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Should the Doctrine of Double Effect Be Used to Guide End-of-Life Decision-Making?


General Reference (not clearly pro or con)
The Stanford Encyclopedia of Philosophy, in its July 28, 2004 entry titled "Doctrine of Double Effect," explained:

"The doctrine (or principle) of double effect is often invoked to explain the permissibility of an action that causes a serious harm, such as the death of a human being, as a side effect of promoting some good end. It is claimed that sometimes it is permissible to cause such a harm as a side effect (or 'double effect') of bringing about a good result even though it would not be permissible to cause such a harm as a means to bringing about the same good end. This reasoning is summarized with the claim that sometimes it is permissible to bring about as a merely foreseen side effect a harmful event that it would be impermissible to bring about intentionally...

A doctor who intends to hasten the death of a terminally ill patient by injecting a large dose of morphine would act impermissibly because he intends to bring about the patient's death. However, a doctor who intended to relieve the patient's pain with that same dose and merely foresaw the hastening of the patient's death would act permissibly."

July 28, 2004 - Stanford Encyclopedia of Philosophy 



PRO (yes)

Judith Kennedy Schwarz, PhD, Consultant in Nursing Ethics and End-of-Life Care, wrote in her 2004 article "The Rule of Double Effect and Its Role in Facilitating Good End-of-Life Palliative Care: A Help or a Hindrance?," published in the Journal of Hospice and Palliative Nursing:

"Many clinicians agree that use of the RDE [rule of double effect] may enhance EOL [end of life] pain management by reassuring uncertain healthcare professionals that prescribing or administering high-dose opiates to terminally ill patients is morally and professionally appropriate palliative care that, when appropriately administered, does not hasten death...

Clinicians sometimes have strongly held personal values and/or religious beliefs that conflict with decisions that patients or families make about continuing life-sustaining measures. Thoughtful application of the RDE may be of value to these clinicians, by helping them accept such decisions as when a patient's informed consent to an intervention hastens his or her dying (eg, the removal of a ventilator necessary for sustained life, or when a terminally ill patient decides to stop eating and drinking). Although the patient's death may be foreseen, it is not the reason for respecting that patient's choice—death may be foreseen without being intended."

2004 - Judith Kennedy Schwarz, PhD 



Daniel Sulmasy, MD, PhD, Director of the Bioethics Institute at New York Medical College, and Edmund Pellegrino, MD, Professor Emeritus of Medicine and Medical Ethics at Georgetown University, wrote in their 1999 article "The Rule of Double Effect: Clearing up the Double Talk," published in the Archives of Internal Medicine:

"A clear understanding of the proper use of the rule of double effect is essential if health care professionals are to maintain their opposition to euthanasia and assisted suicide and yet provide adequate pain relief to dying patients."

1999 - Edmund Pellegrino, MD 
Daniel Sulmasy, MD, PhD 



Nessa Coyle, PhD, Supportive Care Program, Pain & Palliative Service for the Department of Neurology at Memorial Sloan-Kettering Cancer Center, and Mary Layman-Goldstein, Nurse Practitioner for Palliative Care Education at the Memorial Sloan-Kettering Cancer Center, wrote in their 2001 book Palliative Care Nursing: Quality Care to the End of Life:

"The principle of double effect is an essential ethical construct for nurses to understand if they are going to adequately control complex symptoms at the end of life...Giving a patient who is dying, hypotensive, and in pain sufficient opioid dosages to control the pain is good palliative care and not euthanasia."

2001 - Nessa Coyle, PhD 
Mary Layman-Goldstein, RN 



Kevin Glynn, MD, Former Chief of Staff at Mercy Hospital, San Diego, wrote in his Jan. 29, 1999 article "'Double Effect': Getting the Argument Right" that appeared in Commonweal:

"The principle of double effect is an ethical pillar of therapy for terminal illness, and validating it promotes humane care for the dying. The more broadly it is grasped and practiced, the less attractive will be the vision of physicians erasing the most basic commandment of their profession: 'First, do no harm.'"

Jan. 29, 1999 - Kevin Glynn, MD 



CON (no)

Timothy Quill, MD, Professor of Medicine, Psychiatry, and Medical Humanities at the University of Rochester, Rebecca Dresser, JD, Daniel Noyes Kirby Professor of Law and Professor of Ethics in Medicine at Washington University Law School, and Dan Brock, PhD, Frances Glessner Lee Professor of Medical Ethics at Harvard Medical School, wrote in their 1997 article "The Rule of Double Effect—A Critique of its Role in End-of-Life Decision-Making," published in the New England Journal of Medicine:

"Problems arise when the rule [of double effect] is used to argue against physician-assisted suicide. The goal of physician-assisted suicide is to relieve intolerable suffering, but the means to this end is to provide the patient with a death-producing agent. Providing a patient with a means to end life could be held to violate the prohibition against intentionally causing death...even if the physician's overarching purpose is to relieve intolerable suffering... The simple classifications of intent provided by the rule of double effect are not easily applied to the physician's intentions in this clinical setting...

The rule of double effect is also of limited assistance in evaluating the practice known as terminal sedation... Although the overall goal of terminal sedation is to relieve otherwise uncontrollable suffering, life prolonging therapies are withdrawn with the intent of hastening death. Terminal sedation would thus not be permitted under the rule of double effect, even though it is usually considered acceptable according to current legal and medical ethical standards.

...Although there is a clinical, ethical, and legal consensus that patients have the right to refuse life-sustaining treatment, such decisions are sometimes problematic when analyzed according to the rule of double effect.

...The rule may cause confusion about physicians' responsibilities with regard to stopping life support and may account for the reluctance of some physicians to carry out patients' wishes to forgo treatment...

The rule of double effect has many shortcomings as an ethical guide for either clinical practice or public policy."

1997 - Dan Brock, PhD 
Rebecca Dresser, JD 
Timothy E. Quill, MD 



Susan Anderson Fohr, JD, Affiliate Member of the Injury Research Center at the Medical College of Wisconsin, wrote in her 1998 article "The Double Effect of Pain Medication: Separating Myth from Reality," published in the Journal of Palliative Medicine:

"Unfortunately, in ethical articles discussing end-of-life issues, any discussion of relieving pain is invariably followed, almost in the same breath, by a discussion of the double effect. Even when meant to encourage the use of opioids to relieve pain, these double effect discussions have the effect of reinforcing the misperception that cancer patients must die in pain unless medication that hastens death is administered...

Not only is it not necessary to rely on the PDE [principle of double effect] to justify giving adequate pain medication to dying patients, but such reliance on the PDE actually perpetuates the myth of the double effect of pain medication, directly contributing to the undertreatment of suffering at the end of life. It is ironic that an ethical principle that is used to justify adequate opioid analgesics contributes to the undertreatment of pain...

In end-of-life discussions, focusing on the PDE and on a seldom occurring side-effect of pain medications diverts attention from the larger ethical issue of the undertreatment of pain and suffering in the dying patient."

1998 - Susan Anderson Fohr, JD