Double-effect sedation: do physicians not intend a decrease in consciousness when it is caused by drugs that can also reduce specific symptoms?

Abstract

The ethics of palliative sedation has been debated intensely. Recently, it has been emphasised that many drugs with sedating effects are also effective in reducing specific symptoms like pain and seizures. For example, midazolam is commonly used to sedate terminally ill patients but it can also reduce seizures. Hence, when midazolam is administered to a patient suffering from seizures, it may also lower the patient's consciousness. Similarly, morphine is useful in the management of end-stage pain and dyspnoea, but can also reduce the patient's consciousness, especially when administered in large doses. Cases in which a drug thus alleviates a symptom as well as lowers patient consciousness are called double-effect sedation (DES). Many claim that the decrease in consciousness in DES is merely a side effect and not an intended consequence, even if its occurrence was foreseen in advance or it will be maintained for some time until the patient dies. Additionally, it is often contended that DES is therefore justifiable by the doctrine of double effect (DDE) even though the decrease in consciousness is bad. The purpose of this paper is to examine these claims. I argue that the claims, while sometimes correct, are very frequently false. It will be shown that physicians often intend to reduce consciousness in DES. In such cases, as I conclude, DDE may not serve to justify DES, and DES should be subject to the same rigorous moral evaluations as the use of sedating drugs that do not reduce specific symptoms.