The Rule of Double Effect and Its Role in Facilitating Good End-of-Life Palliative Care

Judith Kennedy Schwarz PhD, RN


Journal of Hospice and Palliative Nursing. 2004;6(2) 

In This Article

Abstract and Introduction

The rule of double effect has its roots within the Roman Catholic tradition of moral theology. It has a long history of use by bioethicists and philosophers as a means to resolve a particular type of ethical conflict in clinical cases. These cases involve a clinician who must decide whether to act when the proposed action has two known outcomes—one that is desired, desirable, and the intended effect of the action; and another that is neither desired nor intended, although it may be foreseen. Double effect is often cited as justification by clinicians who assume the risk of hastening death as a secondary but unintended effect of providing high-dose opiates to terminally ill and suffering patients. This article examines arguments that support clinical application of double effect and those that criticize its value in facilitating good end-of-life (EOL) decision making. It includes research that illustrates nurses' use and possible misuse of double effect reasoning when providing EOL nursing care. The article concludes with recommendations that clinicians practice thoughtful moral reflection that includes consideration of intentions when providing EOL care.

In clinical situations in which a proposed intervention is known to have both negative and positive consequences, clinicians often appeal to the principle of double effect as justification for their choice. This "procedural" ethical principle functions in healthcare settings as a rule that is thought to help clinicians decide whether under certain circumstances, known evil effects of an action may be morally acceptable. According to this principle, also known as the rule of double effect (RDE), outcomes that would be morally impermissible if caused intentionally are permitted though they may be foreseen—provided they are unintended. The moral authority of this procedural principle is derived from a distinction between what one intends as an end or as a means to one's end, and what one foresees will occur as a result of one's action or inaction.[1] The RDE is often cited to explain why certain end-of-life (EOL) interventions that result in death are deemed morally and legally permissible while others are not.[1]

To appropriately invoke this principle or rule, the clinician's intentions and motives must be apparent. As Latimer[3] notes, "the practitioner must clearly intend a desirable outcome while recognizing the possibility of other undesirable and unavoidable outcomes."(p332) Several commentators who criticize the clinical usefulness of the RDE base much of their criticism on questions about the nature of intentions and "intent"—a concept considered by many to be complex, multilayered, ambiguous, and difficult to understand.[2]

The purpose of this article is to explore the principle of double effect and to examine arguments that support and criticize its clinical value in facilitating good EOL decision making. A discussion of recent nursing research that includes clinical application of the RDE will be included; the article will conclude with suggestions for clinical use.


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