The ethical and legal aspects of palliative sedation in severely brain-injured patients: a French perspective

Every year, millions of people with serious diseases, as well as their loved ones, are confronted with decisions relating to the quality of the time that remains to be lived. The quality of the end of life may be severely altered by pain or other distressing symptoms. Physicians have a duty to relieve suffering in their patients. However, in most countries, they are not allowed to intentionally shorten life, although treatments given to relieve suffering are permitted even if they are also expected to shorten life (double-effect principle). A major challenge faced by physicians is to honour their patients' wishes and values and to help them safeguard their dignity and peace at the end of life.Some seriously ill patients, such as those with severe brain injuries, are unable to communicate their suffering. In these patients, the effectiveness of palliative care cannot be assessed: the possibility of persistent suffering cannot be ruled out [1]. There is a wide consensus that palliative sedation is appropriate as a last resort in this situation [2]. However, palliative sedation is a complex intervention that is closer to physician-assisted suicide and voluntary active euthanasia than is ordinarily acknowledged. Safeguards are needed whenever a medical intervention may hasten death. Legislation stating which practices are permissible would reassure the numerous patients who fear a "bad" death and would improve practice uniformity among physicians [3]. The French law on patients' rights and the end of life passed on April 22, 2005 (Law n° 2005-370, known as the Leonetti law) [4] indicates that patients should be allowed to die as comfortably and peacefully as possible but should not be made to die. This law reflects the evolution of French medical thinking about the best means of protecting patients' well-being and dignity while refraining from intentionally causing death. It has also led to further ethical discussions, most notably about palliative sedation after treatm