Doctrine of Double Effect

The doctrine (or principle) of double effect is most often recognized as a philosophical principle in medical ethics when the permissibility of an action causes a serious harm, such as the death of a human being, as a side effect of promoting some good end. It is also easily recognized as an issue in just war theory where the serious harm is seen in the killing of innocent civilians. This double effect, that causes a harmful side effect when bringing a good effect, is sometimes permissible. This principle is a part of our every day life in hospital settings where end of life measures such as active and passive euthanasia and physician assisted suicide raise our moral concerns. Shelly Kagan considers moral constrants against harm and Daniel Callahan distinguishes between killing and allowing to die.

 This principle is exercised very often when physicians prescribe drugs that have a beneficial result or end, but may often have undesirable side effects. It is permissible to prescribe the drug if the benefits of the drug outweigh the risks. Patients must always be advised of this double effect and transparency is also an ethical concern when the physician must be sure that the patient understands clearly the benefits and the risks. This reasoning is summarized with the claim that sometimes it is permissible to bring about  a merely foreseen side effect or harmful event that would be, otherwise, impermissible to bring about intentionally.  

The doctrine of double effect can be defended when one understands that life is full of dilemmas and choices that have to be made. There are not always clear choices that only represent positive or good ends, but there may be otucomes that are to some extent harmful.  If the harmful ends or outcomes are fully understood and it is reasonable to accept them when looking at the comprehensive outcome, it then may be considered permissible. It is noteworthy that human beings are faced with making decisions and choices every day of their lives.

 The principle of double effect is not a new ethical principle, but originated with St. Thomas Aqinas. His main focus was on intentionality when he discusses the permissibility of self-defense. One action can have two effects; one of the actions has an intended effect and the other effect is beside the intention. With respect to the permissibility of self-defense, one is saving his life or the life of another and the agressor is killed. The goal of the defensive action is justified. There is however a condition that should be imposed if the action is out of proportion to the end, Summa Theologica (II-II, Qu. 64, Art.7). If however, a man in self-defense uses more than necessary violence, it will be unlawful, whereas, if he repels force with moderation, his defense will be lawful.

Later versions of the double effect principle emphasize the distinction between causing a morally grave harm as a side effect of pursuing a good end and causing a harm as a means of pursuing a good end. We can summarize this by noting that for certain categories of morally grave actions, for example, causing the death of a human being, the principle of double effect combines a special permission for incidentally causing death for the sake of a good end (when it occurs as a side effect of one's pursuit of that end) with a general prohibition on instrumentally causing death for the sake of a good end (when it occurs as part of one's means to pursue that end). Joseph Mangum in “An Historical Analysis of the Principle of Double Effect” states that “a person may licitly perform an action that he foresees will produce a good effect and a bad effect provided that four conditions are verified at one and the same time (1)  that the action in itself from its very object be good or at least indifferent; (2) that the good effect and not the evil effect be intended, (3) that the good effect be not produced by means of the evil effect and (4) that there be a proportionately grave reason for permitting the evil effect.

The four above mentioned principles should be observed in medical ethics and especially in the case of terminal sedation. However, on a much larger scale, drugs that are prescribed to patients, more often than not, have adverse side effects that are duly noted on the package insert. Some of these adverse side effecst are for the most part innocuous, others more severe and finally, terminal sedation. Boyle in the article, “Medical Ethics and Double Effect, makes the argument that the doctrine of double effect can be relied upon to distinguish terminal sedation from euthanasia. There are moral and legal oppositons to euthanasia. This is often seen as the slippery slope where sometimes the lines between terminal sedation and euthanasia are not very clear and distinct.

In thinking about the four conditions, the use of terminal sedation to control the intense discomfort of dying patients satisfies the first condtion; that the action in itself from its very object is good. Pain management is a more recent and acknowledged medical practice that no patient should be in pain. In the case of many terminally ill cancer patients where the pain is very intense, the prescribing of an opiate drug that may hasten death may be morally correct in the sense of giving palliative care. This is the slippery slope. Condition two; that the good effect and not the evil effect be intended does not seem to present a problem in a case of the terminally ill cancer patient in unbearable pain. One would have to look at each situation independently to be able to make the correct moral decision. Condition three, that the good effect and the evil effect not be produced by means of the evil effect presents a problem. In the case of the terminally ill cancer patient in pain, the good effect of alleviating pain is produced by means of the evil effect. Are there any other options that a physician has when looking at this condition?

 Herein lies the rub and the anguish for many who  feel a moral need to do something for the patient. It appears that the doctrine of double effect is morally justified in condtion four; that there be a proportionately grave reason for permitting the evil effect. The author does not give a clear rationale for the conditions and neither does he acknowledge that there is an agreement among ethicists for the conditions. However,  in the literature, theologians state the four conditions for the proper use of double effect. Condition three is a problem because the good effect is produced by the bad effect. Some certainly could argue that this bad effect nullifies all the other conditions and thereby jeopardizes the theory. If in fact, Catholics see the theory as an ad hoc theory that relates to end of life measures, then this third condition presents a real problem.

Boyle understands  the moral doctrine of the double effect in the medical profession; it can be morally good to shorten a patient’s life and it is foreseen and accepted; but the unintended side effect of the action is undertaken for a good reason. This is with the knowledge that intentionally killing the patient is wrong. It is the intent of the physician that comes into question here. The intent of the physician should be found in notations on the patient’s chart. We would like to believe that what is noted on the patient’s chart is in fact the physician’s intent, if there is suspicion of a different motive.

There needs to be a consensus in the medical community that the application of double effect practiced by physicians is understood by all. Boyle points out that in several studies that this type of documentation of giving titrated doses of potential lethal doses is not euthanasis, but palliatative care. It is the moral duty of the physician to prevent pain and ease the pain of any suffering patient. The issue for Boyles regards the prospect that this application of double effect could be an established part of medical ethics and consequently, legally enforced. Since this doctrine emerged from within Roman Catholicism, it becomes a problem of how much this distinctive moral view does the medical profession and the law implicitly accept. Intention of the act is at the forefront of this argument because motive of any action is always morally considered.

Some view a key requirement that the good effect be brought about immediately and not by means of the bad effect. With the use of large doses of opiates, some argue that a resultant death is not intended while knowing that death would be a result. In such a case, one argues that only the good effect of alleviating pain is intended. The four conditions do give us some guidelines for how one should proceed in using the doctrine of double effect and lay the groundwork for further discussion in difficult cases. Boyle points that the two conditions of the “cause” be morally good or indifferent and that there be a proportionately grave reason for doing what brings about evil side effects. This refers to the further moral considerations that are needed for a complete assessment of an action meeting the conditions for upright intention. These conditions address the two areas where an action that cleared the intentionally focused conditions might still fail morally. The first area of concern arises from the possibility that, prior to any consideration of further results that might be intended or accepted as side effects, but not intended, some actions might be simply wrong. However, when a physician prescribes an opiate drug in potentially lethal doses to a suffering and dying patient, might be morally indifferent, i.e. the results, intentions and other circumstances of this chosen behavior will determine its permissibility or impermissibility. This action is unlike acts of adultery or lying, which are described as wrong. Boyle goes on to say that if this condition or either the intentionally focused conditions is not met, then the act is simply and indefeasibly impermissible. These are absolute judgments that cannot be overturned by further considerations of the action’s particular circumstances.

After considering some of the above argument for the doctrine of double effect and some of its weaknesses, there are occaisons in medical ethics where there is far less doubt about its usage. The first principle of medical ethics of the AMA is that a physician shall be dedicated to providing competent medical care with compassion and respect for human dignity and rights. If a physician has a moral duty to alleviate pain and prevent suffering, there are cases where the morality of the principle of double effect is totally justfied. It is documented in medical journals that the pain of the last state of pancreatic cancer is one of the most excruciating pains. In order to alleviate the pain and  to have compassion and respect for the patient’s human dignity and rights, there are times that potentially lethal doses of the opiate must be given with foreknowledge of impending death. A further moral consideration in such situations is the principle of transparency between the physician, patient, family members and all other related medical staff becomes extremely important.

Kagan, in the chapter “Doing Harm”, Normative Ethics, considers two plausible ways of drawing a line between doing and preventing harm. The example that she uses is that of killing one person to save two others from being murdered. If I refrain from killing the one, I have not killed the other two. At the onset, there seems to be a problem if in fact, the other two are killed, I still may have killed them indirectly. This is perhaps in some ways analogous to the physician who has not killed directly the terminally ill cancer patient who has been given a potentially lethal dose of an opiate. Her major emphasis is being able to draw a line and there are two distinct ways of drawing the line. It also appears that she is a hard line deontologist believing that lines can be distinctly drawn. The first distinction or line is that of between doing or allowing and the second is between intending or foreseeing.

The distinction between doing and allowing harm intuitively carries moral weight and; it is the distinction that we seek. The constraint against harming is construed as a constraint against doing harm. Many physicians still struggle with allowing a terminally ill patient who wants to die by withdrawing life sustaining treatments. This may not necessarily be truly analogous, but there are some parallels in the reasoning. For Kagan, it appears that giving the potentially lethal doses of an opiate can be interpreted as doing harm or with the other scenario, foreseeing the harm. As ethicists struggle to understand which of the distinctions has the greater moral weight, Kagan points out hypothetical cases that would determine whether intuition supports a constraint against doing harm or a constraint against intending harm.

The risk of doing harm is, in some circumstances, the same as doing the harm. It then becomes a matter of the probability of how great the risk is, in doing the harm. However, not all risks are prohibited by a constraint against intending risk. Commonsense morality recognizes a constraint against doing harm. Kagan calls any moral theory that incorporates constraints “deontological” (Kagan, 72-3). To be absolute or moderate about constraints depends on whether one believes no consequences could ever be or there are strict rules against some kinds of acts. Moderates, about the constraint against doing harm, need to give some account of where and why they draw the line. With these considerations in mind, physicians who are willing to give potentially lethal doses of opiates to terminally ill patients accept moderate constraints.

In further understanding constraints, Kagan believes that, if someone is worse off as a result of our act, then we have harmed that person. With respect to physicians who give potentially lethal doses of opiates to terminally ill cancer patients to alleviate pain and the patient dies, further discussion could help to understand if that patient is better off dead rather than to be in pain with no hope of recovering. The question still remains if the patient has been harmed. In respecting the patient’s autonomy; if physicians are transparent with all of the options and the patient consents to the analgesic, there may be some moral justification in giving the higher doses

Daniel Callahan, in “Killing and Allowing to Die”, Biomedical Ethics, believes that there is a distinct difference between killing and allowing to die. He may not be in total disagreement with Kagan. He understands the difference by making reference to three overlapping perspectives; physical, moral and medical. His metaphysical understanding of the world is defined by our relationship to it. There are actions for which we can be held responsible and those for which we are blamed. He emphasizes physical causality in the realm of impersonal events and moral culpability i.e., the realm of human responsibility. There appears to be a balance or equilibrium that needs to be met when a physician has to make moral decisions about a patient’s life. There are times when the disease process cannot be stopped and the nature of the disease is disintegration of the body. The doctor is only human and often cannot stop the process of nature.

Callahan points out that if the physician intends the death of a patient, it can be brought about by commission or omission. He takes intention to another level by stating that the crucial moral point is if the physician intends the death. Even though Callahan tries to make the distinction, the term intention is no less ambiguous and there still remains the problem of doing harm and what the intention is or was. To further make his argument of the overlapping perspectives, there is no mistake about the metaphysical world and the control that man would like to have to control nature We can stall death in modern medicine and yet chronic illness remains even with the cure. Death always wins in the long run.

Callahan confesses that at the end of the argument, there is still some ambiguity between killing or allowing to die. The end result is always death. “At the center of the distinction between killing or allowing to die, is the difference between physical causality and moral culpability”. The blur of the argument starts here and perhaps never gets any clearer. As physicians have the medical and moral responsibility to cure and never to kill, they should never use the power of their knowledge to bring about death. This is an intrinsic violation of their role. However, the obligation to resist the lethal power of disease is limited and death is inevitable and the greatest human evil. The physician always struggle against disease, but does not have the power to always conquer it; and if one thinks that he can, the physician falls in the metaphysical trap.

Bibliography

Boyle, Joseph, Toward Understanding the Principle of Double Effect, Ethics, 90, 527-528

Boyle, Joseph, Medical Ethics and Double Effect, Theoretical Medicine and Double Effect, Vol 25, Number

Duff, Antony, Intention, Responsibility and Double Effect, Philosophical Quarterly, 126, 1-26

Kagan, Shelly, Doing Harm, Normative Ethics, Westview  Press, Boulder, Colo. ,1998

Mangum, Joseph, An Historical Analysis of the Principle of Double Effect

Mappes, Biomedical Ethics, McGraw Hill, Sixth Edition, NY, 2006, pg. 399-401

Walzer, Just and Unjust Wars, New York Basic Books, pp 151-159