Professional Documents
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R
ECENTLY, the rule of not bring about the possible good ef- wrong to intend that a patient die by
double effect, which fect by means of the possible bad ef- way of ones clinical act, then there
has a long history in fect, and (4) is undertaken for a pro- is no need to bother with the rule of
ethics, especially portionately grave reason.4-8 This double effect. However, millions of
medical ethics, has moral rule has wide application, but American health care professionals
come under serious criticism in the has played a particularly important and patients are morally opposed to
medical literature.1,2 Because of its role in the care of the dying, allow- euthanasia and assisted suicide. For
immense practical importance in the ing those who are morally opposed such individuals, we argue, the rule
care of dying patients, any attack on to euthanasia and assisted suicide to of double effect is perfectly coher-
this rule must be taken seriously. In provide adequate pain relief with- ent and of great clinical impor-
this article, therefore, we present a out violating traditional medical mo- tance.
systematic rejoinder to what we take rality or their consciences.
to be serious misunderstandings of Treating dying patients in pain LOGICAL INCONSISTENCIES
the nature and use of this rule. with appropriate doses of morphine WITH POTENTIALLY
A clear understanding of the is generally done in a manner that sat- DELETERIOUS EFFECTS
proper use of the rule of double ef- isfies the criteria for double effect. The ON PATIENT CARE
fect is essential if health care profes- use of morphine (1) is not in itself im-
sionals are to maintain their opposi- moral; (2) it is undertaken only with Undermining the rule of double ef-
tion to euthanasia and assisted suicide the intention of relieving pain, not of fect has the potential to affect the
and yet provide adequate pain relief causing death through respiratory de- care of the dying adversely, since
to dying patients. Many Americans, pression; (3) morphine does not re- most physicians report that they are
including health care professionals, lieve pain only if it first kills the pa- personally reluctant to perform eu-
are fearful of unwittingly participat- tient; and (4) the relief of pain is a thanasia or assisted suicide even if
ing in euthanasia if a patients death proportionately grave reason for ac- it is legalized.9-12 Some of the critics
is hastened, however unintention- cepting the risk of hastening death. of double effect seem to want things
ally, as a side effect of attempts to re- Some physicians, who are opposed to both ways. They acknowledge that
lieve pain and suffering. For such in- euthanasia and assisted suicide, might the rule of double effect may be use-
dividuals, the rule of double effect avoid giving opioid analgesics to dy- ful as a way of justifying adequate
provides moral reassurance and thus ing patients out of fear of hastening pain relief and other palliative mea-
encourages optimal care of the dy- death and committing euthanasia. sures for dying patients.1 But at the
ing. This is why the rule figures According to the rule of double effect, same time, they argue that this moral
prominently in the opinions of the however, the appropriate and com- rule is not credible.
American Medical Association.3,4 passionate use of morphine is mor- The rule of double effect is ei-
ally permissible even for those who ther valid or invalid. It cannot be
NATURE AND CONTENT are morally opposed to euthanasia both. If the rule of double effect
OF THE RULE OF DOUBLE and assisted suicide. This rule al- is, in fact, logically and morally valid,
EFFECT lows physicians opposed to euthana- then the most helpful policy for
sia and assisted suicide to treat pain patients would be to educate phy-
Although variously formulated, the adequately in these situations with a sicians about its proper applica-
traditional rule of double effect speci- clear conscience. tion. Those who already approve of
fies that an action with 2 possible ef- euthanasia and assisted suicide can-
fects, one good and one bad, is mor- THE UNDERLYING ISSUE not logically be opposed to giving
ally permitted if the action: (1) is not drugs in a manner consistent with
in itself immoral, (2) is undertaken If one believes that euthanasia and the rule of double effect. They might,
only with the intention of achieving assisted suicide are sometimes mor- in addition, want to give lethal doses
the possible good effect, without in- ally permissible, then the rule of or administer other lethal treat-
tending the possible bad effect even double effect has no role to play in ments, but they cannot be opposed
though it may be foreseen, (3) does the care of dying patients. If it is not to relieving pain. By educating phy-