|
23: 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 never permissible 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.
|
|
