Abstract
Abstract
A variety of moral frameworks can assist clinicians in making ethical decisions. In examining articles on palliative sedation and terminal extubation, we were struck that bioethical discussions uniformly appealed to principlism and especially to the rule of double effect. Other moral frameworks were rarely invoked, an observation consistent with Daniel Callahan's assertion that principlism has a “blocking effect” on broader ethical deliberation. We review here the principle of double effect as it applies to clinical acts that may hasten death, and present one radically different ethical formulation developed by Dan Brock. We then offer brief examples of how clinicians might use other moral frameworks to assess the ethics of preemptive sedation for terminal extubation. We argue for greater moral pluralism in approaching end-of-life decisions.
Introduction
For our discussion, we focus on palliative sedation, an important, newly identified procedure that can be interpreted through various moral frameworks. Palliative sedation receives a great deal of attention in the palliative medicine literature, and its definition and the definition of its various subtypes – most importantly, distinguishing routine or “proportionate” use of sedatives from “palliative sedation to unconsciousness” – continue to evolve.5,6 Among practices that might be seen as hastening death, palliative sedation is a cutting- edge issue that lies conceptually between relatively well-accepted procedures, such as withholding or withdrawing life-sustaining treatments, and controversial acts, such as physician-assisted suicide and euthanasia.
In reviewing a large series of recent articles on palliative sedation and preemptive sedation for terminal extubation, we were struck by the uniformity of appeals to the rule (or principle or doctrine) of double effect.7–11 If an act satisfied the criteria for double effect, it was acceptable. Otherwise, the act was euthanasia or assisted suicide, and, without further deliberation, the act was objectionable. Whereas hastening death in a clinical setting is viewed by some as always unacceptable, a number of moral frameworks allow for such an act in specific circumstances.
Less often invoked in the literature was “principlism,” generally represented as the “four principles approach” of autonomy, beneficence, non-maleficence, and justice, as popularized in Beauchamp and Childress's Principles of Biomedical Ethics. 12 Even other familiar principle-based frameworks, such as deontology or utilitarianism/consequentialism were rarely cited, even though application of the rule of double effect typically requires deontological reasoning (all killing is forbidden in clinical situations) and a utilitarian weighing of benefits and harms. Equally striking was the absence of appeals to the “ethics of care” that is so important in clinical work, as well as to what is broadly described as “virtue ethics,” a framework that is often posed as an alternative or complement to principle-based ethics and that plays a large role in the modern field of moral philosophy.13–15
Callahan disapproves of the individualistic bias of principlism but particularly its “blocking function” for substantive moral inquiry:
Instead of inviting us to think as richly and imaginatively about ethics as possible, in fact it is a kind of ethical reductionism, in effect allowing us to escape from the complexity of life, and to cut through the ambiguities and uncertainties that mark most serious ethical problems. 13
Other ethicists argue that robust moral reasoning emerges most reliably from consideration of diverse perspectives, not from a single overarching ethical framework.1,2 According to Beauchamp and Childress (who present a more inclusive moral theory than implied by their “spare” heuristic framework 16 ) “Rights, virtues, and emotional responses are as important as principles and rules for a comprehensive vision of the moral life.” 12
The complexity and ambiguity of clinical situations at the end of life argues for the use of multiple moral frameworks and for a careful process of ethical discernment. Recognizing the “pluralism of values” 17 and honoring the difficulty of decisions would help achieve what Rawls calls a “reflective equilibrium” that incorporates and balances diverse viewpoints rather than privileging a single approach. 18 Additionally, in a pluralistic society, an awareness of the multiplicity of moral frameworks would seem essential for clinicians in appreciating how their patients' and their own cultural, religious, and ethical background impact on practice. Even within the Western European tradition, a variety of approaches to ethical deliberation have coexisted over millennia, evolving over time, waxing and waning in popularity. None has been the final word.
Importantly, pluralism should not be confused with moral relativism or moral nihilism. An awareness of a range of moral frameworks and of various approaches to addressing ethical issues can promote a more substantive and satisfying deliberation, not acceptance of all constructs as equally valid.
Evidence of Monolithic Ethics
Given the frequently stated impression that principlism dominates current bioethical discussion in the United States, we reviewed the 75 most recent articles retrieved from a search on palliative sedation in PubMed (see Supplementary Data Appendix 1 online at www.liebertonline.com/jpm.) Only 18 articles that were written in English and available electronically revealed any ethical deliberation on this topic. The ethical discussion in all but one of these articles was based on the rule of double effect. Twelve articles only used this principle. Six addressed additional ethical frameworks at least briefly; four of these were studies from Belgium, Switzerland, or the Netherlands where euthanasia is legalized.
This brief review supports informal observations that the rule of double effect dominates ethical discussions and is applied without broader attention to additional and sometimes competing moral frameworks. The dearth of attention to other ethical constructs represents a poverty in moral deliberation.
The Rule of Double Effect
The rule of double effect has a long history in moral philosophy and medical ethics, and is typically attributed to St. Thomas Aquinas. 19 In the thirteenth century, Aquinas wrote in response to St. Augustine (354–430 CE) who had declared that killing in self-defense was not permissible. 20 Both men made exception for the defense of others and for killing condoned by the state.
Aquinas stated that violent means of self-defense are permissible insofar as the intention of the act is to save one's life and that the harm to the aggressor is not the primary intention. He also required moderation: the violent act must be proportional to its end or intention, such that only the necessary amount of force would be used.
In contemporary terms, when faced with an action that can produce both good and bad effects, the rule requires:
1. an act that is, by itself, morally good or at least indifferent
2. an intention to cause a good effect, not an evil or bad one; however, the bad effect may be foreseen and would have been avoided if the good effect could otherwise have been achieved
3. the good effect results from the action, not from the bad effect
4. balance or proportionality: there is a sufficiently grave reason for achieving the good effect, which compensates for possibly permitting the evil effect. 21
The principle of double effect relies on the notion that intentions rather than consequences alone should be used to judge the morality of an act. It allows us, for example, to distinguish between strategic bombing and terror bombing, between accidental killing and intentional homicide.
A full discussion of the principle of double effect is beyond the scope of this article, but controversies about its application have recently been summarized by Quill22–24 and rebutted by Sulmasy.25,26 Common concerns include its abstractness (and hence difficulty applying it unambiguously to clinical situations), predetermined notions of what constitutes “good” and “bad” acts, and the challenge of ascertaining intentions and of distinguishing intended from foreseen consequences. 27 Sulmasy also warns about using the principle in situations where it simply does not apply, as in merely choosing the lesser of two evils. 26
Is Hastening Death ever Permissible?
Many philosophers, including Saint Augustine and Thomas Aquinas, have grappled with the question of whether lethal acts are justified. Brock, following in this philosophical tradition, restates this crucial issue in a fashion that challenges common ethical constructs and language. 28
Brock notes that withholding and withdrawing life supports lead to death, as would administering a lethal poison. He makes a radical yet logical suggestion to use the term, “killing” – a highly charged word – as a morally neutral description of all acts that lead to a death. Rather than proscribing efforts to end a life, he contrasts “permissible” or justifiable forms of “killing,” such as withholding and withdrawing life supports, to murder, genocide, and other “impermissible” forms of “killing.” 29 His formulation is analogous to legal distinctions regarding homicide (e.g., between manslaughter in self-defense and premeditated murder). Whereas murder is proscribed in all familiar ethical formulations, usually with some exceptions, each moral framework must wrestle with distinctions about permissible and impermissible “killing.” Brock's formulation is not an argument for any particular act that hastens death, but it encourages further examination of such acts. He returns critical attention to important arguments that “physicians should not kill.”30,31
For many colleagues, Brock's choice of the term, “killing,” is so off-putting as to make his argument indigestible. However, when we consider patients who face imminent death, we can substitute the term, “hastening death.” We then may profitably and more comfortably appreciate Brock's rejection of the notion that all actions that hasten death are proscribed, and turn our attention to critically important distinctions between permissible and impermissible acts, as well as acknowledging gray areas.
Brock's formulation impacts directly on the first requisite for justifying an act under the principle of double effect: the act by itself must be morally good or at least morally neutral. If hastening death is always an evil action – an unacceptable means to achieve a good outcome – we bypass substantive deliberation about the morality of the act. Conversely, as pointed out by Sulmasy, potentially immoral acts may be excused as “allowing to die.” 32 We suggest that any action that contributes to ending a life (e.g., deep sedation to unconsciousness while withholding fluids and nutrition) requires a rich moral analysis. The blocking effect of the rule of double effect is not necessarily a problem with the rule itself, but with its reflexive, exclusive application.
How Clinicians Might Use Alternative Frameworks in a Challenging Case: Preemptive Sedation for Terminal Extubation
Consider the following case:
Mr. L, a young patient with advanced amyotrophpic lateral sclerosis (ALS) has decided he does not want to continue life-prolonging treatments. He is very limited in his mobility, cannot turn in bed, suffers constantly from musculoskeletal discomforts, and requires nearly continuous noninvasive positive pressure ventilation (NIPPV) with a very uncomfortable facial mask. He has been evaluated carefully about his wish to die, and shows no signs of cognitive impairment, depression, external pressures to end his life (e.g., from family or economic considerations), or existential despair. He repeatedly requests reassurance that he will not suffer as he dies, seeking preemptive deep sedation.
Insofar as the principle of double effect is so uniformly applied in the literature, palliative sedation would be permitted in this situation. Only a very unusual interpretations would conclude that preemptive deep sedation intentionally causes suppression of breathing and leads directly to death, that an evil action is being used to achieve the desired outcome of a peaceful death. But what about other ethical theories?
Following are very brief descriptions of some moral frameworks and examples of how they might be used to approach this ethical dilemma. The illustrations are necessarily brief and consider only one or two of many possible viewpoints. We attempt to give an indication of how one or two (possibly contradictory) conclusions might be generated within each framework, but stress that we do not imply that a definitive judgment would be associated with a particular framework. Also worth noting is that sharp distinctions between frameworks are often artificial, and that the approaches we suggest here do not overtly include religious traditions and their teachings, on which many clinicians rely.
Utilitarian/consequentialist view
Actions are right or wrong according to a balance between their good and bad consequences. How does it make sense that we are sometimes allowed to let patients die but not to hasten their imminent deaths? Whether this patient dies in a few hours or days or dies quickly because of medications, the outcome is the same: a peaceful, welcomed death. The outcome is good according to the patient; therefore, the means to this outcome are morally good.
Deontological (Kantian) view
Actions may be right or wrong not merely because of their consequences but rather based on whether the underlying principle has universal validity. I would not offer preemptive anesthesia for anyone suffering in this fashion. Of course, facilitating a comfortable death shows deep respect for persons, one of our highest goals. And if nobody is harmed by this action and all involved consider it the right thing to do, then the act could be good. But the potential for harm to some patients is great; therefore, the universal application of the procedure is unacceptable.
Communitarian view
Ethics are based on the common good, including communal values and traditions. I fear that allowing this sort of action for a few people will harm society as a whole by encouraging euthanasia for the disabled, poor, minorities, and the elderly. I respect this patient's wishes, but oppose the practice because it may harm the overall community.
Principle of double effect
My intention is to alleviate suffering by preemptively administering opioids and benzodiazepines. In order to be certain the patient is not suffering, I will preemptively administer enough medication to definitively prevent breathlessness. A desired, good effect will be achieved. The foreseen but not intended outcome is hastening death.
Social contractarian view (after Rawls 18 )
Everyone should enjoy liberty, as long as it does not interfere with the liberty of others. Everyone should have equal opportunity to obtain preemptive sedation in this situation, if they wish it.
Rights-based approaches
Moral action should protect the rights of individuals. Patients have a right to self-determination, and they should be allowed to decide the time and manner of their death. But there is no right to assistance in dying. The Supreme Court has rejected this notion.
Ethics of caring (or feminist ethics)
Natural caring for others is the basis for moral behavior. An ideal is to treat patients with unreserved acceptance and deep relatedness. Chronically ill and dying persons are marginalized in our society and require special attention. As an expression of this deeply personal and sympathetic connection with a suffering person, I will provide preemptive sedation.
Virtue ethics
All these principles are interesting, but do not tell me how to live the virtuous life to which I aspire nor what to do in this specific situation. I must use experience and acquired wisdom in turning to such virtues as honesty, fidelity, courage, and benevolence to live a good life and choose moral actions. As I have reasoned and reflected, I must remain true to my best self, which means being loyal and faithful to Mr. L, maintaining my duty and commitment to alleviating suffering, and performing my art with skill and compassion. These are just and noble goals, taught to me by my mentors, expected of me in my societal role, and refined in my practice over the years. Neither slavish devotion to the suffering patient's wishes nor distancing myself from the patient's distress will lead to a wise and temperate approach. I may risk censure but have the courage and integrity to follow what I know internally to be right.
Implications and Cautionary Notes
The rule of double effect can often be used to fashion a clear approach to deciding whether clinical acts are ethical or legal. The principle can provide health care workers with a vital ethical foundation near the end of a patient's life for liberal use of analgesics without fear that one is performing euthanasia or assisted suicide.
Our aim in sketching alternative moral frameworks for analyzing palliative sedation is not to suggest that using the rule of double effect as a moral guide is wrong, or that one or more of these alternatives would lead to right actions. Rather, our point is that considering a variety of approaches will deepen our moral perceptions and provide greater wisdom than uncritical reliance on a single rule, however useful that rule may be. Ethical judgment, like clinical judgment, is always about seeking the best course of action, but it is also about the prior steps of choosing, from a range of possibilities, the best tools to assess the situation. Each tool will bring a different facet of the problem into focus.
We recognize that having clear and unambiguous rules may be more appealing than the effort to discern which ethical tools best fit the case at hand. And it is always possible to pick a framework or set of tools to justify one's preconceived notion, rather than to probe the problem more deeply. (Indeed, brain science now suggests that humans often use moral philosophy to justify behavior rather than to guide it.33,34) But on balance we think that the effort to expand the conversation beyond the single framework of double effect will provide more insights than frustration, and will serve both clinicians and patients well.
Conclusion
As summarized by Arras and Steinbock,
It may be that moral reality is sufficiently complex that any one theory gives only partial insight…It is a mistake to view the various theoretical alternatives as mutually exclusive claims to moral truth. Instead, we should view them as important but partial contributions to a comprehensive, although necessarily fragmented, moral vision. 2
Likewise, according to Beauchamp and Childress,
In everyday moral reasoning, we effortlessly blend appeals to principles, rules, rights, virtues, passions, analogies, paradigms, narratives, and parables. We should be able to do the same in biomedical ethics. To assign priority to anyone of these moral categories as the key ingredient in the moral life is a dubious project of certain writers in ethics who wish to refashion in their own image what is most central in the moral life. The more general (principles, rules, theories, etc.) and the more particular (case judgments, feelings, perceptions, practices, parables, etc.) are integrally linked in our moral thinking, and neither should have pride of place. 12
Our review of very recent articles on palliative sedation reveals a poverty of ethical viewpoints. The rule of double effect should not preempt additional moral reflection or serve as the final word on justifying palliative sedation and related acts. A monolithic moral framework deprives us of the diversity of viewpoints that can inform and deepen our ethical understanding in a pluralistic society.
Footnotes
Acknowledgment
Dan Brock kindly provided review of how his ideas were conveyed here.
Author Disclosure Statement
No competing financial interests exist.
References
Supplementary Material
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