Having to put down a pet can be an incredibly difficult decision. The animal may be in extreme pain and, as much as you might love the pet, you know that the compassionate thing to do is to trust a trained veterinarian’s decision to end their suffering. Would you be prepared to let a doctor make the same decision about your parent?
The doctrine of double effect is a justification used by doctors in cases where they administer drugs to a patient with the intent of alleviating distressing symptoms, whilst in the knowledge that doing so may shorten or end the life of that person.
The most common example of this is in the treatment of terminally ill patients with high doses of painkillers. The doctor has to weigh up the benefit of reducing pain against the possibility of shortening life. The difficulty in this balancing act is that it is often down to personal opinion as to which side of the ‘double effect’ has greater weight.
The contentious point here is that the likelihood of premature or accelerated death is foreseeable.
So is the doctrine a reasonable defence or does it cloud an already murky area? Is it a way of giving doctors the all-clear for physician-assisted suicide? Daniel Sulmasy, professor of medicine and ethics at the University of Chicago, says that each doctor should ask themself: “if the patient were not to die after my actions, would I feel that I had failed to accomplish what I set out to do?”
Intention is the solution, not the problem
When considering the issues surrounding double effect, Prof Sulmasy believes that “intention is the solution, not the problem.” So under what circumstances could a physician justify their problem-solving under the doctrine?
Firstly, if the doctrine is to apply, the benefit must be gained independently of any negative effect. That is to say, the ‘bad’ effect cannot be the actual means to achieving the ‘good’ effect. This ensures that a doctor cannot say that the only way of suppressing pain was to end the life of the patient.
Another vital element in the implementation of the doctrine is the long-term health of the patient. It would be completely inappropriate to claim that you were justified in inadvertently killing a patient with an overdose when they would have recovered from their condition otherwise. The doctrine cannot be used here to claim that the intent was to relieve pain, even if there is no other way of easing the patient’s suffering. It is for this reason that the doctrine can only be applied to the treatment of the terminally ill.
The healthcare professional must also have provided appropriate treatment. A doctor cannot claim the doctrine applies if they gave a fatal dose of a drug that wasn’t appropriate to relieve the patient’s symptoms. This guarantees that the doctrine is only used in the event that the treatment given was actually required.
A final consideration is whether the action taken by the physician was proportional to the suffering of the patient. If a doctor chose to give a patient a dose of painkillers so high it was certain to result in their death, then the doctrine cannot be applied.
We should accept responsibility for all outcomes
A step away from physician-assisted suicide?
Doctors have an incredibly difficult task. They are constantly balancing positive and negative effects to provide the best outcome for each patient. We trust them implicitly to have our interests as patients at the forefront of every decision they take. But they should still be as accountable for their actions as any other person who has a difficult choice to make.
When an action has more than one foreseeable outcome, we are responsible for all of those, not just the ones we intended. We cannot pick out and separate those results that we intended from the undesired results that we knew were distinctly possible, or even highly probable.
It is also important to make the distinction between the action of a family member or carer, who may be motivated by compassion to help end the suffering of a loved one, and the calculated decision of a doctor. The former would be considered euthanasia or assisted suicide, both of which are illegal in the UK.
At this point it’s important to note the subtle distinctions between assisted dying, assisted death and euthanasia. Assisted death is the request of a terminally ill patient to be helped to die, although the fatal medication must be self-administered. Assisted suicide extends this same “right to die” to patients who are chronically ill, meaning death is not an inevitable result of their condition but it makes committing suicide difficult without someone’s help.
Euthanasia is quite different to both of these in that it is someone other than the patient, and sometimes without the patient’s consent, that administers the fatal medication. This has understandably led to fears about the distinction between genuine euthansia and murder, and the legalisation of any of these three acts has remained a hotly debated topic.
There are some crimes for which the intent of the accused is irrelevant: you may not have anticipated an outcome but it does not remove your guilt of committing the illegal act. In other cases the intent of the accused is a vital element in assessing both their guilt and the appropriate punishment.
The current legal view on assisted death is that it is a criminal offence with a maximum jail term of 14 years. However, the motivation behind the actions of an individual will be considered, and may reduce the length of sentence, but they are not a defence under the Act.
Blurring the lines between legal practice and physician-assisted suicide
The assumption is that a doctor would never intentionally aim to bring about the death of a patient. Reducing pain and suffering is something that a doctor clearly would intend but it is possible that the only way of achieving this is to knowingly risk the life of that patient. The doctrine makes the action of administering a potentially lethal dose, with the foremost intent of reducing pain, permissible even if the final outcome is the death of the patient.
But where does the distinction lie between the correct application of the doctrine and physician-assisted suicide? It seems perfectly possible that a doctor could, at the request of the patient, assist in their suicide and claim justification under the doctrine of double effect.
“A clear understanding of the proper use of the rule of double effect is essential if health care professionals are to maintain their opposition to euthanasia and assisted suicide and yet provide adequate pain relief to dying patients,” explains Professor Sulmasy. Merely understanding the proper use will be unlikely to prevent cases of unjustified application of the doctrine. After all, we are all aware that murder is wrong but that doesn’t stop it from happening.
Patients have the right to refuse treatment, regardless of whether that refusal is to their detriment, but they don’t have the right to demand it. You can of course ask for something to ease your pain but you could not tell the doctor to administer a lethal dose of opiates. The decision lies with the medical professional, based on their assessment of each patient, and that is why they are ultimately seen as accountable for the outcomes of treatment.
What would Hippocrates say?
The Hippocratic Oath, traditionally taken by healthcare professionals, clearly lays out the medical stance on such practice:
“I will neither give a deadly drug to anybody if asked for it, nor will I make a suggestion to this effect.”
These are modern times, however, and the winds of change may be blowing. In Scotland, a consultation on assisted dying has been submitted to parliament, which may be the first step towards a bill legalising the act. As for the rest of the UK, Lord Falconer of Thoroton, chair of the assisted dying bill launched in November 2010, has received evidence and an announcement on the findings is expected in the near future.
This could mean that the doctrine will soon be redundant as power shifts from doctor to patient.
The debate forces examination of one central question: is death such a bad thing? Given the choice between living in pain, or death, you might decide that the end actually comes as a welcome relief. If that is the case, doctors have a lot less to answer for in the scenarios discussed. In fact, in some people’s eyes they could be said to be acting in a morally admirable way by helping someone to die.
Images courtesy of José Goulão and Cameron Maddux
Of course terminally ill patients should be allowed as much pain medication as they need, even if it shortens their life.
Keeping a patient in pain just so they might survive a few extra hours or days is cruel and sadistic.
The most vocal opponents of physician assisted suicide, and of effective pain mediation too, are usually religious people who claim "only God should decide a person's time of death".
Well, those people are hypocrites if they have ever voluntarily received medical treatment.
The whole purpose of the medical profession is to NOT allow God to decide the person's time of death, but to prolong life. If God were the only decider, we would have the same mortality rate we had in medieval times.
No one should be forced to endure pain just to coddle other people's squeamishness about death or other people's theological convictions.
Sorry – the mortality rate today IS the same as in medieval times – %100. What I meant was that we would die at the same ages as they did in medieval times. Most people died when they were children or fairly young adults.