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. 2025 Jul 9;24:195. doi: 10.1186/s12904-025-01817-z

Christian perspectives on palliative sedation: a literature study

Jonathan Lambaerts 1,✉, Bert Broeckaert 1
PMCID: PMC12243377  PMID: 40634982

Abstract

Background

Christianity has always been concerned about the fate of the sick and the dying. Charity is one of the seven Christian virtues and is seen as an act of love for one’s neighbour. At the same time, Christianity is a strong defender of the dignity of human life, especially the most vulnerable. In the context of advanced disease and end of life, all major Christian traditions (Anglican, Catholic, Eastern Orthodox and Protestant) advocate appropriate care to protect the dignity of those suffering from illness or facing the prospect of death. This translates into a strong opposition to any treatment that actively seeks to end a person’s life, such as euthanasia or physician-assisted suicide. Less clear is where these Christian traditions stand on palliative sedation; a treatment that aims to alleviate the suffering caused by refractory symptoms by lowering the level of consciousness. However, it is important to know and understand a religious tradition’s position on a particular treatment. Religious beliefs influence the decision-making process of both patients and healthcare professionals.

Method

A comprehensive and systematic literature study was undertaken to determine the position of the four major Christian traditions (Anglican, Catholic, Eastern Orthodox and Protestant).

Results

Although sources are scarce, there are explicit positions on palliative sedation in each of the four Christian traditions has regarding palliative sedation. These positions can be found in official Church documents, in academic debate or in the broader bioethical debate within each community.

Conclusions

Overall, there is a positive but cautious attitude towards palliative sedation in the four major Christian traditions. All recognise that palliative sedation can help alleviate patient suffering. They remain cautious in their support, however, as they consider the line between palliative sedation and life-ending treatments (e.g. euthanasia) to be too blurred. Moreover, the Christian traditions are aware that lowering the level of consciousness is not without its problems. Palliative sedation should therefore not be used without good reason.

Keywords: Palliative sedation, Christian bioethics, Anglicanism, Catholicism, Eastern Orthodox Church, Protestantism

Background

For all Christian traditions caring for the sick and the dying is an important concern, firmly rooted in the example given by Jesus Christ and echoed throughout the Gospels [70]. Caring for a fellow human being in a vulnerable situation, suffering from a serious illness or facing death, is thus seen as an act of charity [32, 67]. A key ingredient of Christian charity is the recognition and protection of human dignity [43, 62]. In the context of contemporary end of life care, there is a strong awareness within Christianity that the physical, psychological and existential suffering the patient is confronted with can threaten this dignity [17, 48]. Consequently, Christianity allows and even advocates medical treatments that help to alleviate the suffering of patients [16, 20]. At the same time, the various Christian traditions tend to object to any treatment that actively and intentionally ends a patient’s life [33, 54], even if it is sometimes presented as an act of mercy (e.g. ‘mercy killing’).

The position of the different Christian traditions on pain control, on euthanasia and on the withdrawing and withholding of life-sustaining treatment is clear, but their view on palliative sedation, a treatment that aims to alleviate a patient’s suffering by lowering his level of consciousness ‘to a level where one or several refractory symptoms can be sufficiently subdued’ [14], remains largely unclear. However, as religion influences the decision-making process of both patients [1, 6] and healthcare professionals [15, 38] and palliative sedation is an important but quite controversial ‘option of last resort’ in palliative care [13], it is important to know and understand the position of religious traditions, including Christianity, on this specific medical treatment too.

Method

Design

We undertook a comprehensive literature study to identify and clarify the normative views on palliative sedation within the major Christian denominations: Roman Catholicism, Eastern Orthodoxy, Protestantism and Anglicanism. We chose to discuss Anglicanism separately from Protestantism, because of the way it self-identifies as midway between Catholicism and Protestantism [7, 34, 84].

This study focuses on the normative position as expressed by authoritative voices, whether formal or informal, and discusses the arguments that those voices in each of the selected Christian tradition make for their position, thus allowing us to identify both similarities and differences between traditions. In order to work in a systematic and transparent manner, we drew inspiration from the methodology of a scoping study [3] – a methodology of literature study intended to systematically identify the available sources on a particular topic [3, 61]. For this literature study we decided to follow the framework of Arksey and O’Malley [3], which is “the most frequently used” [69]. Due to the nature of our study and more specifically the fact that we are not only reviewing academic studies but intentionally are including a wide diversity of normative sources, we realise and acknowledge that a scoping review as such was not possible. Indeed, the majority of sources that helped us identify the normative views on palliative sedation within the selected Christian traditions are not academic, let alone empirical studies, published in academic journals. As a result it is simply impossible to assess these sources on their methodological quality. The emphasis of our study was on a comprehensive coverage of a wide range of sources, rather than on a particular type of source [57]. Relying on the method of a scoping review as much as possible by following the framework of Arksey and O’Malley [3] did however allow us to conduct our study in a systematic and transparent manner.

A detailed search protocol is available on request, as is a list of all sources included in the study.

Search strategy

Twenty academic databases (AnthroSource, ATLA Religion Database, Bibliography of Asian Studies, CINAHL, Cochrane Library, EBSCO Open Dissertations, EMBASE, Index Theologicus, Index Religiosus, JSTOR, MEDLINE, Philosopher’s Index, PhilPapers, PsycArticles, PubMed, ScienceDirect, Scopus) and interfaces (Limo, ProQuest, Web of Science) were searched, in addition to three grey literature databases (OpenGrey, SciVerse Hub, WorldCat) selected for their general nature. Different query strings were used, combining keywords related to palliative sedation and both Christianity and the selected denominations (i.e. Anglicanism, Catholicism, Eastern Orthodoxy, Protestantism) with a Boolean operator. The search strings were optimised by truncation to ensure the broadest possible search. The search was performed in English, French, German and Dutch. An additional Google Scholar search was carried out, mirroring the search strategy for the databases and interfaces. To widen the scope of the search even further, a bespoke Google search was conducted. Given the nature of the study, official church websites too were searched directly for documents dealing with end of life ethics. Experts from both authors’ networks were also consulted in order to point us to additional sources [3]. This broad approach ensured that not only studies on Christianity and palliative sedation are included, but also and more importantly the broader, not necessarily academic normative ethical literature (e.g. church documents, speeches, interviews, individual reflections) written in the different Christian traditions.

Eligibility criteria

Following the search, all retrieved sources were screened based on pre-set eligibility criteria. Only sources in the selected Christian traditions that explicitly addressed palliative sedation from a normative perspective were included (even if they used other terms to denote this practice). Sources dealing only with related issues (e.g. end-of-life treatments, artificial nutrition and hydration) were excluded. Sources, including empirical studies, focusing on the lived beliefs of either patients and their families or health professionals and not on the normative positions of the selected Christian traditions were also excluded, as in this study (unlike in most of our earlier studies on world religions and end of life ethics in which we, using empirical methods, focused on lived religion and lived ethics, i.e. on the views and beliefs of ‘ordinary’ people regarding treatment decisions at the end of life) we were explicitly looking for authoritative religious voices (as they, as we learned from our earlier research, often have an important impact on the views of ‘ordinary’ believers [1, 6].

The sources included using the methods summarized above were subjected to an in-depth analysis, based on the principles of Grounded Theory [25]. Additional sources were added at this stage as a result of snowballing [85], including sources in languages other than the search languages. The findings of our search were structured according to the PRISMA guidelines [76, 82].

Results

The search of the databases and interfaces mentioned above yielded, after removing duplicates, 414 results. After screening, 174 results were assessed for eligibility. Using the pre-set eligibility criteria (see supra), 83 sources were included in this study. The bespoke Google search produced 919 results, of which 302 were included in the study. An further 103 sources were added through snowballing and references from the experts consulted (i.e. citation searches) and after the consultation of official Church websites or ecclesiastical organs. This resulted in a total of 488 sources added to the study (see Fig. 1).

Fig. 1.

Fig. 1

Open in a new tab

PRISMA flow diagram of the study selection process [64]. This work is licensed under CC BY 4.0. To view a copy of this license, visit https://creativecommons.org/licenses/by/4.0/

The results were differentiated by denomination (i.e. Anglicanism, Catholicism, Eastern Orthodoxy and Protestantism). A general category labelled ‘Christianity’ was also created for those texts that could not be attributed to one of the four selected traditions or that dealt with more than one of them. In addition, a category was created for the ecumenical texts (i.e. joint texts published by official bodies of two or more Christian traditions).

Within each category a distinction was made between official documents from the authoritative bodies of the respective tradition (e.g. teaching documents of the Roman Catholic Church, synodal documents of the Eastern Orthodox Churches, documents of the Anglican Communion or Protestant conferences), authoritative voices within the respective tradition (e.g. the pope, metropolitans, (arch)bishops, other members of the clergy), and a wide range of experts from different backgrounds (e.g. ethicists, theologians, health professionals). This subdivision also allowed the authoritative nature (e.g. divine, apostolic, papal, synodal, academic) and scope of each source (e.g. universal, regional, local) to be determined.

General findings

While there are a significant number of sources in Catholicism dealing with palliative sedation or the ethical issues surrounding the treatment, sources in other Christian traditions are scarce. Nevertheless it is clear that each of the selected denominations has its own perspective on palliative sedation, rooted in its own philosophical-anthropological framework and theological tradition. In what follows these different perspectives will be discussed, while respecting the diversity of opinion within each tradition.

Catholic perspectives

In Catholicism we generally found a positive attitude towards palliative sedation. This positive attitude springs from the recognition that it is desirable to approach the end of life ‘with the greatest possible peace and in the best internal conditions’ [23]. Palliative sedation is seen as a morally acceptable treatment to help alleviate suffering caused by refractory symptoms. This approval of palliative sedation goes hand in hand with a strong condemnation of all treatments that deliberately aim to end a patient’s life [72, 22, 23, 47]. This shows that within Catholicism, palliative sedation is seen as distinct from the active termination of life or euthanasia. It is understood that the crux of this difference is to be found in the underlying intention. While treatments such as euthanasia and physician-assisted suicide are intended to end a patient’s life, palliative sedation is intended only to alleviate the suffering of a patient [27, 77].

Even the presumed life-shortening effect of palliative sedation is not an obstacle to the moral approval of palliative sedation. This presumed effect is condoned because it is seen as only an unintended side effect [22, 47, 71, 23]. In Catholic moral theology, the acceptance of this side-effect is justified by the principle of double effect [73] – a principle that also plays an important role in the general ethical debate on palliative sedation [11, 26, 35, 74]. This principle, attributed to Thomas Aquinas [5], allows for the positive evaluation of an action that produces both an intended positive effect and an unintended negative effect. In the case of palliative sedation, hastening death is considered an unintended and unwanted side effect of the intended and morally acceptable goal of relieving the patient’s suffering [22, 47, 71, 23].

This is not to say that there are no reservations within Catholicism about palliative sedation. Various voices, both inside and outside the Church, feel that the lowering of the level of consciousness (especially to the level of unconsciousness) compromises the dignity of the patient. Some argue that with the loss of consciousness, the person loses those faculties that define him [78]. Others argue that the loss of consciousness cuts the patient off from their environment, making care and support more difficult [65]. Loss of consciousness not only cuts the patient off from their environment, but also from the transcendent. Palliative sedation thus deprives the patient of participation in the liturgical life and the celebration of the sacraments [63, 53]. It prevents him from consciously preparing for death and encountering God. Just as it prevents him from discovering and experiencing the spiritual dimension hidden in suffering [31, 36, 46, 63].

These concerns are not dismissed by the official teaching of the Catholic Church. On the contrary, they are taken very seriously. For this reason, every Church document dealing with palliative sedation stresses that palliative sedation can only be performed, when there is sufficient reason to do so and there is no other option available [22, 47, 71]. Church documents also state that the patient should have fulfilled his duties towards his heirs [22, 47, 71] and should have prepared himself spiritually [23] before his or her level of consciousness is lowered. Consciously undergoing suffering, regardless of its spiritual value, is not considered as a moral obligation [47, 71].

Eastern Orthodox perspectives

In Eastern Orthodox Christianity the concern about the effects of lowering the level of consciousness is even more pronounced. The idea of theosis (i.e. ‘partaking in the divine nature’ [19]) is a key concept in the Eastern Orthodox theological tradition. Through liturgical worship, man can transfigure his life and come closer to God [29]. This liturgical orientation to God is particularly important in the case of advanced disease. This is related to the Eastern Orthodox understanding of death. Death is not seen as an end, but as a moment of transition [42]. ‘Our death offers us the last opportunity in this world to unite us through repentance and God's grace with the holiness of God’ [30]. Loss of mental clarity or even of consciousness can jeopardise this union. This challenge becomes concrete in the impossibility of participating in the liturgical life and of receiving the sacraments [80].

According to Eastern Orthodox theologians, modern medicine tends to overlook this spiritual dimension as it focuses primarily on the physical dimension of the human being. As a result, issues such as pain management and symptom control have become central to medical practice [30]. But this is in vain. ‘The attempt to free oneself of pain is a sign of a false way of life, a life in accordance with the senses that increases another, existential, pain’ [42]. Alleviating the suffering caused by pain or refractory symptoms does nothing for the salvation of the human soul. Only a strong emphasis on the spiritual ensures that when man dies, he dies ‘without a dead soul’ [29].

On the other hand there is a broad agreement within Eastern Orthodox Christianity that no one should suffer intolerably [12, 80]. This validates forms of pain or symptom control, but sources in the Eastern Orthodox tradition remain vague about specific treatments, including palliative sedation. An exception is when it comes to treatments that actively seek to end a patient’s life. Like the Catholic tradition, Eastern Orthodox Christianity openly and radically condemns these acts, which are thought to deny God’s lordship over life [2, 4, 37, 41]. The few sources that are somewhat clearer about specific palliative treatments, do indicate that any treatment to help manage pain or refractory symptoms should be seen as a last resort [12, 40, 81, 80] and as an act of kindness towards a person that is suffering. ‘Extreme cases of sustained suffering, demand response, whether related to terminal or chronic illness, disability or intractable pain’ [60].

Anglican perspectives

The goal of alleviating intolerable suffering is shared by the Anglican tradition. It is nevertheless difficult to assess whether palliative sedation would be considered as a morally legitimate way of doing this, as the term is not commonly used in the Anglican bioethical debate, and there does not appear to be a consensus on how the treatment should be understood. There is also a great deal of caution within the Anglican tradition about any form of comfort care that could lead to the death of a patient [55].

As in the Catholic and Eastern Orthodox traditions, there is a strong opposition in Anglicanism to any treatment that actively ends a patient’s life [28]. However, if the intention is not to kill, but to relieve suffering, then death is considered to be acceptable as a side effect [49]. This position, which sometimes is justified by means of the principle of double effect [18, 28], suggests that palliative sedation might be considered acceptable in the Anglican tradition as a means of alleviating the suffering caused by refractory symptoms.

The bioethical debate on end-of-life issues, particularly in the Anglo-Saxon world, also has a distinct social and cultural dimension [56]. In Anglicanism there is a strong sense that decisions in this area reflect a cultural view of how terminal illness and death should be dealt with. Indeed: ‘Moral decisions are not made in a vacuum’ [28]. The Anglican tradition opposes a medical culture that contributes to a diminishing respect for human life, particularly for the vulnerable such as the sick and dying [55]. In a joint statement from the International Commission for Anglican-Orthodox Theological Dialogue, the so-called Pendeli Statement [60], it reads: ‘A culture that privileges individual autonomy as an ultimate value can fail to recognize the unexpected and sometimes profound gifts that can accompany the experiences of being vulnerable and ‘ministered unto’’. For this and other reasons, the Anglican tradition rejects treatments that radicalise the ideal of autonomy, such as euthanasia and physician-assisted suicide.

Protestant perspectives

In Protestantism the main argument in favour of palliative sedation is that it relieves suffering, which is seen as an ethical duty [24]. Therefore, in the cases of terminal illness, palliative sedation is recognised as a possible and morally legitimate treatment [9, 51]. Moreover, individual autonomy and the related notion of freedom of conscience play an important role in Protestant reflection on both theological and bioethical issues [9, 21, 50, 75]. A patient can choose a particular treatment in good conscience.

All this does not mean, however, that there are no reservations about palliative sedation in the Protestant tradition. Indeed, precisely the fact that autonomy is considered essential, raises the question of consciousness. Since the absence of consciousness removes the possibility of autonomous action, the question of whether it is morally licit to knowingly and willingly lower the level of consciousness becomes pressing [59, 52]. In some ways, treatments that actively end someone’s life are less morally challenging. A patient can autonomously choose to have their life ended (i.e. euthanasia) or to end their own life (i.e. physician-assisted suicide), after which there is no longer a moral dilemma due to the absence of an autonomous and moral subject. In the case of palliative sedation, the question remains as to whether it is morally permissible to deprive someone of one of the most fundamental characteristics of the human condition [8, 45].

In addition to the issues of consciousness and autonomy, there is, in Protestantism, also the concern about the possibility of actively ending a patient’s life through palliative sedation, especially among those protestants that condemn euthanasia and physician-assisted suicide. For them, as is the case for the majority of authoritative voices in other Christian denominations, actively ending a human life is a denial of God’s authority over life and considered morally illicit [39, 58]. These protestants want to be reassured that palliative sedation is in no way a form of covert euthanasia. Here too the principle of double effect is used as a means to distinguish palliative sedation from euthanasia and to provide moral justification for the treatment [9, 45, 68]. Those groups that argue, on the other hand, that euthanasia or physician-assisted suicide can be morally licit either remain silent on the issue of palliative sedation or express concern about the deliberate lowering of the level of consciousness (see supra). While the choice of euthanasia or physician-assisted suicide can be seen as an act of autonomy [10], palliative sedation deprives someone of his or her autonomy and thus of his or her humanity. Or at least, the precondition for it [8].

Discussion

The main difficulty in assessing the normative views of the different Christian denominations on palliative sedation is the lack of a common language. This is illustrated by the fact that the term palliative sedation itself is not always used by the traditions to describe the medical treatment that consists of lowering the level of consciousness of a terminal patient in order to alleviate suffering. Different terminology is used (e.g. terminal sedation, deep sedation, continuous (deep) sedation) and sometimes authors even simply use more general terms such as analgesics.

It would be wrong to assume that any of the traditions discussed in this article should be seen as a monolithic bloc. Protestantism, for example, ‘is a term applied to many different Christian denominations’ [66] and particularly in relation to end of life ethics, the distance between these different denominations is increasing [16, 24, 33]. Similarly, the uniqueness of each Church in Eastern Orthodoxy makes it impossible to speak of a single normative view on bioethical issues [79]. Even within Catholicism there is more internal diversity than is often assumed [83]. It is therefore necessary to be cautious when discussing the normative views of any of these traditions on palliative sedation. They are never exhaustive.

Nevertheless, there are clear trends in the views on palliative sedation within each Christian tradition. This is evidenced by the lack of fundamental differences between the included sources (i.e. sources from authoritative bodies and authoritative voices in the respective tradition, and other authoritative voices, and sources of varying scope) (supra). Indeed, each Christian tradition is characterised by its own rationale, resulting in a distinct approach to palliative sedation.

The Catholic tradition has the most coherent and explicit normative position on palliative sedation. The Catholic Church’s history of reflection on the ethical issues surrounding palliative sedation (e.g. possible hastening of death, the loss of consciousness), has led it to conclude that it is morally licit to alleviate the suffering of a patient by lowering the level of consciousness through the use of sedatives [23].

However, as we have shown, this does not mean that this position is universally accepted within the Catholic community. Several authoritative voices have expressed concern that the loss of consciousness prevents patients from receiving the sacraments at a vulnerable time of their lives [63, 53]. and prevents a conscious approach to death and encounter with God. These concerns illustrate that the Catholic and the Eastern Orthodox traditions are not as different as some authors have suggested [29, 44]. The question of consciousness plays a role in both traditions, although the spiritual stance of Eastern Orthodoxy may be more overt.

The Pendeli Statement [60] makes clear that the call to prepare spiritually for death is also shared by the Anglican tradition. Although the Protestant tradition is not deaf to this call, its main reluctance to lower the level of consciousness seems to be that it affects the autonomy of the individual believer [8]. However, the lowering of the level of consciousness is considered acceptable in order to alleviate suffering [51].

Catholicism seems to be the most permissive when it comes to the alleviation of suffering. This is however not to say that the theme of suffering does not play a role in Catholicism, far from it. According to John Paul II ‘in suffering there is concealed the immensity of a specific mystery’ [46]; through it Christians can come closer to God. In the context of palliative sedation, this salvific dimension of suffering is emphasised (especially in Church documents) but it is left to the individual believer to decide whether he wants ‘to share consciously in the Lord’s Passion’ [47, 23]. The fact that undergoing suffering is not presented as a moral duty can be explained by the position of Pius XII. In his reflections on the use of analgesics to relieve pain, he clearly stated that ‘accepting suffering without mitigation is not an obligation and does not meet a standard of perfection’ [71].

Like in Protestantism, the Eastern Orthodox tradition is more cautious. Lowering the level of consciousness, especially rendering someone unconscious, is considered problematic but also permissible as a last resort [12, 40, 80, 81]. The Eastern Orthodox teaching is clear: no one should suffer needlessly [41]. This prevention of unnecessary suffering seems to be a common concern of all the Christian traditions discussed.

Conclusion

Although palliative sedation is a fairly recent and not very well known practice tends to remain below the surface in Christian reflections on medical ethics, this study of authoritative normative texts shows that the subject is addressed in the ethical reflections of the four major Christian denominations. In general, there is a positive but cautious attitude towards palliative sedation as a means of controlling suffering caused by refractory symptoms. There are no fundamental, radical objections to this treatment, as is the case for euthanasia and physician-assisted suicide. At the same time, there is a widespread recognition within the major Christian traditions that the lowering of the level of consciousness is not a trivial matter. It obscures a fundamental feature of the human condition. As such, it should be used only as a last resort and not without the necessary spiritual preparation. For these authoritative Christian normative voices death is an important rite of passage. This passage should preferably be a conscious one, or if this is not possible, should at least be consciously prepared. For them palliative sedation should therefore always be part of a holistic approach that also takes religious concerns into account.

Acknowledgements

The search strategy for this literature study was co-developed with Mar Gil Álvarez.

Authors’ contributions

J.L. carried out the literature study and wrote the main text of the manuscript. B.B. supervised the study and revised the text of the manuscript. Both authors reviewed the final manuscript.

Funding

Bijzonder Onderzoeksfonds (BOF) KU Leuven (reference C14/23/002).

Data availability

A detailed search protocol is available on request, as is a list of all sources included.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Footnotes

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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