Double effect: a useful rule that alone cannot justify hastening death

Author(s): J Andrew Billings

Source: Journal of Medical Ethics, Vol. 37, No. 7 (July 2011), pp. 437-440
Published by: BMJ
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Correspondence to
J Andrew Billings, 11 1/2
Hilliard Street, Cambridge,
MA 02138, USA;
jandrew.billings@gmail.com
Received 5 November 2010
Revised 21 January 2011
Accepted 6 February 2011
Published Online First
8 April 2011
J Med Ethics 2011;37:437-440. doi:10.1136/jme.2010.041160
Teaching and learning ethics
Double effect: a useful rule that alone cannot justify
hastening death
J Andrew Billings
ABSTRACT on justifying palliative sedation and related acts.
The rule of double effect is regularly invoked in ethical A monolithic moral framework deprives us of the
diversity of viewpoints that can inform and deepen
discussions about palliative sedation, terminal extubation
our ethical understanding.'
and other clinical acts that may be viewed as hastening
death for imminently dying patients. Unfortunately, the The current essay focuses on application of the
literature tends to employ this useful principle in rule of double effect to clinical acts that may hasten
a fashion suggesting that it offers the final word on the the death of an imminently dying patient. The rule
moral acceptability of such medical procedures. In fact, regularly appears in ethical considerations of such
the rule cannot be applied appropriately without invoking acts such as administering morphine to a dyspnoeic
moral theories that are not explicit in the rule itself. Four patient, preemptively sedating a patient who is
tenets of the rule each require their own ethical undergoing terminal extubation and palliative
justification. A variety of moral theories are relevant to sedation. The term 'hastening death' is not without
making judgements in a pluralistic society. Much of the important ambiguities, but is used here in its
rich moral conversation germane to the rule has been common clinical fashion. It, therefore, does not
reflected in arguments about physician-asssisted suicide include withholding or withdrawing life supports,
and voluntary active euthanasia, but the rule itself has but does apply to palliative sedation, and is also
limited relevance to these debates, and requires its own sometimes invoked with regard to physician
moral justifications when applied to other practices that assisted suicide (PAS) and voluntary active eutha
might hasten death. nasia (VAE) (although, as discussed below, the rule
does not universally apply to the debate on VAE
and PAS). These are situations often associated
with moral distress when clinicians wonder if their
Bioethical deliberations may reflect a variety of management is ethically justifiable.
moral theories and traditions, such as conse The major conclusion of this essay is that
quentialism, deontology, principlism, communitar applying the rule in such situations must be based
ianism, virtue ethics and so on. These tools or on further consideration of underlying moral
frameworks are regularly employed in clinical theories. Assumptions that the rule offers a solid,
decision making, sometimes simply through intui clear, or unassailable method of determining
tion or informal reflection, sometimes after formal appropriate practice overlooks its reliance on often
deliberation. An awareness of the relevance of
unstated moral tools and traditions, and this
multiple theories and traditions can enrich 'blocking' unfortunately turns attention away
our perspective on bioethical judgementfrom and the important tasks of reflecting on a range
enhance our appreciation of the variety of ethical
of ethical frameworks evident in a pluralistic
frameworks prevalent in a pluralistic society.1-3
society.
Respect for autonomy has become a dominant
principle for bioethical decision making in theAUSA.
BRIEF REVIEW OF THE RULE OF DOUBLE EFFECT
Daniel Callahan4 has noted that principlismThe rule of double effect applies only to situations
(as typified by the popular Georgetown quartet of
in which an act intended to do good runs the
autonomy, beneficence, non-maleficenceforeseeable
and danger of harm. In a simplified form, it
justice)5 has a 'blocking effect' on the appreciation
states that running the risk of a bad outcome is
of other relevant and important moral tools.
acceptable when we intend to produce a good
In reviewing recent ethical discussions on palli
outcome and when taking the risk of the bad
ative sedation, Larry Churchill and I observedoutcome
that seems sensible. For instance, in some
the rule of double effect has been applied as
circumstances, good can be secured for certain
a 'monolithic moral framework'(J A Billings, 2011,
people only if others experience harm.6 The rule is
work in submission). The rule is regularly treated as
consonant with familiar non-medical ethical
the normative and singular criterion fordistinctions
the (eg, between strategic bombing and
acceptability of such procedures, so that clinical
terror bombing) and legal distinctions (eg, between
acts apparently following it are assumed to be
accidental manslaughter and intentional homicide).
ethical, while those not justified by the rule are
In modern medicine and especially in palliative
euthanasia or some other illegal or unethicalcare, a common situation addressed by the rule is
procedure. We conclude our essay as follows: administering morphine to an imminently dying
'Our review of very recent articles on palliative patient with severe, irreversible pulmonary disease
and breathlessness. Appropriately administered
sedation reveals a poverty of ethical viewpoints. The
principle of double effect should not preempt morphine has the beneficial effect of alleviating
additional moral reflection or serve as the final word shortness of breath but may also have the
437
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 Teaching
Teaching and
and learning
learning ethics
ethics

foreseeable, undesirable effect of diminishing respiratory drive from the bad effect. Thus, in the example of the severely
and hastening death. If the value of alleviating suffering dyspnoeic patient, morphine is given with the intention of
outweighs the harm of hastening death, the rule of double easing dyspnoea, not to alleviate that symptom by causing
effects justifies morphine use. death. The bad effect or side-effect is sometimes said to be
The rule of double effect has the important practical function 'indirectly voluntary.' (This component ofthe rule is not always
of sanctioning appropriate symptom relief, including palliative stated.) (5) There is a sufficiently grave reason for achieving the
sedation,7-9 while minimising fears of accusations of PAS or good effect, compensating for hazarding the evil effect. In other
VAE.10 Indeed, even the strictest applications of the rule allow words, a balance or assessment of proportionality between the
for what is almost universally now considered humane good and bad effect is required.20
symptom control near the end of life, and considerable In the following sections, tenets 1, 2, 3 and 5 are reviewed
consensus supports the practice of palliative sedation under the with regard to how they necessarily invoke moral framework
terms of the rule. The rule also corresponds to embedded atti that are not intrinsic to the rule. Many other issues relevant to
tudes among clinicians who distinguish foreseeable side-effects the use of the rule of double effect are not discussed, including
or complications that are unfortunate but consistent with good the nature of intention, situations that seem to suggest that the
medical practice from those that are avoidable or blameworthy rule does not adequately describe moral action, and various other
medical errors. While clinical decisions are often expressed in difficulties interpreting and using the rule. Necessarily, the ethics
terms of balancing benefits and burdens, the rule offers valuable of VAE and PAS will be touched upon, because they are the
refinements.11 As Sulmasy and Pellegrino12 point out, clinicians subtext of so much contemporary discussion of the rule of
have an 'unarticulated, intuitive grasp of the rule of double effect double effect, but neither of those procedures will be addressed
in almost all their therapeutic interventions.' with the intention of entering into ethical or policy debates.
Trepidation about the improper use of the rule of double effect
is also noteworthy, particularly whether it can be twisted to TENET 1: ESTABLISH WHETHER ACTS ARE MORALLY GOOD OR
become a justification for evil acts. A notably vigorous concern NEUTRAL
about such an application is provided in Elizabeth Anscombe's Modern explications of the rule typically stipulate that the act
memorable attack on Truman's decision to use the atomic bomb itself, as opposed to its effects, must not be morally objection
on Japan.13 Causing death to so many innocent civilians had able. Considerable good may arise from killing an innocent
been justified in terms of saving soldiers' lives: person or allowing one to die so that his or her organs can be
transplanted and can save many lives, but such an act is never
'We can now reformulate the principle of "doing evil that good may
permissible. Indeed tenet 1 is a fundamental ethical principle,
come". Every fool can be as much of a knave as suits him....
but can be interpreted differently by different moral traditions.
'...I mean that if you attack a lot of military targets, such as Therefore, the rule of double effect cannot be applied to
munitions factories and naval dockyards, as carefully as you can, questions about hastening death in imminently dying persons
you will be certain to kill a number of innocent people; but that iswithout ascertaining whether a particular act is or is not
not murder. On the other hand, unscrupulousness in considering permissible, a question not answered in any way by the rule
the possibilities turns it into murder....'13 itself. Very few contemplated familiar clinical actions are likely
to be unacceptable per se. Tenet 1 is most easily applied from the
The rule is usually attributed to St Thomas Aquinas,14 whose
viewpoint of the moral frameworks in which good and bad
13th century work, Summa Theologicae, states that killing in self
actions are clearly spelled out, as is typical of deontological
defence is permissible if the intention of the act is to save one's
schemes. Regardless of this, concern about the morality of the
life or rescue another person but there is no intention to harm
primary act is a feature of many moral frameworks and simply
the aggressor and only a necessary amount of force is used to
deserves attention and respect for its importance to some
achieve the the desired end.15 Worth noting, Aquinas was not
persons.11
opposed to all forms of killing; he allowed for the use of lethal
force by government in times of war or for administering civil TENETS 2 AND 3: ASSESSING WHICH EFFECTS ARE GOOD OR
justice.
BAD
The formulation of the rule and how to apply it, along with
Tenants 2 and 3 require that we identify and evaluate the good
an assessment of its value, has been the subject of extensive
and bad effects of an action. The rule does not define good and
philosophical discussion, disagreement and inconsistencies.
bad. The applicability of these tenets thus calls for further moral
Some of its most famous philosophical test cases, the Trolley reflection.
Problems, introduced by Phillipa Foot16 over 40 years ago and
Figuring out whether an intended or foreseen outcome is good
elaborated upon especially by Judith Jarvis Thompson,17 have
or bad is a fundamental question in ethics. Doing good is a basic
been an object of both ethical controversy and fascinating
ethical principle in any moral framework. Different persons
empirical research in cognitive neuroscience.18 19
using the same moral framework may come up with dissimilar
conclusions, while different moral frameworks may lead to
A MODERN FORMULATION OF THE RULE OF DOUBLE EFFECT a consensus or conflict.
As restated and refined in contemporary medical terms, the rule Insofar as the good or bad effect is hastening death for an
is a rather complex, ingenious and occasionally bewildering imminently dying person, considerable debate is familiar. In the
concept that requires that five conditions or tenets are met: Judeo—Christian tradition, the Ten Commandments say, 'Thou
(1) The act, by itself, must be morally good or at least indif shall not kill', yet exceptions exist. Even the definitions of killing
ferent. (2) The clinician must intend to cause a good effect. (3) A and hastening death may be debated; as mentioned above with
bad effect may be foreseen but not intended. (This implies that
regards to Aquinas, killing is often viewed as permissible under
the bad effect would have been avoided if the good effect could
selected circumstances, such as self-defence, rescue, a just war, or
otherwise have been achieved, and that a bad outcome is not civil defence. The notion of 'justified' killing21 lies at the heart of
inevitable.) (4) The good effect follows from the action, not some debates about palliative sedation, PAS and VAE.

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We can imagine how different ethical frameworks might
address these issues. From the vantage of liberal individualism,4
some argue a right to request a hastened death, similar to a right
not to suffer when death is imminent.22 23 Others believe that
respect for patient autonomy trumps other ethical concerns, so
a patient deserves help when requesting hastening of death. In
end-of-life care, many clinicians, patients and family members
have notions of a 'good' or 'peaceful' or 'timely' death; these are
legitimate ends for clinical care and a variety of acts may be
viewed as justifiable for meeting these objectives. From a utili
tarian viewpoint,21 24 humane ends, such as avoiding suffering
or achieving a sense of personal control, may justify hastening
death, and unwanted prolongation of dying may not make sense
when quality of life is poor and death is imminent. In discus
sions based on virtue ethics, VAE and PAS may sometimes be
justified as loving, responsible acts.25
Of course, the ethical frameworks cited above, as well as
other moral systems, may support opposite conclusions. In
addition to a strict prohibition against hastening death, viewed
as a form of unacceptable killing, the impact of such practices
may be seen as undermining public trust in the health
profession, subverting professional ethics, dereliction of duty,
a failure of character, causing damage to surviving family
members, or putting us on the 'slippery slope' that leads to
harm for the infirm or suggests an obligation to die when one is
no longer useful or appreciated by society. The psychological
difference between directly causing death rather than allowing
a death is also relevant to this discussion and to the thinking
and feeling of clinicians.
A continuum in the array of acts that hasten death
is suggested in Justice Souter's comments in Washington
v. Glucksburg:
'Furthermore, because physicians are already involved in making
decisions that hasten the death of terminally ill patients—through
termination of life support, withholding of medical treatment, and
terminal sedation—there is in fact significant tension between the
traditional view of the physician's role and the actual practice in
a growing number of cases.'26
and is developed extensively in Brock's description of 'killing'.21
The key point here, similar to the discussion under tenet 1, is
to ask whether hastening death is ever a good effect in clinical
practice? How does it differ from such apparently acceptable
acts as withholding or withdrawing life supports, which may
not substantially differ from palliative sedation? What are the
situations, the safeguards and trade-offs (eg, between such values
as social justice, autonomy and mercy), if any, that might help us
decide about the acceptability of such practices? Using the
rule of double effect conscientiously, we come back to a funda
mental discussion of whether 'Doctors should not kill'.21 26 27
TENET 5: DECIDING ABOUT PROPORTIONALITY OR BALANCE
Having clarified that an act is morally good or neutral and that
intended effects are good while only foreseen but unintended
effects are bad, we need to decide whether the chance of
achieving a good effect in this particular situation outweighs the
risk of causing the bad effect.
Part of the decision about balance must reflect clinical judge
ment about the odds of producing various outcomes from the
proposed action—the probabilities. A tiny chance of a bad
outcome may be worth risking when there is almost a certainty
of a good outcome. Conversely, if the bad effect is almost sure to
occur while the good effect is highly unlikely, clinical judgement
might rule against the act.
J Med Ethics 2011;37:437-440. doi:10.1136/jme,2010.041160
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Teaching
Teaching and
and learning
learning ethics
ethics
Clinical situations typically focus on the interests of one
person, so the operant values for achieving balance primarily
reflect the informed patient's values, goals and preferences
(although much of the literature on double effect seems to focus
primarily on professional integrity and the physician's viewpoint
of what is acceptable).
Balance is weighed in terms of ethical principles. How do we
compare respecting dignity, valuing individual choice or feelings
of the family, religious precepts, and our sense of professional
responsibility and personal values and that of other involved
clinicians? As stated in the Neve Catholic Encyclopedia:
'...an effect that benefits or harms society generally has more
weight than one that affects only an individual; an effect sure to
occur deserves greater consideration than one that is only probable;
an effect of a moral nature has greater importance than one that
deals only with material things.'20
Assigning a degree of goodness or badness to the various
outcomes and deciding on proportionality, should thus bring us
back to an awareness of moral frameworks. Importantly here,
the value may not be simply good or bad but how good and how
bad, how desirable and how unacceptable are outcomes relative
to each other. In the language of decision analysis, we are
describing utilities,28 but utilitarian calculations necessarily
require (and sometimes conceal) decisions about how outcomes
are valued. In the simplest cases, we might say that saving two
lives is better than saving one, but this assumes that each life is
equally valued rather than recognising schemes that distinguish
between the most and least socially valued, such as the very
young and the very old.
Consequentialism or utilitarianism determine the choice of an
action largely in terms of its effects. A common, perhaps
unstated and often utilitarian, consideration in offering pallia
tive sedation or other measures that are likely to hasten dying is
to say that the patient is going to die soon anyway and that the
limited time for survival is only valuable if suffering is alleviated.
Suffering may be immediate, terrible and unnecessary so it
should be treated vigorously. The patient and family, as well as
the clinical team, may have relatively little concern about the
difference between a more immediate death and a potential
survival for a few hours, days, or weeks in misery or uncon
sciousness. For another patient, survival is highly important, so
avoiding the sedative side-effect of pain-relieving medicines is an
acceptable strategy, while any shortening of survival becomes
the bad effect.
Proportionality can also be viewed in a deontological frame
work. Some outcomes may be considered unacceptable in all
situations. If alleviating suffering near the end of life is always
a higher priortiy than prolonging survival, then acts that may
have the effect of hastening death near the end of life are
regularly permissible under the rule of double effect, or the
converse.
Another common point about these decisions is th
that is good for one patient must necessarily be vie
perspective of broader social policy. Therefore, for e
reflecting the autonomous wishes of a single pati
examined in the context of the larger community, m
on the wellbeing of others.
BEYOND THE RULE OF DOUBLE EFFECT
Proponents and opponents of PAS and VAE have fought some of
their battles by arguing about the rule of double effect. Timothy
Quill and others,29-31 in favouring the liberalisation of policies
that currently forbid such practices, have thoughtfully pointed
439
 Teaching and learning ethics

out problems with the rule and its applications.32 Some impor Competing interests None declared.
tant concerns are worth noting, especially about how propor Provenance and peer review Not commissioned; externally peer reviewed.
tionality is judged and how the rule relies on intentions or
motives that may be difficult to ascertain, but these issues
are peripheral to the argument here.33 Some strongly stated REFERENCES
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