Critical care decisions in fetal and neonatal medicine: ethical issues
Relieving pain and causing death: the doctrine of the double effect
2.38 Measures to end life could include the administration of a chemical that has no other purpose than to end life, such as a lethal injection of potassium chloride. Medicines such as sedatives and analgesics can also have the effect of hastening death, particularly if given at higher doses. Death may therefore occur in cases where doctors provide such treatments with the intention of reducing pain and suffering. The acceptability of administering pain-relieving drugs that may also bring about death is debated under the doctrine of double effect (see Box2.2). The Working Party takes the view that, provided treatment is guided by the best interests of a baby, and has been agreed in the joint decision-making process (paragraphs 2.42–2.57), potentially life-shortening but pain-relieving treatments are morally acceptable.
| Box 2.2: Doctrine of double effect This principle governs the permissibility of actions that have two outcomes, one good and the other bad. The principle states that an action of this kind may be permissible provided the bad outcome is only foreseen, not intended, and is proportionate, that is, the bad that could be caused is not such as to outweigh the good intended.*The principal critics of the doctrine question whether there is a robust moral difference between intending and merely foreseeing an outcome, a difference which would be sufficient to show the permissibility of the act or to excuse the agent.† However, it is important to acknowledge that the principle does not permit cases in which an action has two outcomes, both intended. Thus administering a high dose of pain relief with no intention to kill but with an awareness of the possibility of it hastening death is permitted under this principle, provided the foreseen possibility of death is viewed as ‘proportionate’. By contrast, administration of the same dosage of analgesic with the clear and deliberate intention of bringing about death would not be permitted. Hence if a doctor administers a high dose of pain relief to a newborn baby aiming to hasten death, then what the doctor does could reasonably be described as a deliberate act of killing. The principle of double effect would not be applicable in such a case. The British Medical Association (BMA) has noted that doctors may fear that their motives in providing pain relief could be misinterpreted, but advises that “if the intention is clearly to relieve pain and distress and the dosage provided is commensurate with that aim, the action will not be unlawful”.‡The BMA also emphasises the importance of good symptom control.
† Kuhse H and Singer P (1985) The doctrine of double effect, in Should the Baby Live? The Problem of Handicapped Infants (Oxford: Oxford University Press), pp 85–6. |