Although Theravada Buddhism and Roman Catholicism agree on the moral justification for palliative sedation, they differ on the premises underlying the justification. While Catholicism justifies palliative sedation on the ground of the Principle of Double Effect, Buddhism does so on the basis of the Third Noble Truth. Despite their theological differences, Buddhism and Catholicism both value the moral significance of the physician’s intent to reduce suffering and both respect the sanctity of life. This blurs the demarcation (...) line between Buddhism and Catholicism regarding the moral justification of palliative sedation. -/- . (shrink)

In Catholic moral theology, the principle of double effect has been an effective normative tool for centuries, and it can be used to determine the ethicality of actions that contain both good and evil consequences. The principle of double effect is especially useful in end-of-life care, because many end-of-life treatment options inherently have both good and evil conse­quences. The principle of double effect can be used to make both practical and moral distinctions between (...) the acts of euthanasia, physician-assisted suicide, palliative sedation, and the withholding and withdrawal of life-sustaining treatment, which can be classified as either unjustified acts of killing or jus­tifiable acts of allowing to die. (shrink)

The U.S. Supreme Court's majority opinion in Vacco v. Quill assumes that the principle of double effect explains the permissibility of hastening death in the context of ordinary palliative care and in extraordinary cases in which painkilling drugs have failed to relieve especially intractable suffering and terminal sedation has been adopted as a last resort. The traditional doctrine of double effect, understood as providing a prohibition on instrumental harming as opposed to incidental harming or harming asa (...) side effect, must be distinguished from other ways in which the claim that a result is notintended might be offered as part of ajustification for it. Although double effectmight appropriately be invoked as a constrainton ordinary palliative care, it is not clearthat it can be coherently extended to justifysuch practices as terminal sedation. A betterapproach would reconsider double effect'straditional prohibition on hastening death as ameans to relieve suffering in the context ofacute palliative care. (shrink)

Euthanasia, today, is one of the most debated issues in bioethics. Euthanasia, at the time of Thomas Aquinas, was an unheard-of term. Nevertheless, while there is no direct statement with respect to “euthanasia” per se in the writings of Aquinas, Aquinas’s moral theory and certain theological commitments he held could be applied to the euthanasia question and thus bring Aquinas into contemporary bioethical debate. In this paper, I present the relevant aspects of Aquinas’s account of natural law and his theological (...) views on suffering, examining what conclusions each entails with respect to directly intended euthanasia. I then proceed to discuss cases that involve either the administration of palliative medication that hastens death, terminal sedation, or the non-utilization of life-sustaining treatment. This involves a detailed investigation into Aquinas’s account of human intentional action and the question of whether Aquinas holds some form of the Principle of Double-Effect. I end with a final statement of Aquinas’s position on these various types of cases as a synthesis of the conclusions drawn from the different areas of his thought discussed in this paper. My aim is to provide a set of guidelines, based upon Aquinas’s thought, for those who may be faced with decisions regarding the proper form of palliative treatment to be provided to those suffering from a painful terminal illness. Decision-makers, in such cases, may include a terminally ill patient, a patient’s immediate family, health care providers, and lawmakers concerned with establishing the legality of certain forms of treatment. Establishing a clear set of moral guidelines, specifically addressed to this type of decision, can assist the relevant decision-makers in forming their consciences such that they may take the appropriate course of action in confronting the suffering of a terminally ill patient. (shrink)

The principle of double effect is often used in bioethics as a tool to evaluate significant cases in obstetrics and gynecology. In this article the author, a Catholic priest, presents and interprets St. Thomas Aquinas’s delineation of the principle and discusses several classical applications, namely, to hysterectomy during pregnancy, ectopic pregnancy, and craniotomy. He explains the medical anatomy and physiology of the conjoined Maltese twins, Jodie and Mary, and then examines the arguments of four moralists on (...) their separation. He concludes by arguing that the principle morally justified the surgical separation of Jodie and Mary. National Catholic Bioethics Quarterly 9.1 : 85–96. (shrink)

In “The Contralife Argument and the Principle of Double Effect” (NCBQ, Spring 2011), Lawrence Masek tries to use the principle of double effect to show that natural family planning (NFP) is morally justified. This essay presents a summary explanation of the principle of double effect. It demonstrates that Masek wrongly applies the principle of double effect to NFP. It presents the teaching of the 1968 papal encyclical Humanae vitae with regard to NFP, (...) and contends that to apply the principle of double effect to the case of NFP is not only incorrect but also contrary to teaching of Humanae vitae. Because Masek implies that NFP involves the (justified) permission of evil, his article also counteracts the efforts of the Catholic Church to promote the practice of NFP. National Catholic Bioethics Quarterly 11.4 (Winter 2011): 661–667. (shrink)

Continuous deep sedation (CDS) has the effect of making the patient unconscious until death, and that it has this effect is clearly an undesirable aspect of CDS. However, some authors have recently maintained that many physicians do not intend this effect when practicing CDS. According to these authors, CDS is differentiated into two types; in what is called “gradual” CDS (or CDS as a result of proportionate palliative sedation), physicians start with low doses of sedatives and increase them only (...) gradually, whereas in “rapid” CDS (or palliative sedation to unconsciousness), physicians rapidly administer a heavy dose that clearly induces unconsciousness from the beginning. The claim is that the physicians intend permanent unconsciousness only if they rapidly administer a heavy dose, but they do not intend it when the unconsciousness is the result of a gradual increase of sedatives. This paper attempts to refute these claims based on a close examination of the protocol of gradual CDS. If my argument is valid, the doctrine of double effect would not be useful in justifying most, if not all, cases of CDS. (shrink)

Legal minds have utilized the principle of double effect as proposed by St. Thomas Aquinas for centuries to shape legal authority in cases where moral judgment and legal reasoning meet. The U.S. Supreme Court had uti­lized double-effect reasoning in the realm of self-defense cases. This article discusses more recent use of double-effect reasoning in the landmark Supreme Court case Vacco v. Quill and its companion case, Washington v. Glucksberg. Chief Justice William Rehnquist, writing for the Court (...) in Vacco, introduced double-effect reasoning to identify the distinctions between palliative care and assisted suicide in an effort to uphold the constitutionality of the ban on assisted suicide in New York. National Catholic Bioethics Quarterly 11.1 (Spring 2011): 41–48. (shrink)

Combined oral contraceptives have been demonstrated to have significant benefits for the treatment and prevention of disease. These medications also are associated with untoward health effects, and they may be directly contraceptive. Prescribers and users must compare and weigh the intended beneficial health effects against foreseeable but unintended possible adverse effects in their decisions to prescribe and use. Additionally, those who intend to abide by Catholic teachings must consider prohibitions against contraception. Ethical judgments concerning both health benefits and contraception (...) are approached in this essay through an overview of the therapeutic, prophylactic, untoward, and contraceptive effects of COC and discussion of magisterial and traditional Catholic teachings from natural law. Discerning through the principle of double effect, proportionate reason, and evidence gathered from the sciences, medical and moral conclusions are drawn that we believe to be fully compliant with good medicine and Catholic teaching. (shrink)

The proportionalist position on the revision of the principle of double effect is now an important feature of moral discourse in contemporary Roman Catholic theological discussion. While its claim to being rooted in the work of Saint Thomas Aquinas is defensible, its view on the universal applicability of proportionate reasoning for determining the moral rightness or wrongness of actions is not without problems in some key areas, such as the distinction between direct and indirect consequences of an (...) action. Indeed, proportionalists often argue in manners that would suggest that they have discarded this distinction outright. Such a result, it is argued, would be a grave error for Christian ethics. (shrink)

BackgroundPalliative sedation and analgesia are employed in patients with refractory and intractable symptoms at the end of life to reduce their suffering by lowering their level of consciousness. The doctrine of double effect, a philosophical principle that justifies doing a “good action” with a potentially “bad effect,” is frequently employed to provide an ethical justification for this practice. Main textWe argue that palliative sedation and analgesia do not fulfill the conditions required to apply the doctrine of (...) class='Hi'>double effect, and therefore its use in this domain is inappropriate. Furthermore, we argue that the frequent application of the doctrine of double effect to palliative sedation and analgesia reflects physicians’ discomfort with the complex moral, intentional, and causal aspects of end-of-life care. ConclusionsWe are concerned that this misapplication of the doctrine of double effect can consequently impair physicians’ ethical reasoning and relationships with patients at the end of life. (shrink)

One of the most commonly referenced ethical principles when it comes to the management of dying patients is the doctrine of double effect (DDE). The DDE affirms that it is acceptable to cause side effects (e.g. respiratory depression) as a consequence of symptom‐focused treatment. Much discussion of the ethics of end of life care focuses on the question of whether actions (or omissions) would hasten (or cause) death, and whether that is permissible. However, there is a separate question about (...) the permissibility of hastening or causing unconsciousness in dying patients. Some authors have argued that the DDE would not permit end of life care that directly aims to render the patient unconscious. The claim is that consciousness is an objective human good and therefore doctors should not intentionally (and permanently) suppress it. Three types of end of life care (EOLC) practices will be explored in this article. The first is symptom‐based management (e.g. analgesia); the second is proportional terminal sedation as a means of relieving suffering (also referred to as palliative sedation or continuous deep sedation); and finally, deliberate and rapid sedation to unconsciousness until death (a practice we call terminal anaesthesia in this paper). After examining the common arguments for the various types of symptom‐based management and sedation, we apply the DDE to the latter two types of EOLC practices. We argue that aiming at unconsciousness, contrary to some claims, can be morally good or at least morally neutral in some dying patients. (shrink)

The author uses the central insight of the principle of double effect—that the distinction between intended effects and foreseen side effects is morally significant—to distinguish contraception from natural family planning. After summarizing the contralife argument against contraception, the author identifies limitations of arguments presented by Pope John Paul II and by Martin Rhonheimer. To show that the contralife argument does not apply to NFP, the author argues that agents do not intend every effect that motivates their actions. This (...) argument supplements the action theory of Germain Grisez, Joseph Boyle, John Finnis, and other proponents of new natural law theory. National Catholic Bioethics Quarterly 11.1 : 83–97. (shrink)

According to the contralife argument, because both contraception and natural family planning entail at least a contralife motivation to have marital intercourse but avoid pregnancy, both should be forbidden—a conclusion rejected by the natural law tradition and Church teaching, which forbid contraception but permit NFP. This paper argues that the principle of double effect can be applied to explain why contraception is forbidden but NFP is permissible. This double-effect analysis evaluates the good effect of procreation and unity (...) against the bad effect of lustful sexual pleasure. This paper argues that contraception fails to meet the conditions of the PDE, because it intends sexual pleasure in isolation from procreation and unity and is therefore forbidden. Conversely, NFP meets the conditions of the PDE because, as with all permissible sexual intercourse, it intends sexual pleasure in conjunction with procreation and unity and is therefore itself permissible. (shrink)

The use of terminal sedation to control theintense discomfort of dying patients appearsboth to be an established practice inpalliative care and to run counter to the moraland legal norm that forbids health careprofessionals from intentionally killingpatients. This raises the worry that therequirements of established palliative care areincompatible with moral and legal opposition toeuthanasia. This paper explains how thedoctrine of double effect can be relied on todistinguish terminal sedation from euthanasia. The doctrine of double effect is rooted inCatholic (...) moral casuistry, but its applicationin law and morality need not depend on theparticular framework in which it was developed. The paper further explains how the moral weightof the distinction between intended harms andmerely foreseen harms in the doctrine of doubleeffect can be justified by appeal to alimitation on the human capacity to pursue good. (shrink)

As media reports have made widely known, in November 2009, the ethics committee of St. Joseph’s Hospital in Phoenix, Arizona, permitted the abortion of an eleven-week-old fetus in order to save the life of its mother. This woman was suffering from acute pulmonary hypertension, which her doctors judged would prove fatal for both her and her previable child. The ethics committee believed abortion to be permitted in this case under the so-called principle of double effect, but Thomas J. (...) Olmsted, the bishop of Phoenix, disagreed with the committee and pronounced its chair, Sister Margaret McBride, excommunicated latae sententiae, “by the very commission of the act.” In this article, I take the much discussed Phoenix case as an occasion to subject the principle of double effect to another round of philosophical scrutiny. In particular, I examine the third condition of the principle in its textbook formulation, namely, that the evil effect in question may not be the means to the good effect. My argument, in brief, is that the textbook formulation of the principle does not withstand philosophical scrutiny. Nevertheless, in the end, I do not claim that we should then “do away” with the principle altogether. Instead, we do well to understand it within the context of casuistry, the tradition of moral reasoning from which it issued. (shrink)

The rule of double effect is regularly invoked in ethical discussions about palliative sedation, terminal extubation and other clinical acts that may be viewed as hastening death for imminently dying patients. Unfortunately, the literature tends to employ this useful principle in a fashion suggesting that it offers the final word on the moral acceptability of such medical procedures. In fact, the rule cannot be applied appropriately without invoking moral theories that are not explicit in the rule itself. (...) Four tenets of the rule each require their own ethical justification. A variety of moral theories are relevant to making judgements in a pluralistic society. Much of the rich moral conversation germane to the rule has been reflected in arguments about physician-asssisted suicide and voluntary active euthanasia, but the rule itself has limited relevance to these debates, and requires its own moral justifications when applied to other practices that might hasten death. (shrink)

One's conception of the conditions and applicability of the principle of double effect derive from one's broader convictions about moral methodology. Developed in a Catholic context which presumed the existence of moral absolutes, the principle of double effect was originally a conceptual tool to aid priests in being skilled confessors. In recent decades, as the practice of moral theology has become less connected with its earlier ecclesial and sacramental context, the principle of double (...) effect has fallen into an epistemological crisis. Contemporary moral theological discussion of the principle of double effect usually operates in one of the following four contexts: interpretation of Aquinas; in relation to manualist casuistry; as understood within proportionalist methodology; as defended within the new natural law methodology. The essay argues that juridically-oriented methodologies do not adequately sustain the principle of double effect. To be sustained, it must be viewed as a theological achievement based upon the meaning of our redemption in Christ and the concomitant possibilities regarding our actions in pursuit of our true good and true end. (shrink)

It is often claimed that the intentions of physicians are multiple, ambiguous, and uncertain—at least with respect to end-of-life care. This claim provides support for the conclusion that the principle of double effect is of little or no value as a guide to end-of-life pain management. This paper critically discusses this claim. It argues that proponents of the claim fail to distinguish two different senses of “intention,” and that, as a result, they are led to exaggerate the extent (...) to which clinical intentions in end-of-life contexts are ambiguous and uncertain. It argues further that physicians, like others who make life and death decisions, have a duty to get clear on what their intentions are. Finally, it argues that even if the principle of double effect should be rejected, clinical intentions remain ethically significant because they condition the meaning of extraordinary clinical interventions, such as that of palliative sedation. (shrink)

This article examines the relationship between the principle of double effect and justification for separation surgeries for conjoined twins. First, the principle of double effect is examined in light of its historical context. It is argued that it can only operate under an absolutist view of good and evil that is compatible with the Bible. Given this foundation for application, scenarios for separating conjoined twins are considered against the criteria for the principle of double (...) effect. It is concluded that the principle of double effect cannot be applied to cases wherein one of the twins must be killed. However, it is noted that this does not leave decision makers without options. (shrink)

While some believe that the principle of double effect provides sound ethical guidance, others believe that it does not and have leveled various types of argument against it. One type of argument leveled against it proceeds by applying it to hypothetical “closeness” cases. This objection seeks to show that in such cases the principle permits what patently should not be permitted, and thus is unacceptable because it is too permissive. In this essay, I critically evaluate an argument (...) of this type developed by Alexander R. Pruss. Central to my strategy is to develop and defend a distinction between two kinds of means. I refer to them as closed-ended and open-ended means. I argue that once what is intended is understood in light of this distinction, the principle does not permit what patently should not be permitted, and thus need not be seen as being too permissive. (shrink)

Opioid and sedative use are common ‘active’ practices in the provision of mainstream palliative care services, and are typically distinguished from euthanasia on the basis that they do not shorten survival time. Even supposing that they did, it is often argued that they are justified and distinguished from euthanasia via appeal to Aquinas’ Doctrine of Double Effect. In this essay, I will appraise the empirical evidence regarding opioid/sedative use and survival time, and argue for a position of agnosticism. (...) I will then argue that the Doctrine of Double Effect is a useful ethical tool but is ultimately not a sound ethical principle, and even if it were, it is unclear whether palliative opioid/sedative use satisfy its four criteria. Although this essay does not establish any definitive proofs, it aims to provide reasons to doubt—and therefore weaken—the often-claimed ethical distinction between euthanasia and palliative opioid/sedative use. (shrink)

My essay ‘Weakening the ethical distinction between euthanasia, palliative opioid use and palliative sedation’ has recently generated some critique which I will attempt to address in this response. Regarding the empirical question of whether palliative opioid and sedative use shorten survival time, Schofieldet alraise the three concerns that my literature review contains a cherry-picking bias through focusing solely on the palliative care population, that continuous deep palliative sedation falls beyond the scope of routine palliative (...) care, and that my research may contribute to opiophobia and be harmful to palliative care provision globally. Materstvedt argues that euthanasia ‘ends’ rather than ‘relieves’ suffering and is not a treatment, and that the arguments in my essay are therefore predicated on a ‘category mistake’ and are a non-starter. Symons and Giebel both raise the concern that my Kantian and Millian interpretation of the Doctrine of Double Effect is anachronistic, and that when interpreted from the contemporaneous perspective of Aquinas it is a sound ethical principle. Giebel also argues that palliative opioid and sedative use do meet the Doctrine of Double Effect’s four criteria on this Thomistic account, and that it does not contradict the Doctrine of the Sanctity of Human Life. In this response I will explore and defend against most of these claims, in doing so clarifying my original argument that the empirical and ethical differences between palliative opioid/sedative use and euthanasia may not be as significant as often believed, thereby advancing the case for euthanasia. (shrink)

Objections to the principle of double effect usually concern its first and second conditions (that the act not be evil in itself, and that the evil effect may not be intended). The difficulties often arise from a rejection of the idea that acts have a moral nature independent of context, and a tendency to interpret intention as purely psychological. This article argues that the “act itself” should be understood as the act-type and suggests that examples of evil act-types (...) are not hard to find. It argues that the notion of intention is involved in both conditions, but in different ways. It proposes that these different ways can be interestingly illuminated by Anscombe’s distinction between acting intentionally and acting with an intention. (shrink)

This essay considers whether palliative sedation is or is not appropriate medical care. This requires one to consider whether, in addition to the good of health, relief of suffering is also a proper end of medicine; whether unconsciousness can ever be a good for a human being; and how double-effect reasoning can help us think about difficult cases. The author concludes that palliative sedation may be proper medical care, but only in a limited range of cases.

This special issue of Theoretical Medicine and Bioethics takes up the question of palliative sedation as a source of potential concern or controversy among Christian clinicians and thinkers. Christianity affirms a duty to relieve unnecessary suffering yet also proscribes euthanasia. Accordingly, the question arises as to whether it is ever morally permissible to render dying patients unconscious in order to relieve their suffering. If so, under what conditions? Is this practice genuinely morally distinguishable from euthanasia? Can one ever aim (...) directly at making a dying person unconscious, or is it only permissible to tolerate unconsciousness as an unintended side effect of treating specific symptoms? What role does the rule of double effect play in making such decisions? Does spiritual or psychological suffering ever justify sedation to unconsciousness? What are the theological and spiritual aspects of such care? This introduction describes how the authors in this special issue wrestle with such questions and shows how each essay relates to the author’s individual position on palliative sedation, as developed in greater detail within his contribution. (shrink)

Abstract: In Vacco v. Quill, 521 U.S. 793 (1997), the Supreme Court for the first time in American case law explicitly applied the principle of double effect to reject an equal protection claim to physician-assisted suicide. Double effect, traced historically to Thomas Aquinas, proposes that under certain circumstances it is permissible unintentionally to cause foreseen evil effects that would not be permissible to cause intentionally. The court rejected the constitutional claim on the basis of a distinction marked (...) out by the principle, i.e., between directly intending the death of a terminally ill patient as opposed to merely foreseeing that death as a consequence of medical treatment. The Court held that the distinction comports with fundamental legal principles of causation and intent. Id. at 802. -/- Critics allege that the principle itself is intrinsically flawed and that, in any event, its employment in Vacco is without legal precedent. I argue in response to contemporary objections that double effect is a valid principle of ethical reflection (Part II); claims to the contrary notwithstanding, double effect analysis is a pervasive, albeit generally unacknowledged principle employed regularly in American case law (Part III); and drawing on the preceding two sections, Vacco's application of the principle of double effect is appropriate (Part IV). -/- My conclusion is that [o]peration of some form of the principle, by whatever name, is inevitable. In an imperfect world where duties and interests collide, the possibility of choices of action foreseen to have both good and evil consequences cannot be avoided. In rare circumstances, ethics and the law require that a person refrain from acting altogether. More often, however, they provide that a determination of whether an actor may pursue a good effect although knowing it will or may unintentionally cause an harmful effect requires a more complex analysis - a double effect analysis. -/- Keywords: Equal protection, double effect, intention, physician-assisted suicide, Constitutional Law, Bioethics. (shrink)

Thomas Riisfeldt’s essay1 is a valuable contribution to the literature on palliative sedation, appropriately titrated administration of opioids (ATAOs) and euthanasia. In this response, I will not deal with the author’s empirical claim about the relationship between opioid use, palliative sedation and survival time. Rather, I will briefly critique the author’s discussion of doctrine of double effect (DDE) and its application to palliative sedation and opioid use at the end of life. That is, I will focus (...) on the ethical claims made by the author. Riisfeldt argues that DDE is incompatible with both Kantian deontology and Millian consequentialism. Yet, I will argue that the DDE is coherent and defensible when interpreted from the perspective of the philosophy of Thomas Aquinas, the theorist who first proposed the doctrine. I will also argue that Riisfeldt mischaracterises ATAOs and palliative sedation as procedures that hasten death as a means to relieve pain. While death may indeed be hastened by ATAOs and palliative sedation, it is not at all clear that clinicians intend to hasten death as a means to relieve pain. Indeed, clinical guidelines explicitly prohibit the intentional hastening of death. Riisfeldt provides a brief summary of the DDE. He describes DDE as a ‘strange hybrid of four principles’. He lists the four criteria that must be met for an act with a good and a bad effect to be permissible. These criteria are the ‘intention and means criteria’ and the ‘intrinsic and proportionality criteria’ (p.127). The author uses Kant and Mill as lens through which to highlight a tension between the intrinsic and proportionality criteria of DDE. The author claims that ‘the intrinsic criterion is derived from deontology, the predominant form of which is championed by Kant’, and that ‘the proportionality criterion is derived from consequentialism, the predominant form of …. (shrink)

In a recent article,1Riisfeldt attempts to show that the principle of double effect (PDE) is unsound as an ethical principle and problematic in its application to palliative opioid and sedative use in end-of-life care. Specifically, he claims that (1) routine, non-lethal opioid and sedative administration may be “intrinsically bad” by PDE’s standards, (2) continuous deep palliative sedation (or “terminal sedation”) should be treated as a bad effect akin to death for purposes of PDE, (3) PDE (...) cannot coherently be applied in cases where death “indirectly” furthers an agent’s intended end of pain relief via medically appropriate palliative care, and (4) application of PDE requires sacrificing common beliefs about the sanctity of human life. I respond by showing that Riisfeldt’s understanding of PDE is seriously mistaken: he misattributes Kantian and Millian reasoning to the principle and conflates acts’ intrinsic properties with their effects. Further, a corrected understanding of PDE can address Riisfeldt’s case-specific objections. (shrink)

Many philosophers assume that the principle of double effect (PDE) is meant to cover trolley cases. In fact, trolley cases come from PDE’s critics, not its defenders. When philosophers stretch PDE to explain intuitions about trolley cases, they define intended effects too broadly. More importantly, trolley cases make poor illustrations of PDE because they focus attention away from the agent and onto the victim. When philosophers lose sight of the agent, some intuitions that fit PDE survive, but the (...) rational basis of these intuitions collapses. I avoid these problems by defending a minimalist, agent-based version of PDE. My version is minimalist because I do not try to turn PDE into a complete checklist that explains intuitions about every case. It is agent-based because I consider the agent’s perspective to define intentions and to make moral judgments. (shrink)

In this essay I first provide a brief explanation of the principle of double effect (PDE) and the propositions that it entails regarding the distinction betweenintention and foresight (I/F distinction) and the distinction’s relevance to ethical evaluation. Then I address several recent critiques of PDE and the I/F distinctionby influential ethicists including Judith Jarvis Thomson, Tom Beauchamp and James Childress, and Jonathan Bennett. I argue that none of these critiques issuccessful. In the process of refuting the critiques, I (...) also give prima facie reason to believe that the I/F distinction is relevant to evaluation of agents and their actions and that PDE is a defensible ethical principle. (shrink)

Possession of a BRCA1 or BRCA2 gene mutation puts a woman at very high risk of developing breast and ovarian carcinoma at an early age. One treatment option is surgical removal of the target organs—breasts, ovaries, and fallopian tubes—before the malignancy develops. This risk-reduction surgery has been shown to significantly reduce the likelihood that a woman will develop one of these cancers. This paper argues that such surgeries do not violate Catholic moral principles, but can be justified using the (...) principles of double effect and totality and integrity. The paper does not recommend or endorse any specific treatment option. National Catholic Bioethics Quarterly 15.1 : 75–89. (shrink)

The moral importance of the ‘intention–foresight’ distinction has long been a matter of philosophical controversy, particularly in the context of end-of-life care. Previous empirical research in Australia has suggested that general physicians and surgeons may use analgesic or sedative infusions with ambiguous intentions, their actions sometimes approximating ‘slow euthanasia’. In this paper, we report findings from a qualitative study of 18 Australian palliative care medical specialists, using in-depth interviews to address the use of sedation at the end of life. (...) The majority of subjects were agnostic or atheistic. In contrast to their colleagues in acute medical practice, these Australian palliative care specialists were almost unanimously committed to distinguishing their actions from euthanasia. This commitment appeared to arise principally from the need to maintain a clear professional role, and not obviously from an ideological opposition to euthanasia. While some respondents acknowledged that there are difficult cases that require considered reflection upon one's intention, and where there may be some ‘mental gymnastics,’ the nearly unanimous view was that it is important, even in these difficult cases, to cultivate an intention that focuses exclusively on the relief of symptoms. We present four narratives of ‘terminal’ sedation – cases where sedation was administered in significant doses just before death, and may well have hastened death. Considerable ambiguities of intention were evident in some instances, but the discussion around these clearly exceptional cases illustrates the importance of intention to palliative care specialists in maintaining their professional roles. (shrink)

The Rule of Double Effect (RDE) holds that it may be permissible to harm an individual while acting for the sake of a proportionate good, given that the harm is not an intended means to the good but merely a foreseen side-effect. Although frequently used in medical ethical reasoning, the rule has been repeatedly questioned in the past few decades. However, Daniel Sulmasy, a proponent who has done a lot of work lately defending the RDE, has recently presented a (...) reformulated and more detailed version of the rule. Thanks to its greater precision, this reinvented RDE avoids several problems thought to plague the traditional RDE. Although an improvement compared with the traditional version, we argue that Sulmasy's reinvented RDE will not stand closer scrutiny. Not only has the range of proper applicability narrowed significantly, but, more importantly, Sulmasy fails to establish that there is a morally relevant distinction between intended and foreseen effects. In particular, he fails to establish that there is any distinction that can account for the alleged moral difference between sedation therapy and euthanasia. (shrink)

Few moral theorists would disagree that the fundamental principle of morality – perhaps of practical rationality itself – is “ Do good and avoid evil. ” Yet along with such an uncontroversial principle comes a major question: Can you fulfi l both halves satisfactorily across your life as a moral agent? We all have opportunities to perform acts that do good with no accompanying evil, but these are not as common as we might think. We can avoid evil (...) by doing nothing, but doing nothing implies doing no good either. Clearly the fundamental principle does not require that you go about your life doing good on any and every possible occasion any more than that you sit on your hands and abstain from action out of fear of doing evil. The principle tells us to avoid evil, not to refrain from ever causing it. And the simple fact is that the complexities of life make it inevitable that, much of the time when we go about doing good, we will also be doing evil. Further, they are such that sometimes we can avoid evil only at the cost of not performing a good act which reasonable people would regard as at least permissible, if not sometimes obligatory. So how, as rational, morally responsible agents, are we to satisfy the fundamental principle in an adequate, harmonious fashion, given life ’ s exigencies? This is where the so - called ‘ doctrine of double effect ’ comes into play. Some call it a doctrine, infl uenced by the fact that Catholic ethicists and moral theologians have, since the Middle Ages, codifi ed and ratifi ed it as something akin to a doctrine of Catholic moral philosophy. Others call it the ‘ principle of double effect, ’ though it breaks down into a set of principles unifi ed by a common idea. Yet other writers see it simply as a kind of reasoning about certain types of hard case in ethics. Whatever the preferred nomenclature, the DDE, as I will call it here, is – for all its critics and the diffi culties it faces – a keystone of sound moral thinking, without which the fundamental principle would remain nothing but a high ideal with little consistent applicability. So consider a simple example.. (shrink)

In this essay, some of the signatories to “Medical Intervention in Cases of Maternal–Fetal Vital Conflicts: A Statement of Consensus” respond to “The Placenta as an Organ of the Fetus: A Response to the Statement of Consensus on Maternal–Fetal Conflict,” both recently published in this journal. The response examines Bringman and Shabanowitz’s claims and assumptions about the morally relevant pathologic condition in some cases of peripartum cardiomyopathy complicated by a subsequent pregnancy, the moral status of a normally functioning placenta, and (...) the use of the principle of double effect in these cases. The signatories’ response sets out to demonstrate how Bringman and Shabanowitz do not engage the essential points of the statement of consensus and how their argument is premised on false assumptions. National Catholic Bioethics Quarterly 15.2 : 241–250. (shrink)

Victoria’s Voluntary Assisted Dying Act 2017 (Vic) became the first state law to permit VAD in Australia under limited circumstances from June 2019. Before this, many palliative care physicians relied on the doctrine of double effect (DDE) to justify the use of pain relievers for terminally ill patients that were known to hasten death. The DDE claims that there is a morally significant difference between intending evil and merely foreseeing some bad side-effect will occur as a result of (...) one’s actions. This article argues that the legacy of the DDE is promoting inequitable access to VAD in Victoria due to the assumption that death represents an “evil” for the patient and that the intentions of physicians providing VAD cannot be trusted. The latter claim relies on two common objections to the DDE: the risk of “purifying the intentions” and the issue of “closeness” when evaluating moral acts under this theory. (shrink)

The doctrine of double effect has a firm, respected position within Roman Catholic medical ethics. Neil M. Gorsuch, a judge on the U.S. Court of Appeals for the Tenth Circuit, believes that this doctrine also enjoys a central place within U.S. law. This essay examines and assesses Gorsuch’s thesis. National Catholic Bioethics Quarterly 11.1 (Spring 2011): 31–40.

In the decades since Anscombe re-introduced the distinction between intention and foresight into philosophical ethics, supporters and critics of the related principle of double effect (PDE) have displayed disagreement and confusion about its application and scope. The key to correct interpretation and application of PDE, I argue, is recognition of its limits: (1) the principle does not include an account of the goodness or badness of effects; (2) it does not include an account of intention; (3) PDE (...) does not specify a particular action as right or obligatory; and (4) the privacy of intention limits its application in interpersonal and legal contexts. While all four of these features are “limits” in the sense that they are things PDE does not do, I argue that (a) only the fourth is a real limitation or disadvantage of the principle—and (b) none of the limits implies that the principle should be rejected. (shrink)

This article applies the anthropological concept of liminality to reconceptualize palliative care ethics. Liminality possesses both spatial and temporal dimensions. Both these aspects are analyzed to provide insight into the intersubjective relationship between patient and caregiver in the context of palliative care. Aristotelian practical wisdom, or phronesis, is considered to be the appropriate model for palliative care ethics, provided it is able to account for liminality. Moreover, this article argues for the importance of liminality for providing an (...) ethical structure that grounds the doctrine of double effect and overcomes the impasse of phronesis in the treatment of the terminally ill. (shrink)

Double effect reasoning is central to Catholic moral theology. It is the principle which enables it to maintain absolute moral standards while effectively handling morally difficult choices which entail bringing about some evil as well as the good. DER has been focused on the way in which it applies to human agents and their relation to bringing about evil as well as the good. According to DER, only the good can be brought about intentionally; evil can only (...) be brought about as the side effect of the good. It will be argued that DER also applies to God’s choices. It is our best resource for understanding God’s relation to evil in the world He creates. (shrink)

The aim of the article is to present some of the differences and similari- ties in various versions of the double effect principle. The following formulations will be analyzed: that of Thomas Aquinas and two contemporary ap- proaches, namely those of Mangan and Boyle. It will be shown that the presented modern versions vary significantly and the distinction between their intended and only predicted effects is far from clear. As a result, the different contemporary for- mulations of DDE (...) lead to contradictory conclusions, with some justifying what the others condemn. Moreover, it will be demonstrated that, unlike Aquinas, contem- porary authors mostly concentrate on unintentionality condition while neglecting the proportionality requirement. So, unlike Aquinas, they only take into account a narrow scope of cases, where the evil effect occurs with certainty, which leads to a complicated and intricate hypothetical intention test like Donagan’s. It will be shown that, besides its theoretical indistinctness, DDE lead to serious pragmatic risks. It can be quite easily misused as a kind of psychological mechanism to protect self-esteem from a sense of guilt since wrong-doing is treated as merely a predicted unintended effect. (shrink)

This paper is concerned with the moral justification for palliative sedation until death. Palliative sedation involves the intentional lowering of consciousness for the relief of untreatable symptoms. The paper focuses on the moral problems surrounding the intentional lowering of consciousness until death itself, rather than possible adjacent life-shortening effects. Starting from a Kantian perspective on virtue, it is shown that continuous deep sedation until death (CDS) does not conflict with the perfect duty of moral self-preservation because CDS does (...) not destroy capacities for agency. In addition, it is argued that CDS can frustrate the imperfect duty of self-cultivation by reducing consciousness permanently. Nevertheless, there are cases where CDS is morally acceptable, namely, cases where the agent has already permanently lost the possibility for free action in advance of sedation—for example, due to excruciating and ongoing pain. Because the latter can be difficult to diagnose properly, safeguards may be needed in order to prevent the application of CDS for the wrong reasons. (shrink)