The principle of double effect (PDE) or doctrine of double effect (DDE), sometimes simply called double effect for short, is a thesis in ethics, usually attributed to Thomas Aquinas. The principle seeks to explain under what circumstances one may act in a way that has both good and bad consequences (a "double effect").
It states that the unintended, harmful effect of an action is defensible (e.g. an early death) if Ethics (from the Ancient Greek Ä“thikos, the adjective of Ä“thos custom, habit), a major branch of philosophy, including genetics is the study of values and customs of a person or group. ... Saint Thomas Aquinas (also Thomas of Aquin, or Aquino; c. ...

• The nature of the act is itself good (e.g. the relief of pain and distress)
• The intention is for the good effect and not the bad
• The good effect outweighs the bad effect in a situation that is sufficiently grave to merit the risk of that bad effect (e.g. overwhelming suffering in a dying patient)
• The good effect (the symptom relief) is not through the bad effect (eg. death)

Intentional harm versus side-effects

Although different writers state the doctrine in different ways, it always claims that there is a moral difference between courses of action such as the following:

1. An agent that deliberately causes harm in order to promote some good.
2. An agent that promotes some good in such a way that harm is caused as a foreseen side-effect.

The doctrine of double effect stems from an application of the Hippocratic moral norm, "First, do no harm." and Aquinas' First Precept (Principle) of Natural Law "Good is to be Done and Promoted and Evil is to be Avoided" [Summa Theo I-II Q94 Art 2]. This article or section does not cite any references or sources. ...

Applications

The doctrine has practical applications, for example in just war theory, where the deliberate targeting of civilians to demoralise the enemy may be ruled out, but the bombing of munitions plants may be allowed, even if both actions cause the same number of deaths and end the war in the same length of time. Just war is a specific concept of how warfare might be justified, typically in accordance with a particular situation, or scenario, and expanded or supported by reference to doctrine, tradition, or historical commentary. ...

The doctrine is relevant to certain medical cases. The administration of a high dosage of painkillers is sometimes allowed for the relief of pain in cases of terminal illness, even when this will cause death as a side effect. Some (including most Catholic ethicists) hold that this is morally different from deliberate euthanasia for the relief of pain. For other uses of painkiller, see painkiller (disambiguation) An analgesic (colloquially known as painkiller) is any member of the diverse group of drugs used to relieve pain. ... Terminal illness is a medical term popularized in the 20th century for an active and progressive disease which cannot be cured and is expected to lead to death and or death due to symptoms of disease. ... Euthanasia (from Greek: ευθανασία -ευ, eu, good, θάνατος, thanatos, death) is the practice of terminating the life of a person or animal with an incurable disease, intolerable suffering, or a possibly undignified death in a painless or minimally painful way, for the purpose of limiting suffering. ...

In some circumstances it is possible to argue that the doctrine of double effect is a redundant doctrine; for example within palliative or terminal care. It is possible to argue that since the use of analgesia is better understood (in terms of both pharmacology and delivery of medication) and titration of analgesic dose to the pain experienced by the patient is possible, then the desired effect (analgesia) can be achieved without the undesired effect (respiratory suppression). Thirty years of palliative care experience and research has shown that it is possible to manage pain or distress with titrated doses of drugs, without hastening death.(Oxford Textbook of Palliative Medicine 3rd ed. Doyle D, Hanks G, Cherny NI, Calman K eds. Oxford : Oxford University Press, 2003) (see opioids). This experience has been countered by the claim that that intent cannot be proven in such situations. In reality intent is very easy to identify by reviewing the drug records in any situation where drugs have been given for severe pain and/or distress:
- A palliative care physician will use multiple, small doses of an analgesic or sedative, titrating the dose to the patient and the pain or distress, usually subcutaneously or orally for comfort and avoiding serious adverse effects.
- Other doctors give large doses of an analgesic (usually an opioid), invariably intravenously, ignoring or intending serious adverse effects (such as death).
The intent of a palliative care physician is relief without harm; the intent of the second is relief at any cost and may suggest either negligence or malice. Euthanasia has been suggested as being an exception, but in countries such as the Netherlands, opioids are not considered to be effective agents for euthanasia,^[1] since the wide therapeutic range makes death difficult to achieve while the high doses required risk causing agitation and distress through morphine metabolites M3G and nor-morphine. (See Opioids) The repeated experience that opioids used in palliative care do not hasten death or shorten life lies behind the rejection by palliative care specialists of double effect as a useful principle.^[2] An opioid is any agent that binds to opioid receptors found principally in the central nervous system and gastrointestinal tract. ... An opioid is any agent that binds to opioid receptors found principally in the central nervous system and gastrointestinal tract. ...

These observations should not be surprising. If a patient receiving chemotherapy develops neutropaenia (a dramatic fall in the infection-fighting white blood cells), there is a risk that they may die from overwhelming infection. If the patient does die, no one wistfully quotes double effect. The death would be considered a serious adverse event which needs investigation. Caring for dying patients is no different, and death following treatment for pain or distress should be considered as seriously as death from neutropaenia.

Other examples

A vaccine manufacturer typically knows that while a vaccine will save many lives, a few people will die from side-effects of taking the vaccine. The manufacturing of a drug is in itself morally neutral. The lives are saved as a result of the vaccine, not as a result of the deaths of those who die of side-effects. The bad effect—the deaths due to side-effects—does not further any goals the drug manufacturer has, and hence is not intended as a means to anything. Finally, the number of lives saved is much greater than the number lost, and so the proportionality condition is satisfied. Some moralists add a fifth condition, namely that there must be no alternative. Therefore, if it were possible to find another morally-acceptable way of saving lives, without the risk of death from side-effects, it would not be permissible to produce this vaccine. A vaccine is an antigenic preparation used to establish immunity to a disease. ...

The Principle appears useful in war situations. In a just war, it may be morally acceptable to bomb the enemy headquarters to end the war quickly, even if civilians on the streets around the headquarters might die. For, in such a case, the bad effect of civilian deaths is not disproportionate to the good effect of ending the war quickly, and the deaths of the civilians are not intended by the bombers, either as ends or as means. On the other hand, to bomb an enemy orphanage in order to terrorize the enemy into surrender would be unacceptable, because the deaths of the orphans would be intended, in this case as a means to ending the war early, contrary to condition. Whether the Principle applies to the bombing of Hiroshima and Nagasaki is a highly controversial question. Just war is a specific concept of how warfare might be justified, typically in accordance with a particular situation, or scenario, and expanded or supported by reference to doctrine, tradition, or historical commentary. ... The Fat Man mushroom cloud resulting from the nuclear explosion over Nagasaki rises 18 km (11 mi, 60,000 ft) into the air from the hypocenter. ...

Controversy

Despite some apparent plausibility, the doctrine of double effect is controversial. Utilitarians, in particular, reject the notion that two acts can differ in their permissibility, if both have exactly the same consequences. Utilitarianism (1861), see Utilitarianism (book). ...

A major argument against the DDE is the hypothetical case where some evil must actively be done to bring about an enormous good. For example, suppose a nuclear bomb has been planted in a major city, and a person is held in custody who knows where it is, but who refuses to disclose the bomb's location. May the interrogators torture this person's family in front of his or her eyes, exploiting the family attachment to extract information and save millions of lives?

Even in such an extreme case, the DDE would not permit evil to be done prior to good consequences, where as the utilitarian position states that the order of events is irrelevant. The argument against DDE thus becomes a question of how high must the stakes be before any evil is permissible for good ends, with the DDE position maintaining that evil is never permissible as an instigator to good ends.

In the past few years in the UK, at least two doctors undergoing murder trials for giving large doses of opioids to ill patients, have used the defence of double effect.^[3]

See also

• Opioids
• Trolley problem

An opioid is any agent that binds to opioid receptors found principally in the central nervous system and gastrointestinal tract. ... The trolley problem is a thought experiment in ethics, first introduced by Philippa Foot, but also extensively analysed by Judith Jarvis Thomson and, more recently, by Peter Unger. ...

References

External links

• Principle Of Double Effect
• Stanford Encyclopedia of Philosophy entry
• What is the doctrine of double effect?