Tina is gasping. Her mother and daughter are by her side. They see the horror and exhaustion in her eyes as she struggles along not because she wants to but because of anxiety, confusion, and force of habit. Tina suffers from ALS, a degenerative disease, and is now in the last stage of the disease. She signed a do not resuscitate/do not intubate document (DNR/DNI) which allowed her to forego the futility of dragging on the inevitable. You are the hospice nurse on site. The family is begging you to do something to alleviate her pain. Included in the medical options available to you is a PRN order for an antispasmodic/paralytic agent.
This patient is no doubt suffering from spasticity along with her respiratory problems as this is the nature of the disease. You are, however, faced with moral dilemma. Do you administer the medication? On one hand, administering the paralytic will enable the patient to relax from the painful throws of her broken body which is the desired effect. However, as a direct result of administering this medication, Tina will die. The side effect of respiratory depression which in her earlier stages would not have been fatal will now most definitely bring about respiratory failure.
“The Double Effect”, is a term which was dubbed by early Roman Catholic theologians to describe a scenario in which an action will cause both a positive result as well as negative result. The aforementioned scenario was an extreme example designed to bring out the issue in all its severity. The same moral issue, however, can be applied to less sever situations as well. An example of this which is just as practical is the case of a person who requires an amputation. All amputations result in two effects, the loss of limb (negative effect) and the positive relief and healing that comes from this medically necessary procedure.
My third and last case which I want to focus on in this paper is the use of methotrexate. An ectopic pregnancy is a medical emergency which requires immediate intervention. If a woman’s’ egg is fertilized by the man and implanted in the fallopian tube before it gets to the uterus the fallopian tube will burst open causing the woman to bleed internally resulting in death. Current medical intervention involves the administration of methotrexate which stops the egg from growing causing it to disintegrate. The effect is the survival of the woman and relief from the excruciating pain associated with this emergency. Although the egg is not viable is the fallopian tube this situation is still tied to the double effect. This is because there is an action, namely the administration of methotrexate, which will result in both the survival of the mother as well as the destruction of a fertilized egg which at the moment of administration is, according to Christianity, considered to be alive.
“Historically, the principle of double effect is rooted in the medieval natural law tradition, especially in the works of Thomas Aquinas (1225?-1274)” (Villanova). Thomas Aquinas was both a priest and a doctor receiving his doctorate in Paris at the age of thirty-one (Cathlic.org). After naming, defining, and mulling over the issue Thomas Aquinas designed an approach to deal with such issues. The original question which provoked the Double Effect doctrine to be created dealt with self defense. In an effort to save ones’ life can a person slay his assailant?
The doctrine consists of four conditions which must be met in order to sanction an action which will have both a positive and a negative outcome. These conditions are:
1) The agent may not positively will the bad effect but may permit it. If he could attain the good effect without the bad effect he should do so. The bad effect is sometimes said to be indirectly voluntary.
2) The good effect must flow from the action at least as immediately (in the order of causality, though not necessarily in the order of time) as the bad effect. In other words the good effect must be produced directly by the action, not by the bad effect. Otherwise the agent would be using a bad means to a good end, which is never allowed.
3) The good effect must be sufficiently desirable to compensate for the allowing of the bad effect.
4) The intent must be for the good.
Using these four rules as guidance, Thomas Aquinas postulated that it is prohibited to save ones’ life by killing his assailant even though it will result in his death. This inability to defend oneself using fatal means was based on the grounds that it breaks rule number one which states that the act must be an inherently good act which results in a good and bad result. Killing is an inherently bad act. Thus the action is deemed to be a harmful act with bad intension automatically due to its positive effect coming only as a side effect of the negative result. Later sources state that he retracted his opinion in this scenario but there is no direct quote stating so.
Since America is predominantly a Judeo-Christian society, a discussion dealing with medical ethics would not be complete without including the Jewish philosophical view. As Conservative and Reform Judaism does not abide by biblical law, the only opinion which has practical value is the Orthodox sect.
The Bible states “If the thief is found breaking in, and is struck so that he dies, there shall be no guilt of bloodshed for him” (Exodus, Ch22, V1). Accordingly Orthodox Judaism permits and even encourages one to kill his assailant if that is the only way in which he can take himself out of this life threatening danger. This biblical rule, however, only discusses the most extreme possibility. It does not deal with subcategories such as taking medicine which will render the patient to be sterile (sterilization being Biblically prohibited) or relieving pain while hastening death.
Concerning non-life-threatening situations, Jewish theologians discuss the idea of participating in medical procedures in general. The law books which are rooted in biblical law question why there is a specific stipulation in the Bible which allows medical procedures to be performed. One suggestion is that in performing a medical procedure one is attempting to circumvent G-ds’ wishes, G-d being the one who caused the illness in the first place. This notion is rejected based on logic. G-d also gave us the ability to help ourselves and by doing so has allowed us to intervene when needed.
The reason, the religious leaders submit, that we need a specific verse in the Bible allowing medical intervention is precisely due to situations which entail both good and possible bad results. Medicine, even in the twenty-first century, is not an exact science. Medical procedures carry risks either from the actual procedure or from the anesthesia. Accordingly, interpreters of biblical law (included in them: Maimonides, Rush, Mieri to name a few) postulate that medicine which has both positive results as well as negative side effects may be performed as long as The intention is for the positive effect and the negative effect is not guaranteed to happen. On these grounds any medical procedure which is performed with the intent of a positive result where the negative result is not guaranteed is permitted.
The official policy of the American Nurses Association is, “increasing titration of medication to achieve adequate symptom control, even at the expense of maintaining life or hastening death secondarily, is ethically justified” (ANA, 1991). That being said, it goes without saying that one must also review the scope of practice as defined by the specific state in which each nurse is licensed in as well as the policy of the company in which one is working.
To summarize, the policy of both Jews and Christians in a scenario such as Tina’s is not to allow administration of an antispasmodic where one is sure to cause death. In the second case of a person in need of an amputation, Judaism will allow it in view of the greater good. Strictly speaking the double effect created by the church does not allow for amputation. The reason for this is because one of the requirements of performing an act with both good and bad results is that one’s intention must be only for the good. Where the bad is guaranteed to happen, it must be considered as intentional too. In practice those who abide by the double effect rule do permit amputations. Some of the reasons include the acceptance of the limitations of the double effect doctrine others suggest that the loss of limb is not necessarily a bad result and could be considered neutral.
The third scenario discussed in this paper was the case of an ectopic pregnancy. Judaism does not recognize a fetus in this stage to be anything more than a part of the mother and as such the mother may be given the medicine to annul the threat to her life. Secondly, no matter how old the fetus is, if the mothers’ life is in danger due to the pregnancy than we view the situation as a case of self-defense in which case the woman must protect herself even at the cost of the perpetrator, in this case, the unborn child. According to those who follow the double effect policy, however, one would not be allowed to administer/take methotrexate. Instead the woman would have to undergo surgery in order to remove the fallopian tube containing the fetus.
The Double Effect doctrine is just one reason why every participant in a health care facility should become familiar with its policies concerning hospice care as well as other issues which are connected to ethical practice. As nurses it is imperative that we educate ourselves in preparation for these issues which we are likely to encounter during the course of our career. As one very experienced emergency room nurse told me during my nursing clinical, she stated that when she finds herself under orders which conflict with her judgment or morals she prepares the medicine or for the procedure just as she is told and then hands the medicine over to the doctor and requests the doctor to administer it due to her moral conflict.
Torczyner, Mordechai. (Dec. 19, 2010). Medical Halachah: Double Effect-treatments which help and harm. Retrieved from: www.yutorah.org
THE PRINCIPLE OF DOUBLE EFFECT. The Villanova University. Retrieved from: http://www83.homepage.villanova.edu/richard.jacobs/MPA%208300/theories/double%20effect.html
http://www.catholic.org/saints/saint.php?saint_id=2530 Catholic online
McIntyre, Alison, “Doctrine of Double Effect”, The Stanford Encyclopedia of Philosophy (Fall 2011 Edition), Edward N. Zalta (ed.), URL =< http://plato.stanford.edu/archives/fall2011/entries/double-effect/>.
Palliative Care and Pain Management. Wednesday, Jan. 26, 2005. Retrieved from:http,://www.nysna.org/advocacy/testimonies/pain_mgt.htm