Double Effect and Ethical End-of-Life Care: Assessing the Benefits and Burdens of Lethal Treatment (or Lack Thereof)

Given the wide the range of legally available options for end-of-life care in recent decades: from aggressive, even experimental, treatment to active euthanasia, our ethical analysis struggles to keep pace with technology and law. In this essay I show that the principle of double effect (PDE) remains, and will continue to be, a useful tool for ethical analysis of end-of-life care. According to PDE, an agent may ethically perform an act that s/he foresees will have a significant bad effect (e.g., death) in addition to a good effect (e.g., pain relief) only if s/he does not intend the bad effect, the act is not bad for reasons other than its causing the bad effect, and there is a proportionately serious reason to act. Following a brief explanation of PDE and preliminary considerations in favor of counting death as a bad effect, I analyze several end-of-life options in terms of the principle. I begin with those that enjoy significant consensus among proponents of PDE: active euthanasia, “passive euthanasia,” and palliative care. Then I consider the less-straightforward cases of drug provision, refusing food and water, and terminal sedation, arguing that participation in such actions is justifiable via PDE only under very limited conditions.