The 'Principle of Double Effect'

The 'Principle of Double Effect'

The Principle of Double Effect means that giving pain relief treatment that also hastens death is justified if the main intention was to relieve the pain, not cause the death.

  • Some doctors use the deliberate sedation of patients to deep unconsciousness for the purpose of relieving suffering.
  • Euthanasia advocates claim that doctors are acting in a hypocritical way, hiding under the doctrine of "double effect", when in fact their primary intention is to kill the patients.
  • Providing necessary pain relief, even if it shortens life, is not euthanasia unless the intent was to kill.
  • Surveys often fail to pose questions with accurate or clear wording, making it difficult for respondents.
  • If doctors are breaking the law while euthanasia is illegal, they will be unlikely to obey guidelines were it legalised.
The 'Principle of Double Effect' was developed by Roman Catholic moral theologians of the 16th and 17th centuries.

According to the principle of double effect, it is morally permissible to perform an act that has both a good effect and a bad effect if all of the following conditions are met:
  1. The act to be done must be good in itself or at least indifferent


  2. The good effect must not be obtained by means of the bad effect


  3. The bad effect must not be intended for itself, but only permitted


  4. There must be a proportionately grave reason for permitting the bad effect
Of these four conditions the first two are general rules of morality. A person is never allowed to perform a morally bad action. Nor may one ever positively desire or intend a bad effect of an action, even though the act would otherwise be lawful. The third and fourth conditions listed above apply specifically to the principle of the double effect.

The legal doctrine of 'double effect' justifies giving pain-relief treatment, provided it is given with the primary intention to relieve pain, and excuses any unavoidable, but unwanted, life-shortening effect of doing so. In short, the act of pain relief is justified ? it is a right act; its unwanted consequence of shortening life is excused (ie, tolerated) in the circumstances.

The principle makes intention in the mind of the doctor a crucial factor in judging the moral correctness of the doctor's action because of the Roman Catholic teaching that it is never permissible to 'intend' the death of an 'innocent person'. An innocent person is one who has not forfeited the right to life by the way he or she behaves, eg, by threatening or taking the lives of others.

Assisted suicide (and euthanasia) are defined as "a deliberate act that causes death undertaken by one person with the primary intention of ending the life of another person, in order to relieve that person's suffering."

Language
In May 2002, Canadian Professor Margaret A Somerville of the McGill Centre for Medicine, Ethics and Law in Montreal, debated Dr Phillip Nitschke at at the Australian Medical Association's Annual General Meeting in Canberra. She points out:
"Language is not neutral, especially in the euthanasia debate. We must choose and use our words carefully and precisely if we are to avoid inadvertently opening the way for the legalisation of euthanasia. For instance, saying that patients must be offered all treatment necessary to relieve their pain, even if that treatment could or would shorten life, or they must be offered all treatment necessary to relieve their suffering, may seem the same. But, properly interpreted, the former statement does not open up the possibility of legitimating euthanasia; the latter could do so and could affect the law accordingly."

The doctrine of "double effect" requires, first, that the act resulting in a bad consequence (such as the shortening of life) is morally neutral. Providing pain-relief treatment would qualify as at least a morally neutral act.

Second, the pain relief must not be achieved by shortening life (ie, through a bad consequence).

Third, the bad consequence, the shortening of life, must not be primarily intended as either an end or a means; rather, the primary intent must be the legitimate aim of relieving pain.

Fourth, there must be no other reasonable way of achieving the pain relief without involving the undesired effect of shortening life.

Lastly, the proportionality of good and bad consequences required to justify the bad ones must be present. Providing necessary pain relief, even if it shortens life, fulfils all of these conditions; euthanasia fulfils none of them."1
Euthanasia advocates regard the rule of double effect as seriously flawed.

Terminal Sedation
Some doctors use the deliberate sedation of patients to deep unconsciousness for the purpose of relieving suffering. This is called Terminal Sedation (TS). An essential component of TS is also the withdrawal of all treatment, including even food and water, so that death occurs as soon as possible. There are doctors who condemn assisted suicide who have embraced TS as an ethical "choice".

Euthanasia advocates frequently claim that doctors are acting in a hypocritical way, hiding behind the permissibility of giving pain relief under the doctrine of "double effect", when in fact their primary intention is to kill the patients, not relieve their pain. These claims are often made on the basis that very large doses of opoids are used to relieve pain in terminally ill patients.

Professor Somerville points out that there are serious harms in arguing that giving necessary pain relief is euthanasia: it could make doctors frightened to provide it.

In cases of terminal cancer or some other painful illness, the doctor gradually increases the dosage of pain relief over a period of weeks or even months. The patient builds up a tolerance to the drug. In proper pain management the patient does not usually lose consciousness until near the point of death.

This is different from a patient being given a large dose of morphine without having built up a tolerance. When TS is used appropriately as palliative care, the patient is sedated and death ensues from the underlying illness, not from the sedation itself! If however the patient is sedated and dies of dehydration several days later, the form of TS used is not palliative care but euthanasia.

Deadly Effect
Euthanasia advocates argue that if it is justifiable and acceptable for doctors to be immune from prosecution in using TS, when death is the secondary effect, then it should be allowable to use TS when the primary purpose is to hasten death.

Professor Somerville disagrees:
"The doctrine of 'double effect' requires, first, that the act resulting in a bad consequence (such as the shortening of life) is morally neutral. Providing pain-relief treatment would qualify as at least a morally neutral act. Second, the pain relief must not be achieved by shortening life (ie, through a bad consequence). Third, the bad consequence, the shortening of life, must not be primarily intended as either an end or a means; rather, the primary intent must be the legitimate aim of relieving pain. Fourth, there must be no other reasonable way of achieving the pain relief without involving the undesired effect of shortening life. Lastly, the proportionality of good and bad consequences required to justify the bad ones must be present.

Providing necessary pain relief, even if it shortens life, fulfils all of these conditions; euthanasia fulfils none of them."1
Pain-relief Treatment versus Euthanasia
Euthanasia advocates, in claiming the Principle of Double Effect is hypocrisy on the part of those doctors who use it, are ignoring the fact that it all comes down to intent. A doctor who uses TS with the primary intention of imposing death is not only breaking the law, but acting in an unethical manner.

An anonymous questionnaire investigating the last death attended, in the previous 12 months, was sent to 2602 general practitioners (GPs) in New Zealand.

From a 48% (1255) response, 88.9% (1116) GP's indicated access to an interdisciplinary pain management or palliative care team. Of those attending a death in the previous 12 months, 63% (693) had made a prior medical decision. These decisions included withdrawing/withholding treatment or increasing pain relief with (a) probability death would be hastened 61.8% (428) or (b) partly or explicitly to hasten death 32.6% (226). Moreover, death was caused by a drug supplied or administered by the GP in 5.6% cases (39), actions consistent with physician-assisted death.2

The aim of the study was to explore type and incidence of medical decisions at the end of life (MDELs) that hasten death made by general practitioners (GPs) in New Zealand, within the context of access to palliative care.

The conclusion reached was that "physician-assisted death provided by some general practitioners in New Zealand is occurring within the context of available palliative care."

The Survey
A survey methodology was adopted using the questionnaire from the Remmelink Death Certificate study of the Dutch investigation. The English version of the questionnaire was obtained from the authors of an Australian study. The Australian study claimed to have found a high incidence of secret euthanasia by healthcare professionals.3

However, that Australian study has been severely criticised on the grounds that the respondents replied to questions that did not distinguish between actions intended to shorten life - euthanasia - and other acts or omissions in which no such intention was present - pain-relief treatment or refusals of treatment - that are not euthanasia. Consequently, the researchers' estimates of the number of cases of hidden euthanasia may be grossly exaggerated.4

The authors of the NZ survey said that "demographics were changed to suit the New Zealand environment, i.e. ethnicity and place of practice." With an additional section " added related to access to palliative care services.

MDEL actioned:
Taking into account the probability that end of life hastened by:
- Q3a withholding a treatment
- Q3b withdrawing a treatment
- Q3c intensifying alleviation of pain and/or symptoms

Q4 In part with intention of hastening the end of life by:
- intensifying the alleviation of pain and/or symptoms

With the explicit purpose of not prolonging life or hastening the end of life and death caused by:
- Q5a withholding a treatment
- Q5b withdrawing a treatment

- Q6 Death caused by drug prescribed, supplied or administered with the explicit purpose of hastening the end of life (or patient ending own life)

Several respondents noted difficulties with the wording of the questionnaire. One wrote:
"A very difficult questionnaire to complete - complex issues that I do not believe are able to be determined by yes/no answers. Hence my revisiting some of the questions. NB My response to the questions may have been quite different if Q3 had stated possibility rather than probability. "(NZ GP 292)
The New Zealand researchers had a 48% response rate from two mail-outs. Thirty-two questionnaires could not be delivered (unknown at address). Returned questionnaires numbered 1302 of which 47 were returned blank, some with comments for non-response, which left 1255 useable questionnaires.

Of these, 1100 respondents had access to the patient prior to death and therefore there was the potential to make an end of life decision. 693 (63%) reported making MDELs. The last action before death ranged from decisions to withdraw or withhold treatment or increase the alleviation of symptoms with the probability that death would be hastened 61.8% (428), through to actions partly or explicitly taken to hasten death 32.6% (226).

Of the 693 physicians who reported a MDEL, 5.6% (39) attributed death to a drug that had been prescribed, supplied or administered for that purpose -ie, euthanasia or physician-assisted suicide.2

The authors noted that doctors may have acted in ?palliative' terms, i.e. may have provided Terminal Sedation which is defensible under the principle of double effect, but interpreted this in "euthanasia" terms as an action knowingly taken to hasten death.

Ethics
Euthanasia advocates argue, in support of legalising it, that doctors are secretly carrying it out anyway. Opponents say that just because some doctors are secretly carrying out euthanasia does not mean that it is right. They also point out that, if doctors are presently ignoring the law against murder, why would they obey guidelines for voluntary euthanasia or assisted suicide?

Professor Somerville says:
"Doctors' absolute repugnance to killing people is necessary to maintaining people's and society's trust in them. This is true, in part, because doctors have opportunities to kill, not open to other people, as the horrific story of Dr Harold Shipman, the UK physician-serial killer, shows.

It would be very difficult to communicate to doctors a repugnance to killing in a context of legalised euthanasia. Harm to medicine also harms society. We need to protect the institution of medicine not just for its own sake, but also because it is a very important value-creating, value-carrying and values-consensus-forming institution, especially in a secular society."1
References
1. Somerville M "Death talk": debating euthanasia and physician-assisted suicide in Australia" The Medical Journal of Australia 2003 178 (4): 171-174 www.mja.com.au
2. Mitchell K, Owens G, End of life decision-making by New Zealand general practitioners: a national survey 18-June-2004, Vol 117 No 1196 Journal of the New Zealand Medical Association,www.nzma.org.nz
3. Kuhse H, Singer P, Baume P, et al. End-of-life decisions in Australian medical practice. Med J Aust 1997; 166: 191-196.
4. Kissane DW. Deadly days in Darwin. In: Foley K, Hendin H, editors. The case against assisted suicide: for the right to end-of-life care. Baltimore: The Johns Hopkins University Press, 2002: 192-209.