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The Hippocratic Oath III:
Do no harm, withdrawal of treatment, and the mental capacity act

David Albert Jones

This paper is intended as the third in a series. The first in the series concerned the content of the ancient doctors’ oath attributed to Hippocrates [1]. The second concerned various modern adaptations of the ancient oath, in particular the Declaration of Geneva [2]. The present paper concerns the application of Hippocratic ethical principles in practice. It examines what is widely regarded as a Hippocratic principle, primum non nocere (‘first do no harm’), and explores the application of this principle to the issue of withdrawal of treatment. The paper concludes with some reflections on the Mental Capacity Act 2005.

Primum non nocere

The maxim ‘first do no harm’, also known in its Latin form primum non nocere, is widely attributed to Hippocrates [3]. The first thing that might make us suspicious about this attribution is the language, for Hippocrates did not write in Latin but in Greek. Why should this phrase be known as a Latin dictum? Our suspicions are confirmed when we find that this maxim is absent, not only from the Hippocratic Oath, but from the whole Hippocratic corpus of writings. Nor is it known in its Latin form before the nineteenth century [4]. Sometimes the maxim is traced back to a sentence in the Epidemics (a medical work of Hippocrates): ‘As to diseases, make a habit of two things—to help, or at least to do no harm’ [5]. However, not only does the wording here fail exactly to match the dictum, but the thought also is subtly different. Whereas the Latin dictum insists that do no harm is the first principle (‘first do no harm’), for Hippocrates the first principle is to help, and it is only the second principle, when one cannot help, at least to do no harm. The same order of priorities found in the Epidemics, can be found in the oath itself, ‘(1) to help the sick according to my ability and judgment, and (2) to refrain from harm and injustice’ [6].

The assertion of Worthington Hooker (in the mid nineteenth century) that ‘it is only the second law of therapeutics to do good, its first law being this — not to do harm’ [7], thus represents a clear rejection of the ancient Hippocratic ordering. So too, arguably, does the warning of Florence Nightingale, that ‘a first requirement in a hospital [is] that it should do the sick no harm’ [8]. It is interesting to note that Beauchamp and Childress in their influential textbook on principles of bio-medical ethics, consistently give priority to not harming (non-maleficence) over helping (beneficence). In all five editions of the book, they treat their chosen four principles in the order: autonomy, non-maleficence, beneficence and justice [9]. By starting with autonomy and non-maleficence rather than with beneficence, Beauchamp and Childress effectively follow Hooker rather than Hippocrates. Indeed, if respect for autonomy is understood in terms of not infringing liberty rights, and it is commonly seen in this way, then Beauchamp and Childress’s first principle of autonomy is but a specific example of the broader category of not doing harm. The order in which Beauchamp and Childress treat their four principles could thus be seen as exemplifying the maxim, first do no harm. 

The claim of Cedric Smith that the maxim ‘first do no harm’, and its Latin equivalent, primum non nocere, have their origins in the mid nineteenth century [10] is therefore of more than historical interest. The fairly recent provenance of the phrase alerts us to a departure from the older Hippocratic tradition, and the fact of this departure leads to a question: is this change a change for the better or for the worse?

If we compare the nineteenth century attitude with the ancient one, the more recent approach seems to represent not an advance in understanding but a step backwards. A number of clinicians have complained that the maxim ‘first do no harm’ can lead to physicians being too risk-averse [11]. There is no intervention without risk and failing to intervene can also be a risk. For example, I was told recently of a case in which nursing staff were unwilling to feed a patient orally because the speech and language therapist report had identified a significant risk of choking. They thought the patient should be treated as ‘nil by mouth’. However, the patient had requested oral feeding and refused to have a naso-gastric tube inserted so that he could be fed by tube. If the patient was not fed at all clearly he would die. Oral feeding and tube feeding both impose burdens and both carry risks and the significance of these risks and burdens will change if, for example, the patient is terminally ill. Rather than attempt the impossible – the elimination of all risk – what is necessary is a careful evaluation of the relative risks and the prospective benefits to the particular patient. The maxim ‘first do no harm’, if taken on face value, seems to demand that nothing should be done which would have any harmful effect. If applied in practice, it would effectively paralyze physicians and prevent them from doing anything to help to their patients.

In addition to this practical consideration, that the maxim would prevent helpful treatments being given, the maxim ‘first do no harm’ can also be criticized on philosophical grounds. We understand human action by understanding what it is aiming at,- the human good, to which it is directed [12]. Action is thus first understood in relation to some good, and only secondarily in relation to something bad or harmful. Indeed the idea of badness or harm can only be understood in relation to a desirable good that is lost, impeded or frustrated [13].

Thomas Aquinas thus gives as the first moral precept of the natural law, ‘good is to be done and pursued and evil is to be avoided’ [14]. Doing good comes first and avoiding evil is seen in the light of that. In the practice of medicine the good that is aimed at is the physical and mental health of the patient. Helping the sick comes first, for it gives the aim of the exercise. Avoiding harm and injustice, while it is an essential principle, is understood in relation to the first principle. Hence, for all its popularity and the appearance of authority, the Latin dictum primum non nocere is neither Hippocratic in origin nor practically or philosophically defensible. The authentically Hippocratic ethical injunction is ‘to help, or at least to do no harm’, or again ‘to help the sick… and to refrain from harm and injustice’.

Do no harm

While ‘do no harm’ should not be made the first principle of ethics, nor isolated from the injunction to do good, it clearly remains an important ethical principle. However, to understand this principle one has to be clear what is meant by harm. The Hippocratic oath uses two words for harm: harm (delesei) and injustice (adikie). This helps alert us to that fact that harm in medicine is understood in two ways. Harm can be understood simply as referring to the physical or mental damage that is caused. In this sense a drug may have some harmful side effects, though it may still be the appropriate treatment for a particular disease if the need is great enough. The other main sense of harm is abuse or injustice. Someone who experiences harmful effects from being given the wrong drugs due to someone’s negligence has been harmed in the sense of suffering an injustice. The English word injury originally meant an injustice, though it is often used for the effects of physical trauma even when no-one is to blame (for example a ‘sports injury’). The contrast between the roots of the word ‘injury’, and the word’s present meaning, again illustrates these two distinct senses.

When reflecting on the principle ‘do no harm’ it is crucial to distinguish these two senses of harm. In the first sense, of physical damage the principle is a useful rule of thumb. It alerts the doctor to the possibility that medical interventions may do more harm than good, or that there may be alternatives which are less likely to do harm. Nevertheless, as mentioned above, any intervention risks doing harm and many risks or actual harms may this be in fact appropriate. To take an extreme example, cancer treatment typically involves very severe side effects, often causing much worse symptoms than the disease is causing at that point. In addition to the nausea and hair loss, treatment may render the patient infertile. Nevertheless, people accept these harmful side effects if the treatment will be effective against the disease. The giving of treatments that have serious side effects is justified by the principle of double effects. This stipulates that it can be ethical to cause harmful side effects if the action is not done precisely in order to bring about these harmful effects and if other conditions also hold. [15]

In the second sense of injustice ‘do no harm’ is not a rule of thumb but is an absolute obligation. A doctor must never abuse, ill-treat, or assault a patient in his or her care. Many of the strictures of the Hippocratic oath, and of codes and laws of medicine, are directed against these kinds of harm. It is noteworthy that immediately after mentioning harm and injustice, the oath prohibits the giving of deadly poison, even on request. Facilitating suicide is an action that is altogether ruled out by the oath, not as a rule of thumb but as the kind of action that is incompatible with the aims of medicine. It is the kind of harm a physician should never cause. This example also makes clear that harm, in the sense of abuse or injustice, does not simply mean acting against someone’s will. The patient who asks for poison, wishes to die. Rather the injustice is at a deeper level of failing to respect the dignity or worth of the person, a worth that the person himself might fail to recognize.

There are then two senses of ‘do no harm’, both of which are highly relevant to medical practice. In the first sense of harm the principle ‘do no harm’ calls attention to the harm that can be caused inadvertently in medicine, and seeks to ensure that this kind of harm is only caused when it is for the overall good of the patient. It is a prudent or a pragmatic principle that does not rule out actions in advance, but which requires actions be justified. In the second sense the principle prohibits actions that wrong the patient. This principle rules out actions in advance, for example, the use of human subjects without their consent for dangerous medical experimentation. It is regrettable that while Beauchamp and Childress recognize that the word harm can be used in two distinct sense [16], they only explore the meaning of ‘do no harm’ in relation to the first sense.

Withdrawal of treatment

How does the principle ‘do no harm’ relate to the withdrawing or withholding of treatment, especially where this is life-sustaining treatment? According to the Hippocratic oath, the principle, ‘do no harm’ rules out assisted suicide. This seems to be taking harm in its second, absolute, sense. If we accept that the principle rules out assisted suicide then, for the same reason, it would rule out mercy killing. Physicians should aim to benefit the sick, to cure or to palliate disease. Facilitating suicide contradicts these aims and wrongs the patient by failing to respect the worth of his or her life.

The Hippocratic principle seems to prohibit the deliberate taking of life, but what of inaction as a result of which the patient dies? Is the physician always duty bound to intervene, if by doing so he or she could extend the life of the patient? Here the answer will be contingent on a number of factors: as noted above, all interventions involve risks, costs, burdens, and not intervening involves risks, costs, and burdens. Having considered the case for intervention, it may be better, all things considered, not to intervene. For example, there is no absolute moral obligation to accept or to give life sustaining treatment that extends life only by a fractional amount and at great cost to the patient in terms of discomfort. Here it is the principle in its first, prudential, sense that seems to be relevant.

A good case can be made that Hippocratic ethical principles prohibit bringing life to an end by assisting suicide, but permit the withdrawing or withholding of treatment that could extend life. This raises the question: How are these two cases different? Many people are familiar with a line from Clough’s poem: ‘thou shalt not kill, but needst not strive officiously to keep alive’. In its original context this line was intended to be satirical, a criticism of Victorian moral complacency. Is ‘not keeping alive’ really any different from killing? Those who have sought to overturn the Hippocratic tradition and to permit physician-assisted suicide, have asked the same question: what is the ethical difference between killing and letting die? [17]

An initial answer given in debates on this issue in the 1970s was that the difference between killing and letting die should be understood in terms of the distinction between acts and omissions. The act of killing the innocent (that is killing out the context of war, self-defense or capital punishment) was always wrong. It contradicted the inherent dignity of the human person and transgressed the commandment ‘you shall not kill’ (Exodus 20:13). On the other hand, the omission but which a live is not saved is not necessarily wrong. If I am doing something good and worthwhile, there will always be other good and worthwhile things I am not doing which I could otherwise be doing. I am not to blame if I omit to save a drowning man because I am in fact engaged in trying to rescue a child in a burning building. Not saving the man is completely different from deliberately drowning the man.

There is some truth in the act/omission distinction, nevertheless, it also has a major weakness. For it is possible deliberately to bring about a death by planned omission. A prisoner may be executed by being shot (an action) but he may, just as effectively, be executed by being starved to death (an omission). If I switch a machine off is that  flicking of the switch an act, or is the withdrawal of mechanical assistance an omission? What seems to matter here, more than acts or omissions, is the intention of the act or omission. Was someone done or omitted in order to achieve the desired result? Was the death the aim of the exercise, or was it unintended? Most contemporary philosophers who are defend an ethical distinction between killing and letting die do not concentrate on acts and omissions but on intention. [18]

In relation to withdrawal of treatment the key question is thus: what is the aim of withdrawing treatment. If treatment is being withdrawn in order to bring about death, then it is ethically equivalent to killing. On the other hand, if treatment is withdrawn for some other reason, and it is a sufficiently good reason, as for example the severe side effects and limited gains of the treatment, then it is not ethically equivalent to killing.

This is an important and ethically significant result. The Hippocratic principle ‘do no harm’ prohibits not only assisting suicide and mercy killing, but withdrawal of treatment when this is done in order to bring about the death of the patient. However, the question of intention, while crucial, is not adequate to resolve all the ethical problems in this area. Even when withdrawal of treatment is not intended to cause death, it may nevertheless be wrong to do it. This is seen be considering the question of neglect. A physician may wrongly neglect a patient in his or her care, and fail to give the patient the appropriate treatment, and if the patient dies as a result the physician is responsible because the unjustified omission of treatment. This suggests that as well as the question of intention, there is a deeper question of determining if treatment is required such that omitting treatment would be negligent.

Furious opposites

In relation to matters of life and death it is necessary to keep two things in mind: both to cherish the precious gift of life and to accept the inevitability of death.

Every human life is irreplaceable. From this it follows that every human life, including one’s own, is to be cherished, even when life is hard or is near the end. The life of someone who is sick or dying is not worth any less than the life of someone who is healthy. Someone might fail to appreciate the worth or dignity of his or her own life, yet that life would still possess inherent worth or dignity. This is not necessarily a religious view [19], but can be recognised by natural reason. For example, the declaration on bioethics agreed at the United Nations in 2005 had as its stated aim, ‘to promote respect for human dignity and protect human rights, by ensuring respect for the life of human beings’. [20]

At the same time as cherishing life it is important to acknowledge that, as mortal human being we live our lives knowing that we will die. It is important to acknowledge that life will come to an end and to prepare for this as well as we can. Elisabeth Kübler-Ross in her work on Death and Dying [21] identified five stages in the process of coming to terms with death: denial, anger, bargaining, depression, and acceptance. While elements of this account have been criticised for being too formal or idealised [22] there is very widespread agreement that accepting death is something fundamentally healthy [23].

From a naturalistic perspective, then, there are two elements that need to be kept in tension: cherishing life and accepting death. It might seem that Christianity alters things by making one or other of these elements stronger, but in fact Christianity makes both elements stronger: Christian faith gives more reason to cherish life, especially the lives of those who are marginalised or overlooked by society, while at the same time it also gives more reason to accept death, when it comes, with hope in God. Christianity thus resists the temptation to chose one or other of these elements, but keeps both in tension. As Chesterton remarked, “Christianity [gets] over the difficulty of combining furious opposites, by keeping them both, and keeping them both furious" [24].

The Mental Capacity Act

The Mental capacity Act 2005 is not just about end of life decisions. It is about all the practical choices that have to be made for someone who cannot decide these things for themselves. There may be financial decisions that need taking, or choices about where to live and how someone is cared for. There are also all the day to day choices about how we wish to live – what we do and do not want to eat, for example. However, the Act does explicitly cover decisions made to withdraw life sustaining treatment, and these decisions understandably cause people more anxiety.

In discussing the Mental Capacity Act with physicians I have come across two quite opposite anxieties. Some are concerned that patients will be overtreated, and that dying patients will not be allowed to die peacefully. I am sure I am not alone in having come across examples in my own life of friends or relatives who died in hospital after being subject to unwanted and futile treatments, treatments ‘which are particularly exhausting and painful for the patient, condemning him [or her] in fact to an artificially prolonged agony’ [25].

Other physicians express the opposite anxiety that patients will be undertreated. People are concerned that life-sustaining treatment, and especially artificial nutrition and hydration, is already being withdrawn from patients who need it, because they are not regarded as worthy of keeping alive. Even if this neglect is at the person’s own request, or at the request of a well intentioned friend, it may still express a negative value judgement about living with dependence or disability. If the withdrawal of treatment is intended to bring about death then it amounts to deliberate killing by omission.

In the light of what was said about furious opposites, both of these anxieties concern the real dangers, real harms. Overtreatment is a reality which exists in the current healthcare system, and which will no doubt continue to exist in the future, which harms patients. Undertreatment is equally a reality which exists in the current healthcare system, and which will no doubt continue to exist in the future, which harms patients.

Faced with these opposite dangers there is a temptation to ask: Which is worse? Which is the more pressing danger? However this temptation is to be resisted, for both dangers are real: both the danger of under-treatment, and the neglect or even the starvation of older patients; and the danger of over-treatment, and the potential of modern medicine to make the dying process even worse than it is. It is important to acknowledge both of these concerns, for if to concentrate only on one of these dangers could lead to falling into the opposite danger without realising it [26]. Even if someone thinks that one danger is more pressing than the other, it is essential to acknowledge both.

Principles and safeguards

The Mental Capacity Act 2005 is a piece of compromise legislation. It has been shaped by opposite concerns about overtreatment and undertreatment, and well as by competing world views and ideologies. The euthanasia movement was active in the development of the bill and will no doubt seek to influence its implementation, but the legislation has also been shaped by other voices including a number of exchanges between the government and the Archbishop of Cardiff.

What has emerged is a law that aims to ‘empower and protect people who may lack capacity to make some decisions for themselves’. This aim has been expressed, among other ways, in the new status of advanced decisions and of the creation of lasting powers of attorney by which proxy decision makers can be appointed. As both advanced decisions and attorneys can refuse treatment but cannot demand it, they seem to be directed against the problem of overtreatment, and in comparison, relatively to neglect the problem of undertreatment. Nevertheless, as a counterbalance to the main thrust of the Act there are a number of provisions which aim to safeguard the patient from undertreatment, for example:

The check list for determining best interest of the patient begins with the stipulation that the determination of best interest must not be based merely on his or her age, appearance or condition (4 (1))

This is not an exhaustive list of the intended safeguards present in the Act, but it includes the main ones. There is not scope here to examine each of these provisions in detail and ask whether the safeguard is real or illusory. The aim here is to show how the Act focuses primarily on means by which patients or their proxies can refuse treatment, but that nevertheless, there is some acknowledgement of the opposite problem of neglect and this is the reason behind the putative safeguards.

There are some real problems in the Act, and the central one is probably the legally binding character of advance directives and the decisions of attorneys. This problem is compounded by the prevailing opinion of the medical profession in the United Kingdom, made explicit in the MCA code of practice, that assisted nutrition and hydration is unproblematically categorized as medical treatment. The insistence that the physician be satisfied that an advance decision be both valid and applicable to the circumstances gives scope for a good doctor to give appropriate treatment, even in the face of an apparent advance directive to the contrary. What the safeguards do little to prevent is doctors who are convinced that their elderly frail patients are better off dead withdrawing treatment to accomplish this, especially if they have support from a relative in this course of action. This no doubt occurs at present, but the Act gives the doctor greater legal protection in doing so in the future.

The most pressing concern in respect to the Mental Capacity Act is not that it will require unethical practice (though this may sometimes be the case), but that it will allow unethical practice and that it will shift the ethos of medicine. In is well known that the Abortion Act 1967 led to a culture shift within obstetrics and gynecology and that it has become very difficult for a doctor with such objections to enter that field. The Mental Capacity Act 2005 is not on the same level in terms of what it requires or allows, but there is a danger that it will have a negative effect on the ethos of geriatric medicine, and this is something to be aware of.


The Hippocratic principle, ‘do no harm’, remains relevant to medical ethics and, in particular, to decisions to withhold or withdraw medical treatment. The word harm has two possible meanings, it can mean any adverse effect or it can specifically mean abuse or injustice. In the first sense the principle do no harm is a rule of thumb, alerting the physician to the harm he or she might unintentionally do. In the second sense ‘do no harm’ is an absolute prohibition preventing the ill-treatment of patients, and in particular, the deliberate killing of patients, whether by act or omission. In relation to unintended harms and the question of withdrawal of treatment it is essential to acknowledge the danger of opposite harms: of overtreatment and of undertreatment.

So often it seems to me in my conversations with doctors and with others on this matter that people are so concerned about one of these problems that they fail to acknowledge the reality of the opposite problem. In palliative care, physicians constantly make decisions to withdraw treatment, and tend to emphasize the dangers of overtreatment. In (rightly) fighting this battle it is important also to realize that other patients, especially those with chronic conditions, may be in danger of neglect and undertreatment. On the other hand many of those who are active in the pro-life movement, and who are right to be concerned about withdrawal of treatment as a form of deliberate neglect, may easily fail to acknowledge the opposite danger of overtreatment. Yet a reaction against cases of overtreatment is a great motivating force behind legislation such as the Mental Capacity Act. The euthanasia lobby has sought to shape and to use this legislation, but the reason that it could gain more widespread support was because of the reasonable concern people had about overtreatment. Whether reading this, you are more concerned about one of these harms than the other, it is important to acknowledge both. Only in this case will those who are listening hear their own concern acknowledged so that they can then listen to the opposite concern. For Hippocratic physicians, it is important that both in the giving or the withdrawal of treatment they observe the following injunction: ‘as to diseases, make a habit of two things—to help, or at least to do no harm’ [27].

Talk delivered to the AGM of the Guild 21st April 2007

David Albert Jones is Professor ot Bioethics,
St Mary's University College, Twickenham


  1. Jones DA (2003) ‘The Hippocratic Oath: Its content and the limits of its adaptation’ Catholic Medical Quarterly Vol. 54, No. 3, August 2003
  2. Jones DA  (2006) ‘The Hippocratic Oath II: The declaration of Geneva and other modern adaptations of the classical doctors’ oath’ Catholic Medical Quarterly Vol. 56, No. 1, February 2006, 6-16.
  3. ‘First do no harm: Slogan used in medicine often in the Latin wording "primum non nocere," a fundamental medical precept of Hippocrates (ca. 460-ca. 377 B.C)’. MedTerms Medical Dictionary ; See also: Sihoe, ADL, RHL Wong, and APC Yim (2004) ‘Primum Non Nocere’ Chest. 126:2026-2027; Szasz, T (2004) ‘Primum Nocere’ The Freeman, 54: 24-25 (December); Other examples could easily be cited.
  4. Smith, C (2005) ‘Origin and Uses of Primum Non Nocere—Above All, Do No Harm!’ Journal of Clinical Pharmacology, 45:371-377. Smith also shows that there is no evidence for the attribution of the phrase to Galen. It is sometimes assumed that Galen, being Italian, was responsible for the translation of the Hippocratic corpus into Latin, but in fact Galen wrote primarily in Greek. Many of the works of Hippocrates and Galen remained unavailable in Latin until the early middle ages when they were translated from Arabic. The first Latin translation of the complete corpus of treatises ascribed to Hippocrates was not accomplished until 1515 CE when it was done by Marco Fabio Calvo in 1515.
  5. Hippocrates Epidemics, Bk. I, Sect. XI (tr. by W.H.S. Jones)
  6. The Hippocratic Oath a literal translation in Jones DA (2003) ‘The Hippocratic Oath: Its content and the limits of its adaptation’ Catholic Medical Quarterly Vol. 54, No. 3, August 2003
  7. Hooker, W (1847) Physician and Patient, New York: Baker and Scribner, p.219 cited in Herranz G. (2002) ‘The origin of “primum non nocere”’ rapid response (1 September 2002) to Imre Loefler, (2002) ‘Why the Hippocratic ideals are dead. BrMedJ. 324:1463, emphasizes added.
  8. Nightingale, F (1863) Notes on Hospitals London: Longman, cited by Smith, C (2005) ‘Origin and Uses of Primum Non Nocere—Above All, Do No Harm!’ Journal of Clinical Pharmacology, 45:373, emphasizes added.
  9. Beauchamp, T, J Childress (2001) Principles of biomedical ethics 5th edition New York, N.Y. : Oxford University Press, (see also 1978, 1983, 1989, 1994 editions); for a sympathetic account of the four principles, but one which gives priority to beneficence see ED Pellegrino (1993) ‘The Four Principles and the Doctor-Patient Relationship: the Need for a Better Linkage’ in R. Gillon, A. Lloyd (eds.)  Principles of Health Care Ethics.  John Wiley and Sons, 1994, 353-365.
  10. Smith traces the phrase back to the physician Thomas Inman in 1860: Inman T. Foundation for a New Theory and Practice of Medicine. London: John Churchill; Smith, C (2005) ‘Origin and Uses of Primum Non Nocere—Above All, Do No Harm!’ Journal of Clinical Pharmacology, 45:372.
  11. Halsey, N, L Goldman (2001) Balancing Risks and Benefits: Primum non nocere Is Too Simplistic PEDIATRICS Vol. 108 No. 2 August 2001, pp. 466-467; Shelton, JD (2000) ‘A piece of my mind: the harm of “first, do no harm.”’ JAMA 284:2687-8; Lecroy, K (2001) ‘The Lie of Primum non Nocere’ American Family Physician  64 (12): 1942.
  12. See, for example, GEM Anscombe (2000) Intention 2nd Revised Ed edition Harvard University Press; Taylor, C (1964) The explanation of behaviour London: Routledge and Kegan Paul; Thomas Aquinas Summa Theologiae IaIIae 1.3.
  13. McCabe, H. 2005. ‘Evil’ in God Matters New Ed London: Continuum; see also Thomas Aquinas Summa Theologiae Ia 48.1, IaIIae 29.2. A thorough attempt to construct a philosophy within which rational priority was given to evil over good, was attempted by Arthur Schoppenhauer. His work represents a reduction ad absurdum of the view that avoiding harm should be the first principle of human life, see FC Copleston (1947) Schopenhauer, Philosopher of Pessimism London Burns Oats.
  14. Thomas Aquinas Summa Theologiae IaIIae 94.2
  15. Anscombe, GEM (1982) ‘Action, Intention and Double Effect’ in M Geach and L Gormally (eds.) (2005) Human Life, Action and Ethics: Essays by G E M Anscombe St Andrews, UK: Imprint Academic; Boyle, J (1991) ‘Who is entitled to double effect’ Journal of Medicine and Philosophy 16(5):475-494.
  16. Beauchamp, T, J Childress (2001) Principles of biomedical ethics 5th edition New York, N.Y. : Oxford University Press.
  17. Glover, J. (1997) Causing Death and Saving Lives London: Penguin, is a good example, but this is a common argument.
  18. Finnis, J (1991) ‘Intention and Side effects’ in Frey R G (1991) Liability and Responsibility Cambridge: CUP; Keown, J (2004) Euthanasia, Ethics and Public Policy: An Argument against Legalisation Cambridge: CUP; Watt, H (2000) Life and Death in Healthcare Ethics London: Routledge.
  19. As alleged by Galnville Williams (1958) The Sanctity of Life and the Criminal Law London: Faber and Faber, pp. 30-31.
  20. Universal Declaration on Bioethics and Human Rights, article 2 (c).
  21. Kübler-Ross, E (1969) Death and Dying London: Macmillan.
  22. Silver, RL, CB Wortman, (1980) ‘Coping with undesirable life events’ in J Garber, MEP Seligman (eds.) Human helplessness: Theory and applications New York: Academic Press; De Spelder, LA, AL Strickland (1995) The Last Dance Mountain View, C.A: Mayfield; Branson, R (1975) ‘Is Acceptance a Denial of Death? Another Look at Kübler-Ross’ The Christian Century, (May 7 1975):464-8.
  23. See DA Jones (2007) Approaching the end: a theological exploration of death and dying Oxford: OUP.
  24. Chesterton, GK (1909) Orthodoxy John Lane Company: 1909.
  25. Vatican Charter for Healthcare Workers paragraph 119
  26. “I feel a strong desire to tell you - and I expect you feel a strong desire to tell me-which of these two errors is the worse. That is the devil getting at us. He always sends errors into the world in pairs-pairs of opposites. And he always encourages us to spend a lot of time thinking which is the worse. You see why, of course? He relies on your extra dislike of the one error to draw you gradually into the opposite one. But do not let us be fooled. We have to keep our eyes on the goal and go straight through between both errors. We have no other concern than that with either of them..” C S Lewis 1997 Mere Christianity New Edition London: Fount, Chapter 28.
  27. Hippocrates Epidemics, Bk. I, Sect. XI (tr. by W.H.S. Jones)