The double effect is no doctrine: It’s a reflective tool

Palliative care teams have many difficult ethical issues to consider, as do patients’ families, and these ethical decisions often involve legal issues. Derek Willis, Medical Director, Severn Hospice, Shropshire, UK, and Rob George, Medical Director, St Christopher’s Hospice, London, UK, explain the background to their two-part article published in the July/August and September/October issue of the European Journal of Palliative Care

Professor Derek Willis

Professor Rob George

The doctrine of double effect (DDE) is an ethical and legal term that is loved and loathed in equal measure. To some it’s a way of protecting a practitioner when prescribing drugs appropriately where side effects may happen; to others it’s a way of justifying bad practice. Our articles aimed to clear this matter up and explain that it’s a reflective tool rather than a dogma to be followed slavishly, or some weak excuse for mischief. DDE is applicable in medicine when a therapeutic action runs the risk of leading to a bad outcome. It makes a practitioner blameless if the following criteria are satisfied:

  • the intended act itself is good or at least indifferent.
  • the bad effect is not a means to the good effect.
  • the good effect and not the bad effect (while foreseeable) is intended.

And, importantly:

  • the cited reason(s) for justifying the bad effect are proportionate.

We contend that these four criteria give pegs to structure a practitioner’s reflection upon the robustness of the planned action rather than view them simply as boxes to be ticked so that a treatment is defensible ethically or legally.

The area that we examined in detail in the second article was the mythology of opioid and sedative prescribing and its classical linkage to DDE. In the case of opioids, the ill-informed construe them to shorten life as a matter of course and that DDE helps because it offers a moral defence for a patient to be pain free even if it ends up shortening the patient’s life. In fact, opioid prescribing does not shorten life and, if anything, it lengthens it when prescribed appropriately; in short, DDE has no role here. We also examine whether DDE can be used to justify overdosing or bad prescribing: it cannot.

The doctrine of double effect has been around for a long time and will be around for as long as treatments with side effects remain necessary. Its use is therefore crucial, narrow and, like any moral lens, requires, precision in its focus and usage.

Read the full articles in the European Journey of Palliative Care 

This post relates to ‘The double effect is no doctrine: It’s a reflective tool – parts one and two’, by Rob George and Derek Willis, published in the July and August and September/October 2017 editions of the European Journal of Palliative Care (EJPC), (vol. 24 (4) (5).

If you have a web-based subscription to the journal you’ll be able to download this issue, plus all articles in the journal archive. You can also browse the archive and download articles by taking a 10-minute or 30-minute subscription. Members of the EAPC receive discounted subscription rates to the journal – click here to subscribe online.

Read more posts relating to articles published in the European Journal of Palliative Care on the EAPC Blog

More about the authors

Derek Willis is Medical Director of Severn Hospice, Shrewsbury, Shropshire, UK and Professor of Palliative Medicine at University of Chester, Chester, UK. Contact Professor Willis by email. 

Rob George is Medical Director of St Christopher’s Hospice, Professor of Palliative Care, King’s College London and Consultant in Palliative Care at Guy’s and St Thomas’s hospitals, London, UK. Contact Professor George by email.

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