such as "Introduction", "Conclusion"..etc
The principle of double effect is a fundamental principle in Roman Catholic moral theology. As the name implies it refers to one action with two effects. One effect is intended and morally good; the other is unintended and morally evil. It is not an inflexible rule or mathematical formula, but rather an efficient guide to prudent moral judgment in solving difficult moral dilemmas. 8Historically, many ethicists believe the premises for the principle can be found in the writings of Thomas Aquinas in his famous explanation of the lawful killing of another in self-defense in the Summa Theologicae II, q. 64, a. 7c. However, other ethicists argue that the four conditions of the principle were not finally formulated until the mid-nineteenth century by Jean Pierre Gury. 9The principle of double effect specifies four conditions that must be fulfilled for an action with both a good and a bad effect to be morally justified.
It should be noted that a number of moral theologians known as proportionalists have argued that the first three conditions of the principle of double effect are incidental to the principle, and that in reality it is reducible to the fourth condition of proportionate reason. While this is a legitimate argument, it is not the purpose of this article to reopen the controversy on the validity of the first three conditions. This article will remain within the framework of the four conditions of the principle of double effect, as it exists in fundamental moral theology, and apply these conditions to the use of morphine as an ethical means of palliative care. 11
The use of narcotics to control pain was sanctioned by Pope Pius XII under the principle of double effect. In answer to a group of doctors who posed the question: “Is the suppression of pain and consciousness by the use of narcotics permitted by religion and morality to the doctor and the patient (even at the approach of death and if one foresees that the use of narcotics will shorten life)?” The Pope stated: “If no other means exist, and if, in the given circumstances, this does not prevent the carrying out of other religious and moral duties: Yes.” 12According to the principle of double effect “in this case, of course, death is in no way intended or sought, even if the risk of it is reasonably taken; the intention is simply to relieve pain effectively, using for this purpose painkillers available to medicine.” 13The Church believes that suffering is part of the human condition and has a special place in God's plan of salvation. However, the Church also believes that effective management of pain and suffering is necessary so that the person can die comfortably and with dignity and respect.
The use of morphine to manage pain effectively is ethically justified because it meets the four conditions of the principle of double effect. The first condition allows for the injection of morphine because the action in and of itself is good, in that it effectively alleviates or manages the pain of the patient. According to the State's affidavit these patients were suffering and needed palliative care. While morphine may endanger the patient's life by suppressing respiration, the injection will not directly terminate the patient's life. The second condition allows for the injection of morphine because the good effect is not caused by means of the evil effect. The patient's pain is alleviated by the morphine not by the patient's death. The good effect and the evil effect happen simultaneously. The third condition allows for the injection of morphine because even though there is the possibility that the morphine may harm the patient, the intention of the physician is to alleviate or manage the patient's pain. Dr. Steven Miles, professor of medicine at the University of Minnesota argues that “morphine and Versed are not all that deadly and may not even have been what killed the patients. Many patients develop tolerances to the drugs and can handle high doses. Barbiturates, readily available at the hospital, would be a far more efficient way to kill somebody if that was the intent.” 14Finally, the argument for the ethical justification of morphine for medical use by the principle of double effect focuses on whether there is a proportionately grave reason for allowing the foreseen but unintended possible consequences. Proportionate reason is the linchpin that holds this complex moral principle together.
Proportionate reason refers to a specific value and its relation to all elements (including premoral evils) in the action. 15The specific value in using morphine and other pain analgesics is to relieve pain and suffering associated with treatment for specific illnesses. The premoral evil, which can come about by trying to achieve this value, is the foreseen but unintended possibility of the potential harmful effects of depressing the respiratory system and hastening death. The ethical question is: does the value of relieving pain and suffering outweigh the premoral evil of the potential harmful effects? To determine if a proper relationship exists between the specific value and the other elements of the act, ethicist Richard McCormick proposes three criteria for the establishment of proportionate reason:
The application of McCormick's criteria to the use of morphine supports the argument that there is a proportionate reason for allowing physicians to prescribe it for palliative care. First, the use of morphine to control the pain and suffering of these patients in this situation did not cause more harm than necessary. The medical professionals were in a desperate situation and the only way to relieve the pain of the patients was to use morphine knowing the unintentional side effects. Not treating the pain and suffering of these patients would violate their right to being treated with dignity and respect. Second, the situation at Memorial Hospital was that the water was rising, there was no electricity, food and medical supplies were running low and the hope of evacuation for these patients was unclear. The use of morphine was the only way to respect the value of the patient's life. “In underdeveloped nations, doctors have to make decisions every day about how to proceed when nothing more can be done for a patient. The hospital in New Orleans was reduced to those conditions.” 17Third, the use of morphine if intended for palliative care, gave these patients the dignity and respect they deserved under these desperate conditions. Palliative care is given to respect the value of the patient's life. “Two million deaths a year occur in medical settings, and 85% to 90% of those are preceded by decisions to withhold or end life support. The vast majority involve sedation.” 18Therefore, it would have been ethically justified under the principle of double effect for the medical professionals at Memorial Hospital to give these four patients adequate doses of morphine or other pain medications if it was for palliative care. All individuals, but especially the seriously ill, have the right to effective pain management. To deny them access to such therapies is to deny them the dignity and respect all persons deserve. The greater good is promoted in spite of the potential evil consequences.
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