Daniel P. Sulmasy, MD, PhD; Farr Curlin, MD; Gerard S. Brungardt, MD; Thomas Cavanaugh, PhD
Potential Conflicts of Interest: None disclosed.
Sulmasy D., Curlin F., Brungardt G., Cavanaugh T.; Justifying Different Levels of Palliative Sedation. Ann Intern Med. 2010;152:332-333. doi: 10.7326/0003-4819-152-5-201003020-00016
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Published: Ann Intern Med. 2010;152(5):332-333.
TO THE EDITOR:
We are curious about the repeated invocation by Quill and colleagues (1) of double-effect reasoning regarding palliative sedation. Double-effect reasoning crucially involves the distinction between what one foresees and what one intends, as well as the ability to make a proportionate judgment about the good and bad outcomes of an action (2, 3). Inexplicably, 2 of the authors have elsewhere rejected double-effect reasoning at the end of life (4); nonetheless, they explicitly cite this article to support the application of double effect to palliative sedation. They now write, “Occasionally, PPS requires sedation to unconsciousness, which is considered a foreseen but unintended side effect when lesser degrees of sedation were ineffective” (1). Yet, they previously rejected the distinction between the intended and the foreseen, stating that “ … the analysis of intention used in the rule of double effect is problematic. … Even philosophers and theologians sympathetic to the distinction between intended and foreseen consequences have failed to find an unambiguous way to draw the distinction in many difficult cases” (4).
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