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THE PRINCIPLE OF DOUBLE EFFECT QUESTIONED
PAULINA TABOADA, MD, PhD
In an article published in the Lancet Oncol the application of the doctrine of double effect to palliative care has been questioned (Sykes N & Thorns A: The use of opioids and sedatives at the end of life, Lancet Oncol, 2003; 4: 312 - 18). The authors conclude that this ethical principle is "irrelevant to symptom control at the end of life" (p. 317). They even suggest "to exaggerate its involvement perpetuates a myth that satisfactory symptom control at the end of life is inevitably associated with hastening death." (p. 317). Based on a bibliographical review, the authors show that there is no cogent evidence to support the view that an appropriate use of opioids, or sedatives, at the end of life may actually shorten a patient's life.
In my opinion, the authors' conclusion regarding the uselessness of the ethical principle of double effect in palliative care does not necessarily follow from the empirical evidence they analyze. Moreover, I think that the authors misunderstood the true content of this classical ethical principle. They state, for instance, "the doctrine of double effect is used as an ethical justification for the specific risk of foreseeable life shortening as a result of medical treatment" (p. 317). Nevertheless, this particular application of the principle of double effect does not exhaust the content of this classical ethical principle. In fact, the content of this principle is much deeper and broader, and I do think that it sheds light on various ethical problems that are frequent in palliative care.
The traditional principle of double effect 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 side effects. This is the case not only in the practice of medicine, but also in common daily life. Thus, I do not see any reason why end-of-life care would be an exception. In fact, even if one knows that an adequate use of opiates and sedatives is not associated with an earlier death, the occurrence of other undesired side effects, such as the alteration of the patient's blood pressure, respiration or state of awareness already raises ethical questions. And the principle of double effect helps to discern the cases in which the use of these drugs is morally legitimate.
This principle states that actions with both good and bad effects are ethically legitimate only if certain conditions are simultaneously fulfilled:
1. The action performed is not itself morally evil.
2. The good effect is not caused by the evil effect.
3. Only the good effects are directly intended; the bad effects are not intended but only tolerated (as unavoidable).
4. There is a due proportion between good and bad effects.
In other words, the principle of double effect forbids the achievement of good ends by wrong means. Thus, this principle 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, provided that other pain killers have been tried and shown as inefficient in the control of pain. If the opiates are used in the right way and dose, then opiates would represent the only possible way of benefiting the patient, and their use is therefore morally justified in spite of eventual undesired side effects.
With the sedation of terminally ill patients, this principle applies. If we consider the actual exercise of mental faculties to be good for the person, then it would be morally not allowed to deprive someone from the use of these faculties without a sufficient reason. Hence, in order for sedation to be morally legitimate, the four conditions of the principle of double effect must be fulfilled. It would be morally wrong to sedate a person if there is not a good reason for it. Unfortunately, health care professionals are not always completely aware of the seriousness of this issue. So, in developing countries sometimes the scarcity of medical personnel, and other related circumstances, becomes the reason for sedating patients, which is a morally intolerable situation.
A different but tightly connected issue on which the principle of double effect can shed light is the practice of so-called 'terminal elation', defined as the use of mind altering substances, or techniques, for purposes other than sedation. If we accept the idea that intentionally altering a person's mental state without a legitimate reason is morally wrong, we would need a cogent ethical justification for doing it in a particular case. And it seems evident that the use of mind-altering drugs cannot be justified only as an answer to a person's autonomous request to avoid suffering. If this were the case, we would end up having to accept the use of such drugs to avoid any kind of distress - e.g. physical, psychological, spiritual, or even 'existential' - and in every kind of difficult life-situation. This would clearly be a dangerous conclusion. But, we would have no cogent argument to limit the argument in favor of mind-altering drugs to terminal care only. In fact, some contemporary authors have suggested that society should seriously consider 'terminal elation' not only as a potential solution for intractable suffering during the dying process, but also in other areas as well.
Nevertheless, applying the ethical principle of double effect to this issue, we realize that it is not morally legitimate to directly intend the mind-altering effect of these drugs. The use of mind-altering drugs is legitimate only when sedation is tolerated as an unintended side effect when treating diseases, or symptoms, that cannot be treated by other means. In fact, the ethically legitimate intention for using sedative medication in palliative care is not the reduction of the patient's state of awareness as such, but the treatment of a given physical or mental symptom, such as pain, agitated delirium, etc. Hence, the mind-altering effect of sedatives drugs is tolerated here in the context of the therapeutic principle.
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