Sedation or the limits of palliative care – ethical questions

Abstract

Summary Sedation in palliative medicine continues to elicit questions that sometimes confound even the most experienced caregivers. We begin by examining the boundaries between sedation and euthanasia. The ethics at stake in palliative sedation are almost systematically constructed with the perspective of polemic debates on euthanasia, especially in situations where sedation is wrongly qualified of “terminal”. Perhaps out of fear for a possible confusion between sedation and euthanasia, current recommendations appear to be more of a formalization of the double-effect principle. But the double-effect principle and the principle of intentionality also have their limits. This will prompt us to examine the notions of consent and autonomy. Sedation questions what might be deemed “ideal care”, exposing the limits of palliative medicine: limits to defining a refractory symptom, limits to defining and relieving existential distress, limits to the ethical validity of prognosis, limits to the ideal of a “pacified” death, limits to maintaining a relational life until death. Sedation highlights a triple paradox: benevolence and autonomy vs. maintaining relationships, failure to relieve vs. idealized pacified death, clinical uncertainty vs. ultimate medicalization of the end of life. To prevent the risks of underestimating distress or hastening to relieve, two qualities should be cultivated: availability as a necessary openness to otherness and vulnerability; and resisting the temptation of reducing the ethical legitimacy of sedation to its decisional process.