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The Rule of Double Effect (RDE) holds that it may be permissible to harm an individual while acting for the sake of a proportionate good, given that the harm is not an intended means to the good but merely a foreseen side-effect. Although frequently used in medical ethical reasoning, the rule has been repeatedly questioned in the past few decades. However, Daniel Sulmasy, a proponent who has done a lot of work lately defending the RDE, has recently presented a reformulated and more detailed version of the rule. Thanks to its greater precision, this reinvented RDE avoids several problems thought to plague the traditional RDE. Although an improvement compared with the traditional version, we argue that Sulmasy's reinvented RDE will not stand closer scrutiny. Not only has the range of proper applicability narrowed significantly, but, more importantly, Sulmasy fails to establish that there is a morally relevant distinction between intended and foreseen effects. In particular, he fails to establish that there is any distinction that can account for the alleged moral difference between sedation therapy and euthanasia., (© 2012 John Wiley & Sons Ltd.)

The purpose of this paper is to defend the traditional application of the principle of double effect as a criterion for assessing the permissibility of actions that have as their common aim to end the suffering of seriously ill patients. According to this principle, euthanasia and physician-assisted suicide are always illicit acts, while the same is not said for other actions that bring about patient's death as a foreseen effect, namely, palliative treatments that hasten death or failure or interruption of life support. The reason for this difference is that, in the first two cases, the patient's death is intended as a means of pain relief; whereas, in the latter two, death is only a side effect of a medical act, an act justifiable if it is necessary to achieve a proportionate good. In a recent issue of this Journal, Professor Rodolfo Figueroa denied the soundness of the principle of double effect and maintained that all actions described above should be considered equivalent in law enforcement. Here, the author presents a reply to that argument, and also offers a justification of the afore said principle's core, that is, the moral and legal relevance of the distinction between intended effects and foreseen side effects.

The Bill of Rights for Patients provides the patient with autonomy for disposing of his life, enabling him to reject those treatments that unnecessarily prolong his life. However, the bill does not allow an artificial acceleration of death. Therefore, the bill does not permit euthanasia (at least, certain form of it) nor assisted-suicide. However, according to the practice of medicine and also Chilean doctrine, it is permitted to inject morphine to a patient to relieve his pain, even though that could hasten his death. In consequence, it is allowed for the patient to dispose of his life and also to inject in him morphine for pain relief, endangering his life, but neither euthanasia nor assisted-suicide is allowed. Is this coherent? According to Chilean doctrine, it could be coherent under the condition of accepting the distinction between killing and letting die and also the double effect doctrine. The problem is that there is abundant English literature in the realm of moral philosophy to disregard both conditions. Therefore, it is possible to claim that the Bill is not coherent and that the Chilean doctrine is based upon a distinction and a doctrine that are not acceptable.

There has been much debate regarding the 'double-effect' of sedatives and analgesics administered at the end-of-life, and the possibility that health professionals using these drugs are performing 'slow euthanasia.' On the one hand analgesics and sedatives can do much to relieve suffering in the terminally ill. On the other hand, they can hasten death. According to a standard view, the administration of analgesics and sedatives amounts to euthanasia when the drugs are given with an intention to hasten death. In this paper we report a small qualitative study based on interviews with 8 Australian general physicians regarding their understanding of intention in the context of questions about voluntary euthanasia, assisted suicide and particularly the use of analgesic and sedative infusions (including the possibility of voluntary or non-voluntary 'slow euthanasia'). We found a striking ambiguity and uncertainty regarding intentions amongst doctors interviewed. Some were explicit in describing a 'grey' area between palliation and euthanasia, or a continuum between the two. Not one of the respondents was consistent in distinguishing between a foreseen death and an intended death. A major theme was that 'slow euthanasia' may be more psychologically acceptable to doctors than active voluntary euthanasia by bolus injection, partly because the former would usually only result in a small loss of 'time' for patients already very close to death, but also because of the desirable ambiguities surrounding causation and intention when an infusion of analgesics and sedatives is used. The empirical and philosophical implications of these findings are discussed.

Roman Catholic healthcare institutions in the United States face a number of threats to the integrity of their missions, including the increasing religious and moral pluralism of society and the financial crisis many organizations face. These organizations in the United States often have fought fervently to avoid being obligated to provide interventions they deem intrinsically immoral, such as abortion. Such institutions no doubt have made numerous accommodations and changes in how they operate in response to the growing pluralism of our society, but they have resisted crossing certain lines and providing particular interventions deemed objectively wrong. Catholic hospitals in Belgium have responded differently to pluralism. In response to a growing diversity of moral views and to the Belgian Act of Euthanasia of 2002, Catholic hospitals in Belgium now engage in euthanasia. This essay examines a defense that has been offered of this practice of euthanasia in Catholic hospitals and argues that it is misguided.

Within the context of the debate over the recent suspended sentence given to John Stuart Godfrey by Underwood J in the Supreme Court of Tasmania for assisting his elderly mother with her suicide, this article examines some of the more popular arguments for and against the moral acceptability of euthanasia and assisted suicide. This article considers the arguments put forward on the "difference principle" by Rachels and Nesbitt before critically examining the liberal approach to the euthanasia issue as proposed by Kuhse. It is argued that whilst Kuhse is correct to reject the difference principle, she does so for the wrong reasons. The penultimate section of the article provides an overview of the traditional moral view against killing. The final part assesses whether the arguments put forward by proponents of the liberal approach are capable of overcoming this view.

We are all called to make moral decisions, not only about preserving life and health, but also about accepting our death and dying. There are situations, when it is morally right, and indeed obligatory, to allow a dying person to die in peace and dignity. But there is a world of difference between allowing a peaceful death, and deliberately setting out to bring death of the person either by acts of commission (s.c. 'active euthanasia'), or by acts of omission (s.c. 'passive euthanasia'). The word "killing" seems proper for euthanasia, because "to kill" does mean " to intentionally cause the death of someone." It can be morally acceptable to withhold or withdraw a treatment precisely because it is reasonably judged as inefficacious (futile), or excessively burdensome for the patient. One's reason for withholding such treatment must not be a judgement about the desirability of putting an end to the patient's life, but a judgement about the desirability of putting an end to the treatment, which is futile or burdensome.

Direct active euthanasia is prohibited in most countries while passive and indirect is not. However, many arguments against the legalization of voluntary active euthanasia are flawed, because a critical ethical difference between passive and active euthanasia is difficult to establish especially when the passivity of the actor causes death. The crucial point is not activity or passivity but respect for the autonomy of individual human beings. In particular there appears to be little ethical difference between active and indirect euthanasia. Indirect euthanasia has often been justified by the doctrine of double effect (Thomas Aquinas), which I argue contains a logical fallacy. This rule does not allow foreseen and unwanted adverse effects of an action to occur when they are avoidable. In terminal sedation, an example for indirect euthanasia, hypoxemia and dehydration can easily be prevented by respirator therapy and fluid administration. Therefore the rule of double effect is not applicable. Indirect and direct active euthanasia cannot be ethically distinguished by resorting to the doctrine of double effect.

Those who campaign for law reform to permit "euthanasia" may seek different things and at least some of what they seek may already be permissible under the criminal law of England and Wales. In this paper I examine one means whereby the criminal law delivers outcomes acceptable to the euthanasia lobby, that is the curious notion of "causation" deployed by the law, which adds a value override to the more usual notion of factual causation such that, for example, if medical treatment falls within the acceptable range as normal and proper, the pre-existing injury or illness is treated as exclusively the cause of death and the doctor escapes criminal liability, even where the medical treatment will shorten life to the certain knowledge, possibly even the wish, of the doctor. Thus the law may already be delivering a range of outcomes--euthanasia in a weak sense--acceptable to the euthanasia lobby. If so, it achieves this by stealth. That is inappropriate to the doctor-patient relationship, which is one of trust. So there is a strong case for greater transparency. Moreover, there are limits to the acceptable outcomes which an unreformed criminal law can deliver and in a range of cases the criminal law condemns the doctor to impotence and the patient to a prolonged, miserable and undignified death. So there is also a case for going beyond the current law and legalising euthanasia in a strong sense.

Representatives from eight European countries compared the legal, ethical and professional settings within which decision making for neonates takes place. When it comes to limiting treatment there is general agreement across all countries that overly aggressive treatment is to be discouraged. Nevertheless, strong emphasis has been placed on the need for compassionate care even where cure is not possible. Where a child will die irrespective of medical intervention, there is widespread acceptance of the practice of limiting aggressive treatment or alleviating suffering even if death may be hastened as a result. Where the infant could be saved but the future outlook is bleak there is more debate, but only two countries have tested the courts with such cases. When it comes to the active intentional ending of life, the legal position is standard across Europe; it is prohibited. However, recognising those intractable situations where death may be lingering and unpleasant, Dutch paediatricians have reported that they do sometimes assist babies to die with parental consent. Two cases have been tried through the courts and recent official recommendations have set out standards by which such actions may be assessed.

Health care professionals frequently justify moral decisions by appealing to the acts and omissions distinction and the principle of double effect. These principles are often quoted and criticised in the nursing literature, particularly in relation to active and passive euthanasia. Authors are, however, inclined to acknowledge the fact that they are a philosophical minefield, but fall short of providing a substantial critical analysis. Those who uphold the acts and omissions distinction claim that we are morally less responsible for our omissions than for our acts. The principle of double effect suggests that there is a moral distinction between direct and indirect intention and that we are morally less responsible for that which we intend indirectly. This article offers an examination of these often quoted, but sometimes little understood, principles and it is hoped that it will serve as a basis for debate. Since the intention is to challenge assumptions which can lull us into believing that our moral decisions can be justified by appealing to principles such as these, it is necessary to examine them critically and to go beyond a superficial grasp of the implications of such distinctions. There is a tendency to appeal to the acts and omissions doctrine and the principle of double effect in life and death situations such as euthanasia, infanticide and abortion, but are they valuable tools which should be used in moral decision making, or are they so flawed that they can seriously mislead us when it comes to hard cases? The conclusion reached in this paper is that there is no significant moral difference between an act and an omission, particularly within the context of killing and letting die, and that the principle of double effect encourages hypocrisy rather than honesty.

The objectives of this study are to describe: (a) the presence of; and (b) compliance with guidelines in cases of euthanasia and intensifying the alleviation of pain and symptoms; (c) the opinions of physicians about written guidelines; and (d) the relationship between meeting the requirements for prudent practice and presence of, and compliance with guidelines for euthanasia or assisted suicide (EAS). In 1990 and 1995 interviews were held with 405 physicians (general practitioners, nursing home physicians and clinical specialists). The response rate for the 2 years was 91 and 89%, respectively. The percentage of physicians who reported the existence of EAS guidelines increased from 50% in 1990 to 59% in 1995, and the compliance with these guidelines increased from 51 to 75%, respectively. Of the physicians, 17% stated that there were written guidelines for intensifying the alleviation of pain and symptoms. With regard to meeting the requirements for prudent practice, we found mostly no differences between cases of euthanasia in which EAS guidelines were present, and cases in which there were no guidelines. However, when guidelines did exist and were actually used, it seems there was a better adherence to consultation and notification, although numbers were small. The increase since 1990 in agreement with the statement that an institution should formulate a policy with regard to euthanasia, may reflect the growing awareness of the specific role of the management, and not only the physician, in this matter.

The author critically reviews Dutch court decisions on nonvoluntary euthanasia. First, he examines euthanasia practice in the Netherlands. The author next discusses in detail the 1995 cases of two physicians who were prosecuted for terminating the lives of infants who were severely ill and disabled. The courts accepted nonvoluntary euthanasia and relied on the physicians' defense of necessity. Jochemsen exposes serious flaws in the reasoning of the courts and concludes that newborns with congenital disorders should be given appropriate palliative care. Jochemsen fears that by extending the practice of euthanasia to infants with disabilities the Dutch courts have taken another step toward endangering the lives of all incompetent persons.

Author offers an analytic defense of the coherence of the distinction between "killing" and "allowing to die," based on contemporary philosophy of action and intention.

If a person is suffering from illness or disability and wishes to end their life the law ought to facilitate rather than frustrate that choice argues Graham Oddie in this article. He points out the inconsistencies in current medical practice, and the gross disparity between the practice and the letter of the law. In dismissing many of the commonly raised objections to calls for reform of the law permitting euthanasia he makes a strong case for consistency in our approach to the right to die and patient autonomy.

Palliative care is generally agreed to be the standard of care for the dying, but there remain some patients for whom intolerable suffering persists. In the face of ethical and legal controversy about the acceptability of physician-assisted suicide and voluntary active euthanasia, voluntarily stopping eating and drinking and terminal sedation have been proposed as ethically superior responses of last resort that do not require changes in professional standards or the law. The clinical and ethical differences and similarities between these 4 practices are critically compared in light of the doctrine of double effect, the active/passive distinction, patient voluntariness, proportionality between risks and benefits, and the physician's potential conflict of duties. Terminal sedation and voluntarily stopping eating and drinking would allow clinicians to remain responsive to a wide range of patient suffering, but they are ethically and clinically more complex and closer to physician-assisted suicide and voluntary active euthanasia than is ordinarily acknowledged. Safeguards are presented for any medical action that may hasten death, including determining that palliative care is ineffective, obtaining informed consent, ensuring diagnostic and prognostic clarity, obtaining an independent second opinion, and implementing reporting and monitoring processes. Explicit public policy about which of these practices are permissible would reassure the many patients who fear a bad death in their future and allow for a predictable response for the few whose suffering becomes intolerable in spite of optimal palliative care.

Several cases which have been considered by the courts in recent years have highlighted the legal dilemmas facing doctors whose decisions result in the ending of a patient's life. This paper considers the case of Dr Cox, who was convicted of attempting to murder one of his patients, and explores the roles of motive, diminished responsibility and consent in cases of "mercy killing". The Cox decision is compared to that of Tony Bland and Janet Johnstone, in which the patients were in a persistent vegetative state. In all three cases, the doctors believed that their patients' quality of life was so poor that their continued existence was of no benefit to them, and decided that their lives should not be unduly prolonged, yet the doctor who was prosecuted was the one whose dying patient had requested that her death be hastened. The paper examines the law's seemingly contradictory approaches to such cases.

Unrelieved pain has been cited as an important reason why cancer patients may seek to hasten their deaths. We interviewed 48 patients with painful metastatic cancer to ascertain their interest in various active and passive modes of hastening death. Ninety percent of these patients supported the general right of terminally ill patients to passive modes of hastening death and 80% supported the right to active modes such as assisted suicide and euthanasia. If they developed severe pain that could not be relieved, 80% would instruct their physician write a "do not attempt resuscitation" order, 40%-50% would want to receive suicide information or a lethal prescription from their physician, and 34% would request a lethal injection from their physician. Current pain and depression levels were not associated with interest in hastening death, but current somatic symptom burden was significantly associated with this interest.