Dr Paulina Taboada
Profesor Centro de Bioetica
Pontificia Universidad Catolica de Chile
Alameda 340 Correo Central 1
Santiago, Chile
The principle of the double effect sheds light on various ethical problems that are frequent in Palliative Medicine. This principle sets the ethical criteria for the legitimacy of actions that have well-known, unavoidable bad side effects. There are, indeed, many situations in which one cannot do the good, without also causing undesired bad effects. This is the case, for instance, of using of opiates in terminally ill patients, knowing that they may negatively affect the patient’s blood pressure, respiration and state of awareness.
The principle of the double effect states that actions with both good and bad effects are ethically legitimate only under certain conditions:
Thus, the double effect doctrine forbids the achievement of good ends by wrong means. It forbids doctors to relieve the distress of a dying patient by killing him, but permits the use of drugs which relieve the distress of the dying, even when they may hasten death.
In his article "Two challenges to the double effect doctrine: euthanasia and abortion" (Journal of Medical Ethics, 2002, 28, 2: 102 – 104; www.jmedethics.com ) Shaw strongly criticizes the doctrine of double effect. The author intends to show that it is illogical to use this doctrine to forbid either euthanasia or abortion. He introduces three arguments to prove that logical contractions arise when applying the doctrine to argue against euthanasia. The first argument is based on the assumption that "good effects in medicine do result from evil effects" (o.c., p.102). The author tries to show his point through a few examples. The second argument is that "the patient’s own ethical evaluation of a method or an outcome should determine whether it is good or bad." (o.c., p. 102). His third argument is that "there is little intuitive moral difference between indirect killing, permitted by the doctrine, and direct killing, forbidden by it" (o.c., p. 103).
Even though at first sight Shaw’ arguments may appear convincing, a more profound reading reveals that the apparent logical contradictions stressed by the author rest on a misunderstanding of some fundamental ethical concepts. The author seems to identify the moral object of an action with its physical performance. But thephysical performance of an action ( actus hominis) does not necessarily coincide with a moral act . Only an action in which human freedom is exercised ( actus humanus) can be morally qualified. A moral act is essentially an act in which human freedom is exercised. This means that the moral act itself is marked by an ‘intrinsic intentionality’; it tends towards an object (called moral object).
Hence, the moral act cannot be properly characterized by describing a mere physical performance. In order to find out which is the kind of moral act we are performing (i.e., the ‘moral species’ of the act), the key question is: What are you doing? And an answer like "injecting morphine to this patient" would not do it. The proper answer to this question – relieving pain - revels the ‘intrinsic intentionality’ of the moral act. An analysis of the lived ethical experience shows that the moral character of our free acts is basically determined by this ‘intrinsic intentionality’ of the act, i.e., by the kind (‘species’) of act we perform.
But the ethical experience also shows that the agent’s motivation does in fact play a fundamental role in determining the moral character of a given action as well. Thus, we have to add the question: Why (or for the sake of what) are you doing this? The answer to this question – e.g. in order to allow the patient to enjoy his life - will explain the actual intention or motivation of the agent inasmuch as it goes beyond the motivating role of the intrinsic intentionality of the act itself. Thus, the ‘intrinsic intentionality’ of the act itself and the intention of the agent are not the same thing and need to be carefully distinguished.
A careful analysis of our most basic human moral experience shows that the ethical character of human acts does not primarily depend on the motivation or intention of the agent, but on the moral species of the action to be performed. Hence, the common saying ‘the end does not justify the means’. The principle of double effect intends to secure that this necessary condition for the ethical legitimacy of our free actions will be respected.
Dr. Paulina Taboada, MD, PhD
Palliative Care and Bioethics