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

Support for Use of Double Effect to Facilitate Ethical End-of-Life Decision Making

The nurse's duty to provide effective pain relief to dying patients is clearly articulated in an American Nurses Association position statement[18] that identifies and supports the nurse's obligation to provide relief of pain and suffering to dying patients. Language in the statement specifically identifies the possibility of secondarily hastening death as an ethically justified side effect of proper EOL pain management. "The increasing titration of medication to achieve adequate symptom control, even at the expense of life, thus hastening death secondarily, is ethically justified."[18(p1)] The most recent revision of the code of ethics adds the following stipulation:

The nurse should provide interventions to relieve pain and other symptoms in the dying patient even when those interventions entail risk of hastening death. However, nurses may not act with the sole intent of ending a patient's life even though such action may be motivated by compassion, respect for patient autonomy and quality of life considerations. [19(p8)]

The language in this newly revised code of ethics contains more nuances than the proscription in the previous Code for Nurses that unequivocally stated "the nurse does not act deliberately to terminate the life of any person."[20(p3)] In stipulating that nurses should not act solely to intend death, perhaps members of the Code of Ethics Task Force hoped to engender support for use of double effect reasoning by nurses who care for dying patients.[13] The stipulation that nurses not act with the sole intent of causing death seems consistent with the third condition of the principle of double effect that cautions the agent that the bad effect may not be used as the means to achieve the good.

Encouraging nurses to apply the RDE in support of appropriate administration of opiates to manage EOL suffering is supported by various nurse experts in palliative care. Coyle and Layman-Goldstein maintain that

The principle of double effect is an essential ethical construct for nurses to understand if they are going to adequately control complex symptoms at the end of life...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)]

Sulmasy,[21] a physician/philosopher who also supports use of the RDE as a means to facilitate ethical EOL decision making, focuses attention on the meaning of "intending." He notes that "desire and belief ought not be confused with intention."[21(p59)]

To desire that a patient should die so that his/her suffering might end, and to believe that death will like occur as a result of discontinuing [life-sustaining] treatment, is not the same as acting with the specific intention in acting that the patient should die by way of one's acts. [21(p59)]

Sulmasy maintains that in clinical situations where high doses of opioids are necessary for relief of a dying patient's suffering, although the clinician might hope for his or her patient's death, expect it, or even pray for it, that is not the same as being committed to bringing about the patient's death "as the condition that fulfills her intention. Desire and belief are not intentions... Intention seems to involve something over and above belief and desire. It involves commitment."[21(p59)]

As previously noted, Latimer,[3] a palliative care physician, adds the following caution to clinicians who would apply the RDE to situations in which there is a compelling need to administer high dose opiates to relieve intractable symptoms of pain or suffering. "The undesirable secondary effect must in no way be wished or planned as being the 'true goal' of the action."(p332) When the clinician's "true goal" is symptom relief, the risk of a secondary effect that hastens death is morally acceptable because that risk is not the primarily intended goal and there is a compelling need to act to relieve the pain and suffering.

Determining whether it is morally and professionally acceptable to assume the risk of hastening death is determined by the goals of care. The goals of care indicate whether prolongation of life or comfort is of paramount value to the patient.[3] These goals are patient specific—they reflect the nature and prognosis of the illness, the patient's experience of the illness, and incorporate the patient's life goals, hopes, and values. When patients are incurably ill and dying, full supportive care is always provided, although the range of interventions offered and their associated risk of hastening death may vary when life prolongation is no longer the patient's primary goal.

Other clinicians challenge the view that clinical application of the RDE facilitates good EOL decision making. Most of the disagreement among bioethicists and clinicians about the usefulness of the RDE as a practical guide to decision making centers on the meaning of "intention," and the difficulty in distinguishing, in a morally relevant way, between actions and effects of actions. In addition, palliative care clinicians challenge the need to appeal to double effect when providing appropriate analgesia; they maintain that the actual risk of secondarily hastening death with proper use of opiates is remote and a rarely occurring side effect.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Post as: