Running head: THE PRINCIPLE OF DOUBLE EFFECT 1

Support for the Principle of Double Effect

Cassandra N. Tribe-Scott

ETH 501: Business Ethics

Dr. Bonnie Adams

November 26, 2017

THE PRINCIPLE OF DOUBLE EFFECT 2
Support for the Principle of Double Effect

The principle of double effect (PDE) has been used to guide administration and

prescription of pain medication in the end of life. PDE is defined as the knowledge that the dose

of pain medication needed to relieve pain has a high chance of causing death. It is this writers

belief that the doctrine should be applied to pain medication at end of life and should be a part of

the consideration in prescribing medication for end of life patients (EOL) as to do less increases

the risk of needless suffering.

The history of the principle of double effect

Thomas Aquinas is credited with introducing the doctrine in defining when it is

permissible under Church Law to kill ones assailant (McIntyre, 2014). The answer, as Aquinas

defined it, was you can kill the assailant if that wasnt your intention in defending yourself from

attack. Earlier than Aquinas the reader may find echoes of the principle in the Buddhist

instruction to avoid killing, but that killing in the act of protecting the sacred was permissible,

but came with karmic penalty (Jenkins, 2011). In modern medicine, Dr. Sulmasy is credited as

codifying the study and contextual application of the principle of double effect with the Sulmasy

Test which is recommended to physicians in considering courses of action with the terminally ill

(McIntyre, 2014). The Sulmasy Test asks the physician if, in the context of a terminally ill

patient, would the doctor consider that they had done all they could of to decrease pain and

suffering for the patient in the time they had left for life if they did not administer the

drug/dosage?

Does the Sulmasy Test work?

Sulmasy (1996) wrote on the effectiveness of his own test eloquently. He defined it as a
THE PRINCIPLE OF DOUBLE EFFECT 3
way for a physician to uncover what was belief, what was desire, what was motive and what was

intention. He states that motives precede intention and it is the motive that needs to be drawn out.

A dose of morphine in a narcotic naive patient can be given to relieve pain or to relieve pain

through death; the reveal lies in the dosage amount. His work suggests that PDE can only be

applied within an integrated team environment wherein one person is not left to make the

decision alone because of the greater potential of abuse of PDE through confirmation bias. His

emphasis on the motive under the intention is key to the arguments supporting the use of PDE.

Support from the Supreme Court and the American Nurses Association (ANA)

In 1997 the U.S. Supreme Court found in favor of PDE declaring in Vacco v. Quill and

Washington v. Glucksberg that there was no call to deny any type, choice or dose of pain

medication to the terminally ill providing the intention was not to cause death. The 2017 ANA

ethics guides promotes the same findings (Wholihan & Olsen, 2017). Further, Dr. Paulina

Taboada, in writing a rebuttal to Sykes and Thorns 2003 Lancet Journal criticism of the use of

opioids in treating pain in the terminally ill stated that based on a bibliographical review, the

authors show that there is no cogent evidence to support the view that an appropriate use of

opioids, or sedatives, at the end of life may actually shorten a patients life, (Taboada, 2003).

The strongest critic of the medical principle is its originator

One only needs to return to the same paper cited in support of PDE to find its greatest

criticism. Dr. Sulmasy (1996) points out the great potential for abuse of PDE in rationalizing

physician assisted suicide and euthanasia by creating a path to hiding behind the stated intention

of not meaning to cause death. His criticism of the very system he defined is valid. It pales in

comparison to the more current arguments against PDE.

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Stronger criticism for very different reasons

Both Susan Fohr and Dr. Timothy Quill separately produced oft cited works that speak to

the same concern (ProCon, 2010). That use of PDE perpetuates the myth that all pain can be

alleviated at the time of death. Therefore, if it is not it is a failure of medicine to meet patient

needs and grounds for malpractice.

Conclusion

The arguments against the use of PDE are very valid. The arguments for the use of PDE

are more persuasive as they raise the specter of causing needless suffering to those most

vulnerable in the name of trying to gain perfect assurance about a course of action. As someone

who works in hospice with direct care I have had the privilege of delivering care to patients who

had physicians who adhered to PDE and those who didnt. While not all pain can be alleviated at

the end of life, most can. The delay in formulating and acting on a response to pain causes

exceptional levels of emotional and physical suffering for the patient, family and caregivers. One

of the privileges of rational life is the right to be wrong. It is always better to relieve suffering, to

the fullest extent possible and according to the patients desires to the extent they be known, then

to let a living being suffer for the sake of trying to provide those who arent suffering with the

comfort of rationalization.
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References

Jenkins, S. (2011, May 11). It's not so strange for a Buddhist to endorse killing. Retrieved from

https://www.theguardian.com/commentisfree/belief/2011/may/11/buddhism-bin-laden-de

ath-dalai-lama

McIntyre, A. (2014). Doctrine of Double Effect. The Stanford Encyclopedia of Philosophy.

Edward N. Zalta (ed.). Retrieved from https://plato.stanford.edu/archives/win2014/

entries/double-effect/

ProCon. (2010, Oct 20). Should the doctrine of double effect be used to guide end-of-life

decision-making? Retrieved from https://euthanasia.procon.org/view.answers.php?

questionID=001591

Sulmasy, D. (1996, Mar). The use and abuse of the principle of double effect. Clinical

Pulmonary

Medicine, 3 (2). Retrieved from https://pmr.uchicago.edu/sites/pmr.uchicago.edu/files/

uploads/Sulmasy%2C%20The%20use%20and%20abuse%20of%20the%20principle%20

of%20double%20effect%2C%20Clin%20Pulm%20Med%2C%201996.pdf

Taboada, P. (2003). The principle Of double effect questioned. Retrieved from

https://hospicecare.

com/resources/ethical-issues/essays-and-articles-on-ethics-in-palliative-care/the-principle

-of-double-effect-questioned/

Wholihan, D. & Olsen, E. (2017, Jun). The doctrine of double effect: A review for the bedside

nurse providing end-of-life care. Journal of Hospice and Palliative Nursing, 19(3), pp
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205-211. Retrieved from http://www.nursingcenter.com/cearticle?an=00129191-

201706000-00004