Careful Conversation about Care at the End of Life

TO THE EDITOR:

I agree with Jansen and Sulmasy (1) that terminal sedation and voluntarily stopping eating and drinking are more morally complex than is usually acknowledged (2-4). In their paper, only case 2 was fully consistent with the rule of double effect because sedation was an unintended but foreseen consequence. But might not the purposeful sedation in case 1 have been intended to relieve suffering and the shortening of life only foreseen? (Furthermore, to suggest that this patient, who had severe muscle weakness, required intermittent respiratory support, and feared impending loss of dignity had disproportionately mild existential suffering seems outrageous.) Intention and proportionality are highly dependent on the intender's views, values, self-awareness, and experience and therefore have the potential for self-deception and oversimplification. Furthermore, the generalizability of the rule of double effect remains controversial in many ethical circles (5). The rule of double effect emanates from Catholic moral tradition and focuses primarily on physicians' motivations and value judgments. It is to be hoped that physicians are responsible for both “foreseen” and “intended” consequences and that patients' values, informed consent, proportionate presence of suffering, and absence of less harmful alternatives are more central to evaluating the propriety of given clinical actions (2, 5).