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

Clinical Application of the Rule of Double Effect: Divergent Views

When double effect is discussed by philosophers and bioethicists in the bioethical literature, the following sort of case is frequently described. The reader is asked to imagine a terminally ill patient who experiences intolerable pain and suffering, and who asks her health-care provider for help in ending that misery. If the nurse clinician knowingly and intentionally administers a lethal drug such as KCL and kills the patient in order to end her pain and suffering, the patient's death is intentionally caused. The reader is then asked to further suppose that the clinician could provide opiate medication to relieve the patient's pain and suffering that had an associated and substantial risk that the patient would die earlier as a result of the medication. If the nurse refuses to administer the potentially toxic opiate dose, the patient will continue to endure intolerable pain and suffering; if the opiate is administered, it may hasten the patient's death.[4] If the nurse does not provide the analgesia because of concern about the potentially lethal risk the opiate drug poses, the failure to intervene directly harms the patient by allowing treatable pain to persist. If the nurse provides the opiate the patient's death might be hastened; knowingly hastening death could cause a different harm to the patient. The RDE supports the nurse's administration of high-dose opiate analgesia as an act intended to relieve pain and suffering with a foreseen but unintended risk of causing a hastened death. Doing so would typically not be viewed as violating the moral prohibition against intentional killing.

The RDE has been criticized by numerous clinicians and philosophers who question its usefulness as a practical guide to ethical decision making.[1,2,4,5,6] Experts in palliative care challenge the purported double effect of providing opiates to terminally ill patients,[7] and describe the presumed association between appropriate use of opiates for dying patients and the likelihood of hastening death as an "over-blown myth."[8(p139)] Others caution that, "using the principle of double effect to justify using opioids to treat pain in dying patients contributes to the belief in the double effect of pain medication, which in turn leads to fear of hastening death and the undertreatment of pain."[9(p316)]

Other clinicians disagree with such criticism of clinical application of double effect. They maintain that the RDE is of great practical importance, and when properly understood and applied by clinicians, it can facilitate management of the complex EOL symptoms experienced by dying patients.[3,10,11] Nurse experts in palliative care maintain that, "giving a patient who is dying, hypotensive, and in pain sufficient opioid dosages to control the pain is good palliative care and not euthanasia."[10(p413)]


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