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


Does use of RDE balance, help, or hinder nurses who endeavor to make ethically supportable decisions about EOL care? The best answer to that question may be a qualified "it depends." Appropriate use of the RDE depends upon how well the rule is understood by clinicians and how thoughtfully it is applied to clinical situations of moral uncertainty. Many clinicians agree that use of the RDE may enhance EOL pain management by reassuring uncertain healthcare professionals that prescribing or administering high-dose opiates to terminally ill patients is morally and professionally appropriate palliative care that, when appropriately administered, does not hasten death. Others claim that appealing to the RDE as justification for the presumed risk of an opiate-related hastened death contributes to belief in the myth of the double effect of opiates, which in turn heightens clinicians' fears of hastening death, and leads to more undertreated pain. Further research and guided discussion will be needed in order to resolve these and other related questions.

Nurses and other clinicians are encouraged to be reflective about their clinical practice, and to consider the nature of their intentions when providing palliative interventions at EOL. Acknowledging the nature of one's intentions requires that clinicians engage in thoughtful personal reflection that demonstrates moral integrity and courage. Nurses must be aware of their own moral values and beliefs, and be thoughtful about how those beliefs can influence professional judgments. It may be the case that, when providing care to terminally ill and suffering patients, clinicians will recognize that their intentions may be multiple, ambiguous, and conflicted; one may hope that death comes soon to a suffering patient, intend to aggressively manage EOL symptoms, and do so without intending to cause death.

Clinicians sometimes have strongly held personal values and/or religious beliefs that conflict with decisions that patients or families make about continuing life-sustaining measures. Thoughtful application of the RDE may be of value to these clinicians, by helping them accept such decisions as when a patient's informed consent to an intervention hastens his or her dying (eg, the removal of a ventilator necessary for sustained life, or when a terminally ill patient decides to stop eating and drinking). Although the patient's death may be foreseen, it is not the reason for respecting that patient's choice—death may be foreseen without being intended.

Some maintain that a patient's informed consent to an intervention that may cause a hastened death is of greater importance than whether the clinician intends by that intervention to hasten death.[2] Those who hold that view argue that

The crucial moral considerations in evaluating any act that could cause death are the patient's right to self-determination and bodily integrity, the provision of informed consent, the absence of less harmful alternatives, and the severity of the patient's suffering. [2(p177)]

Nurses are encouraged to consider these differing views of the usefulness of double effect as a means to further ethical decision-making in EOL care. Individual nurses must decide whether, on balance, the RDE helps or hinders their attempts to reach ethically supportable EOL decisions.

The print version of this article was originally certified for CE credit. For accreditation details, contact the publisher. Lippincott, Williams & Wilkins Inc., at 16522 Hunters Green Parkway, Hagerstown, MD 21740-2116.


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