Guy Schofield

We read with interest the extended essay published from Riisfeldt and are encouraged by an empirical ethics article which attempts to ground theory and its claims in the real world. However, such attempts also have real-world consequences. We are concerned to read the paper’s conclusion that clinical evidence weakens the distinction between euthanasia and normal palliative care prescribing. This is important. Globally, the most significant barrier to adequate symptom control in people with life-limiting illness is poor access to opioid analgesia. Opiophobia makes clinicians reluctant to prescribe and their patients reluctant to take opioids that might provide significant improvements in quality of life. We argue that the evidence base for the safety of opioid prescribing is broader than that presented, restricting the search to palliative care literature produces significant bias as safety experience and literature for opioids and sedatives exists in many fields. This is not acknowledged in the synthesis presented. By considering additional evidence, we reject the need for agnosticism and reaffirm that palliative opioid prescribing is safe. Second, palliative sedation in a clinical context is a poorly defined concept covering multiple interventions and treatment intentions. We detail these and show that continuous deep palliative sedation is a specific practice that remains controversial globally and is not considered routine practice. Rejecting agnosticism towards opioids and excluding CDPS from the definition of routine care allows the rejection of Riisfeldt’s headline conclusion. On these grounds, we reaffirm the important distinction between palliative care prescribing and euthanasia in practice.

BackgroundDespite its ubiquity in academic research, the phrase ‘ethical challenge(s)’ appears to lack an agreed definition. A lack of a definition risks introducing confusion or avoidable bias. Conceptual clarity is a key component of research, both theoretical and empirical. Using a rapid review methodology, we sought to review definitions of ‘ethical challenge(s)’ and closely related terms as used in current healthcare research literature.MethodsRapid review to identify peer-reviewed reports examining ‘ethical challenge(s)’ in any context, extracting data on definitions of ‘ethical challenge(s)’ in use, and synonymous use of closely related terms in the general manuscript text. Data were analysed using content analysis. Four databases (MEDLINE, Philosopher’s Index, EMBASE, CINAHL) were searched from April 2016 to April 2021.Results393 records were screened, with 72 studies eligible and included: 53 empirical studies, 17 structured reviews and 2 review protocols. 12/72 (17%) contained an explicit definition of ‘ethical challenge(s), two of which were shared, resulting in 11 unique definitions. Within these 11 definitions, four approaches were identified: definition through concepts; reference to moral conflict, moral uncertainty or difficult choices; definition by participants; and challenges linked to emotional or moral distress. Each definition contained one or more of these approaches, but none contained all four. 68/72 (94%) included studies used terms closely related to synonymously refer to ‘ethical challenge(s)’ within their manuscript text, with 32 different terms identified and between one and eight different terms mentioned per study.ConclusionsOnly 12/72 studies contained an explicit definition of ‘ethical challenge(s)’, with significant variety in scope and complexity. This variation risks confusion and biasing data analysis and results, reducing confidence in research findings. Further work on establishing acceptable definitional content is needed to inform future bioethics research.

Gilbertson et al present a considered analysis of the abstract problem of ‘sedation’ at the end of life,1 and it is reassuring to see the separation of multiple practises that are often grouped under the heading terminal sedation. In their work, the authors attempt to introduce and justify a new practice in the care of those dying with significant suffering—expanded terminal sedation (ETS). This analysis will not, however, help our colleagues at the bedside. Here, we will focus on the flaws which are most relevant to clinicians: jurisdiction, uncertainty and reversibility. The authors’ focus on a jurisdiction that does already allow medically assisted in dying confuses their analysis. For example, either an instance of their proposed ETS does amount to intentionally hastening death, in which case it should be treated as a means of euthanasia and practised only where that is permitted, subject to its limits and regulations; or it does not amount to intentionally hastening death, in which case there is no reason to specify such jurisdictions. To explain that the most controversial elements of terminal sedation have been tacitly ‘accepted’ by the society in question does not invalidate the concerns. It is beyond the scope of this response to explore these, but to us, …

Emotional stimuli (e.g. words, images) are often remembered better than neutral stimuli. However, little is known about how memory is affected by an environmentally induced emotional state (without any overtly emotional occurrences) – the focus of this study. Participants were randomly assigned to discovery (n = 305) and replication (n = 306) subsamples and viewed a desktop virtual environment before rating their emotions and completing objective (i.e. item, temporal-order, duration) and subjective (e.g. vividness, sensory detail, coherence) memory measures. In both samples, a Partial Least Squares Correlation analysis showed that an emotional state characterised by high negative emotion (i.e. threat, fear, anxiety) and arousal was reliably associated with better memory in both objective (i.e. item) and subjective (i.e. vividness and sensory detail) domains. No reliable associations were observed for any temporal memory measures (objective or subjective). Thus, an environmentally induced state of negative emotion corresponds with enhanced memory for indices of episodic memory pertaining to “what” happened, but not necessarily “when” it happened.