Principle of double effect
Encyclopedia
The principle of double effect; also known as the rule of double effect; the doctrine of double effect, often abbreviated as DDE or PDE; double-effect reasoning; or simply double effect, is a set of ethical criteria for evaluating the permissibility of acting when one's otherwise legitimate act (for example, relieving a terminally ill patient's pain) will also cause an effect one would normally be obliged to avoid (for example, the patient's death). Double-effect originates in Thomas Aquinas
Thomas Aquinas
Thomas Aquinas, O.P. , also Thomas of Aquin or Aquino, was an Italian Dominican priest of the Catholic Church, and an immensely influential philosopher and theologian in the tradition of scholasticism, known as Doctor Angelicus, Doctor Communis, or Doctor Universalis...

's treatment of homicidal self-defense (Summa Theologiae
Summa Theologica
The Summa Theologiæ is the best-known work of Thomas Aquinas , and although unfinished, "one of the classics of the history of philosophy and one of the most influential works of Western literature." It is intended as a manual for beginners in theology and a compendium of all of the main...

, IIa-IIae Q. 64, art. 7).

This set of criteria states that an action having foreseen harmful effects practically inseparable from the good effect is justifiable if upon satisfaction of the following:
  • the nature of the act is itself good, or at least morally neutral;
  • the agent intends the good effect and not the bad either as a means to the good or as an end itself;
  • the good effect outweighs the bad effect in circumstances sufficiently grave to justify causing the bad effect and the agent exercises due diligence to minimize the harm. (Double-Effect Reasoning: Doing Good and Avoiding Evil, p.36, Oxford: Clarendon Press, T. A. Cavanaugh)

Intentional harm versus side effects

Although different writers state and employ double effect differently, they share the position that consequentially similar acts having different intentional structures make for ethically different acts. So, for example, advocates of double effect typically consider the intentional terror bombing of non-combatants having as its goal victory in a legitimate war morally out of bounds, while holding as ethically in bounds an act of strategic bombing that similarly harms non-combatants with foresight but without intent as a side effect of destroying a legitimate military target. Because advocates of double effect propose that consequentially similar acts can be morally different, double effect is most often criticized by consequentialists who consider the consequences of actions entirely determinative of the action's morality.

In their use of the distinction between intent and foresight without intent, advocates of double effect make three arguments. First, that intent differs from foresight, even in cases in which one foresees an effect as inevitable. Second, that one can apply the distinction to specific sets of cases found in military ethics (terror bombing/strategic bombing), medical ethics (craniotomy/hysterectomy), and social ethics (euthanasia). Third, that the distinction has moral relevance, importance, or significance.

The doctrine consists of four conditions that must be satisfied before an act is morally permissible:
  1. The nature-of-the-act condition. The action must be either morally good or indifferent.
  2. The means-end condition. The bad effect must not be the means by which one achieves the good effect.
  3. The right-intention condition. The intention must be the achieving of only the good effect, with the bad effect being only an unintended side effect.
  4. The proportionality condition. The good effect must be at least equivalent in importance to the bad effect.


The second of these four conditions is an application of the more general principle that good ends do not justify evil means (cf. ).

Medicine

A vaccine
Vaccine
A vaccine is a biological preparation that improves immunity to a particular disease. A vaccine typically contains an agent that resembles a disease-causing microorganism, and is often made from weakened or killed forms of the microbe or its toxins...

 manufacturer typically knows that while a vaccine will save many lives, a few people may get sick or die from side effect
Side effect
In medicine, a side effect is an effect, whether therapeutic or adverse, that is secondary to the one intended; although the term is predominantly employed to describe adverse effects, it can also apply to beneficial, but unintended, consequences of the use of a drug.Occasionally, drugs are...

s of vaccination. The manufacture of a drug is in itself morally neutral. Lives are saved as a result of the vaccine, not as a result of the deaths due to side effects. The bad effect, the deaths due to side effects, does not further any goals of the manufacturer, and hence is not intended as a means to any end. Finally, the number of lives saved is much greater than the number lost, and so the proportionality condition is satisfied.
This is more a case of side effects/benefit analysis than of a real Principle application and is common in medicine.

The principle of double effect is frequently cited in cases of pregnancy
Pregnancy
Pregnancy refers to the fertilization and development of one or more offspring, known as a fetus or embryo, in a woman's uterus. In a pregnancy, there can be multiple gestations, as in the case of twins or triplets...

 and abortion
Abortion
Abortion is defined as the termination of pregnancy by the removal or expulsion from the uterus of a fetus or embryo prior to viability. An abortion can occur spontaneously, in which case it is usually called a miscarriage, or it can be purposely induced...

. A doctor who believes abortion is always morally wrong may nevertheless remove the uterus or fallopian tubes of a pregnant woman, knowing the procedure will cause the death of the embryo
Embryo
An embryo is a multicellular diploid eukaryote in its earliest stage of development, from the time of first cell division until birth, hatching, or germination...

 or fetus
Fetus
A fetus is a developing mammal or other viviparous vertebrate after the embryonic stage and before birth.In humans, the fetal stage of prenatal development starts at the beginning of the 11th week in gestational age, which is the 9th week after fertilization.-Etymology and spelling variations:The...

, in cases in which the woman is certain to die without the procedure (examples cited include aggressive uterine
Uterus
The uterus or womb is a major female hormone-responsive reproductive sex organ of most mammals including humans. One end, the cervix, opens into the vagina, while the other is connected to one or both fallopian tubes, depending on the species...

 cancer
Cancer
Cancer , known medically as a malignant neoplasm, is a large group of different diseases, all involving unregulated cell growth. In cancer, cells divide and grow uncontrollably, forming malignant tumors, and invade nearby parts of the body. The cancer may also spread to more distant parts of the...

 and ectopic pregnancy
Ectopic pregnancy
An ectopic pregnancy, or eccysis , is a complication of pregnancy in which the embryo implants outside the uterine cavity. With rare exceptions, ectopic pregnancies are not viable. Furthermore, they are dangerous for the parent, since internal haemorrhage is a life threatening complication...

). In these cases, the intended effect is to save the woman's life, not to terminate the pregnancy, and the effect of not performing the procedure would result in the greater evil of the death of both the mother and the fetus.

Palliative care

It is often thought that the administration of a high dosage of opioids is sometimes allowed for the relief of pain in cases of terminal illness
Terminal illness
Terminal illness is a medical term popularized in the 20th century to describe a disease that cannot be cured or adequately treated and that is reasonably expected to result in the death of the patient within a short period of time. This term is more commonly used for progressive diseases such as...

, even when this can cause death as a side effect. This argument played a great part in the 1957 acquittal of suspected serial killer Dr. John Bodkin Adams
John Bodkin Adams
John Bodkin Adams was an Irish-born British general practitioner, convicted fraudster and suspected serial killer. Between the years 1946 and 1956, more than 160 of his patients died in suspicious circumstances. Of these, 132 left him money or items in their will. He was tried and acquitted for...

, a case which established the principle in British law.

Some, including most Catholic ethicists, hold that this concept is morally different from deliberate euthanasia
Euthanasia
Euthanasia refers to the practice of intentionally ending a life in order to relieve pain and suffering....

 for the relief of pain. In addition, support for the view that palliative care and euthanasia are close companions is based on the assumption of a fine line between pain relief, or relief of severe distress, and causing death. In practice, opioids have a very wide safety margin when used appropriately and in the context of pain relief that is titrated (adjusted) to the individual patient. Similarly, sedatives are not lethal when used only to relieve distress and at the lowest dose to avoid dangerous adverse effects. Today, palliative care experience and research has shown that it is possible to manage pain or distress without hastening death (see opioids) and double effect is not viewed as being part of palliative care practice.

War

The principle appears useful in war situations. In a war, it may be morally acceptable to bomb the enemy headquarters to end the war quickly, even if civilians on the streets around the headquarters might die. For, in such a case, the bad effect of civilian deaths is not disproportionate to the good effect of ending the war quickly, and the deaths of the civilians are side effect and not intended by the bombers, either as ends or as means. On the other hand, to bomb an enemy orphanage in order to terrorize the enemy into surrender would be unacceptable, because the deaths of the orphans would be intended, in this case as a means to ending the war early, contrary to condition 2.

Criticisms

Consequentialists
Consequentialism
Consequentialism is the class of normative ethical theories holding that the consequences of one's conduct are the ultimate basis for any judgment about the rightness of that conduct...

, in particular, reject the notion that two acts can differ in their moral permissibility, if both have exactly the same consequences, or expected consequences. John Stuart Mill, a nineteenth-century advocate of the utilitarian version of consequentialism, argues that it is a mistake to confuse the standards for right action with a consideration of our motives to perform a right action: "He who saves a fellow creature from drowning does what is morally right, whether his motive be duty, or the hope of being paid for his trouble; he who betrays the friend that trusts him, is guilty of a crime, even if his object be to serve another friend to whom he is under greater obligations." According to Mill, scrutiny of motives or intentions will show that almost all good behavior proceeds from questionable intentions. Therefore our moral analysis should ignore matters of intention, and so we should reject DDE, which appeals to a distinction between intended and unintended consequences.

Another criticism against the DDE is the hypothetical case where some evil must be intended and acted upon in order to bring about an enormous good, such as in a ticking time bomb scenario
Ticking time bomb scenario
The ticking time bomb scenario is a thought experiment that has been used in the ethics debate over whether torture can ever be justified.Simply stated, the consequentialist argument is that nations, even those such as the United States that legally disallow torture, can justify its use if they...

. For example, suppose a nuclear bomb has been planted in a major city, and a person is held in custody who knows where it is, but who refuses to disclose the bomb's location. May the interrogators torture this person's family in front of his or her eyes, exploiting the family attachment to extract information and save millions of lives? The argument against DDE thus becomes a question of how high must the stakes be before intending and doing any evil is permissible for good ends, while the DDE maintains that intending and doing evil is never permissible even as an instigator to good ends.

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