Double Effect: Does It Have a Proper Use in Palliative Care?

Opioids, Double Effect, and the Prospects of Hastening Death

The relevance of double effect for end-of-life decision-making has been challenged recently by a number of scholars. The principal reason is that opioids such as morphine do not usually hasten death when administered to relieve pain at the end of life; therefore, no secondary "double" effect is brought about. In my article, I argue against this view, showing how the doctrine of double effect is relevant to the administration of opioids at the end of life. I contend that the prevailing view suffers from a misunderstanding of the nature of double effect, which includes application to risking a grave harm.

Pain Management at the End of Life and the Principle of Double Effect: A Jewish Perspective

Controlling the pain of patients at the end of life can be challenging both clinically and ethically. One ethical obstacle arises when analgesia has the potential to hasten the death of the patient, thus, invoking the principle of "double effect" to resolve such dilemmas. This article will develop, analyze, and apply that principle from a Jewish perspective. It is this writer's opinion, that pain management can be administered effectively from a Jewish perspective in most clinical scenarios.

The principle of double effect as a guide for medical decision-making

Many medical interventions have both negative and positive effects. When health care professionals cannot achieve a particular desired good result without bringing about some bad effects also they often rely on double-effect reasoning to justify their decisions. The principle of double effect is therefore an important guide for ethical decision-making in medicine. At the same time, however, it is a very controversial tool for resolving complex ethical problems that has been criticized by many authors. For these reasons, I examine in this paper whether the principle of double effect can serve as a basis for ethical decisions in medicine. The conclusion reached in this article is that even though this principle has desirable effects on clinical conduct, it is only an unreliable guide and physicians and nurses cannot feel secure in continuing to use this principle for ethical guidance.

[Euthanasia in patients with cancer and the continuous-care providers]

During the clinical evolution of patients with cancer there are many occasions, or phases of the disease, when there are no specific treatments and, as such, we need to provide maximum comfort following appropriate symptom control; in this stage it is fundamental to respect personal autonomy together with the option to reject futile treatment. With appropriate control of symptoms it is possible to reach the stage where the majority of the patients do not continue to suffer. Continuous-care providers for cancer patients are those who are responsible for providing help to resolve these situations. In palliative medicine there are highly-efficacious procedures to the help in these last hours. Sedation is applied when it is impossible to control symptoms by other means. With appropriate Carer cover, it is not necessary to introduce laws on assisted suicide and/or active voluntary euthanasia, neither because of the magnitude of demand, nor because of the difficulties in achieving appropriate control of symptoms.

Responding to persistent requests for assistance in dying: a phenomenological inquiry

Little is known about how American nurses understand and respond to requests made by decisionally capable patients for assistance in dying. This article is based on a broader qualitative study first reported elsewhere (Schwarz, 2003). The study used phenomenological interpretation and analysis of stories told by 10 nurses who worked in home hospice, critical care, and HIV/AIDS care settings. Persistent requests for assistance in dying were relatively uncommon, but when heard, participants provided the following responses: refusing assistance, administering palliative drugs that might secondarily hasten dying, tacitly permitting and not interfering with patient or family plans to hasten death, and actively providing direct assistance in dying. Nurses' responses were context-driven; they did not seek guidance from professional codes of ethics or colleagues. Secrecy and collusion were routinely practised. Few participants unequivocally agreed or refused to help patients die; most struggled to find morally and legally acceptable ways to help patients die well. Regardless of how they responded, nurses who believed they had hastened death described feelings of guilt and moral distress. Healthcare professionals who provide care for symptomatic dying patients need opportunities to meet with supportive colleagues, to share the experience of troubling cases and of moral conflict, and to be supported and heard in a 'safe' environment.