Harrison Lee

Many ethicists who have opposed euthanasia have nonetheless approved of various practices which have been believed to hasten, or risk hastening, the death of terminally ill and suffering patients. For instance, they have approved of a practice which I shall call ‘end-of-life sedation,’ or ‘EOL sedation.’ This practice involves administering drugs with sedating effects to relieve suffering at the end of life. Some have believed that EOL sedation risks hastening death by suppressing respiration in certain cases. The main difference, according to these opponents of euthanasia, is that whereas euthanasia by definition involves an intention to kill, EOL sedation does not. At most, it is argued, EOL sedation foreseeably but unintentionally hastens, or risks hastening death as a byproduct of relieving the patient’s suffering while they are still alive. As such, it has been argued that EOL sedation is supported by the rule of double effect (RDE). In his paper, “The last low whispers of our dead,” Daniel P. Sulmasy raises objections to a specific form of EOL sedation called ‘palliative sedation,’ focusing especially on two variants of that practice which have been defended by Timothy Quill and colleagues. Palliative sedation involves intentionally sedating a patient as a means of relieving their suffering rather than foreseeably sedating them as a byproduct of targeting specific symptoms. Sulmasy argues that palliative sedation, so defined, is neither supported by RDE nor permissible. Here it is argued that Sulmasy’s criticisms of this practice, and of the specific variants of it which he singles out for special criticism, are unsuccessful.

Many ethicists who have opposed euthanasia have nonetheless approved of the administration of palliative sedation (PS) under conditions where they have believed it is likely to hasten death. This reasoning typically reflects the doctrine of double effect (DDE), which prohibits causing evil intentionally but permits causing it merely foreseeably under some circumstances. In other ethical contexts, Frances Kamm has emphasized another distinction, namely the distinction between performing an action because one will thereby cause some consequence and performing an action in order to (i.e. from an intention to) cause a consequence. Here I argue that it could be permissible to administer PS to a patient because one would thereby cause him to die rather than causing him to endure suffering that would be worse for him than death. However, I argue that the because/in order to distinction is ethically insignificant in this context. It is no worse, I argue, to act in order to cause a patient to die than it would be to act because one would thereby cause a patient to die. Thus, I conclude that death is not an unconditional evil for the purposes of DDE analysis, and that euthanasia can be permissible.

A novel method of organ donation after circulatory death called normothermic regional perfusion (NRP) could mitigate the organ shortage crisis and lead to superior outcomes for organ recipients. In NRP, following a pronouncement of death by circulatory criteria, arteries leading to the brain are occluded and abdominal circulation is reinitiated in situ. A prominent objection to NRP maintains that it kills the donor since the arterial occlusion prevents blood from reaching the brain after circulation is reinitiated. Proponents of this objection recommend that transplant surgeons use normothermic machine perfusion (NMP) instead of NRP. In NMP, organs are removed from the donor’s body and perfused by machines using nutrient-enriched donor blood following the circulatory determination of death. Here I argue that if NRP kills the donor, then so does NMP. But I argue that features of NMP that clear the practice of the charge of impermissible homicide are also present in NRP. Like NMP, NRP at most preemptively causes the donor to die at the same time he would have died otherwise. It does not hasten death.

Proponents of “broad scope” theories of intention argue that agents cannot intend to achieve given ends without intending certain inevitable or probable consequences. I shall argue that some Thomistic variants of these theories collapse into the Expectation View (EV), i.e., that we intend to produce all of the consequences that we expect to result from our actions. I shall then raise four objections to EV. First, EV falsely implies that we intend to produce all of the expected beneficial consequences of our actions. Second, EV falsely renders altruistic self-sacrifice a species of suicide. Third, EV falsely implies that medical interventions with probable fatalities must involve intentional killing even when, of the available options, they offer the most likely prospects of long-term survival. Fourth, EV falsely implies that foreseeably fatal actions must involve intentional killing even when they will foreseeably prolong the agent’s life before killing him.