Double Effect and Contemporary Bioethics

As noted at the outset, the contemporary bioethics literature generally treats Double Effect as a two-part principle. Interestingly, the two-part contemporary PDE, as the preceding discussion suggests, is closer to its Thomistic origins. Though its traditional applications to abortion, euthanasia, self-defense and suicide (particularly physician assisted suicide) continue to be discussed, the PDE has been applied to some novel contemporary bioethics cases, such as the separation of conjoined twins and the use of embryos in research, as well (Coughlan and Anscombe). The strong resurgence of interest in Double Effect in bioethics, however, is directly attributable to the rise of the palliative care movement (Cantor and Thomas; Cavanaugh; Quill, Lo et al.; Manfredi, Morrison et al.; Patterson and Hodges; Preston; Shorr; Gilbert and Kirkham; Sulmasy and Pellegrino; Hawryluck and Harvey; Nuccetelli and Seay; Sulmasy; Bernat; Luce and Alpers; Thorns). Indeed, the vast majority of contemporary bioethics discussion of Double Effect has centered its application to terminal sedation which, though controversial in some quarters, is usually little more than a logical extension of the morphine drip case considered above (Paradigm 3) (Krakauer, Penson et al.; Wein). A somewhat novel application of Double Effect in terminal sedation is illustrated by the following case.

Terminal Sedation: Agonal Breathing. Mrs. Jones, an eighty-two year old white female, is a vent dependent terminally ill cancer patient. She is conscious and deemed to have decision capacity upon psychiatric evaluation. Though her pain is well controlled, she requests to be removed from the ventilator. She also requests to first be sedated so that she will not have the experience of not being able to breathe once ventilator support is withdrawn.

The use of palliative medicine in the case of Mrs. Jones can plausibly be construed as satisfying the PDE. Here the use of palliative medicine is intended to alleviate the discomfort of agonal breathing and the attendant suffering of Mrs. Jones should she have to experience this. Critics have argued that invoking Double Effect in these types of cases is a thinly veiled attempt to avoid the charge of intentional killing (Quill, Dresser et al.; Kuhse). Such critics argue that, rather than invoking Double Effect as a rationalization for palliative care, it should be acknowledged that there are times when the intentional mercy killing (euthanasia) is appropriate, thus rendering Double Effect concerns irrelevant.

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