Consciousness and Sedation at the End of Life

Death and dying often bring about anxiety and fear, particularly around the topic of pain and suffering. The issue of the adequate and proportionate alleviation of pain and suffering has long been one of the principal concerns across the wide range of modern medicine. While advances in pharmacological interventions during the past century have certainly alleviated symptoms previously perceived as uncontrollable, in the care of the terminally ill there remain some symptoms that can only be sufficiently relieved through either the partial or complete suppression of patient consciousness. Such interventions often involve the administration of high doses of anesthesia, presenting various risks including the potential of hastening death and depriving patients of a conscious experience of their last days.  

An increasingly aging population, combined with advancements in healthcare, especially in life-sustaining interventions, has brought new light to this issue—especially as death and the dying process are no longer realities we regularly encounter but instead are isolated to the halls of hospitals and nursing homes. The fields of palliative care and hospice present a particular challenge to the modern healthcare team as there exists a moral tension between relieving the suffering of the patient and the principle of nonmaleficence—the moral obligation to avoid inflicting harm on another—with an emphasis on the importance of patient consciousness. What many are not aware of is that this moral tension was addressed through a letter from the pope of the Roman Catholic Church in the middle of the twentieth century and has since been the foundation of all subsequent magisterial teachings regarding the proportionate use of anesthetics and sedation.

The Vatican Weighs In 

In February 1957, from the apostolic palace in Vatican City, Pope Pius XII composed a letter in response to a set of questions posed to him by the Italian Society of Anesthesiology. Relatively unknown today, this letter from almost seventy years ago addressed topics that are still major discussion points in the field of pain management, while also addressing the tension between the adequate palliation of suffering and the preservation of patient consciousness.  

Pius XII, addressing the use of anesthetics during illness and the dying process, firmly established that while a person may freely and heroically offer his or her pain and suffering as a free expression of purification and adherence to suffering of Christ, there is no strict moral obligation for a Christian to undergo physical pain. A person with a clear conscience may, keeping in mind proportionality, use available medical and pharmacological means to relieve physical suffering.  

Pius XII also acknowledged that with anesthetic agents, which by nature diminish one’s sensitivity to physical pain, there may also be a simultaneous partial or complete loss of consciousness and thus the suppression of the higher faculties. These higher faculties, such as the affective and intellectual faculties, are essential for free and moral action and therefore ought not to be suppressed without serious cause. Due to the importance these higher faculties enjoy, the Pope clarified in his address that one cannot cloud such faculties simply for the sake of pleasure or intoxication; anesthesia must solely be reserved for the intention of alleviating physical pain with foreseen and tolerated secondary effects of the suppression of consciousness. The Congregation for the Doctrine of the Faith (now known as the Dicastery for the Doctrine of the Faith) has affirmed this principle in its Declaration on Euthanasia (1980), Pope John Paul II’s Evangelium Vitae (1995), and in various addresses by subsequent Roman pontiffs.

In 2020, the congregation echoed Pius XII’s address on the liceity of proportionate use of sedation, with a specific focus on the care of the terminally ill. The document Samaritanus Bonus acknowledged that although it can be admirable to live with physical pain as an offering to God in light of the mystery of redemption, the congregation also affirmed the moral liceity of the use of sedatives to assist patients in experiencing a sense of peace as they approach the end of life, always being done with the patient’s informed consent. What the congregation highlights is not only the need for a prudent and proportionate use of anesthetics and sedation at the end of life, but the fundamental value of human consciousness during the dying process and the vital roles of caregivers and the human community to those approaching death. This gives light to the fact that even in the last moments of one’s life, there lies profound value and opportunity for authentic human fulfillment.

Consciousness at the End of Life

The value of consciousness lies in the fact that it allows for the active exercise of the intellectual and affective faculties of the human person, making possible self-reflection, judgment, and interaction with others and the surrounding world. This allows for free and moral action of the human person, for their good and for the good of all. This fundamental human experience does not cease with the dying process but rather intensifies, becoming a unique opportunity for a person to remember past experiences and reflect upon one’s own earthly life in its totality. Consciousness also permits man the opportunity to contemplate and evaluate his own life and actions in accord with conscience, a profound experience of both intimacy with God and unity with all of mankind, as defined by the pastoral constitution of the Second Vatican Council:

For man has in his heart a law written by God; to obey it is the very dignity of man; according to it he will be judged.(9) Conscience is the most secret core and sanctuary of a man. There he is alone with God, Whose voice echoes in his depths. In a wonderful manner conscience reveals that law which is fulfilled by love of God and neighbor. In fidelity to conscience, Christians are joined with the rest of men in the search for truth, and for the genuine solution to the numerous problems which arise in the life of individuals from social relationships. 

To deprive someone of consciousness, and the sacred sanctuary of conscience, in such a critical chapter of one’s life should never be done casually or without serious cause. The partial suppression of consciousness in palliative care should be only applied in the gravest of circumstances such as in cases of extreme and uncontrollable pain, while the total suppression of human consciousness (such as is seen in continuous deep sedation, which offers its own set of complications) must be seen as a last resort when all other resources have failed.

Considering this, the dying process becomes a unique opportunity for persons to seek the fulfillment of the good in their lives. At the bedside of one who is gravely ill and dying, profound moments of reconciliation, forgiveness, reflection, prayer, and hope are possible if given the opportunity. Through such an exchange, the dying person can experience the love and care of others, shaking off the isolation and despair that so often plagues those nearing death. The deathbed, therefore, becomes a sacred place through which the dying person can experience the empathy, compassion, and consolation of the human community. In this way, as a person approaches his or her own earthly end, this moment can be a precious and profound experience of one’s dignity and singular worth through both one’s own reflection and the compassionate care of others. In this way, a person’s conscious experience comes to its fulfillment during one’s last days.

Those involved in palliative care, therefore, hold a privileged place in this ministry by remaining at the bedside of those who are approaching their earthly end. They give witness to their inherent dignity and unique value as a human person. The family, friends, and caregivers of people in this precious time have a unique and irreplaceable role as they are the main facilitators of compassion and support for their loved ones. This accompaniment, often marked by bed baths, mealtimes, tender conversations, and other moments of sacrificial self-gift, while often overlooked and forgotten by a society so focused on efficiency and autonomy, is a unique and essential expression of humanity and one’s ability to care for another. 

A need for such care demands a reform in the education and formation of those involved in the healthcare field, particularly for those in palliative and hospice facilities, to respect the inviolable nature of life especially in situations of grave or terminal illness. Such care shown for the least and most vulnerable of a society reflects a wider call that all are called to share, as proposed by Pope Benedict XVI in his February 2008 address on the care of the incurably sick and dying to the Pontifical Academy for Life: 

Greater respect for individual human life passes inevitably through the concrete solidarity of each and every one, constituting one of the most urgent challenges of our time.

Death has always been veiled with a sense of fear and mystery. In the closing days of one’s life, the fear of suffering is not only limited to the physical pain that often accompanies death but also extends to existential and spiritual pain brought about through experiences of regret, loneliness, and despair. What death can also be is an extraordinary opportunity for a person to reflect upon life as an integrated whole, while the accompaniment and care for those walking through their final days allows for the virtues of humanity to shine most resplendently. Consciousness, therefore, is not simply a phenomenon that can be arbitrarily dispensed with or suppressed at whim: it is a critical element of the human experience, particularly in the last chapter of one’s earthly existence, during which one comes face to face with the mystery of suffering and the meaning of life. That one is close to death does not mean that he is bereft of meaning or of dignity. Quite the opposite. At the end of life, man has the right to know that his life mattered.

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