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


The principle of double effect has a long history within the Roman Catholic tradition of moral theology. It was developed by Roman Catholic theologians in the Middle Ages and can be traced back to the writings of St. Thomas Aquinas (1225-1274). The traditional Catholic formulation of the RDE stipulates that 4 conditions must be met before an act with both good and bad consequences may be morally justified.

  1. The nature of the act. The act itself must not be intrinsically wrong and not be in a category that is absolutely prohibited (eg, killing of innocent persons), when considered independently of its consequences.

  2. The agent's intention. The agent must intend only the good and not the bad effect, although the bad effect, such as respiratory depression following administration of opiates, may be foreseen but not intended.

  3. The distinction between means and effects. The bad effect, such as death, must not be the means used to bring about the good effect, such as the relief of suffering.

  4. Proportionality between the good effect and the bad effect. The good results must outweigh the bad effect—the bad effect can be permitted only when there is a proportionally grave reason for permitting the foreseen bad effect.[2,4]

The first condition determines whether a potential act is ever permissible, and the second and third conditions are used to determine whether the potentially inflicted harm is intentional or unintentional—either as a means or an end in itself. The fourth condition requires the agent to compare the net good and bad effects of potential actions to determine which course produces an effect of proportionately greater value.[2] Many healthcare professionals and bioethicists appeal to the RDE to explain why a clinician is permitted to administer high doses of opioid analgesic to relieve severe pain or suffering in a terminally ill patient, in amounts that may cause or hasten the patient's death as a secondary result of respiratory depression.[3,7,10,11]

Clinicians' fears about causing an opiate-related hastening or causing death are well documented.[12,13,14,15] Clinicians may be reluctant to provide adequate doses of opioid analgesia, even when they know that their patients are dying, in part because of fears that they will be held legally or professionally liable for contributing to an earlier death—or for facilitating a patient's wish for a hastened death.[13] Because of the prevalence of such clinician fears, Sulmasy and Pelle-grino[11] maintain that "a clear understanding of the proper use of the rule of double effect is essential if health care professionals are to maintain their opposition to euthanasia and assisted suicide and yet provide adequate pain relief to dying patients."(p545)


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