Critique of the Double Effect
Monday, December 11th All Things Considered

NPR's Elizabeth Arnold moderates a discussion between Dr. Timothy Quill, Professor of Medicine and Psychiatry at the University of Rochester School of Medicine and Dentistry, and Dr. Daniel Salmasey, Director of the Center for Clinical Bioethics and Associate Professor of Medicine at the Georgetown University Medical Center. They take up the doctrine of "double effect" that holds that an effect that would be morally wrong is it were caused intentionally is permissible if unintended, even if forseen. The principle has guided physicians for centuries in the cases of giving drugs to patients for the relief of distressing symptoms while at the same time running the risk of hastening their deaths. Dr. Quill's critique of the Rule of Double Effect appears in this week's (Dec. 11) issue of the New England Journal of Medicine.


ELIZABETH ARNOLD, HOST: And I'm Elizabeth Arnold. Imagine this scene at the bedside: you're a physician and your patient, who's dying of cancer, is in extreme pain. Your patient is having some trouble breathing, but the chief complaint is pain. A powerful drug is available for you to use -- one that will certainly control the pain and make your patient comfortable -- but one that also runs the risk of shortening your patient's life. Do you use the drug in that way?

This is an ethical dilemma physicians and patients have struggled with for centuries, often under the guidance of the ethical principle known as "double effect." Historically, the principle grew out of Roman Catholic moral theology and holds that an effect that would be morally wrong if it were caused intentionally is permissible if unintended, even if it's foreseen. In other words, in the case of your patient with cancer, if your intent is to control your patient's pain, you can go ahead and use the powerful drug, even if you run the risk of shortening your patient's life by so doing. In today's issue of the New England Journal of Medicine, the principle of double effect is the subject of a critique written by Dr. Timothy Quill, professor of medicine and psychiatry at the University of Rochester School of Medicine and Dentistry. He joins us from Chicago. Dr. Quill, welcome.


ARNOLD: And with me here in Washington is Dr. Daniel Salmasey, director of the Center for Clinical Bioethics and associate professor of medicine at Georgetown University Medical Center. Dr. Salmasey, welcome to you.


ARNOLD: Timothy Quill, let's start with you. Explain to us your reservations about this principle.

QUILL: Well, for the particular clinical situation that you were describing, actually the double effect is quite helpful. It allows the physician to progressively increase pain medicine, perhaps even use sedation, as long as his or her intent is to relieve the patient's suffering, even if it might contribute to an earlier death. And this has liberated us, I think, to not be fearful about using whatever dose of pain medicine is needed. But take a slightly different scenario. Let's say that that patient is near death and starts talking about wanting to die -- being ready to die -- in fact, wanting to go to sleep to die. All of a sudden, if they start talking about wanting to die, and that is their intent in taking higher doses of pain medicine, then it creates a more difficult dilemma for the clinician because they're not supposed to intend to help somebody to die.

So the double effect rule places a premium of importance on the physician's intentions, but really a much lesser role of the patient's will, their informed consent, which is a much more important consideration.

ARNOLD: Dr. Salmasey?

SALMASEY: Well, I agree 100 percent with Dr. Quill that the situation you described is one in which narcotics should be used judiciously and appropriately for patients in those circumstances. But I think that one of the problems I have with the paper, and Dr. Quill's other comments sort of allude to that, is that the paper in some ways generalizes the use of this principle, somewhat outside of the bounds in which it's typically intended to be used.

So for instance, desire to die is not a symptom that a drug controls. And so, I wouldn't think that we should, under those circumstances, be giving people drugs because it's their desire to die, and that the principle of double effect would actually not allow it under those circumstances.

If he's talking about, for instance, giving people who have no real symptoms, but simply say that it's now a point where I think I'm going to be dying in the next six months and I want to take a large dose of drugs so that I can die quickly, then I think that's the same as physician-assisted suicide. And that would be stopped by the principle of double effect anyway, because the intention that's shared in both cases is that the patient should die.

ARNOLD: Dr. Quill, same as physician-assisted suicide?

QUILL: I don't think suicide is the right term for any of these circumstances, but I think the focus needs to be on the patient's will; their informed consent; the adequacy of palliative care; the nature and severity of their suffering. And if a person starts talking about wanting to die, it seems to me we have an obligation to listen to them and try to respond to them.

ARNOLD: Dr. Quill, in your article, you talk about the difficulty in evaluating a physician's intention. Is it really that -- that difficult to distinguish between intending to kill someone and not intending to?

QUILL: Well, the double effect makes a distinction between a death that is intended and one that is merely foreseen, but not intended. And it's OK if death is foreseen, but not intended, but not if it is done intentionally. And that works in circumstances of usual pain management, where we are taking the risk of providing high doses of pain medicine, but it is neither the doctor's intent nor the patient's intent to help a patient to die. We accept that risk and we use amounts that seem to be in proportion to their suffering. Severe suffering, we take more risk with higher doses.

But the whole equation begins to change when the patient starts talking about wanting to die because then what does it mean when you start giving very high doses to someone in that same circumstance who wants to die -- and can you still say that you're not intending to help them to die, when that's their purpose in taking -- that's one of their purposes in taking their -- this higher dose of medicine?

So in fact, all -- we know -- what we know about intentions from psychology is that they are complex; they're multi-layered; at times, ambiguous. And the double effect thinks of intentions in black and white terms. They're either present or absent. And that is very problematic in the real world of clinical medicine.

ARNOLD: Do you agree with that, Dr. Salmasey?

SALMASEY: Well, I certainly agree that it's very difficult to get inside somebody's mind and read their intentions. I mean, there's no question about that. But I'm troubled by this sort of obfuscation about intentions that sometimes seems to come across in comments from Dr. Quill and within the paper. There's a great quote from Samuel Johnson who once said that, you know, "the fact of dusk does not mean there's no difference between night and day." And if you're giving -- when I give morphine to patients, I think part of the problem is that most -- I'm giving more than most of the clinicians around me who aren't, I think, giving enough of the drug to patients to relieve their pain. And my intention in doing -- in doing that is to relieve their pain. If I give them 10 milligrams or 20 milligrams of morphine and they've never had some before, that's perfectly all right and it's better than giving them two. And I may slightly increase the possibility that they may die more quickly that way.

On the other hand, if I walk up to you, Elizabeth, and you know, inject three grams of morphine over 10 seconds into your veins, any clinician worth his salt would say that that's, you know, way over the amount that's appropriate for treating you if you had a stubbed toe, and that this is problematic and they would question what my intentions are. And it would seem very obvious that my intentions were not simply to relieve your pain in that circumstance. So while there is some ambiguity, and I think we ought to give good clinicians the benefit of the doubt using their judgment, we still ought to reserve the possibility of being able to judge people's intentions on the basis of their actions. And sometimes, it's very clear.


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