliative Care And Assisted Suicide Essay

In Turkey, physician assisted suicide is illegal under Article 84 any person who commits, helps, supports, or encourages a person for suicide is punched with imprisonment from 2-5 years [16]. In United Kingdom, assisted suicide is also illegal under Suicide Act 1961 [17]. In Jordan, physician assisted suicide is not of the physician duties according to article number 3 “it is not permissible to terminate the life of a patient who is suffering from incurable and insurmountable disease and whether accompanied by pain, either directly or indirectly, except brain death, according to the scientific conditions approved by the Medical Association” [18].

Proponents

Physician assisted suicide has been legalized in Switzerland since 1942 and is accessible for noncitizens, and according to swizz law assisting suicide is punishable just if done for “whoever, from selfish motives, induces another to commit suicide or assists him therein shall be punished, if the suicide was successful or attempted, by confinement in a penitentiary for not more than five years or by imprisonment” article 115 of the penal code of Switzerland [19]. In 1994 voters in Oregon approved the Death with Dignity Act, which allowing a physician to prescribe a lethal dose that self-administers voluntarily by the terminally ill patient, the patient and the physician who follow the requirements of the act are protected from criminal prosecution [20].Palliative Care And Assisted Suicide Essay

In 2008, Washington Death with Dignity Act passed with the same to Oregon law [21]. Also in 2013, Vermont Patient Choice and Control at the End of Life Act has been in effect [22,23]. In 2016, California’s physician assisted dying law took effect according to the End of Life Option Act [24]. Also, in Finland, is not a crime and connected to end of life care [24].

Ethical Arguments
Opponents

The ethical principles of beneficence (working to achieve the patient’s best interest), nonmaleficence (avoidance of harm), patient autonomy respect, as well as promotion of justice and fairness (American College of Physicians Ethics, Professionalism, and Human Rights Committee, 2013). Both of the profession and ethical traditions emphasize care and comfort, and physician shouldn’t intentionally participate in ending a person’s life [25].Palliative Care And Assisted Suicide Essay

Proponents

Some patients may get benefit from physician assisted suicide, and for dying patients, the motivation for requesting physician assisted suicide may not be physical pointless suffering but loss of autonomy (97.2%), in ability to engage in enjoyable activities (88.9%), loss of dignity (75%) [26]. Dying process could be beneficial in order to spiritual and existential healing through relational and personal wholeness growth, also individual learning process for the patients, their families, and those who caring for them [27].Palliative Care And Assisted Suicide Essay

Argumentative Statement

Physician assisted suicide is inconsistent with some of ethical principles such as nonmaleficence. Similarly, in laws of many countries physician assisted suicide is illegal. Therefore, the author refutes the use of physician assisted suicide for terminally ill patients in order to end their suffering and end their life, and use palliative care instead it.

Legal Defense

According to the position of the American Medical Association physician assisted suicide is fundamentally inconsistent with the physician’s professional role, their position consistent to the medical constitution and duties of the physician and profession in Jordan. Physician assisted suicide for terminally ill patients is illegal in many countries (Figure 1). In Oregon, the incidence of physician assisted suicide has been increased from 0.6 in 1000 deaths to 3 in 1000 deaths in 1998 and 2014 respectively [28].Palliative Care And Assisted Suicide Essay

palliative-care-medicine-Euthanasia
Figure 1: Euthanasia and Physician Assisted suicide (PAS) around the World.

Ethical Defense

In the last revised of The International Code of Medical Ethics in the section which under the name of duties of physicians to patients states that “A physician shall always bear in mind the obligation to respect human life” [29]. Also, patient autonomy must be respect from physician but also must be balanced with other ethical principles [30]. From the religious perspectives, physician assisted suicide is morally wrong as it showed clearly in the Holy Quran in Surah 5-ayah 32 (AlMaeda) “That was why We wrote for the Children of Israel that whoever killed a soul, except for a soul slain, or for sedition in the earth, it should be considered as though he had killed all mankind; and that whoever saved it should be regarded as though he had saved all mankind. Our Messengers brought those proofs, then many of them thereafter commit excesses in the earth by the Catechism of the Catholic Church, “God is the creator and author of all life.”Palliative Care And Assisted Suicide Essay

Physician assisted suicide is associated with female gender with situations indicate emotional vulnerability such as living alone, and being divorced [7]. Which may explain the large increase in physician assisted suicide incidence of 3 in 1000 deaths to 11 in 1000 deaths found in 2001 and 2013 respectively [31]. Furthermore, terminally ill patients with depression in Oregon have obtained prescriptions for lethal medication [32]. Also physician assisted suicide has been associated with 6.3% increase in the total suicide rates in the US [33]. All these information may indicate malpractice related to physician assisted suicide. Palliative care is intended to im prove the quality of life of patients diagnosed with an incurable life-limiting illness and their families, that offered by a multidisciplinary team [34]. Palliative care is available in many countries around the world, especially those that legalized the use of physician assisted suicide (Figure 2).Palliative Care And Assisted Suicide Essay

palliative-care-medicine-Palliative-care
Figure 2: Palliative care world map.

According to a study conducted in US in 2015 about palliative care and use it among terminally ill patients, they found that 90% of US people don’t know about palliative care, after told the definition, more than 90% say they would request it for themselves and for their family members in such cases [35].

Therefore, the author composed the following recommendations related to use of palliative care for terminally ill patients instead of physician assisted suicide:

• Palliative care is a crucial medical option for treating symptoms among terminally ill patients, which also could extends to their families.

• Improve and develop palliative care programs and target vulnerable patients or groups (uninsured, the poor and elderly people).Palliative Care And Assisted Suicide Essay

• Adequate services related to palliative care must be made available in all setting where terminally ill patients received care.

• Respect competent patient’s right to accept or reject any medical care.

• Investment to improve and develop palliative care and end-of-life care through research and training.

• Conducting courses and seminars to educate patients’ families about possible options which available in palliative care, in order to increase public awareness about palliative care options.

In addition, palliative care can address a broad range of issues, integrating an individual’s and family’s specific needs such as; emotions which accompanies the disease journey, spiritual needs, and practical needs (advance directive).

Summary and Conclusion
The purpose of this paper was to create an argumentative essay to refute the use of physician assisted suicide for terminally ill patients as a last resort to end their suffer and end their life, while taking the legal and ethical points of view of opponents and proponents into consideration, and use palliative care instead it [36-38].Palliative Care And Assisted Suicide Essay

Physician assisted suicide for terminally ill patients is a controversial issue, with a lot of ethical, legal, and moral concerns. In the light of material covered above, we against the use of physician assisted suicide to end patients suffering, instead of that palliative care can provide wide range of care for those patients as well as their families. So that there are need to improve and develop palliative care programs, also increase organizational and societal awareness about palliative care options for terminally ill patients.

Palliative care services are expanding rapidly around the globe.1 Tens of millions
of individuals worldwide are affected by life-threatening illnesses (such as HIV/AIDS
and cancer) that cause them immense suffering and economic hardship. The majority of
cases occur in the developing world, where accessibility to adequate treatment is
frequently scarce.2 The practice of palliative care has thus become increasingly  Palliative Care And Assisted Suicide Essay
recognized as a legitimate area of expertise in modern biomedicine, and specialists in the
field continue to endeavor to establish a concrete evidence-base for their practice. Indeed,
several major centers have now been dedicated to palliative care research and education,
and the number of countries in which palliative care services are currently operative
transcends eighty. As a result, “hospice care”
3 has evolved into a global field of work
concerned with dying individuals and others facing life-threatening illness.4

1. Henk ten Have and David Clark, “Introduction: The Work of the Pallium Project,” in The
Ethics of Palliative Care: European Perspectives, ed. Henk ten Have and David Clark (Philadelphia: Open
2. Cecelia Sepúlveda, Amanda Marlin, Tokuo Yoshida, and Andreas Ullrich, “Palliative Care: The
World Health Organization’s Global Perspective,” Journal of Pain and Symptom Management 24, no. 2
(August 2002): 91-96; see especially p. 91.
3. “Terminal care,” which began in the 1950s and 1960s, later paved way for the “hospice care”
movement. See ten Have and Clark, “Introduction,” 1-12; see especially p. 1.
4. ten Have and Clark, “Introduction,” 1-12; see especially p. 1
Palliative care encompasses a broad range of activities, including pain
management, the deployment of multidisciplinary medical teams, and attention to
psychological, social, and spiritual concerns. While the focus of palliative care is
undoubtedly grounded in some of the oldest aspects of medicine, it also constitutes a
particularly modern development, which has made significant progress in a short time.
Although palliative care centers on the universal human experience of suffering, the
manner of its organization differs significantly from one context to another. In several of
the countries that have adopted palliative care programs, some of the issues facing health
care are held in common. Among these are morally ambiguous medical interventions that
aim to ameliorate pain and suffering associated with the burden of chronic illness, where
the possibilities of cure are slim to none.
1.2 Analytical Method
A persistent misunderstanding of the moral distinctions between the practices of
euthanasia, assisted suicide, and palliative sedation suggests a critical need to revisit the
relationship each shares with licit medical practice in the context of palliative care. To
that end, this essay grounds its arguments in two, straightforward premises: (i) the
licitness of medical practice is largely determined by the balance between (a) good ends,
(b) proportionate means, (c) appropriate circumstances, and (d) benevolent intentions;
and (ii) whereas palliative sedation employs criteria A-D (above), both euthanasia and
assisted suicide fail to secure criteria A-C. Drawing from this syllogism, the aim and
proposal of this essay is to examine the logic inherent to the practices of euthanasia,
assisted suicide, and palliative sedation in the context of palliative care with the intention
of positing the argument that while palliative sedation fulfills the requirements of morally  Palliative Care And Assisted Suicide Essay
licit medical practice – and so successfully executes the tenets of sound ethical logic –
both euthanasia and assisted suicide do not.
To secure the justification of this thesis, the essay will move in three parts. First, it
will address the ontology of palliative care, including a specific analysis of the goals of
palliative care and the proposal of palliative care as a fundamental human right. Second,
it will address the practices of euthanasia and assisted suicide, including a specific
analysis of the definitions and clinical comparisons of each, as well as the moral
arguments against the respective practices. Finally, it will address sedation to
unconsciousness in palliative care, including a specific analysis of the function of
palliative sedation and the ethical justification of palliative sedation as a licit medical
practice.
2. THE ONTOLOGY OF PALLIATIVE CARE
2.1 The Goals of Palliative Care
While various conceptions exist regarding the best “way” to conclude life, this
essay proposes that the goal of palliative care is primarily to ensure that patients are able,
insofar as possible, to live their death well. When referring to a “good death” as opposed
to a “good life,” it is necessary to clarify which characteristics make for a good death,
since the conception of palliative care employed herein includes some period of life. It
seems obvious that “death” refers to at least one of three diverse and consecutive
scenarios. Wim Dekkers and colleagues identify these scenarios as “the process of
dying,” “the event of death,” and “the state of death.”5 Hence, procuring a good death Palliative Care And Assisted Suicide Essay
that resonates with the aims of palliative care may refer to the whole enterprise of
scenarios or to any one of them, and must therefore take into account any complications
that may occur in the event of overlap.6
Dekkers and colleagues identify two cardinal goals of a good death (a peaceful
death, and a death occurring in one’s sleep), yet the latter can be logically subsumed
under the former.7 In this light, practicing palliative care involves ensuring that patients
are able not only to live their death, but also that they are able to do so peacefully. The
primary reason to focus on peacefulness as an explicit goal of palliative care practice is
that, while assuredly abstract, the idea transcends time and culture. The notion of peace in
the context of death has perhaps been communicated best by Daniel Callahan. For
Callahan, a peaceful death is marked by acceptance rather than fear,8 and takes place,
insofar as possible, in the presence of loved ones who are able to offer comfort, support,
and compassion.9 In this way, the goals of palliative care blend personal, medical, and
social strands of morality.10
2.2 Palliative Care as Human Right
Palliative care providers across the globe have become increasingly concerned
that the expansion and support of palliative care services for patients facing diagnoses of
life-threatening illnesses are not receiving adequate attention or commitment from health
policy makers. This has led to a growing call for palliative care to be accepted as a
fundamental human right, and for obligations that flow from that right to be fulfilled –
namely, global access to palliative care services for all patients who would benefit from
its availability. The rationale underlying this call has been clearly delineated by F.
Brennan, who considers the foundation of the right to palliative care with regard to the
International Covenant on Economic, Social and Cultural Rights (ICESR), the obligation
of signatory nations, and the difficulties crossed in the promotion of palliative care as a
human right to be respected.11 While the promotion of palliative care as a human right is
axiomatic to palliative care workers, it remains necessary to develop a further an
5. Wim Dekkers, Lars Sandman, and Pat Webb, “Good Death or Good Life as a Goal of Palliative
Care,” in The Ethics of Palliative Care: European Perspectives, ed. Henk ten Have and David Clark
(Philadelphia: Open University Press, 2002), 106-25; see especially pp. 108, 110-11.
6. Dekkers et al., “Good Death or Good Life,” 106-25; see especially p. 111.

NOW

7. Dekkers et al., “Good Death or Good Life,” 106-25; see especially p. 114-19.
8. That is, fear in the presence of excessive pain and suffering. See Dekkers et al., “Good Death or
Good Life,” 106-25; see especially pp. 115-16.Palliative Care And Assisted Suicide Essay
9. See Dekkers et al., “Good Death or Good Life,” 106-25; see especially pp. 115-16.
10. Dekkers et al., “Good Death or Good Life,” 106-25; see especially pp. 117.
11. Liz Gwyther, Frank Brennan, Dip Obs, and Richard Harding, “Advancing Palliative Care as a
Human Right,” Journal of Pain and Symptom Management 38, no. 5 (November 2009): 767-74; see
especially p. 768.
understanding of the rights instruments whereby palliative care might become accessible
at both the local and international level.12
Both palliative care and human rights are founded on the principles of dignity and
universality, including nondiscrimination. Included in the General Comments13 of the
ICESR is the directive to attend to and care for “chronically and terminally ill persons,
sparing them avoidable pain and enabling them to die with dignity.”14 Hence, palliative
care is already articulated as a human right within the International Bill of Rights.15 At
both the local and international level, several strategies are available.16 First, discussing
the aforementioned documents with government and health officials would alert them to
the need to develop specific palliative care policies. Second, palliative care organizations
could assist their governments to comply with their obligations to provide health care in
the context of palliative care, including policy development, opioid law reform, and
providing adequate palliative care education.17
3. EUTHANASIA AND ASSISTED SUICIDE
3.1 Definitions and Clinical Comparisons
The practices of euthanasia and assisted suicide are complex topics that present
serious moral challenges in contemporary biomedicine. In principal, however, both
opponents and proponents of each practice agree that requests for euthanasia and assisted
suicide are frequently the result of tragic situations. Hence, the prevention of these
requests has become of interest, and this has allowed palliative care to play a critical role
in the solution. However, even in hospices and palliative care units, requests for
euthanasia and assisted suicide remain. With regard to the former, since there is much
confusion in the palliative care literature surrounding the concept of euthanasia, a critical
distinction can be made to uncover the ethical aspects of the practice.18 The distinction
concerns “passive” versus “active” forms of euthanasia. The passive form indicates the
positive action of allowing a patient die by foregoing necessary life-sustaining

12. Gwyther et al., “Advancing Palliative Care,” 767-74; see especially pp. 767-68.
13. The specific Comment is no. 14, in the section concerning the care of older persons. See
Gwyther et al., “Advancing Palliative Care,” 767-74; see especially pp. 769-70.Palliative Care And Assisted Suicide Essay
14. Gwyther et al., “Advancing Palliative Care,” 767-74; see especially pp. 769-70. Quotation
from p. 770.
15. However, these articulations – powerful as they are – do not prevent barriers to access,
including availability, acceptability, and quality. Several factors can be identified as the underlying source
of these barriers: lack of political support and awareness, sociocultural issues, “opiophobia” and
“opioignorance,” entrenched attitudes within the medical profession, and low prioritization of palliative
care among policy makers. See Gwyther et al., “Advancing Palliative Care,” 767-74; see especially pp.
770-71.
16. For a comprehensive overview of these strategies, see Gwyther et al., “Advancing Palliative
Care,” 767-74.
17. Gwyther et al., “Advancing Palliative Care,” 767-74; see especially pp. 770-71.
18. Other significant distinctions concern direct versus indirect, and voluntary, involuntary, and
nonvoluntary forms of euthanasia. See Bert Gordijn, Ben Crul, and Zbigniew Zylicz, “Euthanasia and
Physician-Assisted Suicide,” in The Ethics of Palliative Care: European Perspectives, ed. Henk ten Have
and David Clark (Philadelphia: Open University Press, 2002), 181-97; see especially p. 182.
treatment.19 On the other hand, active euthanasia indicates causing the death of a patient
by giving a certain life-shortening treatment.20 This essay will therefore define euthanasia
as a medically contraindicated action or omission that directly and intentionally causes
death in the effort to indirectly and unintentionally address, control, and eliminate
suffering in full.
In contrast to euthanasia, assisted suicide typically indicates the action of a
licensed clinician – most frequently a physician – who provides to a legally competent
person the means – often in the form of a prescription for a lethal dose of drugs – to
commit suicide.21 While not formally part of the definition, the context of terminal illness
is often assumed and has been part of the prerequisite conditions in all proposed laws in
the United Stated thus far. Yet this is not a formal part of the definition of assisted suicide
as such, since physicians might be permitted to offer such aid to those who wish to
terminate their lives for other reasons.
22 In this sense, assisted suicide is different from
the medically indicated withholding or withdrawing of treatment, on the one hand, and
from the actual killing of the patient by the physician, on the other.23
3.2 Arguments Against Euthanasia and Assisted Suicide
Suffering can have various causes, including pain, other physiological symptoms,
and clinical depression.24 To that extent that these factors play a positive role as motives
for requesting euthanasia, adequately addressing them with the provision of palliative
care is likely to remove most of those requests. However, while even the best palliative
care would not necessarily prevent the dependency and loss of control that are inherently
connected with the process of dying from chronic illness, the existential angst
experienced over dependency or loss of control does not suffice as a persuasive argument
in favor of euthanasia.25 Medicine inherently possesses particular goals, but the direct and
intentional killing of patients has never been one of them. Since clinicians are bound to
save life and not take it, it follows that clinicians should not kill in principle. Therefore,
within the context of palliative care, euthanasia proves to be a morally illicit option.26

19. Examples of this form would include would involve removing life-support equipment or not
delivering CPR when so doing medically contraindicated.
20. Examples of this form would involve injecting controlled substances into the patient, thereby
causing death.
21. Hence, like euthanasia, assisted suicide is also medically contraindicated.
22. In fact, many advocates include conditions which are not terminal in the sense law
traditionally assigns to the term – that is, a condition that is likely to cause death within six months,
regardless of what treatments are implemented. See David F. Kelly, Medical Care at the End of Life: A
Catholic Perspective (Washington, DC: Georgetown University Press, 2006), 118-32; see especially pp.
121-22.
23. Kelly, Medical Care at the End of Life, 118-32; see especially pp. 118-22.
24. Hence, these causes can lead to requests for euthanasia. See Gordijn et al., “Euthanasia and
Physician-Assisted Suicide,” 181-97; see especially p. 194.
25. For a robust analysis of the argument justifying euthanasia, see Henk ten Have and Jos Welie,
Death and Medical Power: An Ethical Analysis of Dutch Euthanasia Practice (New York: McGraw-Hill
Publishing, 2005), 144-79.
26. Gordijn et al., “Euthanasia and Physician-Assisted Suicide,” 181-97; see especially pp. 194-
95.
Even with the appropriate foregoing of life-sustaining treatment and adequate
pain control, there remain some reasons why chronically ill patients may request assisted
suicide. For assisted suicide proponents, there is little, if any, discernable difference
between providing sedation enough to keep terminally ill patients unconscious while they
die and simply assisting them to terminate their lives while they still possess the capacity Palliative Care And Assisted Suicide Essay
to do so.27 However, this essay contends that there is indeed a moral different, and should
be a legal difference, between killing and allowing to die. As with euthanasia, the
illicitness of assisted suicide lies primarily in the intentions of the agents involved – the
intentional termination of life in the effort to relieve suffering – and the means employed
– the prescription for an overdose a drugs that will directly cause death.28 It is doubtlessly
true that the existential anxiety that comes with the dying process will tempt individuals
to request an end that they themselves control. Yet even such neuropsychological
suffering can be alleviated with the promise of pain management, coupled with the care
and compassion of clinicians, family members, and others.29 By abstaining from assisted
suicide, palliative care takes a substantive stance toward this disputable social
development.30
4. SEDATION TO UNCONSCIOUSNESS IN PALLIATIVE CARE
4.1 The Function of Palliative Sedation
Patients suffering from terminal illness, with or without malignancy, often face
severe symptoms during the final phases of life. In the majority of cases, these symptoms
can be treated successfully. However, in some cases, patients experience symptoms that
are largely uncontrollable.31 Refractory symptoms differ from difficult-to-treat symptoms
in that, despite the many efforts of clinicians, they cannot be sufficiently treated without
compromising the consciousness of the patient. Such acute suffering has a
disproportionate impact on patient functioning and well-being, often intensifies as the
patient approaches the end of life, and ultimately interferes with a peaceful dying process.
Palliative sedation has thus been identified as a moral option of last resort when patients
are confronted by refractory suffering. As such, sedation to unconsciousness is
increasingly implemented by palliative care programs.32
The practice of palliative sedation is herein understood as “the use of sedative
medications to relieve intolerable suffering from refractory symptoms through a

27. The appropriate moral response to suffering, the argument goes, is to assist the sufferer in
terminating suffering – whatever the means. See Kelly, Medical Care at the End of Life, 118-32; see
especially pp. 123-24.
28. Kelly, Medical Care at the End of Life, 118-32; see especially pp. 123. Palliative Care And Assisted Suicide Essay
29. Kelly, Medical Care at the End of Life, 118-32; see especially pp. 123-24.
30. Gordijn et al., “Euthanasia and Physician-Assisted Suicide,” 181-97; see especially p. 195.
31. Patricia Classens, Johan Menten, Paul Schotsmans, and Bert Broeckaert, “Palliative Sedation:
A Review of the Research Literature,” Journal of Pain and Symptom Management 36, no. 3 (September
2008): 310-33; see especially pp. 310-11.
32. Classens et al., “Palliative Sedation,” 310-33; see especially pp. 310-11.
reduction in patient consciousness.”33 Many clinicians argue that palliative sedation does
not necessarily require sedation to total unconsciousness and suggest that palliative
sedation therapy can vary in terms of level (mild, intermediate, or deep), duration
(intermittent or continuous), and pharmacological characteristics (primary, by drugs not
proven to be effective in relieving the underlying symptoms, or secondary, by
medications pharmacologically effective for immediate relief of underlying distress).
Others classify sedation as sudden or proportional on the basis of whether it is established
rapidly (“emergency sedation”) in preterminal patients who experience overwhelming
symptoms for catastrophic events such as massive bleeding, severe dyspnea, agitated
delirium, or pain.34 It is therefore clear that deep, continuous sedation is but one of
several forms of palliative sedation therapy.35
4.2 The Ethical Justification of Palliative Sedation
Unlike euthanasia and assisted suicide, this essay contends that the practice of
palliative sedation is morally justifiable. Some authors have hypothesized a negative
impact of palliative sedation therapy on survival.36 However, even if such impact were
present, the use of palliative sedation therapy could nevertheless be ethically justified on
the basis of its fulfillment of the four criteria inherent to the principle of double effect.
The principle indicates that if doing something morally right has an indirect and
unintentional morally wrong effect, it may be ethically permissible to pursue the
particular course of action.37 Moreover, current empirical studies suggest that palliative
sedation therapy does not actually hasten death whatsoever, thus rendering the morally
“wrong effect” inherent to the application of the principle of double effect nonexistent.38
Unlike the practices of euthanasia and assisted suicide, the practice of palliative
sedation clarifies that death is not the means by which palliation is achieved. Typically,
sedation to unconsciousness is directly administered intravenously. Once the patient has
been made comfortable, the medication is titrated.39 Whereas euthanasia and assisted
suicide break the link between the patient’s condition and medical treatment for particular

33. M. Maltoni, C. Pittureri, E. Scarpi, L. Piccinini, F. Martini, P. Turci, L. Montanari, O. Nanni,
and D. Amadori, “Palliative Sedation Therapy Does Not Hasten Death: Results from a Prospective
Multicenter Study,” Annals of Oncology 20 (2009): 1163-69; see especially p. 1163.
34. A further, more specific subtype of palliative sedation therapy is “respite sedation,” a
procedure involving temporary and time-limited sedation. Finally, the possibility of using “routine,”
“infrequent,” or “extraordinary” sedation has also been proposed. See Maltoni et al., “Palliative Sedation
Therapy,” 1163-69; see especially p. 1163.
35. Maltoni et al., Palliative Sedation Therapy,” 1163-69; see especially p. 1163.
36. Some have termed its approach “slow euthanasia” or, more frequently, “terminal sedation.”
See Maltoni et al., “Palliative Sedation Therapy,” 1163-69; see especially p. 1164.
37. Hence, this is true even if the foreseen bad effect is likely to occur. See Maltoni et al.,
“Palliative Sedation Therapy,” 1163-69; see especially p. 1164.
38. Studies range from displaying that no difference exists in survival rates between patients who
do and do not receive varying doses of sedatives at the end of life to multiple regression models concluding
that the use of sedatives in the final forty-eight hours of life renders no increase in survival predictability.
See Maltoni et al., “Palliative Sedation Therapy,” 1163-69.
39. If for no other reason than the chronological order of events, one can identify the direct and
intended effect of the actions involved as being palliative, inasmuch as they occur first.
symptom management, palliative sedation maintains this essential moral link, thereby
retaining its identity as a medical treatment in the traditional sense. Thus, unlike
euthanasia and assisted suicide, palliation is the means to symptom management, not
death. In this way, the direct and intended effect of achieving palliation by means of
sedation to unconsciousness is ethically justifiable, even if the result is death.Palliative Care And Assisted Suicide Essay
5. CONCLUSION
The aim and proposal of this essay has been to examine the logic inherent to the
practices of euthanasia, assisted suicide, and palliative sedation in the context of
palliative care with the intention of positing the argument that while palliative sedation
fulfills the requirements of morally licit medical practice – and so successfully executes
the tenets of sound ethical logic – both euthanasia and assisted suicide do not. To secure
the justification of this thesis, it has drawn from the twofold premises that (i) the licitness
of medical practice is largely determined by the balance between (a) good ends, (b)
proportionate means, (c) appropriate circumstances, and (d) benevolent intentions; and
(ii) whereas palliative sedation employs criteria A-D (above), both euthanasia and
assisted suicide fail to secure criteria A-C.
The implications here are significant. To be sure, the growing misunderstanding
of the moral distinctions between the practices of euthanasia, assisted suicide, and
palliative sedation are a genuine and growing concern. But rather than allowing it to
terminate progress, it may instead serve to remind that while suffering is part and parcel
of the human condition, it will never be eliminated by eliminating the individual who
endures it. Palliative Care And Assisted Suicide Essay

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