Principle of double effect
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The principle of double effect (PDE) or doctrine of double effect (DDE), sometimes simply called double effect for short, is a thesis in ethics, usually attributed to Thomas Aquinas. The principle seeks to explain under what circumstances one may act in a way that has both good and bad consequences (a "double effect").
It states that the unintended, harmful effect of an action is defensible (e.g. an early death) if
- The nature of the act is itself good (e.g. the relief of pain and distress)
- The intention is for the good effect and not the bad
- The good effect outweighs the bad effect in a situation that is sufficiently grave to merit the risk of that bad effect (e.g. overwhelming suffering in a dying patient)
- The good effect (the symptom relief) is not through the bad effect (eg. death)
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[edit] Intentional harm versus side-effects
Although different writers state the doctrine in different ways, it always claims that there is a moral difference between courses of action such as the following:
- An agent that deliberately causes harm in order to promote some good.
- An agent that promotes some good in such a way that harm is caused as a foreseen side-effect.
The doctrine of double effect stems from an application of the Hippocratic moral norm, "First, do no harm." and Aquinas' First Precept (Principle) of Natural Law "Good is to be Done and Promoted and Evil is to be Avoided" [Summa Theo I-II Q94 Art 2].
[edit] Applications
The doctrine has practical applications, for example in just war theory, where the deliberate targeting of civilians to demoralise the enemy may be ruled out, but the bombing of munitions plants may be allowed, even if both actions cause the same number of deaths and end the war in the same length of time.
The doctrine is relevant to certain medical cases. The administration of a high dosage of painkillers is sometimes allowed for the relief of pain in cases of terminal illness, even when this will cause death as a side effect. Some (including most Catholic ethicists) hold that this is morally different from deliberate euthanasia for the relief of pain.
In some circumstances it is possible to argue that the doctrine of double effect is a redundant doctrine; for example within palliative or terminal care. It is possible to argue that since the use of analgesia is better understood (in terms of both pharmacology and delivery of medication) and titration of analgesic dose to the pain experienced by the patient is possible, then the desired effect (analgesia) can be achieved without the undesired effect (respiratory suppression). Thirty years of palliative care experience and research has shown that it is possible to manage pain or distress with titrated doses of drugs, without hastening death.(Oxford Textbook of Palliative Medicine 3rd ed. Doyle D, Hanks G, Cherny NI, Calman K eds. Oxford : Oxford University Press, 2003) (see opioids). This experience has been countered by the claim that that intent cannot be proven in such situations. In reality intent is very easy to identify by reviewing the drug records in any situation where drugs have been given for severe pain and/or distress:
- A palliative care physician will use multiple, small doses of an analgesic or sedative, titrating the dose to the patient and the pain or distress, usually subcutaneously or orally for comfort and avoiding serious adverse effects.
- Other doctors give large doses or an analgesic (usually an opioid), invariably intravenously, ignoring or intending serious adverse effects (such as death).
The intent of a palliative care physician is relief without harm; the intent of the second is relief at any cost and may suggest either negligence or malice. Euthanasia has been suggested as being an exception, but in countries such as the Netherlands, opioids are not considered to be effective agents for euthanasia,[1] since the wide therapeutic range makes death difficult to achieve while the high doses required risk causing agitation and distress through morphine metabolites M3G and nor-morphine. (See Opioids)
These observations should not be surprising. If a patient receiving chemotherapy develops neutropaenia (a dramatic fall in the infection-fighting white blood cells), there is a risk that they may die from overwhelming infection. If the patient does die, no one wistfully quotes double effect. The death would be considered a serious adverse event which needs investigation. Caring for dying patients is no different, and death following treatment for pain or distress should be considered as seriously as death from neutropaenia.
[edit] Other examples
A vaccine manufacturer typically knows that while a vaccine will save many lives, a few people will die from side-effects of taking the vaccine. The manufacturing of a drug is in itself morally neutral. The lives are saved as a result of the vaccine, not as a result of the deaths of those who die of side-effects. The bad effect—the deaths due to side-effects—does not further any goals the drug manufacturer has, and hence is not intended as a means to anything. Finally, the number of lives saved is much greater than the number lost, and so the proportionality condition is satisfied. Some moralists add a fifth condition, namely that there must be no alternative. Therefore, if it were possible to find another morally-acceptable way of saving lives, without the risk of death from side-effects, it would not be permissible to produce this vaccine.
The Principle appears useful in war situations. In a just war, it may be morally acceptable to bomb the enemy headquarters to end the war quickly, even if civilians on the streets around the headquarters might die. For, in such a case, the bad effect of civilian deaths is not disproportionate to the good effect of ending the war quickly, and the deaths of the civilians are not intended by the bombers, either as ends or as means. On the other hand, to bomb an enemy orphanage in order to terrorize the enemy into surrender would be unacceptable, because the deaths of the orphans would be intended, in this case as a means to ending the war early, contrary to condition. Whether the Principle applies to the bombing of Hiroshima and Nagasaki is a highly controversial question.
[edit] Controversy
Despite some apparent plausibility, the doctrine of double effect is controversial. Utilitarians, in particular, reject the notion that two acts can differ in their permissibility, if both have exactly the same consequences.
A major argument against the DDE is the hypothetical case where some evil must be done to bring about an enormous good. For example, suppose a nuclear bomb has been planted in a major city, and a terrorist involved in its construction (being held in custody) knows where it is. Although he is reluctant to give up the bomb's location, his interrogators can exploit his attachment to his family by torturing them before his eyes, in order to extract the information which would save millions of lives.
Many find it difficult to oppose deliberate evil as a means to an end when the stakes are so high. But if evil acts for good ends might be permissible in extreme cases, then where to draw the line becomes a difficult question - just how high must the stakes be?
In the past few years in the UK, at least two doctors undergoing murder trials for giving large doses of opioids to ill patients, have used the defence of double effect.[2]
[edit] See also
[edit] References
- ^ Rurup ML. Et al. Nederlands Tijdschrift voor Geneeskunde. 2006: 150(11): 618-24.
- ^ BBC online: Euthanasia, retrieved on Oct 29, 2006
