Ethical Decision-Making in End-of-Life Care: The Principle of Double Effect
Exploring the ethical complexities surrounding end-of-life care, this discussion delves into the principle of double effect as a framework for navigating morally challenging situations where protecting human life is paramount. It clarifies the concept of being pro-life, the unique value of each individual's right to life, and how this applies to contentious scenarios like euthanasia and the treatment of the terminally ill.
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Double Effect and End of Life Care Dr Gaven Kerr OP
Introduction Being pro-life means seeking to protect human life. But tricky practical situations often entail that sometimes not all lives at risk can be protected. This happens not just when there are strained hospital resources, on the battlefield, etc but also when met with moral dilemmas, e.g. ectopic pregnancies, the dilemma of choosing over the life of a fully grown human and the lives of thousands of frozen embryos, and indeed when deciding on end of life care.
The principle of double effect is an important principle which can be put to use in determining what is the right ethical course of action to be taken in such matters. Today I want to look at how the principle of double effect impacts on decisions pertaining to end of life care.
Structure (i) Being pro-life. (ii) The Principle of double effect. (iii) Application to end of life care.
Being Pro-Life It is important to clarify what it means to be pro- life, because confusion over this issue often results in disastrous moral decisions. To be pro-life means to seek to protect the life of anything that is subject to a right to life. Fundamentally that means taking whatever measures are in one s power to protect the life of something with such a right when it is one s duty to do so. Things which unequivocally have a right to life are persons.
A person has a right to life because every person is utterly unique. There is no more than one of any person who has ever lived. Thus, when a person comes along, something radically new comes into being; something never seen before and never to be seen again. To take the life of that person is to take something which is not yours to take (it doesn t belong to you), and to eradicate from the world something unique.
Confusion over the sorts of things that are persons often leads to confusion over what has a right to life. It is often stated that the unborn and newborns at an early stage of maturity are not persons because they are not conscious; and particularly for our purposes today, it is sometimes stated that the terminally ill who are unconscious are no longer persons. In all these cases it is argued that because they are not persons (the unborn, the newborn, the terminally ill), they are not subject to a right to life and so killing them is no more morally problematic than killing a fish or a tree.
But this is unreasonable. To be a person is to be a certain kind of thing; it is not to display certain abilities. So for instance, a thing which is two legged is still two legged even if that thing does not have use of its legs. To be a person is to be a rational kind of thing, i.e. a substance of a rational nature. One is that kind of thing irrespective if one is able to make use of one s rationality.
Human beings are the kinds of things that are rational; and so human beings are persons. Being in different states does not entail that the kind of thing we are dealing with is not a person. So for instance, water is a kind of thing which is H2O. It can be in different states, i.e. solid, liquid, and gas; and whilst in these states water can do different things, e.g. a bath tub full of water in a solid state could crush somebody, but in a liquid state does not.
Similarly for a person, such a thing can be in a different state at different times, e.g. from conception right up until full maturity, when awake, when asleep, when unconscious etc. Yet that thing remains the same, i.e. it remains a person. So throughout its life a person remains a person which can be in different states whilst remaining the same kind of thing. Therefore, so long as we have a human thing, we have a person, and that person is subject to a right to life.
The Principle of Double Effect Briefly stated the principle is this: An action can have foreseeable but unintended consequences for which one is not morally responsible so long as the direct intention of one s action is morally acceptable. What this means is that you can perform an action which action is good and proper, and even though it has consequences which may well have been foreseeable, it was not those consequences which you were seeking to attain, and so you are not responsible for their coming about.
So for example, a parent goes into the kitchen and sees a child trying to pull the pot of boiling water over himself. The parent runs and pushes the child out of the way; the child falls and cries. What was the parent doing? The parent was rushing to save the child from being scalded; that was his or her intention. The child s falling and crying are a consequence, perhaps foreseeable, of that action, but it is not what the parent was trying to achieve. If the parent was trying to make the child fall and hurt himself, then indeed the parent would be morally culpable, but that s not what the parent was trying to do.
The same reasoning goes for pregnancy cases where there is an ectopic pregnancy (or a need for cancer treatment). What are we trying to do when we remove an ectopic pregnancy (or treat cancer which results in termination of pregnancy)? Are we trying to terminate the pregnancy or treat the patient s illness? In order to answer this we ask: if the child survived, would the procedure be a failure?
If we are treating an illness, the survival of the child does not render the treatment a failure (what makes it a failure is the treatment not working), but if we are trying to end the life of the child, the child s survival renders the treatment a failure. So in ectopic pregnancies (and treatment of cancer) if by some miracle (or technological advance) the child survives, we don t think the treatment a failure because of that; but in the case of abortion, the child s survival means the procedure is a failure. Therefore, in ectopic pregnancies and treatment of cancer and other such cases, what we intend is saving the life of the patient and the ending of the pregnancy is often a foreseeable but unintended consequence of the action yet one for which we are not morally culpable.
This doesnt mean that we cease to be pro-life, because in all these instances out intention was not to end the life of the child. We were not aiming or trying to end the life of the child (just as the parent who pushed the child out of the way of scalding water was not trying to push and hurt the child). The same goes for what are called trolly problems: you are in a burning building and you have to choose between a five year old or thousands of frozen embryos. The choice for the 5 year old does not mean that you value the frozen embryos any less, because in choosing one you are not directly intending the death of the other (that is a foreseeable but unintended consequence of your action).
End of Life Care All of this is important for the consideration for end of life care. The first thing to be noted here is what we have said about the right to life of a person: so long as we have a thing that is human, we have a person, and so that entity is subject to a moral right to life. Our treatment of that entity then has to respect the right to life of that entity. Accordingly, we cannot justifiably end the life by direct intention of the terminally ill who have lost consciousness, the severely disabled, or newborns with severe medical complications. Such actions would not respect the right to life of the people in question.
But what then about our treatment of those who are terminally ill? We consider three general scenarios: (i) cases where medical support ceases and a patient is left to die. (ii) cases where drugs are administered which have the effect of shortening the patient s life. (iii) cases where food and water are withheld from the patient.
Cases where Medical Support ceases and a Patient is Left to Die Often it is the case that a person reaches the end of their life and were it not for the medical support being given, the patient would die naturally. Such treatment is extraordinary such that it is not rectifying some problem from which after a period of recuperation the person would be able to recover and go on living. Rather in such cases the life of the person is ending and the medical treatment is prolonging it. Choosing to cease medical treatment in such circumstances is not a case of directly intending that the patient die, i.e. it is not undertaking a course of action so as to bring about the death of the patient, e.g. by administering a lethal dose of drugs. Rather it is to end a particular kind of medical support keeping the patient alive, but not to end all life giving support e.g. food and water. The principle of double effect is at work here since the death of the patient is not the direct intention of the action, but the foreseeable yet unintended consequence.
Cases where Drugs are administered which have the Effect of shortening the Patient s Life It is often the case that the administration of certain pain relief can shorten a patient s life. The argument is made that just as the administration of such drugs hastens the death of the patient, so does a lethal dose, only the lethal dose does it a lot sooner. So why is the administration of life shortening pain relief ok but a lethal dose is not?
The difference in these cases is that when we administer pain relief drugs what we are trying to do is relieve pain, not kill the patient. The death of the patient at an earlier time as a result of the drugs may be a foreseeable consequence of such drugs, but it is not what we are seeking to attain. Our action would be a success so long as pain is relieved, even if the patient made a miraculous recovery. On the other hand, the purpose of administering a lethal dose is not to relieve pain but to bring about death. If a miraculous recovery were made, the latter action would be a complete failure (since death was not achieved); whereas in the pain relief scenario it wouldn t be a failure. Thus, they are two different actions, and in the pain relief case double effect is at work such that death is not the direct intention of our action though it may be a foreseeable but unintended consequence.
Cases where Food and Water are withheld from the Patient We proceed to the final case which is perhaps the most straightforward yet in practice is the most controversial. So let s say we have removed medical support from a patient and we know that the patient will soon die. Often it is assumed that if we have removed medical support so that the patient can die naturally, we can also remove food and water as well; these being seen as somewhat akin to medical support. The difference between these two cases is as follows.
To begin with, food and water are not extraordinary medical care preserving the life of a patient who would otherwise naturally die. Food and water are the basic necessities of life. The removal of extraordinary medical care is consistent with respecting the right to life of the person because the removal of such care is not an action the direct intention of which is to bring about death. No matter what interpretation you offer, the removal of food and water, the basic necessities of life, is an action the direct intention of which is to bring about the death of the patient through starvation or dehydration.
Furthermore, the removal of food and water from a dying patient cannot possibly respect the right to life of that patient. Dying or not, every human being has a right to life. If a person is under one s care, one has a moral obligation to provide the necessities for life of that person. This fundamentally means providing the person with food and water. This is expected of parents for their children and of society for its members. The patient is in the care of medical professionals, and so such professionals have no less an obligation to ensure that the patient is given adequate food and water, regardless of whether or not the patient is dying.
The withholding of food and water to a dying person over whom one has responsibility constitutes a serious moral evil, since it is by direct intention an action which seeks to end the life of the person. And as we have seen, such an action by direct intention is one for which there can be no justification.
Conclusion Being pro-life entails seeking to protect the lives of those subject to such a right; minimally this involves protecting the lives of all human beings. But we often find tricky moral situations within which it is impossible to protect all such lives. The principle of double effect comes in here such that the direct intention of our action can never be to end the life of one subject to a right to life, yet often an unintended consequence of such action can be that a life is ended anyway. One is not responsible for such a tragedy, since the ending of that life is not that for which one was striving.
