This article appears in the November 2003 edition of the Catholic Medical Quarterly
Moral Absolutes and the Principle of Double Effect
In this paper I argue in favour of the principle of moral absolutes by examining a well known illustration; the case of the dying soldier during the Falklands war. In the second part I suggest that our clinical practice makes frequent use of the principle of double effect. Neither principle need be dismissed as merely `Roman Catholic Doctrine'. The importance of intention in our ethical decision making is also examined.
Down the Slippery Slope in the Falklands
Those who favour the principles of moral absolutes claim that there are certain sorts of action and inaction that are absolutely forbidden. Intentional killing of an innocent person, for example, is absolutely forbidden. In his case against the principle of moral absolutes Raanan Gillon gives the following example: "During the Falklands war a soldier was reported to have shot his trapped comrade in response to his comrade's anguished pleas that he was burning to death in a situation fromwhich there was no possibility of saving him." Was that morally wrong? (1) In response, one may argue that, objectively speaking it was most certainly morally wrong. However, subjectively, given the emotional state of both soldiers, the moral wrongness of the action is quite possibly diminished. Let us now suppose that I were to come across not just one dying soldier but several dying soldiers. The first soldier asks me to provide him with a gun.
I do so and he shoots himself. The second soldier has suffered severe injuries to his hand. He also requests the use of a gun. I provide him with this and I also place his hand on the trigger in order for him to shoot himself. A third soldier has sustained injury to both hands and fingers. He also requests that he be shot. I not only place his hand appropriately but I also assist him in the act of pressing the trigger. The fourth dying soldier is too badly injured to shoot himself. He pleads with me to shoot him, and I do so at his request. Now I come across my fifth dying soldier. He is even more injured that the previous soldiers. He is simply incapable of telling me anything. However, he is clearly in agony and his suffering is greater than that of the other soldiers. In regard to my action towards the first four soldiers, it would appear that there is no real distinction between assisted suicide and euthanasia. It is also clear that when I choose to assist in this manner, I am acting as a moral agent. In other words I develop a sort of scale of suffering in my mind, and I only assist those who are suffering significantly. I do not, for example, assist a suicidal soldier who is requesting to be killed following a failed love affair. However, if I have developed this scale of suffering as a result of following a series of intentional killings, it would seem reasonable for me to perform an act of euthanasia on a patient who does not request this - provided I am firmly of the opinion that his suffering is severe. It would indeed be inconsistent for me not to perform an act of intentional killing on someone whose suffering is so great that he is not even capable of requesting euthanasia. This is, of course, on the assumption that I have already performed acts of intentional killings on those whose suffering is less. It would appear that once we accept that there is such a thing as a morally acceptable act of intentional killing, there really is no distinction between voluntary, non-voluntary and involuntary acts of killing. Again we should consider the principle of the sanctity of life. Pursuing the principle of moral absolutes leads to the prohibition of certain things. I cannot intentionally kill innocent human life for whatever reason. This does not mean that I have to promote the good of life absolutely in all circumstances. This is vitalism and is a very different sort of moral from the sanctity of life principle. I need not strive to keep a dying patient alive at all cost. I violate the good of life by an act of intentional killing. I do not violate the good of life by not promoting it at all cost in all circumstances. "
This is rather like the difference between contraception and natural family planning. The two goods of the sexual act are the procreative good and the unitive good. A contraceptive act violates the procreative good. In contrast, recourse to natural family planning need not entail a violation of either goods. To respect the good need not be the same as promoting that good. The couple who choose to have intercourse during the infertile phase continue to respect the procreative good without promoting that good. The principle of moral absolute tells us not to do certain sorts of actions under any circumstances: we may not intentionally kill innocent life or violate the procreative good. We need not promote the good of life or the procreative good in all circumstances. Of course it goes without saying that there are many circumstances in which we have obligations to promote the good of life and procreation.
The Principle of Double Effect
Raanon Gillon argues that the principle of double effect is a "Roman Catholic moral doctrine"(2). However, I wish to argue that this principle lies at the very heart of our day today medical practice. The principle of double effect states that, although one may never do evil that good may come of it, one may carry out a good action, under certain conditions, despite the fact that one foresees a serious evil possibly resulting from it. We must, however, pay careful attention to the conditions, because, while this principle authorises a series of actions, it also excludes many. The four conditions are:
The act done must be good in itself
The agent must have a right intention, that is he or she must desire the good effect and not the evil one.
The first effect must be good or at least equal first with the evil effect. This impedes the good effect resulting from an evil one.
There must be proportionately grave reason to justify the act (3).
Let us consider a clinical variation of this principle. When I treat a patient who has epilepsy, I prescribe an anti-epileptic drug that is likely to have side effects. My purpose or intention in prescribing the medication is to treat epilepsy. An unfortunate and often foreseen side effect is that my patient is likely to develop weight gain, become sedated or develop a rash. I do not intend my patient to put on weight or feel sedated or develop a rash. My plan of treatment must also be proportionate. I should not cause my patient to suffer severe side effects with medication if hehas, for example, only one seizure in 5 years when on no medication.
Let us now suppose that I have a particular grudge against a patient. I treat his epilepsy by giving him two grams of epilim knowing full well that this is an unacceptable dose for his degree of epilepsy. I may as a side effect treat his epilepsy but my intention is to cause side effects. Intentions really matter and can frequently be objectively assessed. When, for example, Dr Cox injected his patients with potassium chloride, he was not trying to treat their hypokalaemia. His intention was clear. If I were to increase the dose of morphine given to a patient dying of cancer, I surely intend to alleviate the pain. I may foresee that I could hasten death but I may equally foresee that I may prolong life by alleviating distress. This distinction between what I intend and what I foresee is crucial to sound medical practice. I cannot be held responsible for unforeseen effects of my action. Let us suppose that a ship goes down. I have a close relative who has been flung a certain distance from the ship and is likely to drown. I am in a position to rescue my relative knowing full well that by doing so I am going to move away from the main group of people. I rescue my relative but a number of people in the main group drown. I do not, however, intend their death. Were I to be governed by the principle of maximising happiness, I ought to have rescued as many people as possible and allowed my relative to die. A consequentialist will surely accuse me of not having maximised overall happiness by merely rescuing a relative.
I may carry out my intention by act or by omission. I may intend the death of a rich relative by allowing him to slip in the bath and do nothing or by holding him underwater. In the first case I intend his death by omission and in the second case I intend his death by act. The road to hell is paved with good intentions! There need be no moral distinction between "active" and "passive" euthanasia. We ought not to be embarrassed by the principle of double effect as its clinical applications are at the heart of our day to day medical practice.
R. Gillon: Philosophical Moral Ethics (John Wiley) p. 130
R. Gillon: Philosophical Moral Ethics (John Wiley) p. 133
P. Bristow: The Moral Dignity of Man (Four Courts Press) p. 38
Dr Pravathasan is Consultant Psychiatrist in the Shrewsbury area