Saturday, March 18, 2006

Wrestling with the Double Effect

I have written before on issues of ethics in health care. It’s been a while, but you can look back at my posts, “Thinking Ahead,” “Episcopal Thoughts on Suffering and Dying,” and “Spotting the Bad Ones Early,” all posted in January . I’m returning to the topic, and to an issue that I reflect on in a variety of situations.

There are many things we do in health care, risks we take, really, that we do following the principle of Double Effect. This was articulated by Thomas Aquinas, and says, in essence, that if you act toward a good end using good means, unintended side effects are regrettable but morally acceptable. It can get a lot more complicated than that, but that’s the point. There’s a good review of the topic on the web site of the Stanford Encyclopedia of Philosophy.

Now, this principle has its easy applications and its hard ones. Easy? We know that surgery injures the body and causes pain. However, to cure disease we pursue surgical interventions, using the least risky and invasive methods (good end and good means, and proportionality does matter), and so the injury and pain caused by the incision are regrettable but acceptable. We know that medications have risks. If a person participates in a drug study and has a reaction, it is regrettable but acceptable, because new knowledge that would lead to healing is the intent, and not the reaction.

And if you read the review cited above you’ll see that this is true even if the second effect if foreseeable. That is, as with my example of medication research, we can see the possibility of the second effect; but because it isn’t an end in itself, simply being able to predict the possibility of the reaction doesn’t make the research unethical, at least by itself.

But, of course, we’re more conscious in health care of the double effect when it’s really hard. I’m most conscious of it in issues of pain control at the end of life. We will give medication to alleviate pain, not intending to end the patient’s life, but knowing that the medication might hasten that end. I’m not alone in that awareness. I have been too often with nurses who wrestled with that issue, and said when the patient had died, “Well, I’ve killed another one.” They don’t believe that they’ve committed murder. They aren’t happy that the patient has died, and would have been delighted if it hadn’t happened, if the pain could be controlled, and then the injury or disease could be controlled, and the patient had lived. They are simply aware of the moral difficulty of knowing that providing the medicine that will make the patient’s suffering less will also make the patient’s life shorter.

I don’t want to deny or dispense with the principle of double effect. There are many things in health care that we couldn’t do without that consideration. Certainly, I believe in palliative care. I want to see suffering relieved for the dying as best we can, and I appreciate that doctors and nurses pursue that end carefully and compassionately. At the same time, I want to see us approach these situations with fear and trembling and humility. It is one thing, I think, to consider a double effect that is foreseeable; and another to consider one that is inevitable. That’s the sense of those sad and uncomfortable nurses, following the doctor’s order to “titrate medication for pain control,” who speak of “killing another one.” They give each small, incremental dose to relieve suffering, to ease air hunger and physical rigor and rapid heart rate. Each dose is small indeed. But they also know how those doses add up. They know that patients in pain can tolerate and metabolize doses of pain medication that would floor figuratively and literally those of us who are healthy. But they also know that even in great pain there is a limit, a tipping point when breathing is suppressed and metabolism slows. And, barring God’s direct intervention, they know this patient will die of an almost inextricable combination of disease and medication – dying much more comfortably, and also sooner.

Again, I don’t want to suggest we shouldn’t do this, that we shouldn’t practice palliative care. Suffering may be redemptive; but I can only imagine that if it is freely chosen. I cannot make the decision for another to suffer if it is in my power to ease the suffering. I simply believe we need always to hold on to this tension, this moral anxiety: that the double effect may be acceptable, but it is still profoundly regrettable. Unintended consequences may be foreseeable and even inevitable, and we may still find that we can live with them. But we must never become complacent about them.

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