Surveys in different countries (e.g. the UK, Belgium and The Netherlands) show a marked recent increase in the incidence of continuous deep sedation at the end of life (CDS). Several hypotheses can be formulated to explain the increasing performance of this practice. In this paper we focus on what we call the ‘natural death’ hypothesis, i.e. the hypothesis that acceptance of CDS has spread rapidly because death after CDS can be perceived as a ‘natural’ death by medical practitioners, patients' relatives and patients. We attempt to show that the label ‘natural’ cannot be unproblematically applied to the nature of this end-of-life practice. We argue that the labeling of death following CDS as ‘natural’ death is related to a complex set of mechanisms which facilitate the use of this practice. However, our criticism does not preclude the view that CDS may be clinically and ethically justified in many cases.
A 46-year-old-man who wants to die after a stroke that left him almost completely paralysed is bringing a groundbreaking legal action that could effectively lead to the legalisation of assisted suicide in the UK. Martin was a fit and active man who enjoyed rugby, cars and socialising with friends in the pub before suffering a brainstem stroke three years ago. Now requiring round-the-clock care, his mobility is limited to moving his eyes and small movements of his head. He communicates by staring at letters on a computer screen which the machine recognises and forms into words spoken by a digitised voice. Martin has been asking to die since six months after the stroke but says he has no one willing to assist him and cannot on his own organise a trip to the Swiss clinic Dignitas, where he could end his life legally. His wife, who chooses to be known as Felicity, says she will be with him if he dies but will not help bring about his death.
Until quite recently bioethicists have had little of depth and probity to say about the duty of healthcare professionals in general and physicians in particular to relieve pain and suffering associated with disease and/or its treatment. The singular exception is the now arguably canonical work by physician and ethicist Eric Cassell, titled The Nature of Suffering and the Goals of Medicine.2 I invoke the word ‘‘canonical’’ on the grounds that to my knowledge no one has offered a sustained critique of Cassell’s conceptual analysis of suffering or of his inextricable linkage of its nature to the essential features of persons. In doing so, Cassell suggests not that living beings without the status of persons cannot suffer, but rather that the suffering experienced by persons is unique precisely because of their essential features.
The total number of deaths studied was 11,704 of which 1517 involved continuous deep sedation. In Dutch hospitals, CDS was significantly less often provided (11%) compared with hospitals in Flanders (20%) and U.K. (17%). In U.K. home settings, CDS was more common (19%) than in Flanders (10%) or NL (8%). In NL in both settings, CDS more often involved benzodiazepines and lasted less than 24 hours. Physicians in Flanders combined CDS with a decision to provide physician-assisted death more often. Overall, men, younger patients, and patients with malignancies were more likely to receive CDS, although this was not always significant within each country. Conclusion Differences in the prevalence of continuous deep sedation appear to reflect complex legal, cultural, and organizational factors more than differences in patients’ characteristics or clinical profiles. Further