Christian and Indian religions on palliative sedation: a scoping study

Introduction

Background

In 1991, Robert Enck introduced the term ‘terminal sedation’ when he wrote about a practice that was already quite common in palliative care but only rarely discussed before, in which, by reducing the level of consciousness, a terminally ill patient no longer experiences the pain or severe symptoms he/she is suffering from (1). In the years and decades that followed, terminal sedation would receive increasing attention and provoke a great deal of controversy, as is apparent from many well-known international discussions in medicine and academia (2,3), but also in politics and in the legal sphere (4,5). Since these controversies were largely fueled by unclarities in and regarding the practice of sedation—to this day, there is still a large diversity of practices both in Europe and globally—from 1998 on we have set up a research programme on sedation that specifically focuses on crucial conceptual (terminology, definition) and ethical and epidemiological issues regarding this practice. In 2000, we introduced the term ‘palliative sedation’, defining it as “the intentional administration of analgesics and/or other drugs in dosages and combinations required to adequately relieve pain and/or other symptoms”, and distinguishing it in a threefold way from euthanasia (6-8).

Rationale and knowledge gap

Although over the last few decades a lot of research has been conducted on various aspects of palliative sedation (5,9-12) and clinical guidelines on palliative sedation are now available in many countries (13,14), it is notable that in this body of knowledge hardly any attention is paid to the influence of culture and especially of religion on palliative sedation practices and attitudes. This is unfortunate, given that research indicates religion has a significant influence on treatment decisions made by both patients (15-17) and healthcare professionals (11,18-20) in the context of advanced disease.

Religious individuals or communities in an important way do not invent their own beliefs, practices and attitudes. Indeed, these beliefs, practices and attitudes are, to varying degrees (sometimes this influence might be very limited, sometimes it will be very high) shaped and coloured by their respective, these days often global traditions, by a rich and diverse arsenal of normative doctrines or texts that is passed on, shared and developed (21). In order to better understand and respond to the ethical attitudes and concerns of patients, family members and caregivers belonging to a particular religious tradition, it is thus quite helpful to have a general knowledge of the normative positions (i.e., what is considered morally right or wrong) within that tradition regarding the issues in question.

Objective

This paper, part of a larger KU Leuven (Catholic University of Leuven)—funded research project on world religions and palliative sedation (project 3H230262, 2023-2028, two PhDs), discusses the results of our scoping study on the normative perspectives of the major Christian traditions (Anglicanism, Catholicism, Eastern Orthodoxy and Protestantism) and the main Indian religions (Buddhism, Hinduism and Sikhism) on palliative sedation. The perspectives of the other Semitic religions (i.e., Judaism and Islam), which we studied in earlier research projects, will be briefly addressed in the discussion. We present this article in accordance with the PRISMA-ScR reporting checklist (22) (available at https://apm.amegroups.com/article/view/10.21037/apm-2025-aw-129/rc).

Methods

To identify sources discussing the normative perspectives of Christian denominations and Indian traditions on palliative sedation, this study employed the scoping study methodology developed by Arksey and O’Malley (23). While in the identification and selection of sources we followed the method of a scoping review, our aim was not limited to mapping the available literature or to analyse or discuss the types of studies available on palliative sedation and religion as such. Rather, our aim is to examine and interpret the normative views on palliative sedation within these religions that are present in the sources we were able to retrieve using a grounded theory method (24), enabling conceptual comparison and theory building.

Because this interpretative analytical step goes beyond the descriptive synthesis typical of a scoping review, the project is more accurately described as a “scoping study” in the broader sense of Arksey and O’Malley’s framework. The search protocol is not registered but can be accessed upon request by contacting the authors.

Information sources

For this literature study, the following databases were searched: ATLA Religion Database with Atlaserials PLUS, Bibliography of Asian Studies, CINAHL, Cochrane Library, EMBASE, Index Theologicus, Index Religiosus, MEDLINE, OpenDissertations, ProQuest, PsycARTICLES, PsycINFO, PubMed, ScienceDirect, Scopus, The Philosopher’s Index and Web of Science. The grey literature databases and interfaces searched, included OpenGrey, SciVerse Hub, WorldCat and Google Scholar. In addition to these searches, general Internet searches were conducted to ensure the widest scope possible. Since religious authoritative views on palliative sedation are also found in non-academic writing, the scope of sources extends beyond academic literature and studies. The academic and grey literature databases were searched from the moment of creation up until 2024.

Search strategy

The search was conducted using a search string, combining keywords covering a variety of practices descriptions capturing the practice of palliative sedation and the respective religious tradition. Truncations were employed not only to create a wider search, but also to incorporate different terms. We did not base the search for practices related to palliative sedation on one specific definition of palliative sedation, instead the keyword “sedati*” targeted the different terms referring to palliative sedation (e.g., terminal sedation, deep (continuous) sedation, intermittent sedation, sedation at end-of-life), but also adjacent subjects related to the use of sedatives. This keyword (“sedati*”) was combined with a truncated keyword referring to the respective religious tradition, leading, e.g., to 11 results for the combination “sedati*”/“hindu*” in the EMBASE database.

The searches were conducted in English and French for both the Christian and Indian traditions. For the Christian traditions, a search in German was also conducted.

Given the limited results from the initial search for the Indian traditions and the more extensive body of work in these religions on other end-of-life issues, a second search was conducted for the Indian traditions using a broader range of keywords related to typology of treatment decisions in advanced disease developed by Broeckaert and Palliative Care Flanders (25,26) (i.e., withdraw or withholding of curative or life sustaining treatments, symptom control, euthanasia and assisted suicide) to identify additional literature related to palliative sedation. This approach helped us to uncover arguments and perspectives on palliative sedation within the broader context of treatment decisions in advanced disease.

The general internet searches were conducted using a customised search strategy that reflected the one used for the database searches. We set the threshold for these internet sources to the first 50 webpages. As part of the review process, snowballing was used and subject-matter experts were consulted to identify potentially overlooked sources.

Selection of the sources

After gathering the literature, duplicates were removed using Zotero. Then, titles and abstracts were screened in Rayyan to identify sources that met the eligibility criteria. If there was doubt, a full-text review was conducted to determine whether to include the source or not. The sources from the Internet searches were reviewed individually to evaluate their eligibility for this study.

Inclusion and exclusion criteria

The eligibility criteria were guided by the central aim of this study: to identify the normative perspectives of the selected religious traditions on palliative sedation. Eligible sources, whether academic or non-academic (e.g., texts issued by the religious leadership), were required to express or to focus on or make reference to the normative views and/or ethical attitudes of official authorities (the religious leadership) or specialists [e.g., ethicists, theologians, (para)medics] within the selected Christian and Indian traditions regarding palliative sedation. Studies that did not refer to or lacked a specific connection to one of the aforementioned religious traditions were excluded from the study.

Data collection

All included sources were reviewed, and relevant information pertaining to religious perspectives on palliative sedation was systematically mapped. The following data were collected for each source: (I) title; (II) authors and their institutional affiliations; (III) stated aim or objective of the publication; (IV) religious tradition(s) addressed, including specific branches where applicable; (V) classification of the treatment type based on Broeckaert’s typology (25,26); (VI) position regarding the treatments discussed; and (VII) arguments presented in support of the position. The individually charted data served as the basis for identifying, analysing, and comparing the perspectives presented across the sources using the grounded theory method.

Data synthesis

Given the aim of this study, i.e., to identify and discuss the normative perspective on palliative sedation within the major Christian and Indian traditions, the approach extends beyond synthesising the identified sources. A grounded theory methodology, as outlined by Corbin and Strauss (24), was employed to identify and analyse the underlying concepts, values, and reasoning that inform the aforementioned religious positions and finally to enable meaningful comparisons between the different religious traditions, identifying both fundamental similarities and differences. The critical appraisal of each source focused on its normative weight, its origin and scope, because our interest lies in the normative religious positions expressed in the material. Many of the sources we examined are not clinical or empirical studies but are a wide variety of both academic and non-academic writing—the normative religious views we want to reveal are indeed found in various types of literature-, making traditional assessments of methodological validity (e.g., study design, results, or clinical rigour) not applicable. The charting of data for each individual source was part of our preparatory process for synthesising the results using the grounded theory method. The individually charted data were then used to identify, analyse, and compare the normative perspectives on palliative sedation that are presented across the literature.

Results

Indian traditions

For the Indian religions, a total of 235 sources from academic and grey databases were included after screening. These sources were first categorized by religion (Hinduism, Buddhism, Sikhism) and then further subdivided according to the specific search string that was used: a first search string using the keyword palliative sedation and its synonyms, and a second one covering broader end-of-life practices such as euthanasia, assisted suicide, and the withholding or withdrawal of nutrition and hydration. Sources were marked according to origin or writer to properly assess the normative weight of the sources.

As shown in Table 1, for Hinduism, 3 sources were identified using the primary search string, 51 through broader end-of-life keywords, 22 via snowballing, and 10 through Internet searches, resulting in a total of 86 sources. For Buddhism, a total of 124 sources were included: 4 identified through the primary search string, 65 through broader end-of-life terms, 34 via snowballing, and 21 through Internet searches. Sikhism yielded the lowest number of eligible sources, with a total of 25. None were found using the primary search string, 11 were identified using broader search terms, 6 through snowballing, and 8 via Internet searches.

Hinduism

Combining all our searches, we found only sixteen sources that directly refer to (palliative) sedation. Three of these sources are scholarly reflections based on surveys with Hindu physicians (27,28) or Hindu patients (29), while the remaining sources are theoretical reflections, including work by Shirley Firth, a scholar of Hindu medical ethics widely cited in literature on Hindu end-of-life ethics (30,31). These sources emphasize that enduring pain may be a way to eliminate bad karma, and therefore some patients might not wish to receive sedation (27-39). Dewar et al. refer to the Mahabharata when making this claim (29) and Firth draws on the Bhagavad Gita to emphasize the importance of the final thought being directed toward God (40). According to Ramalingam et al., a conscious mind at the time of death is also considered important, though at the same time they note that the Hindu physicians in their study did not object to end-of-life treatments (including palliative sedation) (28). The picture is even more nuanced, as Dewar et al. emphasize that some Hindus may use sedation to keep a family member alive in order to die during a specific astrological period, or view the opportunity to receive palliative sedation as a consequence of good karma and therefore choose to accept it (29). A nuanced stance can also be found in the pamphlet produced by the Hospice and Palliative Nurses Foundation (USA), which states that there is no prohibition of sedation or analgesia in Hinduism, though some Hindus may prefer to be conscious and present with family during their final moments (41).

Another recurring theme in literature on (palliative) sedation in Hinduism is the importance of a good death for a favourable rebirth. Katherine Young, a fairly frequently cited scholar, and scholar Arvind Sharma argue that the final thought and utterance before death influence one’s destination after life, and that focusing on God at the moment of death ensures a good rebirth, therefore pain medication should not cloud the mind (32,42). Authors have drawn on parts of the Bhagavad Gita, on the Mahabharata, and on the Ramayana, when discussing the significance of one’s final thoughts at the moment of death (38,40,43-45). There is however no evidence of these texts being invoked by patients when making treatment decisions at the end of life (29).

Buddhism

In the literature on Buddhism in total 31 sources mention palliative sedation, a synonym or explicitly refer to medication to dull the mind. Of these sources, some come from the hand of Buddhist religious authorities.

The fourteenth Dalai Lama states that in taking medication that dulls the mind, one prevents a crucial moment of virtue development. According to him, the state of mind and virtue you create before death can positively affect the rebirth (46). If pain medicine would be developed that would not alter the person’s consciousness, this would be useful and good (46). The Dalai Lama XIV has also elaborated on the importance of meditation and of mindfulness techniques to help one to let go of the attachment to life and to minimise suffering at the end of life (46).

Several Buddhist religious authorities have explicitly discussed palliative sedation. Paisal Visalo, a Thai monk and abbot of Wat Pasukato, considers it an acceptable second-best alternative to a mindful death. Excessive pain, he argues, can create a negative mental state and harm one’s rebirth; thus, when the intention is to relieve suffering, sedation does not negatively affect karma. He distinguishes, however, between managing physical pain, where sedation may be appropriate, and addressing emotional or spiritual pain, which should be treated in a different way (47). Tenzin Chodron, a nun at the Pure Land of Amitabha Buddha Hospice, also emphasises that one’s state of mind at death influences future rebirths. A calm and compassionate death is ideal, though some flexibility is allowed in cases of extreme suffering (48). Frank Ostaseski, Buddhist teacher and co-founder of the Zen Hospice Project, positively evaluates palliative sedation when the intention is not to hasten death but to ease pain (49). Thai Buddhist monks also state the importance of a conscious and peaceful mind for a good death, which implies that sedation might be a problem (50). Overall, these authoritative perspectives reflect a pragmatic approach, favouring a conscious death but allowing sedation when necessary to prevent mental distress that could affect rebirth.

Scholars writing on Buddhism and palliative sedation tend to make similar points. Most, if not all, scholarly sources discussing palliative sedation emphasize the desirability of a conscious, alert, and calm death; therefore, some Buddhists might choose not to accept sedation. The moment of death, and the state of mind immediately preceding it, are considered crucial for influencing future rebirth—or even achieving enlightenment (51-55). In their argumentation scholars refer to Buddhist authorities such as the Dalai Lama (54,56) or important Buddhist texts, including The Tibetan Book of Living and Dying by Sogyal Rinpoche (51) and the Petavatthu and Vimanavatthu of the Theravāda canon (57).

Sikhism

The literature on Sikhism and palliative sedation is very limited, with only two sources addressing the topic directly. Singh, referencing the Sri Guru Granth Sahib, regards pain as a vehicle for the purification of sin; hence, medication may be disfavoured, with meditation serving instead as an appropriate means of relief (58). Landa et al. emphasise consciousness of God at the time of death is considered important to alleviate suffering; therefore, palliative sedation may be rejected. However, if physical pain results in agitation and distress, the use of sedation is considered equally acceptable by these scholars (59).

Sikh authorities have published medical guidelines for Sikhs, such as those by the Sikh Coalition in the United States and the Sikh Healthcare Chaplaincy Group led by Harinder Singh in the United Kingdom. These guides have been cited by other scholarly sources on palliative and medical care (58,60,61). While neither specifically addresses palliative sedation, both provide guidance on end-of-life practices and care. The Sikh Coalition leaves decisions regarding medication and medical interventions to the patient and their family (62); the manual produced by Harinder Singh emphasizes the importance of prayer and family presence during the final moments before death (63).

Christian traditions

The search for sources on Christianity and the use of sedatives, which was conducted using both academic and grey literature databases, eventually led to 155 sources that were included in the literature study. An additional 247 internet sources were later added. Before analysis, the sources were divided into different categories. Next to the general category ‘Christianity’, the sources were divided per denomination: ‘Anglicanism’, ‘Catholicism’, ‘Eastern Orthodoxy’ and ‘Protestantism’. This led to the following division as illustrated in Table 2: for Christianity in general 34 sources and 81 additional internet sources, 7 for Anglicanism in general and 29 additional internet sources, for Catholicism 65 in general and 42 additional internet sources; for Eastern Orthodoxy, 33 in general and 39 additional internet sources and for Protestantism, 16 in general and 56 additional internet sources.

Within each of these categories, a distinction was made between sources from official authorities (e.g., the Magisterium in case of the Catholic tradition or the synods of the Anglican, Eastern Orthodox or Protestant churches) and individual, authoritative voices (e.g., ethicists, medical practitioners and other healthcare professionals). This allowed a variety of perspectives to be incorporated into the analysis, both within and between each denomination. At the same time, it enabled us to recognize common ground.

Catholicism

The Catholic debate on the use of sedatives to control pain and symptoms dates back to the second half of the 20th century. In response to questions about the legitimacy of the use of anaesthesia, Pope Pius XII declared that the use of sedatives and the lowering of the level of consciousness of a patient are morally licit (64,65). At the same time, Pius XII made it clear that the intention should always be to alleviate the patient’s suffering, rather than to end his life intentionally. This position would become the reference point in the catholic debate on palliative sedation.

The position of Pius XII was reiterated by different congregations, like the Congregation for the Doctrine of the Faith [1980] and different papal institutions (66). Most recently this position was repeated in the document “Samaritanus bonus” (67). John Paul II also defended this position in his writings on end-of-life. According to him, the use of sedatives is permissible, as long as they are not administered with the intent to end the patient’s life, as the decision on life and death belongs to God alone (68).

John Paul II simultaneously voiced a critique towards the modern tendency to run from pain (69). In Salvifici Doloris, the pontiff emphasises the redemptive nature of suffering and explains how suffering can bring someone closer to God (69).

This more critical note comes to the fore in our second category of sources—those written by Catholic theologians, ethicists and healthcare professionals. On the one hand, some sources from this category pick up on the concern that palliative sedation may result in slow or ’stealth’ euthanasia (70,71). On the other hand, some raise concerns about the consequences of lowering the patient’s level of consciousness. According to Pacholczyk, an impaired consciousness prevents the patient from partaking in the spiritual and liturgical life, hindering his preparation for death (72). Some authors such as Sulmasy, argue that impairments to consciousness compromise essential features of the human condition (73). The fact that the patient is no longer able to express his wishes not only puts pressure on the spiritual dimension of palliative care, but also on the principle of autonomy which is a guiding principle in bio-ethics (74). This concern has been echoed by Vatican officials, such as the Secretary of State Cardinal Parolin (75). Despite these critical reflections, the vast majority of Catholic sources are open to using palliative sedation to alleviate a patient’s suffering.

Eastern Orthodoxy

The debate on palliative sedation is less outspoken and elaborate in the Eastern Orthodox tradition. This has to do with a different approach to illness and end-of-life issues in this Christian tradition. The main concern within Eastern Orthodoxy is the salvation of the soul of the patient (76,77). Therefore, the question for Eastern Orthodoxy is rather how treatments in advanced disease can help achieve this goal. This makes some theologians and ethicists critical of palliative sedation as it lowers the patient’s level of consciousness, when necessary, even to the level of unconsciousness. This prevents them from participating in the spiritual and liturgical life of their community or preparing themselves for their impending death (76,78). In the Eastern Orthodox tradition, death is considered as a passage at which one meets God (79), so it is preferable for a patient to be conscious at the moment of death.

Nevertheless, the normative voices within Eastern Orthodoxy—both from official and individual authorities—do not rule out palliative sedation. The Eastern Orthodox tradition recognises that pain caused by illness can become unbearable and that there is a need to alleviate this suffering (80,81). The use of sedatives is considered morally legitimate in this context (81). However, it is always seen as a last resort (82). Approval for the use of sedatives to alleviate unbearable suffering is always accompanied by a warning that this may not result in actively ending a patient’s life (81,83-85).

Anglicanism

There are few sources that deal explicitly with palliative sedation in the Anglican tradition. Like the other Christian traditions, there is the general stance that no patient should have to suffer unbearably. In the so-called “Pendeli Statement” [2023], a document written the International Commission for Anglican-Orthodox Theological Dialogue, it is acknowledged that medical interventions that help alleviate pain or conditions are permissible. At the same time this and other sources warn that these kind of treatments should never lead to actively ending a patient’s life (86,87).

Another concern, shared with the Eastern Orthodox churches, is that lowering the level of consciousness impairs the patient’s “ability to partake in the spiritual and liturgical life of the community” (87). This deprives them of the possibility to prepare themselves on their impending death (88). A careful preparation for one’s death is therefore considered a necessary part of any treatment involving sedation.

Protestantism

As with all ethical decisions, Protestantism in general leave the final decisions to the conscience of the individual (89,90). At the same time all Protestant movements stress the importance of distinguishing treatments that aim to alleviate suffering from those that aim to actively end a patient’s life (91). Although there are some Protestant churches that are open to the possibility of assisted dying (92-94), this remains a minority position. Overall, like the other Christian denominations, Protestantism too states that the decisions over life and death belong to God (95).

Although the use of sedatives to reduce pain and alleviate suffering is considered acceptable, some Protestant sources have reservations, relating to the impairment of the patient’s consciousness (96). Not only does this hinder the spiritual preparation for death (97), according to some Protestant ethicists, it also deprives patients from their ability to express themselves and make autonomous decisions which eventually leads to a loss of self (98,99).

Discussion

The absence of explicit bioethical debate in Indian traditions may be attributed both to the limited availability of palliative sedation in South Asian contexts (32,100-102) and to the fact that religious diversity in end-of-life care is a relatively new topic. Guidelines for addressing religious diversity, such as those from Queensland and the Sikh Coalition, are indeed recent (103). Moreover, in Indian traditions end-of-life decisions are often regarded as deeply individual matters, guided by self-reflection, meditation, and consultation with teachers or spiritual authorities in the absence of a central authority on ethical issues (103-106).

Despite the general absence of formal positions, in various levels of authoritative, scholarly and grey literature sources, shared beliefs in karma and liberation from the cycle of rebirth are the base of many similar stances on palliative sedation among the Indian religions. In all three traditions, the moment before death is viewed as important for attaining liberation or securing a favourable rebirth. Palliative sedation is generally not considered ideal, as it may obscure consciousness at this decisive moment (107,108). Hindu and Sikh sources from various levels of religious authorities and scholars further highlight devotion to God at the time of death as a means of cultivating the necessary tranquillity (60,109-111) and the experience of pain as a way to get rid of bad karma (112).

More broadly, Indian religions provide alternative frameworks for addressing suffering and dying that differ from dominant bioethical models. Their generally reserved attitude toward palliative sedation also reflects a shared acceptance of death and suffering as a natural part of life (38,61,113-115). Both authoritative and scholarly sources place emotional and spiritual well-being at the centre of end-of-life care, prioritizing a conscious, peaceful death in which meditation, mindfulness, prayer, and chanting are preferred over palliative sedation as ways of dealing with (mental) suffering (33,51,55,58,59,63,116,117).

Nevertheless, this ideal death is clearly nuanced, pain management without loss of consciousness is generally accepted and not seen as interfering with karma and sedation may even be chosen by patients under certain circumstances (29,57,59,116,118-122). In fact, in both Buddhist and Hindu traditions, references to ideals of compassion (“karuna” in Buddhism) for others and help them be free from suffering (47,119,123,124) or the duty of doctors to alleviate pain and help patients, are present resulting in accepting palliative sedation (103). Moreover, Hindu patients may see the access to pain control as a result of their good karma (45) or do not see pain control as negatively interfering with karma (121).

In the Indian religious traditions euthanasia and assisted suicide are generally viewed in a very negative way (38,56,58,108,125-128). All three Indian religions discuss the negative karmic consequences of taking one’s own life or assisting in the death of another. Furthermore, prematurely ending one’s life to escape suffering is not considered an effective solution, as karmic forces cannot be avoided and are believed to be carried into the next life (34,48,56,103,112,116,122,128-133). According to the findings presented in the scoping study of Gil-Álvarez et al. on Hinduism and end-of-life ethics, some Hindu’s believe that the moment of death is predetermined at the moment of birth, and tampering with this is not a good idea, though, on the other hand, sometimes life sustaining treatments have been requested in order to keep the person alive until a more auspicious time to die (103). Within Sikhism, death is decided by God, so euthanasia and assisted suicide are not acceptable since one does not accept gods will when carrying out these practices (58,63,126,134). In Buddhism, the first precept to not harm (ahimsa) and the monastic rule against killing, aiding in the death of another monk or inciting death is used as an argument against euthanasia and assisted suicide in Buddhism by scholars (55,128,132,133,135-138). There are, however, both in Hinduism and Buddhism a few exceptional voices that argue that when a patient is suffering greatly with no hope of recovery, a compassionate intention to alleviate that suffering may justify euthanasia, assisted suicide, as a lesser evil compared to letting them suffer (103,131,139-143). In both Buddhism and Hinduism taking one’s own life or that of another person is generally seen as having a very negative effect on the karma of the patient and the physician involved; it contradicts the dharma (duty) of the physician to help the patient and also the important value of ahimsa (non-violence) (55,103,128,133,136,138). Two Buddhist sources, one of which is a Buddhist teacher and founder of the Zen Hospice Project, explicitly state that since the aim of palliative sedation is pain relief, it is very different from killing and thus can be accepted (49,53,105). A possible issue here, as mentioned by Gielen, is that a lack of knowledge in religious traditions on the effects of sedation may lead to the belief that sedation hastens death, which would make it quite euthanasia-like and thus not acceptable (104).

Although all of the Christian traditions discussed have sources that explicitly address palliative sedation, there is a clear imbalance in their number. The Catholic tradition has the largest number of sources and offers the most detailed discussion. However, sources from the other three Christian denominations still allow us to understand how they value palliative sedation. In the four traditions we found no fundamental differences between the position taken by official authorities and that of individual specialists, though on average the latter tend to be more critical of the effect of palliative sedation itself on the spiritual preparation for the end of life.

Overall, the different Christian denominations are open and positive to the possibility of palliative sedation (144). With the principle of charity in mind (145,146), they consider it to be a legitimate means of alleviating suffering caused by refractory symptoms in those who are most vulnerable. This position is not only motivated by the care for others, but also by the strong awareness that suffering can affect the patient’s dignity (147-150). To protect their dignity, which stems from his creation in God’s image (151), treatments that help control and alleviate suffering are therefore welcomed (152,153).

Nevertheless, reflections on palliative sedation vary across the different Christian traditions. Differences in approaches to bioethical issues (154,155) and ethical sensitivities result in different perspectives among the different Christian denominations. In Catholicism, the main issue remains the distinction between palliative sedation and treatments that aim to intentionally end a patient’s life (67,68,156,157), while in both Anglicanism and Eastern Orthodoxy the main concern is the effect of lowering the level of consciousness on the spiritual path towards death (76,78,87), though in these traditions too the moral appreciation of palliative sedation would be very different from that of euthanasia or assisted suicide.

The Protestant sources share the concern regarding the impairment of consciousness, but place it in a broader ethical discussion (18,98,158). The impairment of consciousness, especially the loss of consciousness, makes it impossible for a patient to express himself and to act autonomously.

Loss of consciousness and of autonomy are a challenge in medical practice in general (159), but for the Christian traditions it complicates pastoral care as the patient can no longer indicate their spiritual needs. Therefore, all Christian traditions stress the importance of thorough timely preparation when deciding on treatment possibilities (160). This ensures that, when patients are no longer capable of making their own decisions due to loss of consciousness, healthcare professionals and the next of kin can help to respect the patients’ spiritual preferences.

There are but a few sources on Judaism and Islam dealing with palliative sedation, and no systematic studies are available. However, the sources that do discuss palliative sedation demonstrate a similar openness to that found in Christian traditions. In Judaism, the main argument is based on the principle of alleviating pain (161,162). According to Immanuel Jakobovits, the father of Jewish bioethics, this principle is deeply rooted in the Jewish tradition (163). Based on this principle, Jewish sources advocate alleviating both somatic and psychological pain and suffering (164). This legitimises palliative sedation.

As with Christian traditions, Jewish sources stress that no treatment should intentionally aim for the premature death of the patient. Treatments such as euthanasia and assisted dying are therefore condemned in Judaism (165). Judaism holds the belief that humans should never assume control over life and death (166).

In Islam too there is the strong conviction that one’s lifespan is and should be decided by God only. As a result acts such as suicide, assisted suicide and euthanasia are extremely problematic as they totally disrespect God’s authority (15,166-170).

As palliative sedation does not involve this active, intentional termination of life nor has an intrinsic life-shortening effect, it can be acceptable. In any case, suffering is not exalted in Islam and pain relief is an important positive duty of the physician (171-173). On the other hand, in Islam too being conscious at the end of life is important: it enables a person to repent, to reflect, to pray and to prepare for death. Taking a patient’s consciousness away is a serious matter, that can only be considered when the patient is suffering unbearably and there are no other solutions available (174-177).

When we compare the views of Indian and Semitic traditions on palliative sedation, it is clear that both are concerned about the effect that the lowering the level of consciousness has on the patient’s spiritual life. However, the reasoning behind this concern differs. This should come as no surprise. Each tradition is rooted in its own metaphysical paradigm which might give rise to different concerns. In the Indian traditions an alertness of mind at the moment of death is preferred. This focus allows them to remain focused on God (in Hinduism and Sikhism) and has a positive effect on one’s destination after life (32,42,46,53,58,59). This importance of awareness at the moment of death is also reflected in Eastern Orthodox Christianity, which views death as a moment of passage in which one encounters God (79). Therefore, if possible, Eastern Orthodoxy recommends being conscious at the moment of death. While this belief is shared by other Christian denominations (Anglicanism, Catholicism and Protestantism), it is not explicitly present in debates about palliative sedation specifically, nor in discussions about treatment decisions in the context of advanced disease. Judaism and Islam traditions encourage conscious patients to pray actively (i.e., Viduy and Shema Yisrael in Judaism (166) and Shahada in Islam (178) in preparation for their impending death, though a conscious death is certainly not seen as a necessity.

Another area of overlap between Indian and Christian traditions is the element of experiencing pain consciously. In Indian traditions pain is attributed a purifying effect. It can help lift bad karma, while avoiding pain can have a negative effect on one’s karma (30,31,47,58,116). A similar idea is present in the Christian traditions, especially in Catholicism and Eastern Orthodoxy. In Salvifici Doloris, John Paul II emphasises the salvific dimension of suffering (69)—an idea that is also present in the Eastern Orthodox tradition (179). This notion of redemptive suffering is also present in Judaism and Islam (15,166). Despite this reservation towards the lowering of the level of consciousness and the effect of alleviating suffering, the Semitic traditions agree that palliative sedation is morally acceptable if the suffering of the patient is unbearable. This goes back to the principle of charity and the duty to aid those in distress (146,153,164). The alleviation of suffering, as a duty of a physician or out of compassion for others, is also found in the Indian religions (47,57,59,103,116,119-124). This results in palliative sedation being accepted as an option.

Finally, in the Semitic traditions, there is also the constant alertness that palliative sedation does not result in the actively ending a patient’s life. Judaism, the different Christian traditions and Islam all emphasise that the decision on life and death belongs to God (180). This idea is also present in Sikhism, where death is understood as determined by divine will. In contrast, the other Indian religious traditions oppose euthanasia for different reasons, including the belief in negative karmic consequences for all parties involved or meddling with karmically determined death, the violation of core values such as dharma and ahimsa, and additionally in Buddhism, monastic rules that strictly prohibit killing. This means that for all the traditions we studied it would be important to clearly differentiate palliative sedation from decisions like euthanasia and assisted suicide.

The normative stances of religious authorities and religious specialists, as documented in the academic and non-academic literature reviewed here, play a significant role in shaping practical approaches to palliative sedation of patients, family members and care givers belonging to a religious tradition. Empirical studies involving religious patients and healthcare staff demonstrate that arguments and viewpoints from these religions found in the literature frequently also emerge in personal beliefs and justifications articulated by both religious individuals and professionals.

For the Indian traditions, studies show that both patients (109,120,181,182) and physicians (27,104,183,184) are influenced by their religion when it comes to palliative sedation and other end-of-life practices. The concern to stay conscious at the time of death and the positive effects of experiencing pain for karmic cleansing as reasons to object are found in research on Hindu and Buddhist patients and healthcare staff (104,120,182,184). When broadening the scope to euthanasia, the negative effects on the karma of the patient and doctor as well as the violation of ahimsa were brought up by Indian doctors, as reasons for rejecting euthanasia (27,185,186). The study of Gielen et al. on Hindu palliative-care nurses and physicians shows a general acceptance of mild sedation, though deep continuous sedation was found to be more controversial as it impedes social interaction, interferes with cleansing karma, prevents basic activities or is believed to hasten death (104,183). The last reason mentioned clearly shows the importance of sharing correct information regarding palliative sedation and dispelling myths as if palliative sedation would be nothing more than a type of slow euthanasia (7,8).

They were also less favourable towards euthanasia with 26% of Indian doctors willing to administer it (185). This should be nuanced since some reports note no difficulties of Hindu physicians (28,187) or patients (29,118) with administering palliative sedation or other end-of-life treatments. This could be due to the absence of central authorities and stances on ethics so that the choice is left to the individual. The lack of studies on Hindu, Buddhist and Sikh patients and healthcare professionals’ views regarding palliative sedation and how their views may vary or coincide with the religion’s normative views, is a call for further research.

Studies on the influence of Christian beliefs on the attitudes of both patients (188) and healthcare professionals (18,20,189-191) towards palliative sedation, confirm a correlation with the normative position of the respective denomination.

Christian physicians generally support palliative sedation (190), considering it a ‘humane alternative’ for euthanasia (192). This reflects the importance of distinguishing it from euthanasia or assisted dying, as reservations towards palliative sedation are often motivated by the fear that it might result in ’slow’ euthanasia (20). The study by Cohen et al. [2008] further illustrates differences between physicians belonging to different Christian traditions (i.e., Catholicism and Protestantism), but also between physicians from different countries. It also shows that the correlation between the attitudes of physicians not always correspond with the normative position of the formal authorities of one’s tradition. For example, the attitude of catholic physicians towards euthanasia in some countries (e.g., Belgium) do not always align with the official position of the Magisterium (190). This reflects the diversity of perspectives within each of the Christian denominations and the fact that religion is of course not the only factor influencing moral attitudes (19,193).

The limitations of our scoping study are primarily due to the limited number of available sources on the normative views regarding palliative sedation within the studied religions, particularly the Indian traditions. We addressed this issue in the Indian traditions in part by broadening the search to include key terms related to other end-of-life practices to gather indirect information on views regarding palliative sedation. This article is part of a larger research project on world religions and palliative sedation (project 3H230262, 2023–2028, two PhD’s), the second phase of which involves an empirical study with religious experts from these traditions, aiming to supplement the limited information found in the literature and to provide a more comprehensive understanding of the normative perspectives.

Conclusions

With this study, we aimed to fill a gap in our knowledge of the views of world religions on palliative sedation by discussing and comparing the normative views on palliative sedation within Christian denominations (Anglicanism, Catholicism, Eastern Orthodoxy, and Protestantism) and Indian religions (Hinduism, Buddhism, and Sikhism).

In the different Christian traditions, there is an openness and positive attitude towards palliative sedation as a means to alleviate the suffering of the sick and dying. This openness is motivated by the principle of charity, which is fundamental to the teachings of the Gospel. Concerns remain because of the impact of the lowering of the level of consciousness on the patient’s spiritual preparation for their impending death. In Protestantism, the impairment of consciousness is connected to the broader concern about the loss of self. Another central concern in the Christian traditions is the distinction with euthanasia and physician assisted suicide.

In Indian religions, there are very few explicit authoritative normative stances on palliative sedation. Nonetheless, dying with full consciousness is often regarded as the ideal way to die, as it allows for spiritual growth and a positive rebirth. Though other methods to cope with suffering such as meditation, mindfulness and prayer are recommended, palliative sedation (involving no killing) can be an acceptable way of dealing with extreme suffering.

This article was intended to offer an insight in the normative positions on palliative sedation taken by a number of world religions and the arguments and reasonings supporting them. By doing so, we hope to help medical staff to better understand what is possibly behind the attitudes, concerns and hesitations of religious patients and family members when confronted with severe suffering at the end of life.

Acknowledgments

We would like to thank Mar Gil Alvarez for the provision of study materials and collection and assembly of data as part of our greater research project.

Footnote

Provenance and Peer Review: This article was commissioned by Guest Editors (Johan Menten and Eva Oldenburger) for the series “Multidisciplinary and Holistic Palliative Care” published in Annals of Palliative Medicine. The article has undergone external peer review.

Reporting Checklist: The authors have completed the PRISMA-ScR reporting checklist. Available at https://apm.amegroups.com/article/view/10.21037/apm-2025-aw-129/rc

Peer Review File: Available at https://apm.amegroups.com/article/view/10.21037/apm-2025-aw-129/prf

Funding: This work was supported by Bijzonder Onderzoeksfonds KU Leuven (No. C14/23/002).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://apm.amegroups.com/article/view/10.21037/apm-2025-aw-129/coif). The series “Multidisciplinary and Holistic Palliative Care” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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