The Clinical Guide to Supportive and Palliative Care for HIV/AIDS

A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 17: Ethical IssuesThese limitations to the principle of deliberation are important. They reinforce the point thatclinicians are not ethically required simply to defer to the autonomous desires of their patients,whatever these desires may be. Indeed, as was stressed earlier, honoring a patient’s dignity may,at times,26requirepicasthe clinician not to comply with his or her patient’s requests. These considerationssuggest that clinicians must be capable of bringing other ethical principles to bear on thedeliberative process.One such principle that has special relevance in the palliative care setting is the rule of doubleeffect. This rule has a long history in moral philosophy and in medical ethics. 12-15, 22 In palliativemedicine, it is most frequently invoked by health care professionals to explain the moral differencebetween administering high-dose pain medication to a patient and euthanizing a patient as ameans to treating his suffering. 12, 13, 23 According to the rule of double effect, the essential differencebetween these two acts rests on the important distinction between an intended effect and anunintended side effect of a clinical intervention. In the instance of administering high-dose painmedication to relieve suffering, the intended effect is pain relief, and the unintended side effectmay be the hastening of death due to respiratory depression. By contrast, in the instance ofeuthanasia, the intended effect is the death of the patient as a means to the patient’s pain relief.Despite widespread acceptance of this rule among members of the medical community, manyclinicians remain unsure of how to apply the distinction. 23 Indeed, research suggests that lack ofcertainty in this regard results in inadequate control of distressing pain symptoms in terminallyill patients. 23, 24 Because the distinction between an intended act and an unintended side effectis crucial to understanding the rule, it will be helpful to begin by considering a simple illustration,one that is not controversial and one that is not related to medical practice.Consider the difference between the strategic bomber and the terror bomber. 22 Both are engagedin a war and both drop bombs that result in the deaths of innocent civilians. However, thestrategic bomber, unlike the terror bomber, does not intend to kill any innocent civilians. Hebombs a munitions factory, and although he is aware that doing so will have the side effect ofkilling innocent civilians, he does not intend to kill them. The terror bomber, in contrast, intentionallykills the innocent civilians as a means of weakening the resolve of the enemy. It iswidely believed that the action of the terror bomber is morally worse than that of the strategicbomber. The rule of double effect explains why this is the case.In medicine, physicians rely on the distinction between an intended effect and an unintendedside effect all the time. For example, when a physician treats streptococcal pharyngitis withpenicillin, he or she foresees the possibility that the patient may develop an anaphylactic reactionand die. 13 It is clear, however, that the intent is not to kill the patient. The foreseeable deathof the patient in this kind of case would be an unintended side effect of the intervention.Not every medical ethicist believes that the principle of double effect is as important to medicalpractice as is stressed here. 15 For example, it has been claimed that the rule of double effect isweakened because the intentions of clinicians are inherently ambiguous. 15 Even if this were thecase it is most often clear both to clinicians and to others what their intentions are. And, whenit is not clear what their intentions are, morally reflective clinicians will make some effort toclarify them.We have said that the rule of double effect rests on a distinction between an intended effect andan unintended side effect of an action. Although it has been formulated in different ways, thefull statement of the rule reads as follows:354U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau