Principle Of Double Effect Research Articles

Sedation or the limits of palliative care – ethical questions

Summary Sedation in palliative medicine continues to elicit questions that sometimes confound even the most experienced caregivers. We begin by examining the boundaries between sedation and euthanasia. The ethics at stake in palliative sedation are almost systematically constructed with the perspective of polemic debates on euthanasia, especially in situations where sedation is wrongly qualified of “terminal”. Perhaps out of fear for a possible confusion between sedation and euthanasia, current recommendations appear to be more of a formalization of the double-effect principle. But the double-effect principle and the principle of intentionality also have their limits. This will prompt us to examine the notions of consent and autonomy. Sedation questions what might be deemed “ideal care”, exposing the limits of palliative medicine: limits to defining a refractory symptom, limits to defining and relieving existential distress, limits to the ethical validity of prognosis, limits to the ideal of a “pacified” death, limits to maintaining a relational life until death. Sedation highlights a triple paradox: benevolence and autonomy vs. maintaining relationships, failure to relieve vs. idealized pacified death, clinical uncertainty vs. ultimate medicalization of the end of life. To prevent the risks of underestimating distress or hastening to relieve, two qualities should be cultivated: availability as a necessary openness to otherness and vulnerability; and resisting the temptation of reducing the ethical legitimacy of sedation to its decisional process.

Lessons From a Backache

Lessons From a Backache

The Principle of Double Effect and Safe Sex in Marriage: Reflections on a Suggestion

The Principle of Double Effect and Safe Sex in Marriage: Reflections on a Suggestion

The Principle of Double Effect and Safe Sex in Marriage: Reflections on a Suggestion

The Principle of Double Effect and Safe Sex in Marriage: Reflections on a Suggestion

Preemptive kidney transplantation: an ethical challenge for organ allocation policies.

Preemptive transplants are advisable in advanced stages of kidney disease. The clinical advantages of preemptive transplantation over dialysis are evident. Nevertheless, preemptive transplantations raise ethical concerns, particularly regarding the allocation of medical resources. The present article proposes some criteria for organ allocation policies regarding preemptive transplantations: criteria regarding medical benefit and justice are absolutely essential when addressing the issue of organ allocation, but other ethical values should also be taken into account. The "principle of double effect" offers useful pointers.

Opiates and the Removal of Life Support

Medical and nursing personnel have an obligation to provide the medication necessary for every patient’s pain relief. This includes patients whose life-supporting mechanical ventilation is being removed, who may not exhibit traditional signs of pain or dyspnea. The purpose of this paper is not to argue a position on withdrawing life support. Rather, it argues that nurses and physicians have an obligation to provide pain-relieving medication, such as opiates, when life support is removed, to ensure that those entrusted to their care do not experience pain or significant distress. This is based on the principle of double effect, by which two actions, one intended and one unintended, may be permissible if there is a proportionate reason. The goal in these situations is never to hasten death intentionally but to make patients’ pain and suffering tolerable as a matter of compassionate and loving care.

Controlled drugs and the principle of double effect: the role of the district nurse.

The role of district nurses in the effective management of pain in palliative care has been strengthened by the Misuse of Drugs (Amendment No.2) (England, Wales and Scotland) Regulations 2012 that allow district nurses who are independent or supplementary prescribers to prescribe and administer controlled drugs. However, prescribing controlled drugs brings increased responsibility and accountability for the safe management of these medicines. In this article Richard Griffith considers the principle of double effect that seeks to ensure that patients in intractable pain receive the analgesia they require to manage that pain while district nurses avoid liability and prosecution under the law of murder.

Draper, Kai. War and Individual Rights: The Foundations of Just War Theory.New York: Oxford University Press, 2015. Pp. 272. $65.00 (cloth).

Draper, Kai. <i>War and Individual Rights: The Foundations of Just War Theory</i>.New York: Oxford University Press, 2015. Pp. 272. $65.00 (cloth).

Respect, Coercion, and Religious Reasons

AbstractIt is often assumed that people of faith should not endorse a law for religious reasons, since such an endorsement is considered to be disrespectful. Such a position is increasingly opposed by scholars who argue that such demands unjustifiably force people of faith to compromise their religious ideals. In order to defend their opposition to such demands, some scholars have invoked thought experiments as reductio arguments against the claim that endorsing laws dependent on religious reasons is necessarily disrespectful. I argue that these attempts have failed, and present an alternative thought experiment that demonstrates that such a law is not necessarily disrespectful. Because I conclude that previously proposed principles cannot defend this conclusion, I defend an alternative way of accommodating this intuition; a post‐secular deliberative approach based on the principle of double effect.

La sédation continue jusqu’à la mort. Une voie française pour les soins de fin de vie ?

Continuous sedation until death (CSUD) is a practice which has developed recently in several countries, appearing more acceptable than euthanasia and medically assisted suicide, since more close to a "natural death". The French parliament has just adopted a law which stipulates CSUD on request of the patient in a definite number of circumstances, especially in incurable diseases near to the terminal stage with suffering refractory to treatments. Thus France has adopted a unique international position for the end-of-life care. However several ethical problems raised by CSUD, which corresponds to a psycho-social death preceding the biological one, have been raised in the literature. The legitimacy of CSUD, especially if sedation is deep and not proportional to the degree of suffering, or if it is performed in case of a purely existential distress, is a matter of discussion. The primacy allocated to autonomy is questionable for the more vulnerable patients, who deserve mainly a social solidarity. The double-effect principle is replaced actually in CSUD by a co-intention both to relieve suffering and meanwhile eventually to hasten death, especially when stopping nutrition and hydration. CSUD is thus located in a grey zone between palliative care and euthanasia.

Humanae vitae, Rape and the Zika Virus

Zika virus infection in a pregnant woman may cause severe brain malformations (microcephaly) and other birth defects in her child, and women living in or traveling to areas where it is endemic are urged to postpone pregnancy. Do the dangers posed by microcephaly justify the use of contraceptives under the principle of double effect? The author discusses ambiguities in Humanae vitae n. 14 and the claim that the use of contraceptives was approved by Pope Paul VI for nuns at risk of rape, and uses the principle of double effect to show that the answer to this question is no: the use of the anovulant pill by married couples for the purpose of preventing conception of a microcephalic child cannot be licit.

Caught in a Non-Kosher Pickle.

Caught in a Non–Kosher Pickle Anonymous Two1 I want to share two stories that come from my work at a Catholic hospital. Both stories concern matters of reproductive ethics. It is well known that the Catholic Church has special commitments regarding the protection of prenatal life. These and other ethical commitments are spelled out in the Ethical and Religious Directives for Catholic Health Care Services—better known as the “ERDs.” All Catholic hospitals are expected to follow the ERD’s. At least three principles from the Catholic tradition are relevant to the stories I’ll share. I will try to translate them into lay terms without distorting their essence. First, from the time of conception until a natural death, all human life is sacred and deserves protection. So in the sphere of reproductive ethics this means that we have to be as concerned about the dignity of the fetus as the dignity of the mother. Second, under certain conditions an act may be performed that has foreseen good and bad effects. Crucially, the bad effect cannot be intended and nor can it be the means by which the good effect is accomplished. Further, there must be a proportionately serious reason for performing the act. This is called the principle of double effect. Third, sometimes an individual or institution may cooperate with the wrongdoing of others. Cooperation is more likely to be permissible when it is as far removed from the act as possible. And again, the wrongdoing cannot be intended by the cooperating party. This is called the principle of material cooperation. It is, for example, the principle used to justify paying taxes even when the government engages in some actions that the Church deems immoral. These principles have been in use for hundreds of years in Catholic moral theology. Case 1: A Prolapsed Umbilical Cord The first story I want to share concerns a woman who was 20 weeks pregnant. She arrived at the hospital with an overt prolapsed umbilical cord. This means the umbilical cord dropped through the cervix into the vagina. She was not in labor. Both her primary OB and a consulting OB agreed it was not possible to place the cord back in the uterine cavity. Neither believed the baby would survive. Both were concerned for the well–being of the mother. They called the cord a “wick” meaning it would expose the mother to infection. Ordinarily labor would be induced. However, the ERDs have two directives directly relevant to this case. First, “For a proportionate reason, labor may be induced after the fetus is viable (Dir 49).” In this case both obstetricians agreed the baby was not viable. Second, “Operations, treatments, and medications that have as their direct purpose the cure of a proportionately serious pathological condition of a pregnant woman are permitted when they cannot be safely postponed until the unborn child is viable, even if they will result in the death of the unborn child (Dir 47).” This directive rests squarely upon the principle of double effect. So any action that [End Page 13] would end the life of the baby prematurely needed to have a proportionately serious reason. Both physicians agreed that the prolapsed cord posed a serious threat to the mother. However, the consulting obstetrician, who was a very conservative Catholic, felt that the ERD’s would not permit induction of labor until the mother showed signs of fighting an infection such as elevated fever. The hospital lawyers and I disagreed with this position; however, the consulting obstetrician was adamant. He also was in regular communication with the local bishop’s office. Administration was deeply concerned that the procedure might be described as an abortion and the bishop would initiate disciplinary actions against the hospital. In the end, the mother’s primary obstetrician transferred her to another hospital and induced labor within the hour. I had advised the hospital in a manner I believe was true to the hospital’s faith tradition and my own conscience. But I knew that my advice increased the hospitals risk of disciplinary action. It was a profoundly uncomfortable situation. It may have adversely affected my reputation among the more conservative elements at...

Caught in a Non–Kosher Pickle

Caught in a Non–Kosher Pickle Anonymous Two1 I want to share two stories that come from my work at a Catholic hospital. Both stories concern matters of reproductive ethics. It is well known that the Catholic Church has special commitments regarding the protection of prenatal life. These and other ethical commitments are spelled out in the Ethical and Religious Directives for Catholic Health Care Services—better known as the “ERDs.” All Catholic hospitals are expected to follow the ERD’s. At least three principles from the Catholic tradition are relevant to the stories I’ll share. I will try to translate them into lay terms without distorting their essence. First, from the time of conception until a natural death, all human life is sacred and deserves protection. So in the sphere of reproductive ethics this means that we have to be as concerned about the dignity of the fetus as the dignity of the mother. Second, under certain conditions an act may be performed that has foreseen good and bad effects. Crucially, the bad effect cannot be intended and nor can it be the means by which the good effect is accomplished. Further, there must be a proportionately serious reason for performing the act. This is called the principle of double effect. Third, sometimes an individual or institution may cooperate with the wrongdoing of others. Cooperation is more likely to be permissible when it is as far removed from the act as possible. And again, the wrongdoing cannot be intended by the cooperating party. This is called the principle of material cooperation. It is, for example, the principle used to justify paying taxes even when the government engages in some actions that the Church deems immoral. These principles have been in use for hundreds of years in Catholic moral theology. Case 1: A Prolapsed Umbilical Cord The first story I want to share concerns a woman who was 20 weeks pregnant. She arrived at the hospital with an overt prolapsed umbilical cord. This means the umbilical cord dropped through the cervix into the vagina. She was not in labor. Both her primary OB and a consulting OB agreed it was not possible to place the cord back in the uterine cavity. Neither believed the baby would survive. Both were concerned for the well–being of the mother. They called the cord a “wick” meaning it would expose the mother to infection. Ordinarily labor would be induced. However, the ERDs have two directives directly relevant to this case. First, “For a proportionate reason, labor may be induced after the fetus is viable (Dir 49).” In this case both obstetricians agreed the baby was not viable. Second, “Operations, treatments, and medications that have as their direct purpose the cure of a proportionately serious pathological condition of a pregnant woman are permitted when they cannot be safely postponed until the unborn child is viable, even if they will result in the death of the unborn child (Dir 47).” This directive rests squarely upon the principle of double effect. So any action that [End Page 13] would end the life of the baby prematurely needed to have a proportionately serious reason. Both physicians agreed that the prolapsed cord posed a serious threat to the mother. However, the consulting obstetrician, who was a very conservative Catholic, felt that the ERD’s would not permit induction of labor until the mother showed signs of fighting an infection such as elevated fever. The hospital lawyers and I disagreed with this position; however, the consulting obstetrician was adamant. He also was in regular communication with the local bishop’s office. Administration was deeply concerned that the procedure might be described as an abortion and the bishop would initiate disciplinary actions against the hospital. In the end, the mother’s primary obstetrician transferred her to another hospital and induced labor within the hour. I had advised the hospital in a manner I believe was true to the hospital’s faith tradition and my own conscience. But I knew that my advice increased the hospitals risk of disciplinary action. It was a profoundly uncomfortable situation. It may have adversely affected my reputation among the more conservative elements at...

Maternal–Fetal Conflict and Periviability

A recent statement of consensus held that the principle of double effect would allow the induction of a previable fetus in order to eliminate a grave and present danger to the life of a mother suffering from peripartum cardiomyopathy. The author responds to this declaration, points out some limitations preventing it from being a vehicle for broader agreement, and offers an alternative, namely, medical induction of labor in cases of maternal–fetal vital conflict can be justified if the fetus has at least a fair chance of survival. This support of induction in cases of periviability considers the interests of both fetus and mother and, unlike the earlier consensus statement, can be defended by those who hold that one’s moral intention includes both the ultimate and proximate ends, or the immediate consequences of one’s act.

Principio de proporcionalidad y principio de Doble Efecto. Una propuesta desde la Filosofía del Derecho

The principle of double effect, a classic in moral philosophy, is suggested in this article as a complement to the principle of proportionality, based on the philosophy of law. The principle of double effect is accepted by the dogmatic constitution, on the one hand, and by the constitutional or international courts that adjudicate on human rights. The article begins by posing the problem of proportionality analysis for the philosophy of law, in its fundamentally critical and ethical-political aspect. Then, it introduces the principle of double effect, pursuant to the latest research, followed by a summary of the principle of proportionality, with reference to several works that are representative of the dogmatic constitution. Finally, several comparisons and ways to retain the principle are suggested, despite its limitations. The idea is to improve its use by expressly incorporating the principle of double effect into constitutional adjudication on the protection of fundamental rights.

End-of-life sedation: is there an alternative?

To evaluate the place and the usefulness of sedation in medical practice at the end of life. Continuous sedation is an acknowledged medical practice for the management of refractory symptoms at the end of life. Guidelines and recommendations have been proposed in palliative care. Although considered as a good medical practice at the end of life, sedation is neither the only option nor the best. This article presents the state-of-the-art (definitions, indications, and technical aspects) about continuous sedation, followed by an ethical reflection essentially based on the 'Principle of Double Effect', the impact on life expectancy, and the concept of 'natural death'.

Intrinsic and utilitarian valuing on K'gari-Fraser Island: a philosophical exploration of the modern disjunction between ecological and cultural valuing

In this article, we address a problem found in both ecology and philosophy of culture. In ecology, it appears as the problem of environmental advocacy, within the cultural domain, of geocentric values; and in philosophy of culture, it becomes the question of whether an intrinsic value of nature can attain cultural recognition in late modernity. The concurrence of these two problems becomes apparent when the geocentric valuing of late modern ecology is considered in light of the philosophy of modern culture of Louis Dupré (Passage to Modernity): ecological valuing can be seen to reflect a recognition of an intrinsic value in nature which remains unrecognised in the broader cultural domain. This disjunction between ecological and cultural valuing has a negative impact on advocacy to protect the natural environment of K'gari-Fraser Island. We aim to clarify underlying cultural causes of this disjunction in order to contribute toward more successful advocacy of ecological values in the cultural arena. To this end, we apply our adaptation of the Principle of Double Effect to the problem of environmentally destructive use of motor vehicles on K'gari-Fraser Island.

The Principle of Double Effect in End-of-Life Care

The Principle of Double Effect in End-of-Life Care

Etički aspekti palijativne sedacije

In contemporary society, despite technological advance, death and dying remain inevitable high technology and frightening reality. In response, post-modern society returns to the traditional approach of 'good death' that emphasizes managing with symptoms, treatment in accordance with the wishes, welfare and social support. Palliative care is a re-discover old practice of relief of suffering and the achievement of the highest possible quality of life. It helps to patient to live active and creative as far as possible through the struggle with the 'total pain' (physical, psychological, spiritual and social pain). Despite the efforts of palliative care, there are refractory symptoms whose intensity increases with the approaching of death, which adversely affect the well being of patients. These symptoms can't be treated without compromising patient awareness. Palliative sedation represents the intravenous administration of sedatives which the consciousness of patients lowers deep sufficiently that would provide comfort to the moment of death. Palliative sedation is not 'indirect euthanasia'. It is different from euthanasia by intent. In palliative sedation is intended relief of suffering, not death as in euthanasia, because death is not necessary for the relief of suffering. Predictable effect of shortening the life with palliative sedation is justified by the principle of double effect. One of the possible answers to the question of human dignity in suffering and dying is the one who is, in accordance with the human right to dignity in dying, present in palliative care.

In Defense of a Minimalist, Agent-Based Principle of Double Effect

In Defense of a Minimalist, Agent-Based Principle of Double Effect