John Raubach

1/8/10
Word Count: 4,986

Killing and Letting Die:

A Partial Defense of F.M. Kamms Intricate Ethics
Deontology describes a range of ethical theories that are focused on the deon, or
the ought (SEP, Intro). Deontologists deny both the idea that moral actions are only
relevant in terms of their consequences (as would a consequentialist), or that they are
simply the byproduct of a moral actor achieving properly virtuous dispositions (as would
a virtue ethicist). What deontologists do take to be morally binding are rules, rights and
duties. F.M. Kamm is a prominent deontologist whose Intricate Ethics provides an
impressive account of a deontological theory in action. A large portion of her work is
focused on two moral distinctions: one between harming and not aiding, and the other
between intending and forseeing. These ideas culminate in two mechanisms for moral
resolution called the Doctrine of Triple Effect and the Doctrine of Productive Purity. This
paper will argue that many of the distinctions implicit in the Doctrine of Triple Effect and
the Doctrine of Productive Purity are morally important and critical concepts that a
consequentialist account of morality fails to register; but at the same time the formulation
of the DTE and DPP are based largely on the morally insignificant property of causal
closeness and circumstantially fail to uphold crucial rights.
It is helpful to draw a distinction between agent-centered and patient-centered
deontological theories before going any further. Agent-centered theorists are concerned
first and foremost with persons as individual agents. An agent in ethical terminology is a
moral actor, a person who acts on her own moral deliberations and is held accountable for
doing so. Agent-centered deontological theories often have duties that are not universal.

These duties are still objective as they apply to the agent regardless of her say in the
matter, but they only apply to that particular agent. For instance, parents are considered
to have unique obligations to their children that strangers do not have (and provided these
strangers have children of their own, the same applies to them) (SEP 2.1). Agent-centered
theories are most noteworthy for putting a greater moral weight on intentionality and thus
potentially preventing an agent whose intentions are bad from performing otherwise
morally favorable acts.
Kamms position is best understood as a form of patient-centered deontology, and
an aim of this paper is to show how such an approach is more intuitive. A patient in
moral philosophy is loosely a being which is an object of moral consideration but
nonetheless incapable of making moral choices. Most deontologists would cite infants,
toddlers, the mentally handicapped, and the senile as moral patients. Many go a step
further to include animals. These disagreements may cause us to question just what
exactly the criteria for establishing moral patienthood are. There are a variety of
possibilities: potential toward rationality, possession of interests, self-consciousness,
sentience, etc. Kamm seems to endorse Thomas Scanlons view that we begin to owe
things to any being capable of judgment-sensitive attitudes (Kamm, 232). This leaves
many possibilities open for what beings count as moral patients, but all that is necessary
to understand for our discussion is that most if not all persons are both moral patients and
moral agents, necessarily. We can be assured of the fact that we are always dealing with
at least a moral patient in the deliberations considered in this essay, as they all concern
moral persons in the strictest sense possible. The point is that in order to properly

conceptualize rights, we must consider persons first as patients to whom we have duties,
and then as agents.
Agent-centered theories focus is placed on the agent's mental state or on
whether the agent caused the victim's harm. The patient-centered theory focuses instead
on whether the victim's body, labor, or talents were the means by which the justifying
results were produced (SEP 2.2). Agent-centered deontology may prevent us from doing
an otherwise morally permissible act if we are performing it for some perverse reason.
While the moral agent here may be blameworthy for her objectionable intentions, patientcentered approaches still say the act must be performed in the interest of preserving the
rights of the patients involved. I believe this coincides nicely with our moral intuitions,
and one of Kamms chief aims is to reconcile moral theory with such intuitive judgments.
Still the idea that rights need to be considered in what is often thought of as a monistic
moral theory centered on duty need to be defended, and Kamm does so through another
thought experiment. She has us suppose that having an interest not to be tortured is
sufficient to create for us a correlative duty not to torture. Then, she explains,
One would have a right that any behavior that has a high
probability of resulting in torture be equally prohibited (given the
same cost of doing so), including not helping to prevent torture.
But if [this] right is also about morality ruling out the treatment
of persons in a certain particular manner leading to torture, then we
could account for why there would be a very strong right not to be
tortured that trumps the foreseen loss of utility if we do not torture
and not as strong a right that torture be prevented (Kamm, 267).
Returning to Kamms emphasis on intuitions, it seems right that we see the moral status
of people as something that gives us reason to avoid torturing them rather than trying to
extract some kind of principle only out of interest. With such thoughts in mind, it seems
that rights ought to be a fundamental part of any successful moral theory.

There are two other ideas within the tradition of deontological ethics that are
essential to understanding Kamms theory: prerogatives and constraints. Prerogatives,
according to Kamm, permit an agent (1) to act in ways that do not maximize the
impartial good and (2) to act for reasons that stem from his personal perspective rather
than from the perspective of an impartial judge (Kamm, 15). In other words we are not
necessarily expected to produce moral goods when it is in our reasonable ability: we can
visit our friends one weekend rather than do volunteer work, even though the latter would
produce the most moral good. Introducing prerogatives into an ethical theory means that
you are [permitting] agents to give some fundamental projects lexical priority relative to
some impartial goods (Kamm, 16). We have the right to opt out of many seemingly
supererogatory acts that consequentialism commits us to perform as an obligation.
(Supererogatory acts refer to morally good acts that are above the call of duty. We are
not obligated to do them, but it is all the better if we do.)
It is perhaps easier to argue for prerogatives on both the ground of their intuitive
appeal and the unsavory implications of their alternatives. Kamm gives three fairly
convincing arguments of this sort. First, humans are psychologically predisposed to be
most concerned about their projects (Kamm, 16). Not allowing people to pursue their
personal and non-optimal projects in lieu of the countless interests of others would
cause them to be alienated from their fundamental psychological natures (Kamm, 16).
Banal as this point may be, it is still worth noting. Secondly, any kind of ethical theory
that disallows prerogatives becomes unreasonably demanding. Under strict
consequentialist theories, for instance, we are perpetually required to make enormous
sacrifices to advance the interests of a group potentially as large as six and half billion

people, and to advance their interests in potentially trivial ways. As mentioned earlier, we
must perform theoretically endless amounts of actions that most would consider to be
supererogatory (Kamm, 16). Lastly, prerogatives are grounded in the Kantian idea that
human beings are ends-in-themselves. Reducing any individual to the status of an
instrument to be utilized in the production of the greater good is treating them as a means
rather than an end. Kamm also notes that constraints relate heavily to this Kantian
maxim, which allows for segue into this equally important concept (Kamm, 17).
Constraints are grounded in the idea of negative rights (claims held by others to
not be acted upon against their will). There are some things that we cannot do simply
because it would violate anothers right to not be interfered with. So we can understand a
constraint to be any restriction against a person taking a particular action that would
otherwise produce the greatest good. While prerogatives tell us that we are (at least
usually) not obligated to make an enormous sacrifice to rectify a situation for which we
are not accountable, constraints tell us that is similarly impermissible to perform actions
that directly make others subject to such a sacrifice against their will. However,
constraints make it such that we can perhaps allow someone to become subject to such a
sacrificeeven if we are fully able to change thisprovided we did not instantiate
whatever is putting them in this position. This relates to a standard deontological claim
that there is a morally important difference between killing and letting die. In the first
case we are leaving someone to be less well off than they were without our interference;
in the second, we are not leaving them any worse off had we no involvement in the
situation. Kamm presents a morally plausible case that indicates the differences between

causing something and allowing something to happen, which she calls the Road Case.
The case is stated as follows:
(1) We know that if we drive down one road, we kill someone who cannot
move out of the way. The only alternative is to go down a side road, where
we risk hurting ourselves.
(2) We know that to save someone from drowning, we must go down a
side road, where we risk hurting ourselves (Kamm, 18).
In the first case we are directly responsible killing the man if we go down the first road.
This killing would not take place in our absence. The same does not hold for the latter
situation, however. The drowners death is caused by our presence rather than our
absence. Kamm explains that we introduce a threat that was not previously present
(Kamm, 18). In the second case, we just avoid changing an already present threat. We are
not caus[ing] someone to lose a life that he would have had independently of our
efforts (Kamm, 18). I believe we could understand this to be an injunction against
leaving a victim any worse off than he was prior to our involvement. This idea seems to
be a plausible basis for a patient-centered deontology that respects rights, and Kamm
seems to get at this idea at various times. However, I believe that many uses of the
Doctrine of Double and/or Triple Effect (which we will talk about shortly) end up
violating this principle.
The problems we have been discussing come into play with famous ethical
dilemmas such as the Trolley Case. This case is useful to both shed light on the real life
implications of deontological ethics as well as to show the nuances of F.M. Kamms
views specifically. The problem, first conceived by Philippa Foot, is presented as follows:
Five people [are] on a track toward which an out-of-control trolley is
heading. If it continues, it will kill them. However, if we redirect it away
from them [by pulling a switch], it will go down another track where it
will kill someone who is unable to be removed (Kamm, 92).

A classic deontological appraoch would strictly prohibit pulling the switch because
human lives are not commensurable, and to take an innocent life would be violating one
of the most fundamental deontological constraints. Flipping the switch would clearly
leave the one worse off than he was without your interference. Another response in the
tradition would entail an appeal to the Doctrine of Double Effect [DDE] and say it is
permissible to flip the switch because the death of the one is a side effect that you are not
intending. Consequentialists, on the other hand, would consider someone in such a
position to be morally obligated to flip the switch no matter what. Under such a view any
factor other than the good produced is insignificant. Any appeals to constraints register as
morally moot technicalities. Kamm is intent upon providing a well-developed alternative
to such consequentialist thinking, but she wants to reject the first deontological line that
insists on our not changing the trajectory of the trolley.
Kamms answer is to appeal to the Doctrine of Double Effect. The DDE says,
essentially, that while it is wrong to intend to produce evil to produce a greater good, it is
permissible to use neutral and/or good means to produce a greater good when the same
evil produced is only a side effect (Timmons, 77). It is critical that the evil be merely
foreseen and not intended either instrumentally or on its own terms. However, the bad
effect must not be out of proportion to the good effect (Timmons, 78). In other words
we cannot justify performing an action whose bad side effects that outweighs the good
we are trying to achieve. According to this there seems to be a clear answer to the Trolley
Case. In the original presentation of the case, the death of the bystander is seen under the
DDE as an unintended and merely foreseeable consequence in a causal chain of events
it is the evil side effect. Therefore, according to the DDE, switching the tracks so that the

trolley kills the one person instead of the six is permissible. However, there exists another
variation of the Trolley Case called the Push Case: The Trolley is running out of control,
etc., and it can only be stopped by pushing an innocent bystander in front of it, killing
him and saving the others. Here the Doctrine of Double Effect no longer allows for the
action (Kamm, 92). Changing the tracks is not an evil in and of itself; the evil comes
from an unintended side effect. Pushing a man into a train is intrinsically wrong, on any
deontological account, and in doing so we are now intending to end the mans life rather
than merely foreseeing itwe are directly intervening upon the mans rights to life qua
moral patient rather than allowing something else to cause the intervention (in this case
the trajectory of the trolley).
All of this loosely plays off the killing/letting die distinction, but it seems pushing
the bystander in even the original Trolley Case violates the kind of patient-centered
deontological claims that Kamm makes elsewhere. As mentioned, we are not leaving the
victim (and the only relevant victim here to us is the bystander) as well off as he would
have been prior to our interventionwe are causing his death. Unfortunate as it is that
the five on the Trolley are destined to die given the tracks trajectory, this is the result of
either a contingency or a moral wrong already in place. The bystander has no
responsibility for their condition and has a right to preserve his life. What is really the
differing property in the original formulation and the variant Push Case is, I believe,
causal closeness. Pulling a lever puts a distance between our action and its effect.
Whether the bus hits the patient through a willed cartoonish causal chain of events or by a
direct push is not morally relevant. Causal closeness is an arbitrary criterion with little to
no intuitive appeal.

The Doctrine of Triple Effect is a slight bolstering of the DDE, as it adds one
more distinction: the distinction between performing an action because an evil effect will
result, and performing it in order that it occurs. The former, Kamm claims, does not
necessarily imply intent, and thus leaves open the space for permissibility. To illustrate
what this means, Kamm uses a mundane but elucidative example called the Party Case.
In short, A and B want to throw a party but dont want to be left with the onus of cleaning
up the mess that ensues all by themselves. However, both A and B reason that since they
were generous enough to throw the party, the attendees will feel indebted to help clean
(Kamm, 95). What is important here, though, is that they did not throw the party in order
to either make their friends feel guilty nor to make them help clean; rather, they
continued with an action because of its foreseen likely contingencies. The Doctrine of
Triple Effect is named as such because of this third component. The DDE has two: (1) the
good action and (2) the unwilled evil side effect. The DTE has the same two, but also (3)
a good state of affairs created because of the evil side effect.
In the Party Case, the DTE seems innocuous and acceptable, but this is because of
the nature of the situation. We are not dealing with anyone being killed or having their
bodily integrity compromised; we are just dealing with two people committing to a
mundane chore on behalf of a friend. What is crucial is that this chore is not even
remotely coerced. A and B simply are making a decision based on a reasonable
expectation that their friends will, on their own volition, feel inclined to return a favor.
When we get to more serious cases, like the Trolley Case, I believe the same problem
appears. We are still willing an action that leaves the victim much less well off than he

was before (i.e. killing him). Doing something because of an evil side effect only further
implicates us in the harm and makes it questionable from even an agent-centered view.
Kamm introduces another principle (the Principle of Permissible Harm) which
contains a feature that is relevant to our discussion: the non-causal flipside. This is
important because it highlights the fact that our pulling the lever in the original Trolley
Case really is merely justified by its causal distance. Kamm explains, the five being
saved, which is the greater good when continuing life is a good for the five, is the noncausal flipside of the redirection of the trolley (Kamm, 141). This means that the only
thing necessary to eliminate the threats the five face is the trains movement, and this
movement is an alternative possibility that does not derive from a causal chain. Kamm
attempts to clarify this seemingly opaque idea of a non-causal flipside saying,
By noncausal, I mean something tighter than causation
sometimes identity, sometimes constitution. Here is an analogy:
When I raise my arm, the area under it is greater than it was. The
relation between my arm going up and the increase in space is
noncausal. The relation between the space becoming larger [an
event] and the space being larger [a state of affairs] is also
noncausal.(Kamm, 140-141).
This distinction may be subtle, but Kamm insists it is morally important. In a contrast to
harm vindicated by a non-causal flipside, we can consider another version of the Trolley
Case, in which a bomb explodes in order to (somehow) safely redirect the trolley, but an
innocent bystander is killed by the explosion. In this case, the bomb has a causal effect of
moving the trolley away from the endangered passengers. We cannot see the action of
detonating a bomb as creating a non-causal flipside (Kamm, 25). This being said, the
Bomb Case is not permissible in Kamms view. It produces harm as a causal means of
reducing evil. This seems to unambiguously demonstrate that causal closeness really is

her primary criterion for the permissibility of producing harm. What differentiates this is
that the bomb kills the bystander more directly and quickly than the redirected train
(whether looped or not). This seems insignificant.
Having said all of this, Kamm now goes on to tell us that there is, in fact, a
counterfactual that she sees as causing problems for the DTE. She has us consider the
Tractor Case. Here the trolley is headed toward the five and can be redirected without
returning, but there is an additional threat: a deadly tractor which is also approaching in
their direction. If we go ahead and redirect the trolley, it will push one person into the
tractors path and stop the tractor (but kill him). Kamm asks what she takes to be a
rhetorical question,
Is it possible to say We redirected the trolley in order to stop it from
hitting the five from the first directly only because we knew that the one
person would be pushed into the tractor and so stop it, but we did not
redirect the trolley in order to push him into the tractor? (Kamm, 137)
This being the type of causal structure Kamm objects to, she allows this counterfactual to
limit the application of the DTE. The DTE must now be supplanted with what she calls
the Doctrine of Productive Purity (DPP) in such cases.
The DPP is Kamms most comprehensive of the doctrines, as it absorbs what she
takes to be the correct core of her earlier ideas and adds some further qualifications .The
inclusion of the word productive in this principle is essential, as we shall see Kamm
makes a questionable and controversial distinction between producing and sustaining the
greater good. The DPP is summarized as follows:
1. If an evil* cannot be at least initially sufficiently justified, it
cannot be justified by the greater good that it is necessary (given
our act) to causally produce. However, such an evil* can be
justified by the greater good whose component(s) cause it, even if

the evil* is causally necessary to help sustain the greater good or

its components.
2. In order for an act to be permissible, it should be possible for
any evil* side effect (except possibly indirect side effects) of what
we do, or evil* causal means that we must use (given our act) to
bring about the greater good, to be at least the effect of a [greater
good that] is working itself out (Kamm, 164).
Here is the new qualification this principle offers: given that an evil-involving act is
already sufficiently justified (by the DTE), the evil must not have a productive role in the
greater good (i.e. it must not create new conditions that causally involve a person against
their will). Such an action can have a sustaining role in the greater good, meaning it can
help advance the greater good already contingently in place. She seems to think as if one
case is a matter of creating an option, and the other is a matter of choosing an option
already in place. This is reflected by analogous language she uses when she says that it is
wrong to subordinate a person for the greater good, but not (always) to substitute one. For
instance in the Transplant Case, where five patients can survive by taking the organs
(vital ones included) from one man, this man is being subordinated in his status to serve
the interests of the five. (Kamm, 165). The thought is that in most of the Trolley Cases,
we are just switching victims already embedded in an evil situation. This distinction
seems flimsy and unclear, but it is still important to note it as a possible feature to
consider. The second part of the DPP just rehashes the causal structure that justifies an
evil-including act. The evil must be a side effect of the greater good and not something
used instrumentally to achieve it. However, this instrumental use seems to only come up
if the action has a causal structure (i.e. too direct) that Kamm does not like. In any case
the person is an instrument for saving the five, as they would not be saved without him.

We can see how, even under the new DPP, the controversial variation called the Loop
Trolley is still permitted. It can be summarized as follows:
Here a trolley is headed toward five people, and it can be
redirected onto another track where one person sits. However, the
track loops back toward the five. The trolley will either kill the five
in its original direction, or if we redirect it, it would kill the five
after it loops, were it not that the trolley hits the one person
(thereby killing him) and grinds to a halt (Kamm, 25).
If instead of allowing the trolley to perform a full loop one were to push someone in front
of the train, the situation becomes different. In allowing the loop to continue, one is
merely sustaining the greater good; in pushing someone in front of the train, one is
producing it. This only points out the queerness of Kamms emphasis on the causal
structure of an action. Here we push the victim, but it is now somehow permissible
because we have to wait (presumably a few seconds) for the train to come back around
and complete the intended course of action we set about through the initial push.
John Harris provides an especially thoughtful critique of Kamms theory. The core
of his objection lies in what he sees as the implausibility of there being any real moral
difference between doing something because the result will occur and doing it in order to
see that result come into fruition.
Suppose I am a pilot and if I fly with hangover I may crash the plane or, I
must testify in a crucial trial tomorrow and with a hangover I know I will
forget the relevant evidence. While it is true.... that I do not intend to have
the hangover, it will not be true that I am innocent of the consequences of
that hangover (Harris, 46).
Harris is essentially advancing a reductio argument that is asking, if am not responsible
for the consequences of an action simply because I do not desire or strictly intend the
consequences, how far can I stretch this logic? For it could well be that a bank robber

only intends to be put into a situation of fiscal security, and that the theft and violence
enacted was wholly undesired. Of course, this is a ridiculous defense for such an act.
While there is the component of the agent bringing about the moral wrong in the drunkpilot situation that there is not in the Trolley Case, there is a certain ring of truth in
Harriss claim: we seem to want to perform the act creating the most utility without
accepting the consequences of the rights-violation entailed.
Most of Harriss critique centers on the Triple Effect. Adopting Kamms
technique, he constructs a hypothetical case to demonstrate its implausibility. Two
brothers have a different illness. The first one (1) is a terminal illness in which the victim
experiences three weeks of pain and then death. The drugs ameliorate the pain but cause
him to die two weeks earlier. The other illness (2) is not terminal. It too causes three
weeks of pain but is instead followed by remission. Again, the only drugs to control the
pain for this period cause death after one week. Harris continues,
Tom suffers from illness (1) and Dick from illness (2). Is there any
difference in the ethics of effective pain control for the two brothers? In
each case the doctrine of double effect allows the doctor to say, and
sincerely intend, the same thing. 'I am intending to treat pain not to hasten
death.' Yet hastening death (killing) is something the doctors must do if
they are to relieve pain in each case. Kamm's doctrine of Triple Effect
would not help here because in either case the doctor would be acting
'because the drugs will relieve pain', and in neither case will she be acting
in order to bring about death or because death will result (Harris, 55).
The implication is that the DTE would permit using the drug in both cases whereas we
feel it should only be used in the first. Harris seems to think (or at least say) that the DTE
can take up only one factor at a time so that the only good to be considered is the drugs
relieving the pain (it thus draws the same conclusion and fails to register the two cases
sizable moral differences). It is probable that unless the victim wills his death or the pain

is simply unbearable, administering the drugs is the second case is impermissible, and I
highly doubt Kamm would assert otherwise. That said I do not think that this example
invalidates the usefulness of the because/in order to distinction (the Triple Effect); it
rather shows that it is contextually sensitive and is not meant to stand alone. Here,
administering the deadly drugs with foresight about Dicks imminent remission is no
longer an act aimed at a proportionately superior side effect, as Dicks survival almost
certainly trumps temporary pain. There needs to be additional considerations made,
however: the degree of pain, the quality of life for both of them, their projected
intentions, etc. While Kamm may or may not see her view as contextually sensitive, I
argue that this, along with a constraint against violating the rights of moral patients, is the
only way it can be useful. At that point it remains a tool (and only a tool) for deciding
moral conflict when fundamental rights are not involved.
Kamms version of patient-centered deontology is compelling for a number of
reasons. Placing the emphasis on the patient does away with the common worry that
moral acts are contingent upon the moral actors subjective emotional state. We have an
objective criterion for performing actions (the preservation of the victims rights) that can
withstand bad intentions but does not lapse into consequentialism. While I believe the
Doctrine of Triple Effect as conceived by Kamms actually goes against this idea, it still
remains a useful tool for deciding moral conflicts that do not involve incommensurable
rights. Despite the (rectifiable) flaws and inconsistencies noted, Kamms theory remains
both compelling and practicable.

Bibliography
Alexander, Larry and Michael Moore, "Deontological Ethics", The Stanford
Encyclopedia of Philosophy (Fall 2008 Edition), Edward N. Zalta (ed.),
<http://plato.stanford.edu/archives/fall2008/entries/ethics-deontological/>.
Accessed 4/4/09.

Harris, John. "The Doctrine of Triple Effect and Why a Rational Agent Need Not Intend
the Means to His End." Proceedings of the Aristotelian Society 74 (2000): 41-57.

Kamm, F. M. Intricate ethics. New York: Oxford UP, 2006.

Timmons, Mark. Moral Theory. New York: Rowman & Littlefield, Inc., 2002.