Terminal sedation: pulling the sheet over our eyes.

Terminal sedation--also called "palliative sedation," "continuous deep sedation," or "primary deep continuous sedation"--has become a new favorite in end-of-life care, a seeming compromise in the debate over physician-assisted dying. Like all compromises, it offers something to each side of a dispute. But it is not a real down-the-middle compromise. It sells out on most of the things that may be important--to both sides. To corrupt an already awkward metaphor, terminal sedation pulls the sheet over our eyes. Terminal sedation may still be an important option in end-of-life care, but we should not present it as the only option in difficult deaths. Proponents of assisted dying point to autonomy and mercy. The principle of autonomy holds that people are entitled to be the architects, as much as possible, of how they die. (Of course, autonomy has limits--one cannot inflict harm on others--and when one is no longer competent, values and interests may be expressed only indirectly; advance directives or surrogate decision-makers must be brought into play. But the principle itself is clear enough.) The principle of mercy requires that pain and suffering be relieved to the extent possible. These two principles operate in tandem to underwrite physician-assisted dying: physician assistance in bringing about death is to be provided just when the person voluntarily seeks it and just when it serves to avoid pain and suffering or the prospect of them. Both requirements must be met. Opponents base their objections to physician-assisted dying on two other concerns. One is the sanctity of life, a religious or secular absolute respect for life that is held to entail the wrongness of killing, suicide, and murder. This principled objection holds regardless of whether a patient seeks assistance in dying in the face of pain and suffering. The second objection is that physician-assisted dying might lead to abuse. This concern is often spelled out in two ways: physician-assisted dying risks undercutting the integrity of the medical profession, and institutional or social pressures might make people victims of assisted dying they did not want. These latter objections operate independently. One could be opposed to aid in dying on sanctity-of-life grounds even without fearing the slippery slope, and one could worry about the slippery slope without accepting the sanctity-of-life concerns. Often, however, these two concerns are fused in a general objection--a joint claim that it is wrong for doctors to kill and that if doctors do kill, even in sympathetic cases like that of the seriously suffering and already dying patient who begs for help, then they might start killing in other, more worrisome cases as well. In short, it's autonomy and mercy on the one side, sanctity of life and/or the possibility of abuse on the other. That's the standoff over physician-assisted dying, argued in a kaleidoscope of ways over the past several decades. Terminal sedation is often proffered as an alternative last resort measure that can overcome these practical and ideological disputes. In the 1997 cases Washington v. Glucksberg and Vacco v. Quill, the Supreme Court recognized the legality of providing pain relief in palliative care even if doing so might shorten life, provided the intention was to relieve pain. But careful scrutiny of terminal sedation--particularly sedation to unconsciousness, in which nutrition and hydration are withheld--suggests that it is not much of a compromise after all. An Inadequate Compromise Consider how terminal sedation fails to meet the concerns that underlie the dispute. Autonomy. Consent of the person affected is central to the concept of autonomy, but it is not and--as a consequence of some political interpretations--cannot be honored in decisions to use terminal sedation. First, terminal sedation is often used for patients suffering from severe pain, for whom pain management has failed, but if pain is severe enough, reflective, unimpaired consent may no longer be possible. …