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

When Philosophers Discuss Clinical Application of the Rule of Double Effect

Much of the criticism of clinical application of the RDE arises from the attempt to distinguish "intended" from "foreseen but unintended" outcomes. How does one draw a line between what one intends and what one foresees as an inevitable outcome of one's actions—but does not intend? Philosopher Cavanaugh[16] explains the intended/foreseen distinction in the following way. He argues that the intention of a particular end is the result of deliberation—in deliberation, the agent searches for means that are effective to achieve the desired or intended end. He maintains that foresight does not result from deliberation because it does not concern the problem of how to cause some intended end.

Like other philosophers who write about double effect, Cavanaugh illustrates his argument in support of the RDE by discussing a "case" of an opiate-related death. He states that when clinicians apply double effect reasoning to determine the moral permissibility of providing death-hastening or death-causing opioids to terminally ill and suffering patients, the intentions of the agents are critical. He notes that Aquinas described the meaning of intention as "to tend towards," which involves a space through which the tending occurs. "In intention, the analogue to the space intervening between the one intending and the object intended towards is the means, that through or by which one achieves one's end."[16(p252)]

Thus, Cavanaugh's example continues, when a physician prescribes an escalating range of opioid drug that the nurse administers following his or her assessment of the patient's level of pain, these actions follow their deliberation about how to relieve their patient's pain or distress. The nurse and physician do not deliberate about how to kill the patient and, although they may foresee that she will die, they do not intend her death. The more severe and intractable the patient's pain, the greater the justification for risking an earlier death—provided that assuming the risk of an earlier death is consistent with the patient's wishes.[3]

When clinicians administer an opioid drug knowing that it may hasten or cause the death of their patient, Cavanaugh[16] argues that they will be responsible for bringing about a foreseen harm, which is the risk of hastening or causing the patient's death. How may an act with such a risk be justified? Cavanaugh states that clinicians face 2 competing duties when they consider whether to administer a drug that may hasten or cause a terminally ill patient's death: the obligation to not harm patients, and the obligation to relieve severe pain or suffering. Cavanaugh argues that it is because the death of a terminally ill patient cannot be prevented that the clinician's obligation to control his or her pain is so great. That the patient will die is beyond clinician control, what is not beyond clinician control is whether the patient's death will be preceded by unacceptable levels (to the patient) of pain or suffering. Thus, one's moral obligation to relieve the pain or distress experienced by dying patients is greater, all things considered, than one's obligation to avoid hastening or causing death. Palliative care clinicians note that, "to leave a person in avoidable pain is a fundamental breach of (the patient's) human rights."[17(p644)]


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