an unintended side-effect of medication,
such as from opioids for pain relief".
Furthermore, a distinction of intention of
palliative sedation and of euthanasia is
presented in the framework. Thus, palliative
sedation differs from euthanasia in terms of
aim (to relieve suffering and not to end life),
means (to lower consciousness
proportionally until distress is relieved,(2)
and not induce death by lethal medication),
result (relief of suffering with life-shortening
as an exceptional side-effect and not lifeshortening by
definition) and timing
(continuous deep palliative sedation being
reserved for the terminal phase of life). The
use of sedation for patients at the end of life,
under the cover of alleviating symptoms, but
with the intention of hastening death, has
sometimes been wrongly associated with
palliative sedation. (3, 4) Therefore, a clear
distinction can be drawn between
continuous deep palliative sedation and
euthanasia. (5-16)
to outweigh the potential bad effect, and
evidence on hastening death through
palliative sedation - even if not intended - is
weak. (17) Therefore, recent discussion in
the literature clarifies that the doctrine of
the double effect is not applicable to
palliative sedation and doesn´t add useful
characteristics for moral reasoning in the
context of this medical practice. (17)
It has been debated if - and how - the
doctrine of the double effect is applicable to
palliative sedation. The doctrine "is used to
justify an action that produces a good effect
- in this case the relief of suffering - even if
it may produce a bad effect, for example
hastening death". (17) Others claim that the
"bad" effect may be unconsciousness. (18)
An analysis of the Kantian ethics of virtue, for
example, has shown that "continuous deep
sedation until death (CDS) does not conflict
with the perfect duty of moral selfpreservation because
CDS does not destroy
capacities for the agency". (19) However,
there is no commonly shared ethical
framework defining what is good and what is
bad. Moreover, the good effect must be felt
Suffering
Doctrine of the double
effect
Suffering has a normative function, requiring
others to act upon it. (20) In the medical
context of palliative sedation, there has been
a controversial debate on which kind and
intensity of suffering may justify palliative
sedation, how to prove that suffering exists,
measure suffering and determine suffering
as a justifiable indication for this measure.
Whereas the term symptom refers to
something caused by an illness, it is
debatable if, for example, existential
suffering may fall into this category or is part
of the human condition as suffering from
problems with meaning or existential fear in
the light of awareness of one's own
mortality. Schumann-Olivier et al. distinguish
existential suffering from existential distress
by the fact that it occurs in terminally ill or
dying people. (21) The updated framework
reflects this debate and follows an approach
that tries not to distinguish in general
between certain categories of symptoms and
distress. It (nearly) consistently uses the
term suffering wherever appropriate. It is
acknowledged that existential suffering as an
indication for palliative sedation on its own is
not broadly accepted and that refractoriness
is much more difficult to establish, as the
severity of the distress may be very dynamic
and idiosyncratic, and psychological
adaptation and coping may occur. However,
the prevalence of one kind of suffering as
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