Double Effect and the Ethical Dilemma

(This post is by Chris Smith and is the next post in the series on Philosophy and Theology that the ThM students are engaged in.)

The article that I have chosen to post about is “The Rule of Double Effect—A Critique of Its Role in End-of–Life Decision Making” by Timothy E. Quill. This is how I understand the double effect rule: The double effect rule states that a doctor is ethically justified in prescribing medicine that is intended to treat a terminally ill patient’s pain even if this same medicine may decrease the patient’s expected lifespan or result in death. The double effect rule justifies a doctor’s actions based on the nature of their intentions. If a doctor prescribes medicine with the intention of minimizing pain but causes a patient’s death, his actions are justified under the double-effect rule; however, if a doctor prescribes medicine with the intention of causing death, his actions are not justified. (The assumption behind this rule is that there is not a less harmful drug available to treat the kind of pain the patient is experiencing.) The rule is called double effect because a doctor’s intention can have two effects: the intended relief of pain and foreseen but unintended death.
The double effect rule begs the question: Can the desire to alleviate extreme and terminal pain ever outweigh a doctor’s imperative to preserve physical life? Quill states: “The word ‘intentional’ suggests, however, that the deaths of innocent persons may be permissible if brought about unintentionally” (1768).  Here we need to understand the meaning of unintentional not as an accidental effect that is unexpected but as a potential effect that is not intended. When a doctor seeks to alleviate pain by increasing dosages that will have a harmful effect on the patient, can he really by justified when he knows that his actions are further contributing to the patient’s inevitable death? I would say he is justified in this act because his intention is to alleviate.

A case Quill describes makes the double effect rule even more reasonable in my opinion. He describes a patient who is on a respirator in order to help him breath. Is a doctor justified in his decision to turn off a respirator in hopes that the patient will be able to breathe without it? I would say the act of turning off the machine is justified even if the patient dies because the hope was to draw on the patient’s strength to stimulate his own breathing. The patient’s death may have been possible (“foreseen”) but unintentional because the desire was to see the patient breathe on his own. I find this to be a more effective use of the double effect rule because the doctor was attempting to stimulate the patient to greater health rather than attempting to prevent pain.


Posted on November 9, 2010, in Philosophical Theology, Th.M. Program and tagged , , . Bookmark the permalink. 24 Comments.

  1. Your description of the double effect rule is clear. i haven’t read this article as yet, but this use of medical ethics has always fascinated me. The first example is a bit trickier as you state. if a doctor is supposed to “do no harm”, how can they justify then giving pain relief that they know will probably cause a shorter life span? I am sure doctor’s are faced with these kinds of decisions regularly and so have to operate on some form of utilitarianism (?) in which the immediate relief of pain outweighs the shorter lifespan that will result. the second example, though, has interested me more and more when we speak of life support. The point I want to make, or rather question to ask, is related to this, though not directly (sorry to get off double effect topic). Because we have the technology to keep someone alive longer than they would have without it (i.e. respirator and the like sustaining life), is it justified to use it if they are in pain and their quality of life is severely diminished and they no longer want to use it? Let’s say they are not in a vegetative state and can make this conscious choice for themselves (to be taken off support). I am curious what you all think about this.

    • Andy – thanks for the note. Your query is important ;however, it falls within the contours of proportionality and commensurate reasoning rather than double effect. There is a subtle but important distinction according to at least the Roman Catholic bioethicists.

      A note to all- carefully tease out the distinction when reading the Sulmasy and Knauer articles.

  2. I as well seem to find the principle of double effect reasonable. There is a sense though to me that it seems like it can be taken advantage of. It seems like the physician when faced with a tough decision could just use the principle of double effect to say what he did was right. There needs to be a careful understanding of what double effect means and it must be agreed upon across all circles of thought and organization. If there is a common understanding (which there might be I am unsure about this aspect of the principle) then it seems like there would be a proper checks and balance system here.

    • Just to add another twist… I was wondering how lawfulness relates to morality…

      for example… in the beginning of Knauer’s article he cites the example of self-defense… there is the good ‘intention’ of self-preservation… if one’s actions were ‘proportionate’, killing the one threatening you could be seen as justified… how would this situation change (or would it) if the threat was coming from a correction officer administering the death penalty?

      It could be argued that the intentions are still good… and that the force used in “self-preservation’ was proportionate…. but I’d have a hard time saying it was ‘morally good’ ….


      • upon reflection I think my ‘twist’ is a bust….

        ‘self-preservation’ and ‘self-defense’ are not the same thing… and this fails as a ‘proportionate/commensurate’ reason…

  3. My desire was to respond last night, but that unfortunately did not happen. At least I had good intentions… 😉

    I wonder, does approach to ethics not lead to us letting our intentions define what is actually ethical? I’m not sure why it matters what the intentions of the doctor are…how could intentions ultimately make my decisions more ethical? Does this not imply that ignorance is bliss?


    • But, it would certainly seem that intentions are important to our moral intuitions. If I hurt someone without intent (an accident) or with good intent (I was trying to help), our moral intuitions would normally suggest that these are better than hurting someone with evil intent. And, if I have evil intent, we usually think that the act is immoral even if the result ends up (by chance) working out to the benefit of the person in question. So, either our moral intuitions are wrong, or intentions are at least part of the equation.

      • Hmm, yeah, just curious about where this could lead, especially if we look at the big picture. What if I am part of an corrupt system where even the best of my intentions are in fact really bad? Does that really make me less responsible? For instance, many Swedes enjoy paying taxes, and they even have good intentions doing so. As an American you can probably smell this nasty evil without even go there for a visit.

        Hehe, I guess, what I’m trying to say is this, does this theory take structures into account, the fact that I’m part of a fallen system? Sure intentions matter but I’m not sure that I’m encouraged to know more about the world. I’d rather hide behind my good intentions… Make sense?

  4. Andreas’ concern seem to have been one noted in the articles. There was an attempt to repel the accusation that this ethic is relativistic because in the end it comes down to each person making “value” judgments which then determine the right and wrong of the matter. While I am sympathetic to the rule of double effect I’d like to hear more in class as to how we can put some structure in place that prevents the dangers Andreas just noted.

  5. Fascinating discussion, concrete moral norms are often clarifying to formal moral norms i.e. …

    At the bedside of a bioethics client, terminal and in the last hours of biological life-according to evidenced based medical norms, she began suffering from a severe sense of suffocation (air hunger) due to fluid build up in the lungs that was not treatable. Opiates relieve the sense of air hunger but also slow respiration and thus may hasten death.

    Should we deny her relief? What ought her health care representative advise the physician?

    What is the difference in moral culpability between one actor who suggests administration of opiates with the intention to hasten death-hypothetically, a second actor with the intention to minimize suffering knowing death might be hastened, and hypothetically a third in charge of medicare resource allocation hoping that death will occur so as to distribute resources to another needy but not terminal patient?

    The action of administration despite intention was exactly the same…4 mg Dilaudid every 2-3 hours as needed for relief of suffering. She did die about 8 hours after opiate administration, probably due to sequlae from metabolic acidosis. The effect of the opiate on the cause of death is not known.

  6. Chris, great job on your article.
    First let me say that I see a great deal of benefit in this principle, especially in guiding very difficult decisions in the medical profession (although the application is far more pervasive than in just that area.) BUT, there appear to be two problems with the principle of double effect for me: 1) There is no standard other than intentions or the measurement of a commensurate act. Commensurate reason seems to be established as the thing that polices intentions. However, who decides if the intention of an act is proportional to the effect of the act itself? This was my problem with Thomas Aquinas illustration at the beginning of the chapter in Readings in Moral Theology (If a man who is defending his life uses greater violence than necessary, it is unlawful and morally evil). Who decides this? The man who was defending and fearful for his life, or those whose lives were not threatened but sit in judgment on the individual? You don’t get much more relative than this, and we would never stand for such a principle in other matters of life. Although I agree with Marc that intentions are important and relevant, there seems to be a need for some type of universal standard which governs them. Which lead to my second point (which ironically agrees with Andreas), 2) I question if double effect takes into consideration the extent of the fallen nature of man and institutions. The fall has affected even the best intentions and the intellect to form commensurate reasons. It seems this would also lead to possible fallen interpretation of affirmative and negative laws, which if I understand, are one of the guidelines for intentions but that are ruled by double effect. Are both of these problems solved by Revelation in the Word?

    I look forward to Jerome correcting all of the false conclusions I possibly just propounded.

  7. In Jerome’s scenario I am sympathetic toward relieving the pain. Death is natural. We all die. If postponing someone’s death is chosen because relief may accelerate death it seems obvious to me that this person, still dying, should be allowed to do so peacefully. What is the point of sustaining someone for the mere sake of sustaining someone?

  8. I believe the “relief” should be given. I agree with Brian L., at least in this scenario.

    This might present a slippery slope for some, but I don’t think the scenario provided by Jerome vs. the points made in favor of euthanasia or assisted suicide are parallel.

  9. In regards to the risk of slippery slope, standard of intention, judge of intention and proportionality of grave reason:

    You astutely open the the space to consider the “tragedy of ethics” and “the necessity of mystery.” For some 25 years I have been a participant in this tension from the sphere of bioethics. I have ‘never’ participated in the process of bioethical decision making where suffering, limit, and loss were absent. Every step navigated slopes readily greased for misstep.

    One answer to Brian’s question by pro-life vitalist: ‘Sustain ad extremis biologically until all efforts fail’ and no slippery slope will appear for intention, reasoning, and necessity to judge ar all removed.’ Would such a biological view of ‘being,’ an ontology question, be idolatrous?

    Regarding who can judge intention: Is there narrative from Scripture that might clarify options?

    For Bobby G. What is the difference between “killing” and “letting die?”

    How does one’s understanding of the impeccability of conscience play into the discussion?

    Where does God’s illumination of the Spirit in community address questions of commensurate reasoning?

    Finally does Sulmasy’s, the Franciscan-physician, four criteria and his example of morphine provide an relief from the concern of relativism?

  10. ps: Timothy Quill is seriously pro-euthanasia and Daniel Sulmasy is radically pro-life. Both are physicians, bioethicists, well-published, and well respected.

  11. Chris, I’m interested if you thought any about natural law as you read this article. It seems that some who desire to have life sustaining treatments ended (and this is the only situation I think this would apply to at this point), knowing and possibly intending that the desired effect would be death, are not attempting suicide (in the strict definition of the word or in the way a person who desired to take a lethal dose of prescription pain medication would), but simply hoping for nature to takes its course. One of the benefits of advances in medicine appears to be length of life. One of the disadvantages seems to be length of life as well. Does the rule of Double Effect take into account death as a natural process in end of life decisions in your opinion, if life is being sustained by external means?

  12. I am glad that Jerome opened the door to the use of scripture in this discussion. It seems to me that scripture indicates that while intentionality matters, even unintentional actions carry responsibility. For example:Nu 35:16-28 shows that the difference between murder and manslaughter is one of intent. The murderer is put to death. The one gulty of manslaughter is also liable for death, if he does not go to and remain in the city of refuge for the allotted time. The one guilty of manslaughter is described as “without enmity” and “not his enemy nor seeking his injury”. Yet he bears the responsibility despite the fact that it was uintentional.Furthermore, there is a whole set of sacrifices for unintentional sins. Lev 4:27 describes a person sinning unintentionally as guilty.

    From this it would seem that it is appropriate for a person to be fully responsible for intentional consequences, and at least partially responsible for unintended consequences.

    Since this discussion started with a bioethical bend, I will try to return to that application. Our medical system has some allowance for the concept of unintentional consequence. We call it malpractice. While I would agree that the concept has been streched and abused, at its core though it is a way of holding medical professionals accountible for unintended consequences. We have all heard about a docto who forgot x tool inside their patient and sewed it in, or who cut off the wrong limb, operated on the wrong patient, etc. I doubt there are any doctors out there who would do those things on purpose, yet unintentionally they do these things that do have an effect upon the victim (I use that word intentionally) and we call that malpractice. It is, of course using an extreme to help define a principle.

    With regard to the aleviating the suffering of a dying patient I think Prov 31:6 might apply: “give strong drink to him who is perishing”.

    • Thanks for bringing up the concept of malpractice… a situation where the ‘intentions’ may be benign, but real harm occurs…. this leads me to wonder if we can classify (in very rough terms):

      1) sometimes negligence or lack of due-diligence is the problem, and we fail because we are not responsible…

      good intentions +
      lack-of-due-diligence +
      avoidance of risks
      = morally culpable

      1b) good intentions +
      lack-of-due-diligence +
      acceptance of secondary risks
      = morally culpable

      2) sometimes we make right choices, and bad things still happen, but we are not ‘at fault’
      good intentions +
      due-dilligence +
      acceptance of secondary risks
      = morally acceptable (doctrine of double effect)

      3) sometimes we act out of evil desires, yet the consequences remain hidden… yet we are still guilty…
      bad intentions +
      X (anything)
      = morally culpable

      This probably needs lots of refinement, but it’s a first stab….

  13. I have been thinking about this from the perspective of shepherding/pastoring someone going through this situation and I keep coming to this question:

    Should the patient’s salvation play a factor in this decision?

    If the person is a Christian one can appeal to the fact that death is not something to be afraid of. Because of Christ, there if victory even in death. There is assurance for both the patient and for the family of the patient, that as followers of Christ, though death may part them now, one day there will be reunited and will have fellowship again.

    But for the patient who is not a believer or is unsure of where they stand with God, the relief of pain might seem to be better at the time, but they will not know what death brings. Is death better for them?

    Which leads to another question: how does the religious views of the patient and their family affect the decision of the doctor who faces the dilemma? Is there are general rule to follow, or does the doctor have the right to choose regardless of their views?

  14. @Renjy: While I am sympathetic to this question I think it only takes a moment for one to ask a dying person if they are ready to confess Jesus Christ as Lord. If we keep someone alive for the express purpose of drawing a confession from their lips this seems like coercion rather than persuasion.

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