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

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ARNOLD: What about the patient's autonomy? Certainly, there are limits to that, aren't there? If a patient comes to you with a headache and asks for an MRI, presumably you'd say no. If a dying patient asks you to shoot them, presumably you'd say no.

QUILL: Sure, there are many limits to that. The patient's informed consent and autonomy is just -- is one element of many. Another element is the nature and extent of their suffering. How severe is it? How effective are our means to relieve it? And the third is, and this is one element of the double effect rule with which I am in complete sympathy, and that is that the intervention has to be proportionate to the situation.

So again, with small amounts of pain, you may take the risks of small amounts of pain medicine, but with severe suffering at the very end -- severe pain -- you may take the risk of very, very large doses of pain medicine. So proportionality is -- and the nature of suffering -- are also key elements, as well as autonomy. It's not simply a matter of autonomy.

SALMASEY: I -- I think that we also want to be careful that we're using the right medication to treat the right symptom, or the right modality of treatment for the proper symptom. Suffering is much broader as a concept than pain, and Dr. Quill and I will certainly agree on that. Not all people who have pain are suffering, and not all suffering is -- has pain as its root cause. So when the patient's problem is pain, I'm going to give them a narcotic or other drug that's designed to treat their pain. If their problem is depression, I'm not going to use narcotics to treat that depression. I'll use an anti-depressant. If their problem is existential angst, or as the Dutch say, "tiredness of life," I'm not sure that we have a drug that treats those sorts of things.

Maybe what the patient needs in those circumstances is somebody who's going to not abandon them -- be at the bedside with them; remind them that they have dignity and value and meaning, even as the bonds that keep them and us together are slowly dissolving. I mean, that's the kind of thing that the patient may really be asking for, and that's the kind of treatment we ought to be giving people.

And I worry sometimes that with all the talk about physician- assisted suicide and euthanasia, we're -- we're really jumping the gun. There's so much more work we have to do in making the care of the dying better that we ought to be putting much more of our energy into doing that, rather than focusing on this particular case of one modality of euthanasia or assisted suicide.

ARNOLD: Dr. Quill?

QUILL: Yeah, in general, I actually agree with that. I think we need to improve care of the dying. We need to improve access to hospice programs and good pain management. Those are all things that we need to devote -- and I think we are beginning to devote resources to this as a culture. But we also need to learn how to really listen to people who are getting good care -- have access to these things -- but still are suffering in ways that are very extreme at the very end. And they achieve a readiness for death. They are ready to die.

And again, if they're on life supports, for example, we deal with that conversation very explicitly. We say -- the message we give to clinicians is: "listen to your patient because generally they know what they need. Listen to them very carefully. Assess them for depression and other things, but listen to them."

If they're not on life support, suffering in otherwise exactly the same way, the message is very different, and I think the message should be the same: "listen to that patient." Try to find every alternative you can to help them keep living, but if there are no alternatives and the suffering is extreme, I think we have to be much more creative and open- minded in our response. There's nothing magical about assisted suicide as a response, but there is something very important about not abandoning such patients and really searching with them for acceptable solutions. So if not assisted suicide, then what? And we're beginning to open up some other ways of potentially responding to that that may be important and may allow a compromise between those who have different beliefs about this narrow issue.

ARNOLD: Well on that, I think you two agree. Gentlemen, I want to thank the two of you for talking with us today.

Dr. Timothy Quill is professor of medicine at the University of Rochester School of Medicine, and was the lead physician plaintiff in a New York State legal case challenging physician-assisted suicide. His critique of the rule of double effect appears in today's issue of the New England Journal of Medicine. Dr. Daniel Salmasey is the direct of the Center for Clinical Bioethics and associate professor of medicine at Georgetown University Medical Center. He's a senior research scholar at the Kennedy Institute of Ethics. For listeners who want more information or more reading on this topic, join us at our website,

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