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01-12-2008 | Scientific Contribution

The principle of double effect as a guide for medical decision-making

Author: Georg Spielthenner

Published in: Medicine, Health Care and Philosophy | Issue 4/2008

Abstract

Many medical interventions have both negative and positive effects. When health care professionals cannot achieve a particular desired good result without bringing about some bad effects also they often rely on double-effect reasoning to justify their decisions. The principle of double effect is therefore an important guide for ethical decision-making in medicine. At the same time, however, it is a very controversial tool for resolving complex ethical problems that has been criticized by many authors. For these reasons, I examine in this paper whether the principle of double effect can serve as a basis for ethical decisions in medicine. The conclusion reached in this article is that even though this principle has desirable effects on clinical conduct, it is only an unreliable guide and physicians and nurses cannot feel secure in continuing to use this principle for ethical guidance.

Its historical roots are in the medieval natural law tradition. Some hold that it was already visualized by Thomas Aquinas who argued in the Summa Theologiae (2a2ae, 64.7) for the permissibility of killing in self-defence. This origin has, however, been denied by others (e.g., Anscombe 2001; Bennett 1995). Scholastic theologians further developed the thinking underlying the PDE in the sixteenth and seventeenth centuries, but the principle was explicitly formulated only in the nineteenth century in J. P. Gury’s Compendium theologiae moralis. In recent years, the PDE has been repeatedly applied by the magisterium of the Catholic Church (see, for instance, International Theological Commission (2000–2002). Communion and Stewardship: Human Persons Created in the Image of God; and Trujillo, A. L. (2000). Declaration by the Pontificate Council for the Family regarding “Embryonic Reduction”.

See the examples discussed by McIntyre (2001).

It has, for instance, been regarded as “unjustified, hypocritical, sophistic, disingenuous and obfuscatory” Williams (2001, p. 52); and Brody (1998) calls it obscure and complicated.

Compare, for instance, Davis (2001), FitzPatrick (2003), Mapel (2001), Quinn (2001), and Marquis (1991) who discusses four versions of the PDE.

This does not mean that the first and fourth conditions are plain sailing. There is an extensive debate about both of them as many philosophers hold that acts cannot be good or bad in themselves; and determining whether the good effects of an act outweigh its bad consequences is a notoriously difficult problem. However, discussing these conditions also would go far beyond the scope of this paper.

Some authors focus on the causation clause (e.g., Kockler 2007; Marquis 1991; Martin 2001; Shaw 2002), while others emphasize that a bad means must not be used for a good end (e.g., Bennett 1995).

I agree here with Bennett (1995) and also with Boyle (2001) who states that the third condition “does not assume that the causal sequence of the effect is itself morally significant, as is often supposed” (p. 11).

It should be noted that ‘means’ is in the literature on the PDE used ambiguously. It sometimes refers to the act and sometimes to the bad effect of an act. Kagan (1989, p. 130) has therefore suggested calling a means in the latter sense a vehicle to the good effect. However, I think it is safe to set this issue aside, and since this ambiguity will not cause confusions I shall follow the traditional terminology.

Compare to this the explanation of the PDE given by Kamm (2000, p. 23).

See, for instance, Cavanaugh (1999, p. 181) or Mapel (2001) who claims that “an act that is intended to have the effect of harming a person as a means to our ends is morally worse, other things being equal, than an otherwise identical act that brings about harm to a person as a foreseen but unintended effect” (p. 257).

Compare to this also Brody (1998) and Krakauer et al. (2000).

Be it noted that in this essay I assess what is good and bad only at an intuitive level. For instance, I postulate that ending a human life is always a bad effect, although this is questionable. But there is no room here for dealing with problems of value theory.

The example has been taken from Munson (1996, pp. 54–55).

In any case, weighing intentions is in ethics necessary for the simple reason that it is a well-established fact of modern psychology that our actions have often multiple intentions. For instance, in a study of physicians, quoted by Schwarz (2006, p. 2), one third of doctors who used analgesia and sedatives while at the same time withholding life-sustaining treatments admitted that they intended both to reduce the pain and to hasten death. Similar results have been reported by Williams (2001).

It is worth noticing that traditional Catholic moral thinking has justified surgical operations such as amputations, for example, by the so-called “principle of totality,” which is centrally relevant to the question of mutilation. This principle asserts that the part exists for the whole and that the part therefore remains subordinated to the good of the whole. From this Catholic theologians inferred that removing parts of a body is allowed when and to the extent necessary for the body as a whole. However, the PDE does not include the doctrine of part-for-whole and therefore it does not allow mutilating operations.

For instance, the Brazilian bishop Eugenio Rixen of Goias uses this principle to justify the use of condoms by holding that the principle of the lesser evil makes the “use of condoms less serious, morally speaking, than getting infected or infecting other people with the AIDS virus.” See: A Catholic Response to Alleviating the AIDS Pandemic. In Catholics, Conscience and Condoms: A Catholic Response to Alleviating the AIDS Pandemic. Available at: http://www.actupny.org/YELL/catholiccondoms.html.

The example is taken from Munson (1996, p. 198).

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Title: The principle of double effect as a guide for medical decision-making
Author: Georg Spielthenner
Publication date: 01-12-2008
Publisher: Springer Netherlands
Published in: Medicine, Health Care and Philosophy / Issue 4/2008
Print ISSN: 1386-7423
Electronic ISSN: 1572-8633
DOI: https://doi.org/10.1007/s11019-008-9128-0

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