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COMMENTARY

The Rule of Double Effect


Clearing Up the Double Talk

R
ECENTLY, the rule of not bring about the possible good ef- wrong to intend that a patient die by
double effect, which fect by means of the possible bad ef- way of ones clinical act, then there
has a long history in fect, and (4) is undertaken for a pro- is no need to bother with the rule of
ethics, especially portionately grave reason.4-8 This double effect. However, millions of
medical ethics, has moral rule has wide application, but American health care professionals
come under serious criticism in the has played a particularly important and patients are morally opposed to
medical literature.1,2 Because of its role in the care of the dying, allow- euthanasia and assisted suicide. For
immense practical importance in the ing those who are morally opposed such individuals, we argue, the rule
care of dying patients, any attack on to euthanasia and assisted suicide to of double effect is perfectly coher-
this rule must be taken seriously. In provide adequate pain relief with- ent and of great clinical impor-
this article, therefore, we present a out violating traditional medical mo- tance.
systematic rejoinder to what we take rality or their consciences.
to be serious misunderstandings of Treating dying patients in pain LOGICAL INCONSISTENCIES
the nature and use of this rule. with appropriate doses of morphine WITH POTENTIALLY
A clear understanding of the is generally done in a manner that sat- DELETERIOUS EFFECTS
proper use of the rule of double ef- isfies the criteria for double effect. The ON PATIENT CARE
fect is essential if health care profes- use of morphine (1) is not in itself im-
sionals are to maintain their opposi- moral; (2) it is undertaken only with Undermining the rule of double ef-
tion to euthanasia and assisted suicide the intention of relieving pain, not of fect has the potential to affect the
and yet provide adequate pain relief causing death through respiratory de- care of the dying adversely, since
to dying patients. Many Americans, pression; (3) morphine does not re- most physicians report that they are
including health care professionals, lieve pain only if it first kills the pa- personally reluctant to perform eu-
are fearful of unwittingly participat- tient; and (4) the relief of pain is a thanasia or assisted suicide even if
ing in euthanasia if a patients death proportionately grave reason for ac- it is legalized.9-12 Some of the critics
is hastened, however unintention- cepting the risk of hastening death. of double effect seem to want things
ally, as a side effect of attempts to re- Some physicians, who are opposed to both ways. They acknowledge that
lieve pain and suffering. For such in- euthanasia and assisted suicide, might the rule of double effect may be use-
dividuals, the rule of double effect avoid giving opioid analgesics to dy- ful as a way of justifying adequate
provides moral reassurance and thus ing patients out of fear of hastening pain relief and other palliative mea-
encourages optimal care of the dy- death and committing euthanasia. sures for dying patients.1 But at the
ing. This is why the rule figures According to the rule of double effect, same time, they argue that this moral
prominently in the opinions of the however, the appropriate and com- rule is not credible.
American Medical Association.3,4 passionate use of morphine is mor- The rule of double effect is ei-
ally permissible even for those who ther valid or invalid. It cannot be
NATURE AND CONTENT are morally opposed to euthanasia both. If the rule of double effect
OF THE RULE OF DOUBLE and assisted suicide. This rule al- is, in fact, logically and morally valid,
EFFECT lows physicians opposed to euthana- then the most helpful policy for
sia and assisted suicide to treat pain patients would be to educate phy-
Although variously formulated, the adequately in these situations with a sicians about its proper applica-
traditional rule of double effect speci- clear conscience. tion. Those who already approve of
fies that an action with 2 possible ef- euthanasia and assisted suicide can-
fects, one good and one bad, is mor- THE UNDERLYING ISSUE not logically be opposed to giving
ally permitted if the action: (1) is not drugs in a manner consistent with
in itself immoral, (2) is undertaken If one believes that euthanasia and the rule of double effect. They might,
only with the intention of achieving assisted suicide are sometimes mor- in addition, want to give lethal doses
the possible good effect, without in- ally permissible, then the rule of or administer other lethal treat-
tending the possible bad effect even double effect has no role to play in ments, but they cannot be opposed
though it may be foreseen, (3) does the care of dying patients. If it is not to relieving pain. By educating phy-

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sicians about the rule of double ef- tion might have dangerous side ef- for the physicians assistance in pro-
fect, more patients will receive ad- fects. This is a different idea from the viding a possible way out. The
equate pain control from physicians notion that one simply picks the physician writes the lethal prescrip-
who are opposed to euthanasia and lesser of 2 evils. tion knowing that the patient has al-
assisted suicide and might other- ready formed a provisional commit-
wise be reluctant to provide such DOUBLE EFFECT ment to the possibility of taking
treatment. AND ASSISTED SUICIDE these drugs. Without the physi-
On the other hand, if one be- cians cooperation, this possible in-
lieves that the rule of double effect The critics have created a straw man tent could not be carried out in the
is somehow incoherent, how can one when they suggest that if the rule of way the patient intends it. If the phy-
argue that physicians who are op- double effect were true, then phy- sician is morally opposed to eutha-
posed to euthanasia or assisted sui- sician-assisted suicide should be per- nasia and suicide, the physician has
cide should use it in the care of pa- mitted by its adherents.1 They pro- thus cooperated in the death if the
tients? If this rule really makes no vide no citation of such an argument patient goes on to commit suicide.
sense, then it follows logically that by anyone who subscribes to the rule Double effect would apply here
those physicians who are conscien- of double effect. only if the patient expressed no in-
tiously opposed to euthanasia and They also make a category mis- tention either to commit suicide or
assisted suicide should not pre- take by applying this rule to the situ- to have a lethal dose available just
scribe opioid analgesics for the dy- ation of assisted suicide. The rule of in case. A physician might write a
ing. They would have no choice but double effect is only 1 moral rule prescription for an opioid analge-
to refrain from using these drugs, be- among many. It is only designed to sic to treat pain, and the patient
cause without the rule of double ef- cover certain kinds of actions, while might surreptitiously stockpile the
fect, they would be forced to con- other rules cover other kinds of ac- pills and take them in a suicide at-
sider all actions that risk hastening tions. According to the standard ac- tempt. This is always a possibility
the death of the patient to be eutha- count, the rule does not apply to with any drug that is used clini-
nasia. And this would be a horrify- situations in which the effects un- cally, whether it is an opioid anal-
ing consequence for patients. der consideration involve the inten- gesic or digitalis. If one recognizes
If, however, as we argue later, tions of intervening agents. The rule that this is a possibility, but has no
the rule of double effect is valid, then of double effect can only be applied indication that this is the patients
those opposed to euthanasia and as- to situations in which the possible intention, one is not an accomplice
sisted suicide can feel morally reas- good and bad effects follow di- in the suicide. However, if the pa-
sured when using appropriate doses rectly on an agents actions.13 For ex- tient clearly signals such a possible
of opioid analgesics in the care of dy- ample, Quill et al1 claim that the phy- intention, one is an accomplice if the
ing patients. sician writing a lethal prescription patient commits suicide.
might only intend to reassure the To illustrate this, consider
MISCONSTRUING patient by providing a potential es- someone who is asked to give a stick
DOUBLE EFFECT cape from suffering that the physi- of dynamite to a distraught em-
cian hopes or expects will not be ployee who has recently been fired
Critics misconstrue this moral rule used. Assisted suicide, however, re- and is expressing a vague wish to
when they suggest that it is simply quires that a patient form an inten- blow up his place of former employ-
a rule that enables one to decide tion to bring about the bad effect that ment. It is hardly plausible in such
whether one potentially harmful ac- the physician is allegedly claiming a situation to invoke the rule of
tion is preferable to another.1,2 This to intend to avoid, ie, suicide. The double effect and say that one would
is not true. The rule of double ef- suicidal death of the patient does not only be intending to ease the em-
fect is not simply an instrument of follow directly from the writing of ployees anxiety by giving him the
consequentialist reasoning, ie, de- the prescription, but from the pa- dynamite. It is true, he might or
termining the moral status of an ac- tients intentional use of that pre- might not blow up the building. But
tion on the basis of net utility. One scription. Therefore, the rule of if the employee does blow up the
does not begin double effect reason- double effect does not apply. building, one is a moral accom-
ing by first examining the conse- Presuming, as proponents of plice because one has supplied the
quences of a proposed action and the rule of double effect do, that eu- means, knowing of the former em-
then deciding whether the net con- thanasia and suicide are morally ployees possible intention. The same
sequences are such that there might wrong, the moral question for the is true of assisted suicide. If one
be a good reason to override some physician in cases of assisted sui- knowingly supplies the means, one
prima facie prohibition against the cide is whether the physicians as- is an accomplice.
action. Rather, one sets out to do a sistance in the suicide is morally ac- Furthermore, suppose one were
morally good action, taking full ac- ceptable. Therefore, the proper to try to stretch the rule of double
count of the foreseeable conse- moral category for such physicians effect to cover the situation of as-
quences. If the action conforms to is not double effect but coopera- sisted suicide. Even so, the rule of
the conditions of the rule of double tion (ie, whether the physician is an double effect would prohibit this ac-
effect, one may proceed even un- accomplice and therefore morally tion, provided one were morally op-
der circumstances in which that ac- culpable).14,15 The patient is asking posed to suicide in the first place. To

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try to make assisted suicide fit un- ence diminished consciousness as a As long as these were ones intentions,
der the rule of double effect, one consequence of the natural progres- and one were only to use as much bar-
would need to make the claim that sion of her disease, in extreme pain, biturate as was necessary to suppress
one was giving pills without intend- and asking for relief. Under the rule these symptoms, having established
ing the patients possible suicide. of double effect, it is perfectly appro- with the patient that unconsciousness
However, the third condition of the priate to treat the patients pain with might result as an unintended side ef-
rule of double effect requires that the an opioid analgesic, recognizing that fect, one could proceed with such
possible bad effect not be the means the patient may subsequently lose measures under the rule of double ef-
of producing the possible good ef- consciousness as an unintended side fect. This should be a measure of last
fect. In this case, what one would be effect, consequently not eat, and die resort, but one that might, in ex-
claiming not to intend, the possibil- sooner. tremely rare circumstances and in
ity that the patient might actually This is a different case from a careful hands, be necessary. This is
take the overdose and die, is, in fact, patient with early Alzheimer dis- the sort of case of terminal sedation
the very means by which the pa- ease who is suffering because of fear that has traditionally been permitted
tient is reassured. Therefore, the rule of what the future might bring, ask- but rarely performed under the rule
of double effect would not justify as- ing for help in hastening death. In of double effect.
sisted suicide. sedating such a patient to the point Thus, some kinds of terminal
of unconsciousness, the intention is sedation are permitted under the rule
DOUBLE TALK ABOUT to hasten death. This would there- of double effect, and some are not.
TERMINAL SEDATION fore not be permitted under the rule In those kinds that are permitted, se-
of double effect and ought not be dation is an unintended but fore-
Terminal sedation, in which dying permitted on that basis under law so seen side effect. In those kinds that
patients may be given doses of drugs long as euthanasia remains illegal. are not permitted, the intended pur-
to treat specific symptoms, but sub- Or consider an elderly patient pose of the sedation is the termina-
sequently lapse into coma and die, without pain but with severely lim- tion of the patients symptoms by
is an extraordinarily rare event in the ited mobility because of inoperable means of the termination of the pa-
hands of experts in hospice and pal- degenerative arthritis, who may be tients existence.
liative care.15 Good palliative care experiencing a kind of existential
physicians aim at maximizing symp- angst, or what the Dutch eu- WITHDRAWING
tom control and function at the same thanists call tiredness of life.17 The LIFE-SUSTAINING
time. Under the rule of double ef- only way that a barbiturate could re- TREATMENT IS NOT
fect, however, they sometimes can lieve the symptoms of tiredness of AN APPLICATION
accept sedation to the point of un- life would be by causing the uncon- OF DOUBLE EFFECT
consciousness as a side effect of a sciousness and death of the pa-
specific treatment aimed at a spe- tient. But this violates the rule of A further mistake is the suggestion
cific symptom. That is, they accept double effect, since the allegedly un- that the withdrawal of life-
sedation that may happen to be ter- intended possible bad effect (uncon- sustaining treatments is tradition-
minal. They do not sedate as part of sciousness and death) is the means ally justified by the rule of double
a plan to terminate. However, some of achieving the possible good effect effect.1 Once again, this is a misap-
authors2,16 are now erroneously sug- (relief from tiredness of life). There- plication of the rule of double ef-
gesting an extension of the mean- fore, this sort of terminal seda- fect, albeit one that has been per-
ing and scope of this practice to in- tion is simply a form of active petuated in the literature.18 Once
clude the practice of certain forms euthanasia and would not be per- more, it pays to understand that the
of euthanasia under the legal cover mitted under double effect. rule of double effect is but one rule
of what has traditionally been per- However, consider the sort of among many. Traditionally, the re-
mitted as double effect. case in which a patient with metastatic fusal of life-sustaining treatments has
To use the rule of double effect cancer has been treated for many been justified under the rule that one
properly, one must be careful to months with opioid analgesics and is permitted to withdraw life-
specify the effects one is aiming at, has developed myoclonus as a side ef- sustaining treatments in circum-
and be reasonably sure that the pro- fect of these drugs. Suppose the pa- stances in which their use is
posed intervention can possibly tient has been treated with benzodi- considered extraordinary or dis-
achieve this effect. Relief of suffer- azepines for the myoclonus, but the proportionate.19,20 Like the rule of
ing is far too broad an effect to have myoclonus persists. Suppose the pa- double effect, the ordinary vs ex-
practical clinical meaning. Good cli- tient has also been treated with ad- traordinary distinction requires a
nicians use specific drugs to treat spe- juvant tricyclic antidepressants, a proportionately grave reason, but it
cific symptoms, and under the rule nerve block, and biofeedback and the is a distinct moral rule.21 Morally
of double effect, can, at times, accept pain is still not relieved. Under such cautious patients or health care pro-
the possibility of loss of patient con- extraordinary circumstances, one fessionals who do not support eu-
sciousness as a side effect of treating could consider the use of barbiturates thanasia or assisted suicide have
these symptoms. For example, con- as a way to suppress the myoclonus been permitted to withhold and
sider a patient who is days away from and bring the patient relief from anxi- withdraw life-sustaining treat-
death, already beginning to experi- ety that may be exacerbating the pain. ments that are futile or dispropor-

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tionately burdensome under Ro- bacteria, not to kill the patient. The ment has been offered that this might
man Catholic moral theology since death of the patient is not the cause lay the groundwork for establish-
at least the 1500s,19 years before the of the death of the bacteria, and the ing a constitutional right to ad-
rule of double effect had ever been rarity of anaphylaxis and the harm equate pain relief for the dying.35 But
explicitly formulated in the moral lit- of not treating makes the risk pro- the justices made no moral argu-
erature.22 Under this rule, one is per- portionate and worth taking. Even ments for accepting the rule of
mitted to refuse life-sustaining treat- so simple an action as prescribing double effect, and the recent discus-
ments that are of no benefit or are penicillin already presumes some- sions of the courts decision in the
disproportionately burdensome. It is thing about intention and is actu- medical literature do not attempt to
a rule for refusing treatment, not a ally an application of the rule of find such a moral argument. Fur-
rule to guide active treatment. double effect. This is the case with thermore, the fact that critics of pro-
There is no need to invoke the any powerful drug. hibitions on assisted suicide and eu-
rule of double effect in withdraw- At times, of course, it can be dif- thanasia point out that physicians
ing life-sustaining treatments. One ficult to judge human intentions. But accused of assisted suicide are of-
need only invoke the dictum that as Samuel Johnson once said, The ten acquitted is not an argument
there is no moral obligation to use fact of twilight does not mean there against the logical and moral valid-
futile or excessively burdensome is no difference between night and ity of the rule of double effect. Judges
treatments. day.25 If a clinician gives 10 mg of and juries and legislators may make
morphine intravenously over 5 min- decisions within the bounds of law
THE DISAMBIGUATION utes to a nonopioid-tolerant pa- and yet make morally incorrect judg-
OF CLINICAL INTENTIONS tient with significant pain, this ac- ments.
tion is consistent with an intention
Quill23 has argued forcefully that to relieve pain and not to kill the pa- RELIGION, MORALITY,
clinical intentions are inherently am- tient. But if a clinician were to give AND SOCIETY
biguous, and cannot be used to 5000 mg of morphine intrave-
evaluate the morality of clinical ac- nously over 15 seconds to a non- Quill et al1 suggest that among the
tions. This is an extremely problem- opioid-tolerant patient to relieve the shortcomings of the rule of double
atic position, reiterated in the re- patients suffering, knowledge- effect as a guideline for medical mo-
cent attacks on the rule of double able clinicians would have no doubt rality in a pluralistic society is the fact
effect.1,2 Common sense and the law about that clinicians intentions. This that the rule originated in the con-
place important weight on inten- difference is as clear as the differ- text of a particular religious tradi-
tions in evaluating the morality of ence between night and day.26 tion. This is a very odd position.
human actions, and properly so. In- Contrary to the contentions of Should the commonly held posi-
tentions are vital to our understand- the critics, a great deal of contem- tion that stealing is morally wrong
ing of virtuous actions, and in ex- porary work in the philosophy of ac- be rejected simply because it can be
plicating what it means sincerely to tion shows how intentions differ found (Exodus 20:15) in the com-
act with respect for anothers dig- from beliefs and desires and sup- mandments of a particular reli-
nity.5 Careful distinctions are also ports the importance of distinguish- gious tradition? The religious ori-
drawn, for instance, between man- ing between the foreseen and the in- gins of a moral principle or rule
slaughter, murder in the first de- tended. 27-31 Space requirements should not preclude its discussion
gree, and so forth, purely on the ba- prohibit a full discussion of this mat- in civil society. Nor should the con-
sis of judgments about human ter herein. The application of this in- gruence between a moral argu-
intentions. What is done with mal- tention theory to bioethical dis- ments conclusions and the teach-
ice aforethought is deemed far more course is only just beginning.32 ings of a religion undermine the
troubling morally than what is done validity of the argument. An exhor-
unintentionally. LAW DOES NOT SETTLE tation to exclude such rules and
The morality of everyday clini- THE MORAL QUESTION principles in the name of tolerance
cal practice depends heavily on the seems itself highly intolerant.
concept of intention, and clini- Legal arguments do not settle moral There is nothing about the rule
cians have an unarticulated, intui- questions. It is a truism to state that of double effect that is inherently re-
tive grasp of the rule of double ef- all that is legal is not moral, and that ligious. The fact that it was devel-
fect in almost all their therapeutic all that is moral is not necessarily le- oped by theologians does not viti-
interventions. This is because the gal. Therefore, legal opinions about ate the fact that it might be morally
whole notion of a side effect is to- assisted suicide or euthanasia re- true. Nothing about the rule pre-
tally dependent on the rule of double ally only have moral weight to the sumes any knowledge of scripture or
effect and the concept of inten- extent that they are morally persua- the teachings of any religion. All that
tion.24 For instance, when physi- sive. The legal arguments of the crit- is required is a belief that certain ac-
cians treat streptococcal pharyngi- ics do not address the moral issues. tions are absolutely morally prohib-
tis with penicillin, they foresee the The recent US Supreme Court ited, or, more controversially, at least
possibility that the patient might de- decision regarding assisted suicide a belief that consequences are not the
velop an anaphylactic reaction and invoked double effect reason- sole determinants of the morality of
die. But they only intend to kill the ing.33,34 An interesting legal argu- an action. 36 Many clinicians be-

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lieve, for a variety of reasons, some to actions that cause death,33,34 but death of the patient can be consid-
religious and some not, that eutha- the moral question remains the cen- ered a morally permissible side ef-
nasia and assisted suicide are al- tral one that must be debated. Cer- fect. Recent attacks on this moral
ways morally wrong. Such clini- tainly, no one has yet seriously ar- rule therefore do the medicomoral
cians need a rule of double effect. gued that physicians have a moral community a disservice, since these
A logically rigorous argument obligation to provide assistance with attacks have been fraught with mis-
against the rule of double effect suicide or euthanasia on demand interpretations, misapplications,
would deal with the rule on its own even if they conscientiously object hasty generalizations, and logical fal-
terms. To raise the question of the to these practices. This would vio- lacies.
origin of the rule as a reason to dis- late the autonomy of the clinicians. It goes without saying that
credit it is a form of the logical fal- While space considerations pre- those who accept the moral permis-
lacy of the ad hominem argu- clude a full discussion, multiple ar- sibility of euthanasia and assisted
mentto claim to discredit an guments about the nature of the suicide have no need for a rule of
argument because of who states it. practice of medicine,41 the value of double effect. For them, hastening
Moreover, while it has had its preserving life,42 and concerns about the patients death is not a bad ef-
origins in a particular religious tra- the slippery slope consequences of fect to be avoided. But for most phy-
dition, the rule of double effect has legalizing euthanasia and assisted sicians, who report that they per-
been widely discussed and de- suicide43 have been made to argue sonally would not perform
fended in the philosophical litera- against allowing patients the au- euthanasia, the rule is important. It
ture apart from its origins.36-39 Its ap- tonomy to demand these practices. allows them to treat specific symp-
plications are far wider than Others44 have argued that assisted toms of dying patients even at the
medicine. For instance, it is the ba- suicide can never itself truly be au- risk of hastening death while pre-
sis of the distinction between ter- tonomous. The central moral issue serving their conscientious objec-
ror bombing and strategic bomb- in the debate about euthanasia and tion to euthanasia. The importance
ing in just-war theory.7,25,27,40 The assisted suicide is whether these are of the rule of double effect needs to
argument that it should be rejected good arguments. be underscored at a time when the
out of hand simply because it origi- As the critics point out, the rule public is clamoring for improved
nated with a particular religious tra- of double effect is only morally im- care of the dying and the US Su-
dition is completely unwarranted. portant if euthanasia and assisted preme Court has declared that there
suicide are considered immoral. An is no constitutional right to as-
PATIENT AUTONOMY: A attack on the rule of double effect sisted suicide. Recent attacks on this
MORAL ABSOLUTE? therefore only makes sense when rule are therefore not only to be
viewed as part of a strategy to pro- faulted as ill-conceived, but also as
While we agree with the critics that mote the legalization of physician- ill-timed. For the benefit of pa-
autonomy holds an important place assisted killing by undermining phy- tients, we hope that this article ad-
in Western medical ethics and law, sicians confidence in a commonly dresses these objections to the rule
we fail to see how this justifies the accepted moral rule that depends on of double effect and that clinicians
conclusion that the patients autono- the presumption that killing pa- will understand and apply that rule
mous preference for death is more tients is morally wrong. But if the ar- properly.
fundamental than whether the phy- guments against double effect are
sician intends to cause death. 1,2 themselves inadequate, mistaken, or Daniel P. Sulmasy, OFM, MD, PhD
These authors36 simply assume that confused, then one must face The John J. Conley Department of
there can be no moral absolutes, squarely the real question at stake Ethics
such as a prohibition on the direct whether patient autonomy is such St Vincents Hospital and Medical
killing of patients by physicians. This a moral absolute that countervail- Center
begs the central moral question in ing considerations will not stand. 153 W 11th St
the debate over assisted suicide. We, New York, NY 10011
on the other hand, are making a CONCLUSIONS (e-mail: daniel_sulmasy@nymc.edu)
more limited claim, and making our Edmund D. Pellegrino, MD
assumptions explicit. We are only ar- The rule of double effect has tradi- Washington, DC
guing that if one believes, for what- tionally played an important role in
ever reasons, that euthanasia and as- medical ethics. It is the philosophi- Dr Sulmasy is a Faculty Scholar of the
sisted suicide are always morally cal underpinning for the critically Open Society Institutes Project on
wrong, even if requested by a pa- important concept of a side effect. Death in America.
tient, then the rule of double effect The rule of double effect needs to be
can be used sensibly and coher- accurately understood and care-
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