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Euthanasia and Assisted Suicide

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Title: Euthanasia and Assisted Suicide


1
Euthanasia and Assisted Suicide
2
Content
  • General overview
  • Arguments for voluntary euthanasia
  • A right to die?
  • Arguments against voluntary euthanasia
  • The slippery-slope argument
  • Non-voluntary and involuntary euthanasia
  • Active vs. Passive euthanasia
  • Physician-assisted suicide
  • End-of-life care

3
General overview
  • In earlier periods of human history, physicians
    could do little to stave off death now,
    improvements in public sanitation, the
    development of immunization, the development of
    antibiotics, and the many technologies of modern
    medicine have combined to lengthen the human
    lifespan, particularly in the developed world.

4
General overview
  • In the developed world, with its sophisticated
    healthcare systems, the majority of the
    population dies at comparatively advanced ages of
    degenerative diseases especially cancer and
    heart disease with characteristically long
    downhill courses, marked by a terminal phase of
    dying.

5
General overview
  • The developments in medical technology and
    treatments, which prolong and sustain life of a
    patient, mean that more patients stay alive for
    longer.
  • However, this extension of life is often
    associated with severe pain and intense and
    burdensome treatments for the terminally ill
    patients.

6
General overview
  • At the same time, there has been progress in the
    legal acknowledgement of patients rights at the
    end of life.
  • In many developed nations, patients have the
    right to refuse unwanted treatment or to
    discontinue it once it has been started.

7
General overview
  • Euthanasia is the termination of a very sick
    persons life in order to relieve them of their
    suffering. The following are some related terms
    and definitions
  • Voluntary euthanasia death is brought about or
    hastened at the patients request.

8
General overview
  • Non-voluntary euthanasia euthanasia conducted
    where the explicit consent of the individual
    concerned is unavailable.
  • Involuntary euthanasia euthanasia performed on
    a person who is able to provide informed consent,
    but does not, either because he or she does not
    choose to die, or because he or she was not
    asked.

9
General overview
  • Active euthanasia hastening death by the use of
    drugs or other means, with a doctors direct
    assistance.
  • Passive euthanasia hastening death by
    withholding or withdrawing life-sustaining
    treatment.
  • Physician-assisted suicide the practice of a
    physician providing the means for a patient to
    end his own life.

10
General overview
  • Can life become so burdensome, so filled with
    pain and suffering, that it loses all meaning and
    value?
  • Is it ever right to end the life of a terminally
    ill patient who is undergoing severe pain and
    suffering?
  • Under what circumstances can euthanasia be
    justifiable, if at all?

11
General overview
  • Should life be preserved at the cost of pain when
    modern medicine makes this possible?
  • Should life be preserved without hope of
    consciousness?
  • Is there a moral difference between killing
    someone and letting them die?

12
General overview
  • An accident or illness may bring people to an
    extreme of pain, disability, distress or
    dependency, so that their lives become
    intolerable and there is no reasonable prospect
    of substantial improvement.
  • Some people in such circumstances may wish for
    death and consider it cruel to be denied their
    release.

13
General overview
  • There are circumstances in which hastening the
    end of a life seems to be the only way to relieve
    suffering.
  • Mercy killing, as it became known, occur on
    battlefields throughout the world. Animals with
    painful and fatal injuries would also be released
    from their suffering.

14
General overview
  • Most people think unbearable pain is the main
    reason people seek euthanasia, but some surveys
    in the USA and the Netherlands showed that less
    than a third of requests for euthanasia were
    because of severe pain.

15
General overview
  • Terminally ill people can have their quality of
    life severely damaged by physical conditions such
    as incontinence, nausea and vomiting,
    breathlessness, paralysis and difficulty in
    swallowing.

16
General overview
  • Psychological factors that cause people to think
    of euthanasia include depression, fearing loss of
    control or dignity, feeling a burden, or dislike
    of being dependent.

17
Arguments for voluntary euthanasia
  • The main arguments for voluntary euthanasia are
    1 the argument from autonomy (or
    self-determination), and 2 the argument from
    the relief of pain and suffering.

18
Arguments for voluntary euthanasia
  • Autonomy or self-determination refers to peoples
    right to making important decisions about their
    lives for themselves according to their own
    values or conceptions of a good life, and the
    right to be left free to act on those decisions.

19
Arguments for voluntary euthanasia
  • Self-determinism pays respect to an individuals
    personal values and enables the individual to be
    responsible for his or her own life.
  • It is one of the main pillars of a free and
    democratic society that individuals can enjoy
    liberty to do what they like as long as they
    actions do not harm others.

20
Arguments for voluntary euthanasia
  • In exercising autonomy or self-determination,
    people take responsibility for their lives.
  • Since dying is a part of life, choices about the
    manner of their dying and the timing of their
    death are, for many people, part of what is
    involved in taking responsibility for their lives.

21
Arguments for voluntary euthanasia
  • Counterargument Though a patient has a negative
    right to be left alone, this does not translate
    into a positive right to whatever he or she
    wants.
  • If that were the case, there would be no need for
    laws to regulate prescription drugs a patient
    could just buy whatever he or she felt was
    appropriate.

22
Arguments for voluntary euthanasia
  • Proponents of euthanasia argue that human beings
    are free and autonomous and have a right to
    self-determination in end-of-life decisions.
  • Individuals should have the right to control the
    circumstances of their own death and to determine
    how much suffering is too much.

23
Arguments for voluntary euthanasia
  • Patient autonomy includes the right to full
    information concerning the nature and development
    of the terminal illness.
  • Any decision about how to die must be made on the
    basis of informed consent.

24
Arguments for voluntary euthanasia
  • People should be informed of their diagnosis,
    their prognosis, their options in responding to
    their condition and all other relevant
    information.
  • Generally speaking, informed consent exists when
    patients can understand what they are agreeing to
    and voluntarily choose it.

25
Arguments for voluntary euthanasia
  • Counterargument For a decision about death to be
    voluntary, the individual must give explicit
    consent.
  • Patients in an indefinite coma or persistent
    vegetative state are not candidates for
    euthanasia. Nor can euthanasia be justifiably
    administered in cases of serious dementia or
    clinical depression.

26
Arguments for voluntary euthanasia
  • Counterargument We can never be absolutely sure
    that we have voluntary and informed consent. The
    pain and drugs may prevent patients from making a
    fully rational decision.

27
Arguments for voluntary euthanasia
  • Another argument for euthanasia is based upon
    compassion, mercy and beneficence.
  • In cases of intractable suffering and inevitable
    death, a spirit of mercy and compassion is
    supposed to be the correct response to a
    patients desire to die.

28
Arguments for voluntary euthanasia
  • According to this view, life is devoid of quality
    and of meaning to patients subject to severe and
    unremitting physical or mental suffering.
  • These patients should have the option of quick
    and painless relief, whether or not the condition
    is terminal.

29
Arguments for voluntary euthanasia
  • Thus, physicians have an obligation to do
    everything within their power to relieve that
    suffering, even to the point of hastening death
    if there are no realistic alternatives acceptable
    to the patients.

30
Arguments for voluntary euthanasia
  • Counterargument Suffering is almost always
    relievable without killing the person.
  • Thanks to techniques of pain management and
    better end-of-life care, it is possible to treat
    virtually all pain and to relieve all suffering.

31
A right to die?
  • Many people think that each person has the right
    to control his or her life and so should be able
    to determine at what time, in what way and by
    whose hand he or she will die.
  • They believe that human beings should be as free
    as possible, and that unnecessary restraints on
    human freedom are morally unjustifiable.

32
A right to die?
  • Most countries that put a value on individual
    liberty allow competent adults to refuse medical
    treatment even if such treatment is life-saving.
  • Besides, people have the right to die in the
    sense that they can commit suicide attempted
    suicide is decriminalized nearly everywhere in
    the world.

33
A right to die?
  • Some people, however, invoke the right to life to
    justify banning suicide and euthanasia.
  • According to this view, if we have the right to
    life, we owe ourselves the obligation to keep
    ourselves alive under any circumstances.

34
A right to die?
  • Kantians, in particular, believe that persons
    must be treated as ends in themselves and never
    merely as means.
  • To kill oneself because ones life is no longer
    worth living is to treat ones personhood as a
    means and not as an end in itself.

35
A right to die?
  • Does the right to life include the right to die?
  • Do the terminally ill have a right to die?
  • Does an individual who has no hope of recovery
    have the right to decide how and when to end his
    or her life?

36
A right to die?
  • It can be argued that the right to die is an
    integral part of our right to control our own
    destinies so long as the rights of others are not
    affected.
  • But euthanasia is not a completely autonomous
    act it requires the assistance of another person.

37
A right to die?
  • We may have a right to do whatever we like,
    including ending our own lives, so long as we do
    not unjustly violate other peoples rights.
  • However, even if we have a right to die, that
    does not mean that doctors have a duty to kill
    no doctor can be forced to help patients who want
    euthanasia.

38
A right to die?
  • Apart from that, the decision to die by
    euthanasia will affect other people such as our
    family and friends, and we must balance the
    consequences for them against our rights.

39
Arguments against voluntary euthanasia
  • The main arguments against voluntary euthanasia
    are 1 the argument from the intrinsic
    wrongness of killing, 2 the argument from the
    integrity of the medical profession, and 3 the
    argument from potential abuse (i.e. the
    slippery-slope argument).

40
Arguments against voluntary euthanasia
  • One objection to euthanasia invokes the sanctity
    of life principle which argues that all killing
    is morally wrong.
  • Human life is sacred and valuable intrinsically
    because it is a gift from God. Deliberately
    shortening life is against Gods will. Only God
    should determine the time of death.

41
Arguments against voluntary euthanasia
  • According to this view, euthanasia is wrong
    because of the sanctity of human life.
  • The deliberate taking of human life should be
    prohibited except in self-defense or the
    legitimate defense of others.

42
Arguments against voluntary euthanasia
  • Modern medicine has been accused of playing
    God. Thou shalt not kill and Man should not
    play God are typical objections to euthanasia
    based on religious faith.

43
Arguments against voluntary euthanasia
  • Counterargument In a free, democratic society,
    we do not use the criminal law to enforce the
    religious views held by some people on others who
    do not share these views.
  • A government which respects the right of its
    citizens to choose their own religious values
    cannot use the criminal law to enforce such views.

44
Arguments against voluntary euthanasia
  • Counterargument For those who believe that all
    matters of life and death must be decided by God,
    to use medicine to keep a sick person from dying
    is playing God.
  • If playing God simply means doing what will
    affect the chances of life and death, then a lot
    of responsible social action does that.

45
Arguments against voluntary euthanasia
  • Counterargument In the euthanasia debate, the
    use of the term killing should be avoided
    because it usually refers to taking a persons
    life against his or her will.
  • But as far as voluntary euthanasia is concerned,
    this is clearly not the case.

46
Arguments against voluntary euthanasia
  • Counterargument The trouble with the sanctity of
    life principle is that it implies that every
    human being should be kept alive as long as
    possible, and that is a proposition few
    thoughtful people would accept.
  • Most would agree, for example, that it is
    pointless to keep alive patients in an
    irreversible coma or a persistent vegetative
    state.

47
Arguments against voluntary euthanasia
  • Opponents to euthanasia point out that
    depression is very often a contributing factor in
    the desire for hastened death.
  • Clearly, if a patient is depressed or suffering
    from a mental disturbance, therapy and counseling
    not euthanasia should be recommended.

48
Arguments against voluntary euthanasia
  • There is also the justifiable fear that some
    elderly patients might be pressured by family,
    friends, the government, health care providers,
    social workers or by the example of other
    terminally ill patients, to choose euthanasia.

49
Arguments against voluntary euthanasia
  • For the elderly, the right to die may become a
    duty to die.
  • The old and ill often feel themselves to be an
    unwelcome burden on their children, and if
    suicide becomes more widely accepted, the
    pressure on the parent to commit suicide could
    become hard to resist.

50
Arguments against voluntary euthanasia
  • Counterargument It is a mistake to think that if
    euthanasia is strictly prohibited no such
    tragedies will occur. The sick will continue
    occasionally to attempt suicide in ways which are
    neither painless to themselves or others.

51
Arguments against voluntary euthanasia
  • Another objection to euthanasia is that there is
    always the possibility of an incorrect diagnosis
    or the discovery of a treatment that will permit
    either survival or recovery.
  • Allowing euthanasia undermines the commitment of
    doctors and nurses to saving lives and discourage
    the search for new cures and treatments for the
    terminally ill.

52
Arguments against voluntary euthanasia
  • Besides, asking doctors to abandon their
    obligation to preserve human life could damage
    the doctor-patient relationship.
  • Patients could become distrustful of their
    doctors efforts and intentions, thinking their
    doctors would rather kill them off than take
    responsibility for them.

53
Arguments against voluntary euthanasia
  • Counterargument If euthanasia is restricted to
    cases in which it is truly voluntary, then no
    patient should fear getting it unless he or she
    has voluntarily requested it.
  • Patients trust of their physicians could be
    increased, not eroded, by knowledge that
    physicians will provide aid in dying only when
    patients ask for it.

54
Arguments against voluntary euthanasia
  • Opponents to euthanasia also draw attention to
    the extraordinary development of palliative care
    and pain control in recent years as a more
    positive and safer response to patients
    suffering.

55
Arguments against voluntary euthanasia
  • Counterargument There are indeed drugs which, if
    properly administered, can control pain.
  • But there are other forms of distress such as the
    terror of breathlessness, uncontrollable
    vomiting, paralysis, incontinence, inability to
    swallow and sheer weakness and helplessness which
    cannot always be adequately controlled.

56
The slippery-slope argument
  • The main argument against legalizing euthanasia
    is the slippery slope argument.
  • Critics of euthanasia claim that legalizing
    voluntary euthanasia will lead to a slippery
    slope effect, resulting eventually in
    non-voluntary or even involuntary euthanasia.

57
The slippery-slope argument
  • Some believe that permitting voluntary euthanasia
    would weaken societys prohibition of intentional
    killing, and thereby undermine the safeguards
    against non-voluntary or involuntary euthanasia.
  • Thus, in order to prevent these undesirable
    practices from occurring, we need to resist
    taking the first step.

58
The slippery-slope argument
  • Slippery slope arguments have been used by
    conservatives and traditionalists to oppose all
    sorts of social change.
  • But is there sufficient evidence for the
    slippery-slope argument against euthanasia?

59
The slippery-slope argument
  • Some people think that euthanasia should not be
    allowed because it could be abused and used as a
    cover for the murder of innocent people.
  • For example, the horrors that characterized the
    Nazi regimes attempt to weed out the unfit had
    given euthanasia a bad name.

60
The slippery-slope argument
  • The Nazi practice of euthanasia the killing
    about 100,000 disabled people on the grounds that
    they had lives not worth living has been
    regarded by some as an example of how the removal
    of restrictions against killing can result in
    mass murder.

61
The slippery-slope argument
  • Counterargument In Nazi German, doctors took the
    lives of thousands of their fellow citizens on
    orders from the government.
  • These unfortunates were neither terminally ill
    nor in pain. The murder of these people was
    thinly disguised as euthanasia.

62
The slippery-slope argument
  • Counterargument The Nazi program of euthanasia
    was neither voluntary nor based on compassion it
    was, rather, motivated by the desire to preserve
    the purity of the German race, and hence was the
    result of a vicious and racist ideology.

63
The slippery-slope argument
  • For a contemporary example, many scholars focus
    their attention on the Netherlands, where the
    criteria of legalized euthanasia had been
    formalized since the 1980s.
  • Some of them see the Dutch experience of
    conducting euthanasia as evidence for the
    slippery slope effect.

64
The slippery-slope argument
  • Statistics show that in the Netherlands, families
    request euthanasia more often than patients and
    some studies there too show that some elderly
    people fear their lives will be ended without
    their consent.

65
The slippery-slope argument
  • However, more recent studies of the Netherlands
    found no evidence that legalizing voluntary
    euthanasia will lead us down the slippery slope
    to involuntary euthanasia.
  • Researchers conclude that, generally speaking,
    1 abuse of the Dutch euthanasia system is rare,
    and 2 no slippery slope effect has occurred.

66
The slippery-slope argument
  • Suppose slippery-slope evidence did suggest that
    some patients would be abused, how should this
    weigh against the freedoms of other patients to
    make specific end-of-life choices?

67
The slippery-slope argument
  • Just because a practice can be abused does not
    entail that it should not be used at all. Knives,
    cars, and drugs can be abused, but that does not
    mean they should be outlawed.
  • The abuses envisioned in slippery-slope arguments
    can be prevented by strict legal guidelines, like
    those currently used in the Netherlands.

68
The slippery-slope argument
  • The legal guidelines for euthanasia in the
    Netherlands include
  • 1 The patient must face a future of unbearable,
    interminable suffering
  • 2 The request to die must be voluntary and
    well-considered

69
The slippery-slope argument
  • 3 The doctor and patient must be convinced
    there is no other solution and
  • 4 A second medical opinion must be obtained and
    life must be ended in a medically appropriated
    way.

70
The slippery-slope argument
  • Another widely discussed example is the state of
    Oregon of the United States.
  • Since 1994, euthanasia has been legalized in
    Oregon under limited conditions for terminally
    ill patients who experience unacceptable
    suffering.

71
The slippery-slope argument
  • Data collected by the Oregon Health Department
    show that the practice is stable and relatively
    rare, accounting for approximately one in 1,000
    deaths.
  • We also know that pain management has improved in
    Oregon, and hospice utilization is among the
    highest in the nation.

72
Non-voluntary and involuntary euthanasia
  • A non-voluntary decision about death refers to
    cases in which the decision is not made by the
    person who is to die.
  • Such cases would include situations where,
    because of age, mental impairment, or
    unconsciousness, patients are not competent to
    give informed consent to life-or-death decisions
    and where others make the decision for them.

73
Non-voluntary and involuntary euthanasia
  • In those instances where the patient is not able
    to communicate wishes, medical staff and family
    are faced with a dilemma.
  • For example, this may happen when an otherwise
    healthy person has entered a persistent
    vegetative state without having expressed their
    wishes or intentions concerning end-of-life
    treatment.

74
Non-voluntary and involuntary euthanasia
  • The family may seek to exercise substituted
    judgment and, on the basis of statements the
    dying person made in the past, request the
    withdrawal of life support.
  • Otherwise, such a person may be kept alive by
    medications and gastric tube feeding for many
    years.

75
Non-voluntary and involuntary euthanasia
  • In these cases, family members or relatives try
    to make a decision for the patient according to
    what the patient would choose or in the best
    interests of the patient.
  • Some hospitals have established ethics
    committees to provide guidance.

76
Non-voluntary and involuntary euthanasia
  • Involuntary euthanasia occurs when patients are
    killed against their will or without their
    consent.
  • This kind of euthanasia is almost always
    considered wrong and is rarely debated.

77
Non-voluntary and involuntary euthanasia
  • Most people tend to equate involuntary euthanasia
    with murder, but it is possible to conceive of
    cases where the killing would count as being for
    the benefit of the person who dies.

78
Active vs. passive euthanasia
  • In active euthanasia, death is brought about by a
    physicians act, for example, when a person is
    killed by a lethal injection.
  • In passive euthanasia, death is the result of
    withholding or withdrawal of treatment.

79
Active vs. passive euthanasia
  • In active euthanasia, the proximate cause of
    death is the physicians act. But in passive
    euthanasia, the proximate cause of death is the
    patients disease, not the physician.
  • Some regard the difference as one between killing
    as an act of commission, and letting die as an
    act of omission.

80
Active vs. passive euthanasia
  • The distinction between active and passive
    euthanasia is consequential because some people
    who reject active euthanasia do accept passive
    euthanasia as a practice that provides benefits
    to the dying person without violating ethical
    standards and religious values.

81
Active vs. passive euthanasia
  • Opponents to active euthanasia deem this action
    wrong because they believe that taking an
    innocent persons life in all circumstances is
    morally impermissible.
  • On the other hand, it is believed that no one has
    to take direct responsibility for a persons
    death in the case of passive euthanasia.

82
Active vs. passive euthanasia
  • James Rachels, however, argues that there is no
    moral distinction between active and passive
    euthanasia.
  • He uses the example of Smith and Jones to prove
    this point.

83
Active vs. passive euthanasia
  • Smith stands to gain a large inheritance if
    anything should happen to his 6-year-old cousin.
    One evening while the child is taking his bath,
    Smith sneaks into the bathroom and drowns the
    child, and then arranges things so that it will
    look like an accident.

84
Active vs. passive euthanasia
  • Jones also stands to gain if anything should
    happen to his 6-year-old cousin. Like Smith,
    Jones sneaks in planning to drown the child in
    his bath. But as he enters the bathroom Jones
    sees the child slip, hit his head, and fall
    face-down in the water. Jones watches all this
    happen without doing anything, and the child
    drowns all by himself accidentally.

85
Active vs. passive euthanasia
  • Is Joness behavior, Rachels asks, any less
    reprehensible than Smiths?
  • If the answer is no, then we must conclude that
    the difference between killing and letting die
    does not really make a moral difference.

86
Active vs. passive euthanasia
  • Rachels If one simply withholds treatment, it
    may take the patient longer to die, and so he may
    suffer more than he would if more direct action
    were taken and a lethal injection given.

87
Active vs. passive euthanasia
  • once the initial decision not prolong his agony
    has been made, active euthanasia is actually
    preferable to passive euthanasia, rather than the
    reverse the process of being allow to die can
    be relatively slow and painful, whereas being
    given a lethal injection is relatively quick and
    painless.

88
Active vs. passive euthanasia
  • If death is the inevitable outcome, there are no
    morally relevant differences between not
    providing the treatment and taking active steps
    to end life.
  • Active steps to end a patients life in a quick
    and painless manner may be the morally right
    thing to do because unnecessary suffering can be
    avoided.

89
Active vs. passive euthanasia
  • The reason why killing is normally a great wrong
    is that dying is normally a great harm. But if it
    is in the best interests of a patient to die now
    rather than suffer a prolonged and painful dying,
    then killing is no longer a wrong.

90
Physician-assisted suicide
  • Assisted suicide usually refers to cases where
    people who want to die need help to kill
    themselves and ask for it.
  • It may be something as simple as getting drugs
    for them and putting those drugs within their
    reach.

91
Physician-assisted suicide
  • In physician-assisted suicide, the physician does
    not directly cause the patients death but
    enables the patient to choose the time and
    circumstances of his or her own death, usually by
    prescribing a lethal dose of drugs.

92
Physician-assisted suicide
  • The main difference between physician-assisted
    suicide and euthanasia lies in who performs the
    last causal act leading to death.
  • In the case of physician-assisted suicide it is
    the patient in the case of euthanasia it is the
    physician.

93
Physician-assisted suicide
  • Without the assistance of their doctors, patients
    can choose to die by refusing food and water.
    They will die more slowly than with
    physician-assisted suicide but die they will.
  • Advocates of physician-assisted suicide argue
    that alternatives should be provided so that
    patients need not choose this unpleasant way of
    dying.

94
Physician-assisted suicide
  • Arguments against physician-assisted suicide
    include considerations such as the possibility of
    discovery of cures, the dangers of mistaken
    diagnosis, the difficulties of knowing when
    requesters are rational, the dangers of patients
    being coerced by others, and so on.

95
Physician-assisted suicide
  • Is it morally wrong to help another person commit
    suicide?
  • If a patient asks to be withdrawn from a
    respirator, would it make a moral difference if
    the patient, rather than the doctor, pulled the
    plug?

96
End-of-life care
  • We are getting better at providing effective
    palliative care, and hospice care is more widely
    available.
  • Because of advances in palliative care and mental
    health treatment, there is no reason any person
    should ever feel they are suffering intolerably,
    whether it is physical or mental suffering or
    both.

97
End-of-life care
  • Palliative care is physical, emotional and
    spiritual care for a dying person when cure is
    not possible. It provides relief from pain and
    suffering and thereby offers an alternative to
    euthanasia.
  • Good palliative or hospice care has the goal of
    helping the patient to live each day as well as
    possible.

98
End-of-life care
  • Advocates of palliative and hospice care
    emphasize the importance of reducing human
    suffering.
  • Palliative management of suffering is trusted to
    substantially decrease the number of requests for
    both euthanasia and physician-assisted suicide.

99
End-of-life care
  • According to this view, palliative and hospice
    care including excellent pain and symptom
    management and psychosocial support for patients
    and families should be part of the standard of
    care for all severely ill patients.

100
End-of-life care
  • Some of the practices used in end-of-life care,
    however, have been likened to euthanasia.
  • For example, there is the practice of making a
    Do Not Resuscitate (DNR) order, where patients
    request that no treatment be given to them if
    their hearts stop beating or they stop breathing.

101
End-of-life care
  • Another controversial practice is known as
    palliative sedation. When a person experiencing
    extreme suffering, for which there is no
    effective treatment, he or she may be put to
    sleep using sedative medication.
  • For example, palliative sedation is often used to
    treat burns victims who are expected to die.
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