Ethical Framework of Palliative Sedation: The Principle of Double Effect

The ethical rationale for the use of palliative sedation derives from the principles of double effect, informed consent, and autonomy, although double effect is by no means necessary to endorse appropriate and proportionate sedation to alleviate refractory suffering.

Principle of Double Effect

The doctrine of double effect was developed by the Roman Catholic church (Quill 1997) and dates back to the Salmanticenses theologians of the 16th and 17th centuries (Walton 2002). However, the greatest credit in modern times for the thorough exposition of this principle as a norm applicable to the whole field of moral theology is owed to the Jesuit theologian Jean Pierre Gury.

The principle of double effect is a rule of conduct frequently used to determine when a person may lawfully and ethically perform an action from which two effects will follow, one bad, and the other good.

It is applied to situations in which it is impossible to avoid all harmful actions, helping clinicians decide whether one potentially harmful action is preferable to another. In fact, double effect was utilized by the Attorney General of New York in the Vacco v Quill Supreme Court case to support the state’s distinction between assisted suicide and what was then referred to as terminal sedation (Vacco v Quill 1997, Gauthier 2001).

Four Basic Components of the Principle of Double Effect

  1. The nature of the act must be good or morally neutral and not in a category that is absolutely prohibited or intrinsically wrong.
  2. The intent of the healthcare provider must be good, and while the good effect and not the bad effect must be intended, the bad effect can before seen, tolerated, and permitted.
  3. A distinction between means and effects must be envisioned, in that death must not be the means to the good effect. In other words, the good effect must be produced directly by the action, not by the bad effect. Otherwise, the agent would be using a bad means to a good end, which is never allowed
  4. A proportionality between the good and bad effects must be substantiated by reason, in that the good effect must exceed or balance the bad effect (Rousseau 2000, Quill 1997) i.e. the good effect must be sufficiently desirable to compensate for the allowing of the bad effect.


The principled and ethical use of palliative sedation incorporates the four conditions that constitute the doctrine of double effect, although some argue that at times the beneficial intent of the clinician may be unclear and that whether death is intended or merely foreseen is ambiguous and less clear (Stone 1997).

Factors to be Considered before Instituting Palliative Sedation

Clinician intent

There is a perceived ambiguity of clinicians intent of sedation. Palliative sedation is appropriate only in situations when the 4 basic conditions of the “double effect” principle are satisfied (as described above).

Informed consent

There is a distinct possibility that sedation can also be initiated without explicit consent of the patient or surrogate: Palliative sedation should not be instituted without the explicit informed consent of the terminally ill patient (who is suffering from refractory symptoms) or surrogate. Such a practice is legally, ethically and morally wrong.

Patient intent

The intent of the patient, like that of the clinician, must also be considered. Ethical and moral dilemmas may arise when a patient furtively desires a quick death by requesting palliative sedation; if the patient’s intent is known or suspected, ethical and psychiatric consultations are obligatory (Rousseau 2000).


Finally, autonomy and informed consent are closely intertwined with double effect. They allow a reasonable person to make self-directed and personal treatment choices based upon a truthful and understandable presentation of information, and they are unquestionably mandatory prior to initiation of palliative sedation (Rousseau 2000). Both autonomy and informed consent require the patient or surrogate to have decision making capacity, defined as the ability to receive and understand information, to deliberate and choose between alternatives, and to communicate wishes. However, clinicians should be mindful of the fact that decision making capacity may fluctuate and vary from time to time, thus encouraging frequent reassessment. Also, decision making capacity is different than the legally determined attribute of competency (Cowan 2002), and the two terms should not be used interchangeably.


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