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The aim of this entry is to present the principle of the act of double effect (PADE): its concept, its roots in the Catholic Thomistic tradition, and its application in the health-care ﬁeld, mainly in some conﬂicting situations at the beginning (cases of complicated pregnancy) and end of human life (pain management in caring for the dying patients). There are four criteria in discerning the morality of human act: (1) The act must be good in itself or at least indifferent. (2) The good intended must not be obtained by means of the evil effect. (3) The evil effect must not be intended for itself, but only permitted or tolerated. (4) There must be a proportionate reason to tolerate the evil effect. Finally, the PADE is important as a “technical instrument” to achieve prudent and reasonable decisions and choices among human values that are in conﬂict as well as to discern the “good” that is directly intended and to tolerate the “side and unintended effect” of a speciﬁc human action.
The principle of the act of double effect (PADE) known also as “principle or doctrine of double effect,” in the moral literature, originated from Roman Catholic Scholastic Moral Philosophy and was the primary operational principle pre-Vatican II Catholic medical ethics. The expression principle of the act of double effect (PADE), and not simply the principle of double effect, was used for the fact that this latter expression privileged primarily the effects that result from one determined act. Therefore, the key expression is act and not the result of a determined act characterized by the expression effect. This principle is applied to conﬂict situations in which an action can cause numerous effects or at least two: one good and the other bad. The PADE is still widely used, not only in Catholic medical ethics but for some issues in secular bioethics as well. In Roman Catholic bioethics literature, the PADE has been invoked to deal with cases of maternal-fetal conﬂict, to distinguish between permissible interventions that may result in the death of the fetus, and abortion, which is absolutely forbidden in this religious tradition. The vast majority of contemporary bioethics discussion of the PADE has centered on issues of end-of-life care, especially related with terminal sedation in the practice of palliative medicine.
The reﬂective journey on this issue will start with the concept of PADE and its historical roots and then continue with the application of this principle to issues of the beginning of human life, on one side, and on issues at the end of human life, on the other side, for example, with palliative medicine with terminal patients.
The Concept Of The Act Of Double Effect (PADE)
The PADE is an answer to this question: Is it right to perform an action from which two or more effects will result where some of which are good and may rightly be intended and some of which are bad and may not rightly be intended? According to this principle, an action with both good and bad effects is right (licit, permissible) if and only if all four of the following conditions are met or respected: (1) The act in itself must not be morally wrong. (2) The bad effect must not cause the good effect. (3) The agent must not intend the bad effect (as an end to be sought). (4) The bad effect must not outweigh the good effect (proportionate reason). According to this principle, actions and omissions are permissible only when their gravely bad effects are allowed for good reason (proportional reason) and are unintended. In the PADE, the distinction that plays a key role is that of the “direct” and “indirect” intention or the distinction between results that are merely expected (tolerated, side effects) and those that are intended (Garcia 1995).
The ﬁrst condition is clearly deontological which was and often interpreted in a physicalist manner. The act in itself must not be morally wrong. The act in itself, considered apart from its circumstances and consequences, must not be morally wrong. According to a deontological framework, the action is wrong regardless of circumstances, situations, or consequences. In the second condition it is rare for one to hold that an end can be justiﬁed by any means. No ethicist has ever argued that ends always justify the means and that a good end justiﬁes virtually any means, regardless of consequences or intentionality. Nor has any ethicist ever held that a good end can justify an immoral, wrong mean. Wrong acts are never justiﬁable. What the proportionalists say in rejecting deontology is that one cannot know for sure that an act is wrong without examining its circumstances (concrete situation) including its effects (consequences) and the intention of the moral agent. In the third condition the agent may not intend the bad effect as an end to be sought. People ought not to want evil. The meaning of intentionality in the third condition is what the agent intends as an end to be sought. In the fourth condition, known also as having a proportionate reason, it refers to the measure of good and bad effects (Kelly 2004; Byrne 2003; Virdis 2006).
The ethicist William May, in the ﬁrst edition of the Encyclopedia of Bioethics (1978), describes the PADE as follows: “as the PADE is formulated, it establishes that we can cause a legitimate evil thru an act of choice, only if four conditions are observed: (1) The act in itself is good or at least indifferent; (2) The good effect of the act is what the moral agent intends directly, and only tolerates the bad or side effect; (3) The good effect is not obtained thru (as a means) the evil effect; (4) There must be a proportionate reason to permit that the evil effect may occur” (May 1978).
In analyzing the several applications of the PADE, Keenan (Keenan 1993) sees the four conditions in the following way: (1) object of the act, (2) intention, (3) material cause, and (4) proportionate reason. Consequently, we can speak of the act of double effect as a special human act, a moral act that has the same roots with any human act. As the Catechism of the Catholic Church says, “the morality of the human acts depends on: the object that we have chosen; the intention; the circumstances of that action. The object, intention and the circumstances are the ‘fonts’, the elements that construct the morality of the human acts” (Catechismo Della Chiesa Cattolica, n. 1750, p. 450).
Historical Origins Of PADE
Most scholars in the ﬁeld of ethics trace the origin of the PADE to St. Thomas Aquinas’ (1224–1274) discussion on killing in self-defense. Aquinas notes that the Christian tradition had, until his time, almost universally forbade “killing in self-defense.” This prohibition probably stemmed from the teaching of St. Augustine (354–430) in De Libero that Christians should not kill others to save themselves because bodily life is that which “they ought to despise.” In his justiﬁcation of killing in self-defense that Aquinas invoked, later, it became the essential conditions of the PADE. He argued that, “A single act may have two effects, of which only one is intended, while the other is incidental to that intention. But the way in which a moral act is to be classiﬁed depends on what is intended, not what goes beyond such an intention. Therefore, from the act of a person defending himself a twofold effect can follow: one, the saving of one’s own life; the other, the killing of the aggressor” (Summa Theologiae, II-II, q.64, a.7).
The crucial distinction of PADE between intention and foresight is clear. An act of self-defense is classiﬁed as such provided that it is the saving of oneself and not the killing of the aggressor that is intended. If the killing was intended, and not merely foreseen, then, for Aquinas, the act would properly be a homicide. For Aquinas, not to have intended evil is a necessary, but not a sufﬁcient, condition to justify self-defense. He offers a second condition: “An act that is properly motivated may, nevertheless, become vitiated if it is not proportionate to the end intended. And this is why somebody who uses more violence than is necessary to defend himself will be doing something wrong” (Summa Theologiae, II-II, q.64, a.7). Consequently, the fourth condition of the traditional PADE, on proportionality, can be elicited from this passage. Although, it is not clear from this passage that proportionality refers to the measure of good and bad effects, later, moralist interpreted the condition in this way.
The Application Of The PADE In The Field Of Medicine And Clinical Bioethics: Issues At The Beginning Of Human Life
A classic example in the context of casuistry in medical ethics is the case of a woman with uterus cancer that can be saved only through a hysterectomy. This is an example of how we can put in action the PADE. The objective of the act is the extraction of the organ with cancer with direct and explicit intention to save the life of the women, but with the possibility of foreseen one or more bad effects, not directly intended, as the death of the fetus. The death of the fetus is not part of the intended structure of the act, neither as an objective nor as a mean.
The possibility of having negative effects and positive effects puts the agent in front of a very difﬁcult situation in which it is necessary to discern the goods that are at stake in the possibility of an alternative choice in this context. For example, the woman can legitimately decide to go on with the pregnancy and give permission to the son/daughter to be born with the sacriﬁce of the mother’s life for the life that she has in her uterus. In this case, the choice could be also heroic and admirable characterized by a strong moral meaning of the value of sacriﬁcing her own life for the life that she carries in her womb. A testimony of this choice is Gianna Beretta Molla, a young Italian physician that in front of this dilemma opted for the life of her child, renouncing her own life of only 39 years. She was declared Saint by Pope John Paul II on May 16, 2004. The Cardinal of Milan, Carlo Maria Martini, described her as “a marvelous woman, lover of life, spouse, mother, exemplary physician, [whom] offered her life for not violating the mystery of the dignity of life.”
In the ﬁeld of moral theology and bioethics, there is a hard discussion related with the indirect death of the fetus, especially in the case of an ectopic pregnancy. In this case, if the pregnancy is permitted, both the woman and the fetus will die. In this circumstance, there is no alternative choice but to save the life of the mother or to save the fetus. There is only one possible choice: to save the mother. One example of the contemporary use of PADE is the document of the USA Catholic Bishops entitled The Ethical and Religious Directives for Catholic Health Care Services. In the issues related to the care of the beginning of life, it says, “Direct sterilization of either men or women, whether permanent or temporary, is not permitted in a Catholic health care institution. Procedures that induce sterility are permitted when their direct effect is the cure or alleviation of a present and serious pathology and a simpler treatment is not available” (United States Conference of Catholic Bishops 2009, 53).
In the same document, it afﬁrms that the PADE can be implemented when the death of an embryo or fetus is foreseen but not intended. It reads as follows: “Operations, treatments, and medications that have as their direct purpose the cure of a proportionately serious pathological condition of a pregnant woman are permitted when they cannot be safely postponed until the unborn child is viable, even if they will result in the death of the unborn child” (United Sates Conference of Catholic Bishops 2009).
Issues On The End-Of-Life Situations: Palliative Medicine And Patients At The Last Stage Of Their Lives
A paradigmatic application of the PADE pertains to the context of the care of terminal patients. For example, assume a physician intends to alleviate the pain of a patient by administering a high level of morphine as pain medication. He recognizes that the dosage of morphine probably will shorten the physical life of the patient. The physician does not intend to shorten the life of the patient, but only to alleviate the pain of the patient, and with this action as the end, it hastens the involuntary death of the patient.
Pope Pius XII (1957), responding to some questions on moral problems related to the use of narcotics that would have a secondary effect of shortening the duration of life, placed the accent on the object of the act and on the intentions and stressed that between narcotics and abbreviation of life, there was no direct causal nexus (Congregation for the Doctrine of the Faith 1994).
The document of the USA Catholic Bishops, The Ethical and Religious Directives for Catholic Health Care Services in relation to the Issues of Care for the Seriously Ill and Dying, says, “Patients should be kept as free of pain as possible so that they may die comfortably and with dignity, and in the place where they wish to die. Since a person has the right to prepare for his or her death while fully conscious, he or she should not be deprived of consciousness without a compelling reason. Medicines capable of alleviating or suppressing pain may be given to a dying person, even if this therapy may indirectly shorten the person’s life so long as the intent is not to hasten death. Patients experiencing suffering that cannot be alleviated should be helped to appreciate the Christian understanding of redemptive suffering” (United States Conference of Catholic Bishops 2009, n. 61).
The PADE is used to justify medical actions at the end of life, to alleviate the pain and suffering (action directed intended – good effect) for the dying person, but it has also as a side effect, the possibility of shortening the patient’s life (indirect effect, side effect tolerated). This is not considered euthanasia in the ﬁeld of Catholic medical ethics and bioethics. For many secular scholars, this is clearly a situation of euthanasia. They also do not make any moral distinction between the act of killing and the act of letting die, which is so important in Catholic medical ethics and bioethics (Rossi 1973; Leone and Privitera 2001; McCormick 1976).
A lot of discussions and debates exist today in the ﬁeld of bioethics related to the treatment of patients in persistent vegetative state (PVS). The US Bishops updated their teaching on this matter in 2009 and they said, “There is an obligation, but only in general principles, to provide medically assisted feeding (nutrition and hydration) to patients in chronic and irreversible conditions, such as PVS patients. However, in speciﬁc cases medically assisted feeding is morally optional, not morally obligatory, if it cannot reasonably be expected to prolong life or it is excessively burdensome or it causes signiﬁcant physical discomfort to the patient such as when a patient draws close to death” (United States Conference of Catholic Bishops 2009, n. 58). This teaching reﬂects a more basic distinction that guides decision-making in health care by differentiating between proportionate and disproportionate means, reﬂecting the long-standing distinction in the Catholic tradition between ordinary and extraordinary means. The PADE can be used to resolve dilemmas in the end-of-life care in which withholding or withdrawing treatment, including medically assisted feeding, is deemed futile. Because Catholic teaching recognizes that the life of the body is not an absolute good, there is no moral obligation to keep a patient alive whatever the circumstances or cost. The Catholic tradition has developed a working principle that permits allowing patients to die when futile measures are legitimately withdrawn. However, any form of direct euthanasia or assisted suicide is not permitted according to Catholic moral teaching. Withdrawing futile measures lets patients die of their underlying pathology and does not constitute killing them. The intent to withdraw futile treatment is distinct from intending the inevitable and foreseen death of the patient.
The PADE has its roots in Thomistic moral philosophy. One of the main contributions of this principle in the ﬁeld of medicine is to help resolve conﬂicts in concrete moral situations. It helps to deal with and analyze the human act in those situations where the result of one action can produce a bad effect or effects (evil, unintended collateral effects). In these situations, the PADE is important as a “technical instrument” for the attainment of prudent and reasonable decisions and choices when human values are in conﬂict. Its function is not only to justify the choice of some acts that can cause negative effects but also to analyze the objective and the intention of the moral agent.
In any situation, to discern the true nature of the human act means always to reﬂect on the roots of morality in the light of the deﬁnition of the moral object of the act and, in the perspective of the agent, the person. In this sense, maybe the most important contribution of the PADE to medical ethics and bioethics is that human actions cannot be judged morally only in terms of consequences. It is necessary to take into consideration the conditions in which these actions are conducted including the intention as well.
Despite the many critics of the PADE, which is seen as insigniﬁcant by some scholars from the different secular philosophical traditions, it is still important and valid in many conﬂicting situations nowadays. It functions as a tool that helps to discern about choices especially in the end-of-life context and also as a search for a more reﬁned qualiﬁcation and concretization of what constitutes the humanum factor in any human act that can be qualiﬁed as a “moral act.” Finally, the PADE is a signiﬁcant contribution of the tradition of the Catholic Moral Theology to contemporary bioethics and can be seen as an important instrument to help discern a prudent decision that lead to an necessary action when we are facing a situation or fact with conﬂicting of values.
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