Doctrine of Double Effect

• 1. Formulations of the principle of double effect
• 2. Applications
• 3. Criticisms
• 4. One principle or many?
• Bibliography
• Other Internet Resources
• Related Entries

1. Formulations of the principle of double effect

Thomas Aquinas is credited with introducing the principle of double effect in his discussion of the permissibility of self-defense in the Summa Theologica (II-II, Qu. 64, Art.7). Killing one's assailant is justified, he argues, provided one does not intend to kill him. Aquinas observes that “Nothing hinders one act from having two effects, only one of which is intended, while the other is beside the intention. … Accordingly, the act of self-defense may have two effects: one, the saving of one's life; the other, the slaying of the aggressor.” As Aquinas's discussion continues, a justification is provided that rests on characterizing the defensive action as a means to a goal that is justified: “Therefore, this act, since one's intention is to save one's own life, is not unlawful, seeing that it is natural to everything to keep itself in being as far as possible.” However, Aquinas observes, the permissibility of self-defense is not unconditional: “And yet, though proceeding from a good intention, an act may be rendered unlawful if it be out of proportion to the end. Wherefore, if a man in self-defense uses more than necessary violence, it will be unlawful, whereas, if he repel force with moderation, his defense will be lawful.”

Aquinas does not actually say that intending to kill the assailant as a means to self-defense would be prohibited. The passage can be interpreted as formulating a prohibition on apportioning one's efforts with killing as the only goal guiding one's actions, which would lead one to act with greater viciousness than the goal of self-defense would allow. In contrast, Augustine had earlier maintained that killing in self-defense was not permissible, maintaining that “private self-defense can only proceed from some degree of inordinate self-love.”

Later versions of the double effect principle all emphasize the distinction between causing a morally grave harm as a side effect of pursuing a good end and causing a harm as a means of pursuing a good end. We can summarize this by noting that for certain categories of morally grave actions, for example, causing the death of a human being, the principle of double effect combines a special permission for incidentally causing death for the sake of a good end (when it occurs as a side effect of one's pursuit of that end) with a general prohibition on instrumentally causing death for the sake of a good end (when it occurs as part of one's means to pursue that end). The prohibition is absolute in traditional Catholic applications of the principle. Two traditional formulations appear below.

The New Catholic Encyclopedia provides four conditions for the application of the principle of double effect:

1. The act itself must be morally good or at least indifferent.
2. The agent may not positively will the bad effect but may permit it. If he could attain the good effect without the bad effect he should do so. The bad effect is sometimes said to be indirectly voluntary.
3. The good effect must flow from the action at least as immediately (in the order of causality, though not necessarily in the order of time) as the bad effect. In other words the good effect must be produced directly by the action, not by the bad effect. Otherwise the agent would be using a bad means to a good end, which is never allowed.
4. The good effect must be sufficiently desirable to compensate for the allowing of the bad effect” (p. 1021).

The conditions provided by Joseph Mangan include the explicit requirement that the bad effect not be intended:

A person may licitly perform an action that he foresees will produce a good effect and a bad effect provided that four conditions are verified at one and the same time:

1. that the action in itself from its very object be good or at least indifferent;
2. that the good effect and not the evil effect be intended;
3. that the good effect be not produced by means of the evil effect;
4. that there be a proportionately grave reason for permitting the evil effect” (1949, p. 43).

Double effect might also be part of a secular non-absolutist view according to which a justification adequate for causing a certain harm as a side effect might not be adequate for causing that harm as a means to the same good end under the same circumstances. Warren Quinn provides such a non-absolutist account that also recasts double effect as a distinction between direct and indirect agency. On his view, double effect “distinguishes between agency in which harm comes to some victims, at least in part, from the agent's deliberately involving them in something in order to further his purpose precisely by way of their being so involved (agency in which they figure as intentional objects), and harmful agency in which either nothing is in that way intended for the victims or what is so intended does not contribute to their harm” (1989, p. 343). Quinn explains that “direct agency requires neither that harm itself be useful nor that what is useful be causally connected in some especially close way with the harm it helps bring about” (1989, p. 344). He remarks that “some cases of harming that the doctrine intuitively speaks against are arguably not cases of intentional harming, precisely because neither the harm itself (nor anything itself causally very close to it) is intended” (1991, p. 511). On this view, the distinction between direct and indirect harmful agency is what underlies the moral significance of the distinction between intended and merely foreseen harms, but it need not align perfectly with it.

2. Applications

Many morally reflective people have been persuaded that something along the lines of double effect must be correct. No doubt this is because at least some of the examples cited as illustrations of DE have considerable intuitive appeal:

1. The terror bomber aims to bring about civilian deaths in order to weaken the resolve of the enemy: when his bombs kill civilians this is a consequence that he intends. The strategic bomber aims at military targets while foreseeing that bombing such targets will cause civilian deaths. When his bombs kill civilians this is a foreseen but unintended consequence of his actions. Even if it is equally certain that the two bombers will cause the same number of civilian deaths, terror bombing is impermissible while strategic bombing is permissible.
2. A doctor who intends to hasten the death of a terminally ill patient by injecting a large dose of morphine would act impermissibly because he intends to bring about the patient's death. However, a doctor who intended to relieve the patient's pain with that same dose and merely foresaw the hastening of the patient's death would act permissibly.
3. A doctor who believed that abortion was wrong, even in order to save the mother's life, might nevertheless consistently believe that it would be permissible to perform a hysterectomy on a pregnant woman with cancer. In carrying out the hysterectomy, the doctor would aim to save the woman's life while merely foreseeing the death of the fetus. Performing an abortion, by contrast, would involve intending to kill the fetus as a means to saving the mother.
4. To kill a person whom you know to be plotting to kill you would be impermissible because it would be a case of intentional killing; however, to strike in self-defense against an aggressor is permissible, even if one foresees that the blow by which one defends oneself will be fatal.
5. It would be wrong to throw someone into the path of a runaway trolley in order to stop it and keep it from hitting five people on the track ahead; that would involve intending harm to the one as a means of saving the five. But it would be permissible to divert a runaway trolley onto a track holding one and away from a track holding five: in that case one foresees the death of the one as a side effect of saving the five but one does not intend it.
6. Sacrificing one's own life in order to save the lives of others can be distinguished from suicide by characterizing the agent's intention: a soldier who throws himself on a live grenade intends to shield others from its blast and merely foresees his own death; by contrast, a person who commits suicide intends to bring his or her own life to an end.

3. Criticisms

Does the principle of double effect play the important explanatory role that has been claimed for it? To consider this question, one must be careful to clarify just what the principle is supposed to explain. Three misinterpretations of the principle's force or range of application are common.

First, it is a misinterpretation to claim that the principle of double effect shows that agents may permissibly bring about harmful effects provided that they are merely foreseen side effects of promoting a good end. Applications of double effect always presuppose that some kind of proportionality condition has been satisfied. Traditional formulations of double effect require that the value of promoting the good end outweigh the disvalue of the harmful side effect.

For example, a physician's justification for administering drugs to relieve a patient's pain while foreseeing the hastening of death as a side effect does not depend only on the fact that the physician does not intend to hasten death. (After all, physicians are not permitted to relieve the pain of kidney stones with potentially lethal doses of opiates simply because they foresee but do not intend the hastening of death!) A variety of substantive medical and ethical judgments provide the justificatory context: the patient is terminally ill, there is an urgent need to relieve pain and suffering, death is imminent, and the patient or the patient's proxy consents.

Michael Walzer has argued that an additional condition is required: that agents minimize the foreseen harm even if this will involve accepting additional risk or foregoing some benefit. Whether this kind of condition is satisfied may depend on the agent's current circumstances and the options that exist. Thus, for example, as techniques of palliative care have improved and as new techniques for managing pain have been refined, what might in the past have been an adequate justification for hastening death in the course of pain relief might now be inadequate because current techniques may provide the better alternative of managing pain without hastening death.

A second misinterpretation is fostered by applications of double effect that contrast the permissibility of causing a harm as a merely foreseen side effect of pursuing a good end with the impermissibility of causing the same kind of harm as one's end. Since it is widely accepted that it is wrong to aim to produce harm to someone as an end, to rule this out is not part of double effect's distinctive content. The principle presupposes that agents do not aim to cause morally grave harms as an end and seeks to guide decisions about causing harm in pursuing a morally good end. For example, double effect contrasts those who would (permissibly) provide medication to terminally ill patients in order to alleviate suffering with the side effect of hastening death with those who would (impermissibly) provide medication to terminally ill patients in order to hasten death in order to alleviate suffering. In the allegedly impermissible case, the physician's ultimate end is a good one — to alleviate suffering — not to cause death.

The principle of double effect is directed at well-intentioned agents who ask whether they may cause a serious harm in order to bring about a good end of overriding moral importance when it is impossible to bring about the good end without the harm. A third common misinterpretation of double effect is to assume that the principle assures agents that they may do this provided that their ultimate aim is a good one that is ordinarily worth pursuing, the proportionality condition is satisfied and the harm is minimized. That is not sufficient: it must also be true that causing the harm is not so implicated as part of their means to this good end that it must count as something that is instrumentally intended to bring about the good end. Some discussions of double effect wrongly assume that it permits acts that cause certain kinds of harm because those harms were not the agent's ultimate aim or were regretted rather than welcomed. The principle of double effect is much more specific than that. Harms that were produced regretfully and only for the sake of producing a good end may be prohibited by double effect because they were brought about as part of the agent's means to realizing the good end. When minor harms are permissibly brought about as part of the means to a good end — for example, dentists are allowed to probe causing pain saying “tell me when it hurts” as a means to their diagnostic end — double effect does not explain their permissibility. Double effect is silent about cases in which a small harm might permissibly be brought about as a means to a good end. To invoke double effect, as it has traditionally be understood, is to make a comparative judgment: it is to assert that a harm that might permissibly be brought about as a side effect in promoting a good end could not permissibly be brought about as a means to the same good end.

Those who defend double effect often assume that their opponents deny that an agent's intentions, motives, and attitudes are important factors in determining the permissibility of a course of action. If the permissibility of an action depended only on the consequences of the action, or only on the foreseen or foreseeable consequences of the action, then the distinction that grounds double effect would not have the moral significance claimed for it (see the related entry on consequentialism). Some opponents of double effect do indeed deny that the distinction between intended and merely foreseen consequences has moral significance.

Yet many criticisms of double effect do not proceed from consequentialist assumptions or skepticism about the distinction between intended and merely foreseen consequences but instead ask whether the principle adequately codifies the moral intuitions at play in the cases that are taken to be illustrations of double effect. Doubts about the explanatory value of double effect have often focused on the difficulty of distinguishing between harmful effects that are regretfully intended as part of the agent's means and harmful effects that are regretfully foreseen as side effects of the agent's means. Since double effect deems the former to be impermissibly brought about, while the latter may be permissible, those who wish to apply double effect must provide principled grounds for drawing this distinction.

For example, if the soldier who throws himself on the grenade in order to shield his fellow soldiers from the force of an explosion acts permissibly, and if the permissibility of his action is explained by double effect, then he must not intend to sacrifice his own life in order to save the others, he must merely foresee that his life will end as a side effect of his action. But many have argued that this is an implausible description of the soldier's action and that his action is permissible even if he does intend to cause his own death as a means to save the others. Shelly Kagan points out that if someone else were to shove the soldier on the grenade we would certainly say that that the harm to the soldier was intended by the person who did the shoving. Equally, Kagan argues, we should say that it is intended in this case (p. 145). The same kind of argument can be made for cases of killing in self-defense.

Those who take this view can claim that what is often called the proportionality condition associated with double effect is really doing all of the explanatory work: it is because the end is judged to be worthy that the harmful means is considered to be permissibly brought about. Those who reject double effect for this reason may still maintain that there is a morally significant difference between self-sacrifice of this sort and suicide, but that the difference depends on a difference in the agent's motives and ends, not a difference in the means adopted.

This kind of criticism about the explanatory reach of the principle of double effect might also be associated with the worry that we will be inclined to describe a harm as a merely foreseen side effect if we believe that it is permissibly brought about in the course of pursuing a good end, and, similarly, we will tend to describe a harm as one that is intended as part of the agent's means if we believe that it is not permissibly brought about in the course of pursuing a good end. Disputes about the permissibility of killing a fetus in order to save the life of a pregnant woman have often been thought to take this form. Those who say that it would be impermissible to perform an abortion to save the life of a pregnant woman say that this is because this would involve intending the death of the fetus. However, if it is also maintained that a hysterectomy may be performed on a pregnant woman with uterine cancer because the death of the fetus would be a merely foreseen side effect of surgery, it is hard to find a principled ground for drawing this distinction that could serve as a guide to moral judgment.

Warren Quinn has argued that double effect does not rest on the distinction between intended and merely foreseen harm, but instead is best formulated using a distinction between direct and indirect agency (see the Formulations section). Quinn's view would imply that typical cases of self-defense and self-sacrifice would count as cases of direct agency. One clearly intends to involve the aggressor or oneself in something that furthers one's purpose precisely by way of his being so involved. Therefore, Quinn's account of the moral significance of the distinction between direct and indirect agency could not be invoked to explain why it might be permissible to kill in self-defense or to sacrifice one's own life to save the lives of others. But perhaps this is as it should be: double effect might be easier to explain and justify if the range of cases to which it applies is limited in this way. If Quinn's view is correct, and if the distinction between direct and indirect agency is easier to draw clearly, and is not subject to redescription under the influence of our moral judgments about permissibility, then perhaps the objections outlined above can be answered.

A second striking feature of Quinn's interpretation (or revision) of double effect is that it analyzes the disfavored kind of agency as conduct that subordinates the victim to purposes that he or she either rightfully rejects or cannot rightfully accept, thereby violating the victim's right not to be surbordinated in this way (1991, p. 511). Equally harmful indirect agency would not violate this right, but it is violated, according to Quinn, only when other rights are violated. Therefore, its force is not entirely independent from the kind of wrong that is present in cases of indirect agency, since it amplifies this, but it is additional to it, and distinguishable (Quinn 1989, p. 349). Thus, the harms brought about by fair competition, or in justifiable punishment do not violate any right of the persons affected, and so, on Quinn's view, do not violate this additional right even if they are brought about intentionally.

4. One principle or many?

It is not at all clear that all of the examples that double effect has been invoked to justify can be explained by a single principle.

Proponents of double effect have always acknowledged that a proportionality condition must be satisfied when double effect is applied, but this condition typically requires only that the good effect outweigh the foreseen bad effect or that there be sufficient reason for causing the bad effect. Some critics of double effect have maintained that when double effect has been invoked, substantive independent justifications for causing the kind of harm in question are implicitly relied upon, and are in fact, doing all of the justificatory work. These independent justifications are not derived from the distinction between intended and merely foreseen consequences, and more significantly, might presuppose different ways of drawing the distinction (Davis, McIntyre). Thus, self-sacrifice and killing in self-defense might involve permissibly causing death as a means to a good end, while dispensing medication to relieve pain in terminally ill patients and the strategic bombing of military targets might involve causing death as a side effect. If this is true, then perhaps the cases that have been cited as applications of double effect are united only by the fact that each is an exception to the general rule that it is wrong to cause the death of a human being.

The historical origins of double effect as a tenet of Catholic casuistry might provide a similar explanation for the unity of its applications. If one were to assume that it is absolutely prohibited to cause the death of a human being, then it would not be permissible to kill an aggressor in self-defense, to sacrifice one's life to protect others, to hasten death as a side effect of administering pain-relieving medications, or to endanger non-combatants in warfare. If one were to assume instead that what is absolutely prohibited is to cause the death of a human being intentionally, then these exceptional cases can all be classified as cases of non-intentional killing.

Critics of double effect might then claim that a better way of explaining what these cases have in common is to point out that they are exceptions to the prohibition on causing the death of a human being, and that the pattern of justification that they share requires that the agent acts in order to promote a good end and shows adequate respect for the value of human life in so acting. What the critics of double effect emphasize is that the distinction between what is intentional and what is foreseen does not explain the permissibility of these exceptions.

Bibliography

• Anscombe, Elizabeth. (1982). “Medallist's Address: Action, Intention and ‘Double Effect’”. Proceedings of the American Catholic Philosophical Association, 12-25; reprinted in Woodward, ed.:50-66.
• Aquinas, Thomas. (13^th c). Summa Theologica II-II, Q. 64, art. 7, “Of Killing”, in On Law, Morality, and Politics (Indianapolis/Cambridge: Hackett Publishing Co., 1988), William P. Baumgarth and Richard J. Regan, S.J., eds., p. 226-7.
• Augustine. (4^th c). De Libero Arbitrio Voluntatis. (Charlottesville: University of Virginia, 1947): 9-10.
• Bennett, Jonathan. (1966). “Whatever the Consequences” Analysis 26, 83-102.
• Bennett, Jonathan. (1981). “Morality and Consequences”. The Tanner Lectures on Human Values. Vol. 2, ed. Sterling McMurrin (Salt Lake City: University of Utah Press), especially Lecture III “Intended as a Means”.
• Bennett, Jonathan. (1995). The Act Itself (New York: Oxford), 194-225; reprinted in Woodward, ed.: 85-118.
• Boyle, Joseph. (1991). “Who is entitled to Double Effect?”. The Journal of Medicine and Philosophy 16, 475-494.
• Boyle, Joseph M., Jr. (1980). “Toward Understanding the Principle of Double Effect”. Ethics 90, 527-38; reprinted in Woodward, ed.: 7-20.
• Connell, F.J. (1967). “Double Effect, Principle of”. New Catholic Encyclopedia Vol. 4 (New York: McGraw-Hill), pp. 1020-2, p. 1021.
• Davis, Nancy. (1984). “The Doctrine of Double Effect: Problems of Interpretation”. Pacific Philosophical Quarterly 65, 107-23; reprinted in Woodward, ed.: 119-142.
• Duff, Antony. (1982). “Intention, Responsibility and Double Effect”. The Philosophical Quarterly 32:126, 1-16.
• Foot, Philippa. (1967). “The Problem of Abortion and the Doctrine of Double Effect”. Oxford Review 5, 5-15; reprinted in Bonnie Steinbock and Alastair Norcross, eds. Killing and Letting Die 2nd ed. (New York: Fordham University Press, 1994), pp. 266-279; reprinted in Woodward, ed.:143-155.
• Foot, Philippa. (1985). “Morality, Action, and Outcome”. Morality and Objectivity: A Tribute to J.L. Mackie, Ted Honderich, ed. (London: Routledge & Kegan Paul), pp. 23-38; reprinted in Woodward, ed.:67-82.
• Garcia, Jorge. (1995). “Double Effect” entry in Encyclopedia of Bioethics, revised edition, Warren Thomas Reich, ed., (New York: Simon & Schuster Macmillan): 636-641
• Grisez, Germain G. (1970). “Toward a Consistent Natural-Law Ethics of Killing”. The American Journal of Jurisprudence. 15, 64-96
• Kagan, Shelly. (1999). The Limits of Morality. (New York: Oxford University Press): 128-182.
• Kamm, Frances M. (1999). “Physician-Assisted Suicide, the Doctrine of Double Effect, and the Ground of Value”. Ethics. 109, 586-605
• Kamm, Frances M. (1991). “The Doctrine of Double Effect: Reflections on Theoretical and Practical Issues”. Journal of Medicine and Philosophy 16, 571-585.
• Mangan, Joseph. (1949). “An Historical Analysis of the Principle of Double Effect”. Theological Studies 10, 41-61.
• Marquis, Donald B. (1991). “Four Versions of Double Effect” The Journal of Medicine and Philosophy 16, 515-544; reprinted in Woodward, ed.: 156-185.
• McIntyre, Alison. (2001). “Doing Away with Double Effect”. Ethics 111, 2, 219-255.
• McMahan, Jeff. (1994). “Revising the Doctrine of Double Effect”. Journal of Applied Philosophy 11, 2, 201-12.
• Quinn, Warren. (1989). “Actions, Intentions, and Consequences: The Doctrine of Double Effect”. Philosophy and Public Affairs 18, 4 (Fall): 334-351; reprinted in Woodward, ed.: 23-40.
• Quinn, Warren. (1991). “Reply to Boyle's Who is Entitled to Double Effect?”. The Journal of Medicine and Philosophy 16, 511-514
• Uniacke, Suzanne. (1984). “The Doctrine of Double Effect”. The Thomist 48, 2, 188-218.
• Walzer, Michael. (1977). Just and Unjust Wars. (New York: Basic Books), pp. 151-9; reprinted in Woodward, ed.: 261-269.
• Woodward, P. A., ed. (2001). The Doctrine of Double Effect: Philosophers Debate a Controversial Moral Principle. (Notre Dame, IN: University of Notre Dame Press.

Other Internet Resources

• List of References for the Principle of Double Effect [PDF], maintained by Jörg Schroth.
• Whether it is lawful to kill a man in self-defense?, New Advent, Catholic Encyclopedia.
• The Principle of Double Effect, originally written by David Solomon in The Encyclopedia of Ethics.
• U.S. Supreme Court decision Vacco v. Quill, concerning the challenge to laws prohibiting assisted suicide posed by Quill, et al., Legal Information Institute, Supreme Court Collection.
• Respondent's brief in Vacco v. Quill, Laurenc H. Tribe, counsel of record.
• Just War Theory, Internet Encyclopedia of Philosophy.

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