Continuous deep sedation at the end of life: Balancing benei ts and harms in England, Germany and France

Introduction Although various terms and definitions are used to describe continuous deep sedation (CDS) at the end of life (Morita et al. 2002a; Aubry et al. 2010), there is broad agreement that this involves the use of medication to induce and maintain unconsciousness until the patient dies, in order to relieve refractory symptoms. CDS generates significant controversies, regarding its arguable life-shortening effect (e.g. Sykes & Thorns 2003a; Maltoni et al. 2009; Rady & Verheijde 2010), the sustained privation of consciousness, the (frequently) associated discontinuation or withholding of food and fluids (Rady & Verheijde 2012) and the possibility that the practice can be used as a camouflage for euthanasia (Tännsjö 2004a; Jansen 2010). CDS accordingly prompts substantial questions about what it means to ‘benefit’ – and, indeed, to ‘harm’ – the terminally ill patient whose symptoms appear intractable. In this chapter we consider how these questions are dealt with legally, practically and ethically in three countries: England, Germany and France. Common to these countries is the prohibition of euthanasia and a long-established (if beleaguered) principle that would appear to support the use of CDS: the doctrine of double effect (DDE), according to which purportedly ‘bad’ effects (like death or the removal of consciousness) might be justified, provided they are not directly sought but are merely pursuant to the achievement of some greater good (like the removal of otherwise intractable symptoms). Yet, there are, of course, also important differences between the three jurisdictions, not least in terms of the legal frameworks that govern palliative (and related terminal) care.