Correspondence

The Rule of Double Effect

N Engl J Med 1998; 338:1389-1391May 7, 1998

Article

To the Editor:

Quill et al. (Dec. 11 issue)1 discuss the problems associated with the use of the rule of double effect in making decisions about care at the end of life. It would be a mistake to impugn the rule of double effect, since it is the leading ethical principle by which we can ethically and legally relieve the suffering of dying patients. The problem is not with the principle itself but with its varied and unequal application, which in turn depends on the different perspectives, interpretations, and language of patients and physicians.

By training, physicians are concerned with causation and consequence. Although intent is important in law, in medicine we assume our intent is to benefit patients, and it is otherwise of peripheral relevance in a scientific endeavor. Applying a legal and ethical principle to a medical practice produces cross-cultural dissonance. Physicians who think in terms of the pharmacologic effects of a drug view as hypocritical those who judge medical use on the basis of stated intent rather than consequence, whereas physicians philosophically steeped in the principle of double effect view as immoral those who would give a drug for the purpose of its likely consequence.

However, even physicians who, in an effort to relieve the suffering of their dying patients, would give a drug knowing its likely consequence, would not intend to kill their patients. The true intention of such physicians is to relieve suffering, and the well-intentioned principle of double effect allows us to do so, although we are aware of the consequences. We act to relieve suffering, and if we understand that we are not automatons giving drugs but doctors with human and spiritual purpose, we can all accept the principle of double effect to the greater benefit of our patients.

Thomas A. Preston, M.D.
University of Washington, Seattle, WA 98144

1 References

1
Quill TE, Dresser R, Brock DW. The rule of double effect -- a critique of its role in end-of-life decision making. N Engl J Med 1997;337:1768-1771
Full Text | Web of Science | Medline

To the Editor:

The rule of double effect is a great aid to those of us who care daily for patients who are very ill and dying. Fortunately, it is easy for patients and their families to grasp the fundamental concept that it is permissible to provide whatever is required for comfort, even if it hastens death, if comfort is the primary goal. Not all patients and certainly not all families are comfortable with mercy killing, but all can understand that the relief of pain and suffering is fundamental to the care of the ill and dying.

The problem in the care of patients who are very ill and dying is not unrelievable suffering but lack of training and skills on the part of physicians in recognizing and accepting the process of dying, managing pain and other symptoms adequately, and attending to the emotional needs of the dying and their families. It is sad that our care of the dying has lagged behind other forms of medical care, justifying the fear of many persons that they will not be able to die with dignity and comfort. Our emphasis must be on providing the necessary training.

James R. Patterson, M.D.
Oregon Clinic

Marian O. Hodges, M.D., M.P.H.
Providence Portland Medical Center, Portland, OR 97213

To the Editor:

Quill et al. seem to confuse the distinction between the rule of double effect and the debate about physician-assisted suicide. The rule of double effect is essentially a tool for resolving competing ethical claims that can be applied in a number of situations. Thus, demonstrating the weaknesses of the rule does not necessarily bear on the issue of physician-assisted suicide.

Those of us who oppose the legalization of physician-assisted suicide base our case on the moral responsibility of physicians to be healers, the belief that the autonomy of patients is not absolute, and concern about the potential for abuse. Attacking the rule of double effect does not undermine the case against physician-assisted suicide. The prohibition against physician-assisted suicide is much more complex.

(The opinions expressed above are not to be construed as official or as reflecting the policy of the Department of the Army or the Department of Defense.)

Andrew F. Shorr, M.D., M.P.H.
Walter Reed Army Medical Center, Washington, DC 20302

To the Editor:

The critique by Quill et al. of the rule of double effect and its role in care at the end of life perpetuates the myth that opioids, when used for the treatment of pain, are associated with a substantial risk of respiratory depression and death. Physicians who are accustomed to administering opioids only to moribund patients might believe that these agents contribute to the process of dying. This belief, though logical, has little medical foundation, unless a large dose of an opioid is given specifically for the purpose of deep sedation rather than analgesia. Furthermore, in patients who receive opioids over a period of several days tolerance of the sedative and respiratory depressant effects of these agents may develop, making it quite difficult to use them to hasten death. The clinical impression of those treating pain in the terminally ill with opioids is that the patient's death is related to the progression of the disease, not to the use of opioids, and that proper treatment of pain may actually prolong life rather than hasten death.1 We therefore believe that the rule of double effect may apply to the use of benzodiazepines and barbiturates for terminal sedation of a suffering patient, but that it applies no more to the use of opioids to treat pain than to the use of hypnotic agents to induce sleep.

Paolo L. Manfredi, M.D.
R. Sean Morrison, M.D.
Diane E. Meier, M.D.
Mount Sinai Medical Center, New York, NY 10029

1 References

1
Wall PD. The generation of yet another myth on the use of narcotics. Pain 1997;73:121-122
CrossRef | Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: We agree with Dr. Preston and with Drs. Patterson and Hodges (who are on opposite sides of the debate in Oregon about physician-assisted suicide) that the physician's primary responsibility in caring for dying patients is to relieve suffering and provide comfort. We also agree that lack of medical training and skill in palliative care and the inadequacy of current delivery systems are major problems that deserve our utmost attention. Nevertheless, we must still address the question of how physicians should respond to patients who receive excellent palliative care yet reach a point where suffering becomes so intolerable they are ready to die. Here we agree with Dr. Preston that the rule of double effect, with its emphasis on stated intent rather than consequence, can often cloud rather than clarify complex clinical decisions. We also agree with Drs. Patterson and Hodges that the physician's commitment to “provide whatever is required for comfort, even if it hastens death,” is fundamental, as long as that which is provided is consistent with the patient's wishes. How one carries out that commitment remains a challenge that the rule of double effect does not clearly resolve.1

We agree with Dr. Shorr that demonstrating the complexity and ambiguity of the rule of double effect does not resolve the debate about physician-assisted suicide. The rule is a general tool for ethical analysis; that is why we assessed its application to a variety of end-of-life practices. Other dimensions of the analysis that he raises include the healer's role in the care of the dying, the limits of patients' autonomy, and the possible abuses of allowing physician-assisted suicide as a matter of policy. To this we would add concern about whether there is informed consent, whether the level of suffering is proportionate to the risk of hastening death, and whether there are less harmful alternatives. Simultaneous consideration of all these ethical dimensions of clinical actions would lead to a more meaningful understanding of the core issues than that provided by an exclusive reliance on the rule of double effect.1

Finally, it was not our intent to perpetuate any myths about the role of opioids in hastening death. We agree with Manfredi et al. that opioids prolong life much more frequently than they shorten it and that they contribute vitally to an enhanced quality of life.2 In the vast majority of cases in which opioids are used, neither the patient nor the doctor intends to hasten death, and death is not accelerated. In some cases, however, the use of opioids or sedatives creates the possibility of earlier death as an escape from severe suffering.3 In such situations, simple analyses of intention begin to break down for many physicians and patients,4 and fear of violating the rule of double effect may make some physicians reluctant to prescribe sufficiently high doses of opioids to relieve suffering if they might also hasten death.

Timothy E. Quill, M.D.
University of Rochester School of Medicine, Rochester, NY 14607

Rebecca Dresser, J.D.
Case Western Reserve University, Cleveland, OH 44106

Dan W. Brock, Ph.D.
Brown University, Providence, RI 02912

4 References

1
Quill TE, Lo B, Brock DW. Palliative options of last resort: a comparison of voluntarily stopping eating and drinking, terminal sedation, physician-assisted suicide, and voluntary active euthanasia. JAMA 1997;278:2099-2104
CrossRef | Web of Science | Medline

2
American Pain Society Quality of Care Committee. Quality improvement guidelines for the treatment of acute pain and cancer pain. JAMA 1995;274:1874-1880
CrossRef | Web of Science