Palliative Sedation in End-of-Life Care

Susan D. Bruce, RN, BSN, OCN; Cristina C. Hendrix, DNS, APRN-BC, GNP, FNP; Jennifer H. Gentry, RN, MSN, ANP, APRN-BC, PCM


Journal of Hospice and Palliative Nursing. 2006;8(6):320-327. 

In This Article

The Doctrine of Double Effect and Principle of Proportionality

In addition to the principles of beneficence, maleficence, justice, autonomy, and futile care, two ethical principles that play a lead role in guiding the clinical practice of palliative sedation are the doctrine of double effect and the principle of proportionality. At the heart of the ethical debate over palliative sedation is the differentiation between sedation for intractable symptoms and euthanasia. The distinction lies in the intent. The intent of palliative sedation is relief of intractable distress, whereas the intent of euthanasia is to end life. The ethical justification for palliative sedation is the doctrine of double effect.

The doctrine of double effect has its roots in Roman Catholic theology.[14] It is used when it is impossible to avoid harmful effects. It helps us choose between two actions when neither choice is what we would want. The doctrine of double effect makes the distinction between an intended effect and an unintended effect of an intervention. The doctrine of double effect holds that intentionally causing death is not acceptable but prescribing high doses of sedatives and opioids to relieve pain is, even if the resulting death is foreseen. The doctrine has four conditions according to Sulmasy and Pellegrino:[15]

An action with two possible effects, one good and one bad, is morally permitted if the action (1) is not in itself immoral, (2) is undertaken only with the intention of achieving the possible good effect, without intending the possible bad effect, although it may be foreseen, (3) does not bring about the possible good effect by means of the possible bad effect, and (4) is undertaken for a proportionately grave reason.

In palliative sedation, the act itself must be good or at least neutral (administering pain medications or sedation); the intention of the act is to produce a good effect (relief of pain or suffering), although a harmful effect (death) is foreseeable in some cases; the harmful effect of the act must not be the means to the good effect (death is not the means to relieve suffering); and the good effect must outweigh or balance the harmful effect (principle of proportionality). The principle of proportionality is established by the terminal condition of the patient, the urgent need to relieve suffering, and the consent of the patient or healthcare proxy. Simply stated, it can be said that death with palliative sedation is "foreseen" but not "intended" and the sedation itself is not causing the death of the patient.

In a patient who is terminally ill, the physician has an obligation to provide effective palliative care, including pain control, although it may foreseeably hasten death. In 1997, the Institute for Ethics at the American Medical Association reiterated some of the fundamental tenets of ethical-medical practice for patients facing death.[16] These tenets constitute an imperative within the healthcare professions to attend to the comprehensive needs of dying patients. These tenets are summarized in Table 1 .


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