One act can embrace two effects – an intended good effect and an unintended bad effect Morality of the act is governed by the intended effect Ethically permissible only if: –act is morally good or at least morally neutral –only good effect is intended –good effect is not achieved by way of the bad effect –good result outweighs the bad result Principle of Double Effect

Application of double effect Palliative care Therapeutic abortion Breaching confidentiality Separation of conjoined twins

Legal recognition of doctrine of double effect R v Bodkin Adams (1957) –GP acquitted of murder by administration of increasing doses of opiates to elderly patients. –Devlin, J (judge) introduced double effect doctrine: if the first purpose of medicine, the restoration of health, could no longer be achieved, there was still much for the doctor to do, and he was entitled to do all that was proper and necessary to relieve pain and suffering even if the measures he took might incidentally shorten life”

Legal recognition of doctrine of double effect (cont) Airedale NHS v Bland (1993) –Lord Goff “.[It is] the established rule that a doctor may, when caring for a patient, who is, for example, dying of cancer, lawfully administer painkilling drugs despite the fact that he knows that an incidental effect of that application will be to abbreviate the patient’s life …Such decisions may properly be made as part of the care of the living patient, in his best interest; and, on this basis, the treatment will be lawful”.

Legal recognition of doctrine of double effect - problems Contrary to traditional notions of criminal law intention and causation Airedale NHS Trust v Bland (1993) –concern expressed about dubious demarcation between primary (direct) and secondary (oblique) intention

Legal recognition of doctrine of double effect – problems (cont) Double effect – is it hypocrisy ? - isn’t the actor who foresees the consequences of an action acting intentionally and therefore culpable or responsible for the act and its outcome ?

Best Interests and the Principle of Necessity F v West Berkshire Health Authority (1989) Re F (Mental Patient: Sterilisation) (1990) Principle of necessity: –a necessity to act in a situation where it is not possible to communicate with the patient –the action taken is what a reasonable person would do in the best interests of the patient

Sanctity of Life Inherent value of life Life requires no justification Quality and quantity of life irrelevant Differing versions: –vitalism –human life of absolute value –life a basic but not an absolute good

Quality of Life Opposite end of spectrum from the principle of the sanctity of life Life not intrinsically of value Involves a value judgment Emphasis on type of life being lived Focuses on an individual’s capacity or potential to live a ‘normal life’

Legal decisions concerning Sanctity of Life and Quality of Life Best interests test applied: –Re B (A minor) (Wardship: Medical Treatment) (1981) - operation in patient’s best interests – court applies the ‘demonstrably awful’ test –Re C (A minor) (Wardship: Medical Treatment) (1989) - best interests not to prolong life – active treatment withdrawn where necessary Quality of life as means of determining best interests: –Re J (A minor) (Wardship: Medical Treatment) (1990) - quality of life principle applied Medical profession not required to carry out treatment against their clinical judgement: –Re J (A minor) (Wardship: Medical Treatment) (1993) – not always in patient’s best interests for aggressive therapy to be pursued

Sanctity of Life and Quality of Life (cont) Application of parental views: –Re C (A Baby) (1996) – clinical factors determinative not parents’ views –Re C (A Minor) (Medical treatment) (1998) – parents adopted sanctity of life approach but court applied best interests principle –Re T (A Minor)(Wardship:Medical Treatment) (1997) – quality of life with or without operation considered - confirmed that sanctity of life is not an absolute principle Treatment using force not in patient’s best interests: –Re D (Medical Treatment: Consent) (1997) – best interests not to receive burdensome treatment

Legal decisions concerning Sanctity of Life and Quality of Life (cont) Best interest test reaffirmed: –Airedale NHS Trust v Bland (1993) - sanctity of life principle not absolute - but forbids the taking of active measures to shorten life of a terminally ill patient –A NHS Trust v D (2000) - best interests test only criterion –Central Manchester Healthcare Trust v (1) Mr and Mrs A: and (2) A child (by the Official Solicitor, her guardian ad litem); Re A (Children)(Conjoined twins: medical treatment) (2000) - best interest overrides parental wishes