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The principle of ‘Double Effect’

 

The ethical principle of Double Effect is used to justify medical treatment designed to relieve suffering where death is its unintended (though foreseen) consequence. It comes from “the rule of double effect” developed by Roman Catholic moral theologians in the Middle Ages as a response to situations requiring actions in which it is impossible to avoid all harmful consequences.

The rule makes intention in the mind of the doctor a crucial factor in judging the moral correctness of the doctor’s action because of the Roman Catholic teaching that it is neverpermissible to “intend” the death of an “innocent person”. An innocent person is one who has not forfeited the right to life by the way he or she behaves, eg, by threatening or taking the lives of others.

The rule applies if:

  • the desired outcome is judged to be “good” (eg relief of suffering);
  • the “bad” outcome (eg death of patient) is not intended;
  • the “good” outcome is not achieved by means of the “bad”;
  • the “good” outcome outweighs the “bad”.

Under the rule, administering medication in dosages likely to cause death in order to relieve a terminally ill patient’s suffering is morally correct, provided the above four conditions are met.

There are many who regard the rule of double effect as seriously flawed. Grounds for its rejection include:

  • The rule is not consistently applied. For example, when serious suffering cannot otherwise be relieved, “terminal sedation” is permissible in law and in medical ethics. This means rendering the patient unconscious until death occurs. Yet it also means withholding life-preserving measures so that death, which is thereby hastened and inevitable, must be considered intentional.
  • Intentions are often ambiguous. They may be contradictory, and they are always subjective. They cannot be realistically analysed in terms of the presence or absence of one clear purpose.
  • In some cases the moral and legal validity of a particular medical treatment will hinge on the claimed intention of the doctor. This is an unsound basis for public policy.
  • In ordinary life we hold ourselves and others morally responsible for the reasonably foreseeable consequences of our actions. Doctors should not be exempt from this.
  • While the rule offers the doctor a convenient evasion of responsibility, it takes no account of the wishes of the patient whose life (and death) it is. Many regard that:
  • the requirement that a doctor should always work in the best interests of the patient;
  • the patient’s right of self-determination and bodily integrity;
  • the provision of informed consent;
  • the absence of less harmful alternatives acceptable to the patient and
  • the severity of the patient’s suffering
  • as the factors which should determine the moral and legal validity of the doctor’s actions rather than whether or not the doctor “intended” the patient to die.

Further reading, including 42 references, is contained in the New England Journal of Medicine of 11 December 1997 (Quill TE, Dresser JD, Brock DW. The Rule of Double Effect – A Critique of Its Role in End-of-Life Decision Making. N Engl J Med 1997; 337: 1768-71). See also Correspondence, N Engl J Med 1998; 338:1389-90.

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