Anyone who has taken a course in ethics may well recall, if not fondly, the deployment of numerous concepts and fine distinctions. You may wonder if they matter much, and the suspicion may have crossed your mind that they seem to invite as much obscurantism as clarity. Not until recently, however, did they appear of great importance in public issues, and not simply odd, out-of-the-way cases for classroom debate, such as the rare case of a woman with a potentially lethal fallopian tube pregnancy, a favorite example of the principle of double effect. A broad look at such moral distinctions shows some recent shifts and new imputations of self-deception.
Two old distinctions have been quietly retired. The notion of ordinary and extraordinary treatment, often misunderstood to apply to the complexity of the technology used to sustain a dying person, is now more commonly referred to as the burden of treatment on the patient. This is a judgment of the degree of pain or comfort a specific treatment will bring. Even a technologically simple treatment, such as the use of an antibiotic, can be burdensome if it prolongs the life of someone who is slowly dying of an otherwise painful and fatal condition. Who would want that, and why would any doctor be obliged to prescribe an antibiotic in that circumstance?
The distinction between withholding and withdrawing treatment is another one that is fading. Many doctors had long considered it acceptable not to provide any life-saving treatment when the outlook was poor or hopeless, but not right to withdraw such treatment once initiated. Experientially at least, the latter felt like a killing of a patient in a way that providing no treatment did not. Yet in recent years it has been accepted (even if there is lingering hesitation among some doctors) that there is no meaningful distinction between them. If a patient's condition morally warrants treatment, even if unlikely to succeed, it should be provided, but it can then be withdrawn if the patient fails to improve.
While the principle of double effect still has good standing, and is often invoked in the case of providing drugs such as morphine to relieve pain, critics have begun to appear. The full conditions necessary to invoke the principle are multiple and complex, but the core thrust is that it is morally legitimate to intend to carry out an otherwise morally acceptable act that will have foreseeable--but not intended--wrongful results as a consequence. Tubal pregnancy, which is potentially lethal and which can be dealt with by removing the tube even though it will foreseeably, though not intentionally, kill the fetus, is a classic instance of invoking the principle. So is the use of fatal doses of morphine.
The criticism of the double effect principle takes two forms. One of them argues that it is illogical to distinguish between intended and unintended consequences if both lead to the same practical result, for example, the death of a fetus because of tubal ligation and of a patient given a pain-relieving, but also lethal, dose of morphine. According to these critics, whoever carries out the act that brings about death is morally responsible for the death. "Foreseen but not intended" does not relieve one of direct culpability.
The other criticism goes a step further. This argues that the principle of double effect is not only illogical, but is self-deceptive, allowing people, by a moral sleight-of-hand, to do things they would otherwise consider wrong. I am sympathetic to this criticism, even though I do not share the cynical perspective that some critics (mainly of secular persuasion) bring to it, attributing all-but-deliberate obfuscation to its supporters.
It would be more straightforward to use a principle of lesser evil to judge acts that have both good and bad consequences, taking full responsibility for both, whether intended or only foreseen. In the case of a high dose of morphine, it seems to me morally legitimate to run a foreseeable risk that it will kill the patient, but not a dose so high that it will surely kill him. …