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Feature
Moral differences in deep continuous palliative sedation and euthanasia Niklas Juth, Anna Lindblad, Niels Lynöe, Manne Sjöstrand, Gert Helgesson
Stockholm Centre for Healthcare Ethics, Karolinska Institutet, LIME, Stockholm, Sweden Correspondence to Niklas Juth, Stockholm Centre for Healthcare Ethics, LIME, Karolinska Institutet, Stockholm 171 77, Sweden; [email protected] Received 6 December 2012 Accepted 8 February 2013 Published Online First 6 March 2013
To cite: Juth N, Lindblad A, Lynöe N, et al. BMJ Supportive & Palliative Care 2013;3:203–206.
ABSTRACT In palliative care there is much debate about which end of life treatment strategies are legitimate and which are not. Some writers argue that there is an important moral dividingline between palliative sedation and euthanasia, making the first acceptable and the latter not. We have questioned this. In a recent article, Lars Johan Materstvedt has argued that we are wrong on two accounts: first, that we fail to account properly for the moral difference between continuous deep palliative sedation at the end of life and euthanasia, and, second, that we fail to account properly for the difference between permanent loss of consciousness and death. Regarding the first objection, we argue that Materstvedt misses the point: we agree that there is a difference in terms of intentions between continuous deep palliative sedation and euthanasia, but we question whether this conceptual difference makes up for a moral difference. Materstvedt fails to show that it does. Regarding the second objection, we argue that if nothing else is at stake than the value of the patient’s life, permanent unconsciousness and death are morally indifferent.
In a recent article,1 we addressed the European Association for Palliative Care (EAPC) ‘recommended framework for the use of sedation in palliative care’.2 One of our main concerns was the lack of clarity in the framework regarding the relation between continuous deep palliative sedation at the end of life and euthanasia. In response to this article, Lars Johan Materstvedt has authored a criticism of our discussion.3 We read Materstvedt as having two main objections: first, that we fail to account properly for the moral difference between continuous deep palliative sedation at the end of life and euthanasia and, second,
Juth N, et al. BMJ Supportive & Palliative Care 2013;3:203–206. doi:10.1136/bmjspcare-2012-000431
that we fail to account properly for the difference between permanent loss of consciousness and death. In the following, we will address these objections. DIFFERENT INTENTIONS The focus of interest in our original article was what Materstvedt and Georg Bosshard have called ‘deep and continuous palliative sedation’ (DCPS), that is, when the patient is rendered totally unconscious by sedation until death.4 The reason for this focus was that this kind of sedation is considered to be especially controversial in comparison with other kinds of sedation, for example, mild or intermittent sedation. DCPS means the ‘social death’3 of the patient and the experiential death: the patient receiving DCPS will never have any experiences again. From the patient’s subjective point of view (s)he has therefore ceased to exist. We argued that the EAPC framework failed to account for the alleged moral difference between DCPS and euthanasia.1 With regard to our argument, Materstvedt writes:3 Juth et al disagree with the EAPC ethics task force as far as intention and outcome in palliative sedation and euthanasia are concerned—that is, they think there is no difference between the two clinical actions in this respects…
This interpretation of our point is not entirely correct. In explaining why, we will start out by stating in what ways we agree with Materstvedt, the EAPC ethics task force (where Materstvedt was the main author),5 and, presumably, the EAPC framework. First, we do agree with the definition of euthanasia in accordance with the ‘Dutch understanding’ (contrary to what Materstvedt implies), that is, 203
Downloaded from http://spcare.bmj.com/ on July 11, 2015 - Published by group.bmj.com
Feature euthanasia is ‘intentionally killing a person by the administration of drugs, at that person’s voluntary and competent request’.5 In fact, this was the explicit point of departure in our text; hence the description of euthanasia as an action ‘where the intention is to kill the patient by administering a lethal drug’1 and the ensuing reference to the definition in the EAPC the ethics task force.5 Accordingly, we also think that there are clear differences between DCPS and euthanasia, both in terms of outcomes and intentions. For instance, as we wrote in our original article, DCPS may, or may not, result in the hastening of death of the patient, whereas successful euthanasia always will result in the hastening of death of the patient. Moreover, and more importantly, we agree that there is a difference in intention between DCPS and euthanasia. This difference can be described in different ways. According to Daniel Sulmasy, to ‘have an intention in acting means that an agent has acted or is acting, and that one can ascribe to the agent’s act the choice of a complete act—both an end and a means of achieving that end’.6 So, in DCPS the intention in acting is to stop suffering by means of administering (adequately titrated) sedatives, while in euthanasia, the intention in acting is to kill the patient on her request by means of administering lethal drugs. This difference between DCPS and euthanasia in terms of intentions is indisputable, since it is a matter of definition (of DCPS and euthanasia respectively), which we explicitly acknowledged in the original article.1 MORAL DIFFERENCE IN INTENTIONS? Our point was not that ‘there is no difference between the two clinical actions’ as regards intention and outcome, pace Materstvedt. The point was another, namely, that ‘the EAPC framework (as well as other texts on this) fails to notice an ambiguity in the concept of intention, the awareness of which makes the initial impression of a vast moral difference between palliative sedation and euthanasia fade somewhat’ (italics added).1 This was our main point, a point that Materstvedt does not address at all. In order to make this point even clearer, let us elaborate. Two distinct propositions constitute the core of our argument: (1) the term intention can be used in several ways and (2) it is unclear what sense of ‘intention’ is morally relevant. When understanding these propositions, one will see why the EAPC texts and Materstvedt fail to provide an explanation of why there is a moral difference between DCPS and euthanasia. Let us start with proposition (1): the term ‘intention’ can be used in several ways, that is, it is ambiguous. Sometimes when we talk about intentions, we mean something equivalent to intention in acting, according to Sulmasy’s definition above.6 However, sometimes we use the term intention to refer to what
204
Sulmasy calls further intentions, that is, ‘the agent intends to act upon a complex prior intention that includes not only the immediately intended event, but also some further event that the agent has chosen as part of her plan’.6 And sometimes, when speaking loosely, we use the term intention to refer to the underlying rationale of a complex plan (in the original text, we used the word ‘ultimate end’ to speak about this). Really, what we are talking about then is motives, that is, reasons for forming an intention, rather than intentions.6 Thus, the difference between DCPS and euthanasia regarding intentions is a difference, more precisely, between intentions in acting. However, when it comes to further intentions or the underlying rationale for DCPS and euthanasia, it is highly likely that intentions (in these senses, then) are identical or very similar. The underlying rationale, that is, that something which one wants to achieve with one’s course of action, in the case of euthanasia is, in Materstvedt’s words, to ‘stop suffering’3 (we acknowledge that it was misleading to talk about relieving suffering1— stopping or ending is better). The further intention or underlying rationale is no different regarding DCPS: to stop or end suffering. Surely, as we repeatedly stated,1 the means are different: in the case of euthanasia it is by killing the patient and in the DCPS case it is by rendering the patient unconscious until death. But, again, the underlying rationale is the same. Now enters the question of which actual differences between DCPS and euthanasia make for moral differences. Materstvedt explicitly agrees with us that if there is a moral difference between DCPS and euthanasia, it should be accounted for in terms of intentions rather than outcomes: even if DCPS would hasten death, it may still be permissible when ‘the intention remains the relief of suffering’.3 But in what sense of the term ‘intention’ do intentions matter morally, in what way and why? In order to answer this question, we need a moral principle that says something about the moral relevance of intentions. Materstvedt refers to the doctrine of double effect (DDE), as is customary in discussions of the moral difference between DCPS and euthanasia. Simply put, the DDE holds that it may be permissible to harm an individual while acting for the sake of a proportionate good, given that the harm is not an intended means to the good but merely a foreseen side-effect. We briefly discussed the DDE in the original article1 and have discussed it at length elsewhere.7 We will not repeat that discussion here, but only make a few brief remarks. When using the DDE as a way to defend the moral difference between DCPS and euthanasia, one has to defend a number of specific moral assumptions. One such assumption is that it is enough for one’s intention in acting to include a bad effect in order for an action to be wrong, even if one’s further intention
Juth N, et al. BMJ Supportive & Palliative Care 2013;3:203–206. doi:10.1136/bmjspcare-2012-000431
Downloaded from http://spcare.bmj.com/ on July 11, 2015 - Published by group.bmj.com
Feature does not include any bad effects. This is highly questionable: one can agree that intentions matter morally, but hold that good further intentions or motives sometimes outweigh problematic intentions in acting when judging a course of action.7 Another assumption Materstvedt has to defend is that some types of effects (and thereby some intentions in acting) are always morally problematic. With regard to the present discussion, Materstvedt has to defend that death is always morally problematic, while rendering someone unconscious till death need not be. This brings us to the second of Materstvedt’s objections. MORAL DIFFERENCE BETWEEN PERMANENT LOSS OF CONSCIOUSNESS AND DEATH? Materstvedt quotes our original article, where we write: ‘there is no morally relevant difference between the permanent loss of consciousness and death’.1 Materstvedt continues: ‘which, they state, ‘has been forcefully argued elsewhere’. However, they neither clarify what such arguments are, nor explain what they find so ‘forceful’ about them’.3 Since this is true, we would now like to remedy this shortcoming. The argument is straightforward: whether someone dies at a certain time or enters a state of total unconsciousness at that time, which lasts till he/she dies (the state is, in this sense, permanent), cannot matter for the value of this person’s life. We are here talking about personal intrinsic value, that is, value in itself. This implies that life in a purely biological sense does not have intrinsic value. We agree with Materstvedt that DCPS means that all aspects of life but the purely biological one are permanently lost. If biological life as such has no intrinsic value, then DCPS and euthanasia are on a par regarding the value of the patient’s life. Here is a thought experiment to underscore this point. Imagine that you are terminally ill and hospitalised. In comes your physician and says: ‘Sadly, you only have one more month to live.’ This leaves you devastated. After a while he returns: ‘We have news—we were wrong. In a month’s time, you will enter a stage of total unconsciousness, in which you will remain for 2 years. After that, you will die.’ No one, we think, would find any reason to look brighter on their future after such news. Nor would things in any other sense have become better. Or imagine you could create a world with people who are totally unconscious throughout their entire existence (as in the Matrix, minus dreams). Would you thereby have made the universe a better place? We think no one could seriously answer yes. If biological life had intrinsic value, we could easily make the world a better place, for example, by starting to grow a lot of bacterial cultures. If thought experiments do not convince you, we invite you to come up with a plausible theory on the
value of life according to which biological life without any consciousness at all would have value. None of the classical suggestions would do: hedonism, preferentialism and objective lists theory would all agree to what we have said here regarding the intrinsic value of human life.8 One proviso: according to some versions of preferentialism it would matter what you yourself want when your consciousness has permanently ended: if you prefer to go out by DCPS, your life as a whole can be better if this is the way you actually go out.9 But according to these theories, the same goes for euthanasia. So there is no difference in principle between them. However, there is one obvious difference between DCPS and euthanasia: in the former case, unlike the latter, one can be brought back to consciousness. Here is how Materstvedt puts it:3 The loss of consciousness per se is neither permanent nor irreversible; it is the ongoing administration of sedative drugs that results in the patient remaining unconscious. True, when patients never regain consciousness the loss of it turned out, with hindsight, to be permanent—but the potential for reversibility exists as long as the patient is alive.
First, a short terminological point: in our original article, when we talked about ‘permanently losing consciousness’ we meant nothing but dying or being unconscious, as a matter of fact, until one dies. But, as Materstvedt correctly points out, dying, unlike DCPS, means irreversibly losing consciousness: there is no possibility of regaining consciousness after euthanasia. The difference, then, between DCPS and euthanasia is one of modality, that is, what is potentially possible (within certain time-limits) and not. However, a difference in modality cannot make a difference in value. A world with people who are totally unconscious throughout their entire existence who could potentially wake up but, as a matter of fact, never do wake up is not better than a world where they cannot wake up. Of course, sometimes modalities matter for practical decision-making. There may be reasons to keep someone in a state where it is possible to wake them up again, for example, if we are on the verge of developing a cure for the ailment they suffer. This, however, does not change the argument regarding the lack of a moral difference between permanently losing consciousness and death, although it may make for a moral difference in some situations between DCPS and euthanasia. Moreover, there may be other indirect reasons to prefer DCPS to euthanasia (or the other way around) that do not have to do with the value of the patient’s life. For instance, some healthcare professionals may be more at ease with one of them. However, in the absence of such practical or indirect reasons, DCPS and euthanasia seem to be morally on a par; ceteris paribus the one does not affect the value of the
Juth N, et al. BMJ Supportive & Palliative Care 2013;3:203–206. doi:10.1136/bmjspcare-2012-000431
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Feature patient’s life more than the other. At least, we would be eager to hear an argument that suggests otherwise. One more short clarification with regard to Materstvedt’s criticism:3 by referring to Harris,10 we were not thinking about the concept of personhood, but the value of life. We agree with Harris10 that there are circumstances when a person’s life ceases to have value, for instance, ‘when unbearable suffering, as judged by the patient, is an unavoidable consequence of being conscious and this goes for the remainder of her existence’.1 In such circumstances, ending consciousness is morally defensible, be it by euthanasia or DCPS. CONCLUSIONS Materstvedt has objected to our critical analysis of EAPC’s framework for sedation on two accounts: first, that we fail to account properly for the moral difference between continuous deep palliative sedation at the end of life and euthanasia, and, second, that we fail to account properly for the difference between permanent loss of consciousness and death. Regarding the first objection, we argue that Materstvedt misses the point: we agree that there is a difference in terms of intentions between DCPS and euthanasia, but we question whether this conceptual difference makes up for a moral difference. Materstvedt fails to show that it does. Regarding the second objection, we argue that if nothing else is at stake than the value of the patient’s life, permanent unconsciousness and death are morally indifferent. Contributors NJ contributed with designing the main
argument of the manuscript, drafted and revised the manuscript. AL, NL, MS and GH contributed to the argument of the manuscript and critically revised
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the manuscript. All authors read and approved the final manuscript. Competing interests None. Provenance and peer review Commissioned; internally
peer reviewed.
REFERENCES 1 Juth N, Lindblad A, Lynöe N, et al. European Association for Palliative Care (EAPC) framework for palliative sedation: an ethical discussion. BMC Palliat Care 2010;9:20. http://www. biomedcentral.com/1472-684X/9/20 (accessed 6 Dec 2012). 2 Cherny NI, Radbruch L. European Association for Palliative Care (EAPC) recommended framework for the use of sedation in palliative care. Palliat Med 2009;23:581–93. 3 Materstvedt LJ. Intention, procedure, outcome and personhood on palliative sedation and euthanasia. BMJ Support Palliat Care 2012;2:9–11. 4 Materstvedt LJ, Bosshard G. Deep and continuous palliative sedation (terminal sedation): clinical-ethical and philosophical aspects. Lancet Oncol 2009;10:622–7. 5 Materstvedt LJ, Clark D, Ellershaw J, et al. Euthanasia and physician-assisted suicide: a view from an EAPC Ethics Task Force. Palliat Med 2003;17:97–101; discussion 102-79. 6 Sulmasy DP. ‘Reinventing’ the rule of double effect. In: Steinbock B. ed. The Oxford handbook of bioethics. Oxford: Oxford University Press, 2007:114–49. 7 Lindblad A, Lynöe N, Juth N. End-of-life decisions and the reinvented rule of double effect: a critical analysis. Bioethics 2012. Published Online First: 2012. doi:10.1111/bioe.12001. 8 Brülde B. The human good. Gothenburg: Acta Universitatis Gothoburgensis, 1998. 9 Furberg E. Advanced directives and personal identity. Stockholm: Acta Universitatis Stockholmiensis, 2012. 10 Harris J. The value of life. London: Routledge & Kegan Paul, 1985:82–3.
Juth N, et al. BMJ Supportive & Palliative Care 2013;3:203–206. doi:10.1136/bmjspcare-2012-000431
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Moral differences in deep continuous palliative sedation and euthanasia Niklas Juth, Anna Lindblad, Niels Lynöe, Manne Sjöstrand and Gert Helgesson BMJ Support Palliat Care 2013 3: 203-206 originally published online March 6, 2013
doi: 10.1136/bmjspcare-2012-000431 Updated information and services can be found at: http://spcare.bmj.com/content/3/2/203
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Feature
Moral differences in deep continuous palliative sedation and euthanasia Niklas Juth, Anna Lindblad, Niels Lynöe, Manne Sjöstrand, Gert Helgesson
Stockholm Centre for Healthcare Ethics, Karolinska Institutet, LIME, Stockholm, Sweden Correspondence to Niklas Juth, Stockholm Centre for Healthcare Ethics, LIME, Karolinska Institutet, Stockholm 171 77, Sweden; [email protected] Received 6 December 2012 Accepted 8 February 2013 Published Online First 6 March 2013
To cite: Juth N, Lindblad A, Lynöe N, et al. BMJ Supportive & Palliative Care 2013;3:203–206.
ABSTRACT In palliative care there is much debate about which end of life treatment strategies are legitimate and which are not. Some writers argue that there is an important moral dividingline between palliative sedation and euthanasia, making the first acceptable and the latter not. We have questioned this. In a recent article, Lars Johan Materstvedt has argued that we are wrong on two accounts: first, that we fail to account properly for the moral difference between continuous deep palliative sedation at the end of life and euthanasia, and, second, that we fail to account properly for the difference between permanent loss of consciousness and death. Regarding the first objection, we argue that Materstvedt misses the point: we agree that there is a difference in terms of intentions between continuous deep palliative sedation and euthanasia, but we question whether this conceptual difference makes up for a moral difference. Materstvedt fails to show that it does. Regarding the second objection, we argue that if nothing else is at stake than the value of the patient’s life, permanent unconsciousness and death are morally indifferent.
In a recent article,1 we addressed the European Association for Palliative Care (EAPC) ‘recommended framework for the use of sedation in palliative care’.2 One of our main concerns was the lack of clarity in the framework regarding the relation between continuous deep palliative sedation at the end of life and euthanasia. In response to this article, Lars Johan Materstvedt has authored a criticism of our discussion.3 We read Materstvedt as having two main objections: first, that we fail to account properly for the moral difference between continuous deep palliative sedation at the end of life and euthanasia and, second,
Juth N, et al. BMJ Supportive & Palliative Care 2013;3:203–206. doi:10.1136/bmjspcare-2012-000431
that we fail to account properly for the difference between permanent loss of consciousness and death. In the following, we will address these objections. DIFFERENT INTENTIONS The focus of interest in our original article was what Materstvedt and Georg Bosshard have called ‘deep and continuous palliative sedation’ (DCPS), that is, when the patient is rendered totally unconscious by sedation until death.4 The reason for this focus was that this kind of sedation is considered to be especially controversial in comparison with other kinds of sedation, for example, mild or intermittent sedation. DCPS means the ‘social death’3 of the patient and the experiential death: the patient receiving DCPS will never have any experiences again. From the patient’s subjective point of view (s)he has therefore ceased to exist. We argued that the EAPC framework failed to account for the alleged moral difference between DCPS and euthanasia.1 With regard to our argument, Materstvedt writes:3 Juth et al disagree with the EAPC ethics task force as far as intention and outcome in palliative sedation and euthanasia are concerned—that is, they think there is no difference between the two clinical actions in this respects…
This interpretation of our point is not entirely correct. In explaining why, we will start out by stating in what ways we agree with Materstvedt, the EAPC ethics task force (where Materstvedt was the main author),5 and, presumably, the EAPC framework. First, we do agree with the definition of euthanasia in accordance with the ‘Dutch understanding’ (contrary to what Materstvedt implies), that is, 203
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Feature euthanasia is ‘intentionally killing a person by the administration of drugs, at that person’s voluntary and competent request’.5 In fact, this was the explicit point of departure in our text; hence the description of euthanasia as an action ‘where the intention is to kill the patient by administering a lethal drug’1 and the ensuing reference to the definition in the EAPC the ethics task force.5 Accordingly, we also think that there are clear differences between DCPS and euthanasia, both in terms of outcomes and intentions. For instance, as we wrote in our original article, DCPS may, or may not, result in the hastening of death of the patient, whereas successful euthanasia always will result in the hastening of death of the patient. Moreover, and more importantly, we agree that there is a difference in intention between DCPS and euthanasia. This difference can be described in different ways. According to Daniel Sulmasy, to ‘have an intention in acting means that an agent has acted or is acting, and that one can ascribe to the agent’s act the choice of a complete act—both an end and a means of achieving that end’.6 So, in DCPS the intention in acting is to stop suffering by means of administering (adequately titrated) sedatives, while in euthanasia, the intention in acting is to kill the patient on her request by means of administering lethal drugs. This difference between DCPS and euthanasia in terms of intentions is indisputable, since it is a matter of definition (of DCPS and euthanasia respectively), which we explicitly acknowledged in the original article.1 MORAL DIFFERENCE IN INTENTIONS? Our point was not that ‘there is no difference between the two clinical actions’ as regards intention and outcome, pace Materstvedt. The point was another, namely, that ‘the EAPC framework (as well as other texts on this) fails to notice an ambiguity in the concept of intention, the awareness of which makes the initial impression of a vast moral difference between palliative sedation and euthanasia fade somewhat’ (italics added).1 This was our main point, a point that Materstvedt does not address at all. In order to make this point even clearer, let us elaborate. Two distinct propositions constitute the core of our argument: (1) the term intention can be used in several ways and (2) it is unclear what sense of ‘intention’ is morally relevant. When understanding these propositions, one will see why the EAPC texts and Materstvedt fail to provide an explanation of why there is a moral difference between DCPS and euthanasia. Let us start with proposition (1): the term ‘intention’ can be used in several ways, that is, it is ambiguous. Sometimes when we talk about intentions, we mean something equivalent to intention in acting, according to Sulmasy’s definition above.6 However, sometimes we use the term intention to refer to what
204
Sulmasy calls further intentions, that is, ‘the agent intends to act upon a complex prior intention that includes not only the immediately intended event, but also some further event that the agent has chosen as part of her plan’.6 And sometimes, when speaking loosely, we use the term intention to refer to the underlying rationale of a complex plan (in the original text, we used the word ‘ultimate end’ to speak about this). Really, what we are talking about then is motives, that is, reasons for forming an intention, rather than intentions.6 Thus, the difference between DCPS and euthanasia regarding intentions is a difference, more precisely, between intentions in acting. However, when it comes to further intentions or the underlying rationale for DCPS and euthanasia, it is highly likely that intentions (in these senses, then) are identical or very similar. The underlying rationale, that is, that something which one wants to achieve with one’s course of action, in the case of euthanasia is, in Materstvedt’s words, to ‘stop suffering’3 (we acknowledge that it was misleading to talk about relieving suffering1— stopping or ending is better). The further intention or underlying rationale is no different regarding DCPS: to stop or end suffering. Surely, as we repeatedly stated,1 the means are different: in the case of euthanasia it is by killing the patient and in the DCPS case it is by rendering the patient unconscious until death. But, again, the underlying rationale is the same. Now enters the question of which actual differences between DCPS and euthanasia make for moral differences. Materstvedt explicitly agrees with us that if there is a moral difference between DCPS and euthanasia, it should be accounted for in terms of intentions rather than outcomes: even if DCPS would hasten death, it may still be permissible when ‘the intention remains the relief of suffering’.3 But in what sense of the term ‘intention’ do intentions matter morally, in what way and why? In order to answer this question, we need a moral principle that says something about the moral relevance of intentions. Materstvedt refers to the doctrine of double effect (DDE), as is customary in discussions of the moral difference between DCPS and euthanasia. Simply put, the DDE holds that it may be permissible to harm an individual while acting for the sake of a proportionate good, given that the harm is not an intended means to the good but merely a foreseen side-effect. We briefly discussed the DDE in the original article1 and have discussed it at length elsewhere.7 We will not repeat that discussion here, but only make a few brief remarks. When using the DDE as a way to defend the moral difference between DCPS and euthanasia, one has to defend a number of specific moral assumptions. One such assumption is that it is enough for one’s intention in acting to include a bad effect in order for an action to be wrong, even if one’s further intention
Juth N, et al. BMJ Supportive & Palliative Care 2013;3:203–206. doi:10.1136/bmjspcare-2012-000431
Downloaded from http://spcare.bmj.com/ on July 11, 2015 - Published by group.bmj.com
Feature does not include any bad effects. This is highly questionable: one can agree that intentions matter morally, but hold that good further intentions or motives sometimes outweigh problematic intentions in acting when judging a course of action.7 Another assumption Materstvedt has to defend is that some types of effects (and thereby some intentions in acting) are always morally problematic. With regard to the present discussion, Materstvedt has to defend that death is always morally problematic, while rendering someone unconscious till death need not be. This brings us to the second of Materstvedt’s objections. MORAL DIFFERENCE BETWEEN PERMANENT LOSS OF CONSCIOUSNESS AND DEATH? Materstvedt quotes our original article, where we write: ‘there is no morally relevant difference between the permanent loss of consciousness and death’.1 Materstvedt continues: ‘which, they state, ‘has been forcefully argued elsewhere’. However, they neither clarify what such arguments are, nor explain what they find so ‘forceful’ about them’.3 Since this is true, we would now like to remedy this shortcoming. The argument is straightforward: whether someone dies at a certain time or enters a state of total unconsciousness at that time, which lasts till he/she dies (the state is, in this sense, permanent), cannot matter for the value of this person’s life. We are here talking about personal intrinsic value, that is, value in itself. This implies that life in a purely biological sense does not have intrinsic value. We agree with Materstvedt that DCPS means that all aspects of life but the purely biological one are permanently lost. If biological life as such has no intrinsic value, then DCPS and euthanasia are on a par regarding the value of the patient’s life. Here is a thought experiment to underscore this point. Imagine that you are terminally ill and hospitalised. In comes your physician and says: ‘Sadly, you only have one more month to live.’ This leaves you devastated. After a while he returns: ‘We have news—we were wrong. In a month’s time, you will enter a stage of total unconsciousness, in which you will remain for 2 years. After that, you will die.’ No one, we think, would find any reason to look brighter on their future after such news. Nor would things in any other sense have become better. Or imagine you could create a world with people who are totally unconscious throughout their entire existence (as in the Matrix, minus dreams). Would you thereby have made the universe a better place? We think no one could seriously answer yes. If biological life had intrinsic value, we could easily make the world a better place, for example, by starting to grow a lot of bacterial cultures. If thought experiments do not convince you, we invite you to come up with a plausible theory on the
value of life according to which biological life without any consciousness at all would have value. None of the classical suggestions would do: hedonism, preferentialism and objective lists theory would all agree to what we have said here regarding the intrinsic value of human life.8 One proviso: according to some versions of preferentialism it would matter what you yourself want when your consciousness has permanently ended: if you prefer to go out by DCPS, your life as a whole can be better if this is the way you actually go out.9 But according to these theories, the same goes for euthanasia. So there is no difference in principle between them. However, there is one obvious difference between DCPS and euthanasia: in the former case, unlike the latter, one can be brought back to consciousness. Here is how Materstvedt puts it:3 The loss of consciousness per se is neither permanent nor irreversible; it is the ongoing administration of sedative drugs that results in the patient remaining unconscious. True, when patients never regain consciousness the loss of it turned out, with hindsight, to be permanent—but the potential for reversibility exists as long as the patient is alive.
First, a short terminological point: in our original article, when we talked about ‘permanently losing consciousness’ we meant nothing but dying or being unconscious, as a matter of fact, until one dies. But, as Materstvedt correctly points out, dying, unlike DCPS, means irreversibly losing consciousness: there is no possibility of regaining consciousness after euthanasia. The difference, then, between DCPS and euthanasia is one of modality, that is, what is potentially possible (within certain time-limits) and not. However, a difference in modality cannot make a difference in value. A world with people who are totally unconscious throughout their entire existence who could potentially wake up but, as a matter of fact, never do wake up is not better than a world where they cannot wake up. Of course, sometimes modalities matter for practical decision-making. There may be reasons to keep someone in a state where it is possible to wake them up again, for example, if we are on the verge of developing a cure for the ailment they suffer. This, however, does not change the argument regarding the lack of a moral difference between permanently losing consciousness and death, although it may make for a moral difference in some situations between DCPS and euthanasia. Moreover, there may be other indirect reasons to prefer DCPS to euthanasia (or the other way around) that do not have to do with the value of the patient’s life. For instance, some healthcare professionals may be more at ease with one of them. However, in the absence of such practical or indirect reasons, DCPS and euthanasia seem to be morally on a par; ceteris paribus the one does not affect the value of the
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Feature patient’s life more than the other. At least, we would be eager to hear an argument that suggests otherwise. One more short clarification with regard to Materstvedt’s criticism:3 by referring to Harris,10 we were not thinking about the concept of personhood, but the value of life. We agree with Harris10 that there are circumstances when a person’s life ceases to have value, for instance, ‘when unbearable suffering, as judged by the patient, is an unavoidable consequence of being conscious and this goes for the remainder of her existence’.1 In such circumstances, ending consciousness is morally defensible, be it by euthanasia or DCPS. CONCLUSIONS Materstvedt has objected to our critical analysis of EAPC’s framework for sedation on two accounts: first, that we fail to account properly for the moral difference between continuous deep palliative sedation at the end of life and euthanasia, and, second, that we fail to account properly for the difference between permanent loss of consciousness and death. Regarding the first objection, we argue that Materstvedt misses the point: we agree that there is a difference in terms of intentions between DCPS and euthanasia, but we question whether this conceptual difference makes up for a moral difference. Materstvedt fails to show that it does. Regarding the second objection, we argue that if nothing else is at stake than the value of the patient’s life, permanent unconsciousness and death are morally indifferent. Contributors NJ contributed with designing the main
argument of the manuscript, drafted and revised the manuscript. AL, NL, MS and GH contributed to the argument of the manuscript and critically revised
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the manuscript. All authors read and approved the final manuscript. Competing interests None. Provenance and peer review Commissioned; internally
peer reviewed.
REFERENCES 1 Juth N, Lindblad A, Lynöe N, et al. European Association for Palliative Care (EAPC) framework for palliative sedation: an ethical discussion. BMC Palliat Care 2010;9:20. http://www. biomedcentral.com/1472-684X/9/20 (accessed 6 Dec 2012). 2 Cherny NI, Radbruch L. European Association for Palliative Care (EAPC) recommended framework for the use of sedation in palliative care. Palliat Med 2009;23:581–93. 3 Materstvedt LJ. Intention, procedure, outcome and personhood on palliative sedation and euthanasia. BMJ Support Palliat Care 2012;2:9–11. 4 Materstvedt LJ, Bosshard G. Deep and continuous palliative sedation (terminal sedation): clinical-ethical and philosophical aspects. Lancet Oncol 2009;10:622–7. 5 Materstvedt LJ, Clark D, Ellershaw J, et al. Euthanasia and physician-assisted suicide: a view from an EAPC Ethics Task Force. Palliat Med 2003;17:97–101; discussion 102-79. 6 Sulmasy DP. ‘Reinventing’ the rule of double effect. In: Steinbock B. ed. The Oxford handbook of bioethics. Oxford: Oxford University Press, 2007:114–49. 7 Lindblad A, Lynöe N, Juth N. End-of-life decisions and the reinvented rule of double effect: a critical analysis. Bioethics 2012. Published Online First: 2012. doi:10.1111/bioe.12001. 8 Brülde B. The human good. Gothenburg: Acta Universitatis Gothoburgensis, 1998. 9 Furberg E. Advanced directives and personal identity. Stockholm: Acta Universitatis Stockholmiensis, 2012. 10 Harris J. The value of life. London: Routledge & Kegan Paul, 1985:82–3.
Juth N, et al. BMJ Supportive & Palliative Care 2013;3:203–206. doi:10.1136/bmjspcare-2012-000431
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Moral differences in deep continuous palliative sedation and euthanasia Niklas Juth, Anna Lindblad, Niels Lynöe, Manne Sjöstrand and Gert Helgesson BMJ Support Palliat Care 2013 3: 203-206 originally published online March 6, 2013
doi: 10.1136/bmjspcare-2012-000431 Updated information and services can be found at: http://spcare.bmj.com/content/3/2/203
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