Principle of double effect

"If there is a single element within Catholic casuistry that characterizes its analyses, it is the doctrine of the double effect. This doctrine originates in Aquinas’ claim that killing in self-defense need not involve the intent to end the assailant’s life. Thus, killing in this case does violate the prohibition of intentional killing this doctrine can be applied to many issues in bioethics, including mutilations whose intent is not to destroy bodily function but to save the patient’s life, terminations of pregnancy where there is no intent to kill or harm the fetus (or even precisely to end the pregnancy); decisions to withhold treatment whose intent was not to shorten life but to avoid other evils; and actions in which support is given to wrongdoing, but not for the sake of fostering wrongdoing. Recent analysis of the case of the conjoined twins of Malta, for example, makes use of the doctrine of double effect to determine whether the loss of one twin’s life, in an operation to separate the two, was intended as a means, or accepted as a side effect. There has been much dispute over the doctrine of the double effect among Roman catholic theologians since the debates over contraception began in the 1960s (Boyle, 1993, pp. 11-18). These are part of the larger controversy over moral norms and the conduct of Catholic casuistry, which has dominated catholic moral theology for the last sixty years. The view of the Vatican on these matters has been stated in Pope John Paul II’s Veritatis Splendor (1993, pp. 108-127)."

"The first application of the principle of double effect, and one of the most consistently important issues in medical ethics, is that of abortion. Gradually, Roman Catholic medical ethicists arrived at a consensus as to the exact application of double-effect physicalist criteria, which enabled them to make clear and precise judgments in each kind of abortion situation. These distinctions and judgments are now questioned in part by some proportionalist/revisionist Catholic scholars, but they remain the basis for official Catholic teaching (National Conference of Catholic Bishops 1995, dir. 45-50). Direct abortions are those in which the act-in-itself is the removal of the fetus “directly” from the body of the woman, or the “direct” killing of the fetus by any other means while still within the mother’s body. These acts are never permitted and are considered gravely immoral, identical to murder. Indirect abortions are, however, permitted according to the principle of double effect. Here the act-in-itself is specified as an operation or other procedure whose directly intended effect is the preservation or restoration of the mother’s health. The foreseen but unintended death of the fetus is “indirect”. The two classic cases are the removal of a pregnant cancerous uterus and the removal of a fallopian tube in the case of ectopic pregnancy. Other cases are the use of certain medications or operations where there is some danger that the fetus may die as a result, but where the procedure is directed at some other effect. Thus, for example, an appendectomy may be performed on a pregnant woman, even though some (perhaps even great) danger exists of a consequent abortion (miscarriage)."

"The use of contraceptives can be morally acceptable in other contexts as well, again, because such uses do not constitute acts of contraception. For example, when a woman has severe menstrual bleeding, or pain from ovarian cysts, the hormonal regimen contained in the Pill may sometimes provide a directly therapeutic medical treatment for the bleeding or the pain. This use of contraceptives is an act of medical therapy to address a pathological situation, not an act of contraception. The secondary effect from the treatment, namely, marital infertility, is only tolerated, and should not be willed, desired, or in-tended in any way by the couple. It is worth noting that it would not be acceptable to make use of contraceptives like the Pill for these medical cases if other pharmacological agents or treatments were available which would offer the same therapeutic benefits and effects without impeding fertility."

"The Roman church argues that although the death of the fetus is foreseen, it is not intended because the intention is to preserve the health and life of the woman. Isn't it just as reasonable to assert that the intention of most women is the separation of the fetus from the woman, not the killing of the fetus, though its death may be foreseen?"

"At first, no Catholic theologians supported even this qualified endorsement of the pill for contraceptive purposes. Until the end of 1961, Catholic theologians concurred that oral contraception constituted a deliberate act of direct sterilization and consequently was illicit. As Pius XII made clear in a 1958 speech to the Seventh International Congress of Hematology, the individual’s intentions determined the morality of ingesting an ovulatory medications: “If the woman takes the pill with no intention of preventing contraception, but solely for a medical purpose as a necessary remedy for a disease of the uterus, she brings about an indirect sterilization, which is permissible according to the general principle concerning actions that have a double effect. But a direct sterilization and consequently an illicit one, is brought about whenever ovulation is impeded with the goal of protecting the uterus and the body from a pregnancy that it cannot support.” If the aim was contraceptive, the Church condemned the use of the pill. December1961 witnessed the first significant modification of this position. In response to reports of multiple rapes of nuns stationed in the Congo, the Italian Catholic theological journal Studi Cattolici posed the following theoretical question: Could an unmarried woman (particularly a nun) who had reason to fear being raped take the pill as a means of protection?"

"It is important to note once again that the prohibition of murder and abortion must be appreciated in a therapeutic, not a juridical or punitive light, with which such offenses are often regarded in most Western moral, philosophical, and theological systems: the goal is not to subject the sinner to just punishment, but to bring the sinner through repentance and God’s grace to holiness. Because of this perspective the Orthodox Church never endorsed a doctrine of double effect, such as developed in the West, which allowed Roman Catholicism to approve of indirect abortions. The doctrine of double effects holds that when an action produces two effects, one good and one evil, one may nevertheless act, as long as the act is not evil in itself, the good effect is not produced by the bad effect, the evil effect is not intended,, and there is a proportionate reason (more good will be produced than evil). According to the doctrine of double effect, when these conditions are fulfilled, one is held to be juridically innocent. In contrast, the Orthodox Church recognizes that close causal involvement in the death of another, whether a guilty or an innocent person, may harm one’s spiritual life. Orthodox Christianity recognizes harms from both involuntary and “justifiable” homicide, including homicide in a just war, both of which incur excommunication not as punishment, but as spiritual therapy (Basil, 1983, Canon 13, pp. 801-802). It is in this spiritually therapeutic context that one should understand the absolution of women who miscarry. The absolution expresses the Orthodox Christian healing approach to the involuntary loss of life."

"Deliberately we have always used the expression 'direct attempt on the life of an innocent person,' 'direct killing.' Because if, for example, the saving of the life of the future mother, independently of her pregnant condition, should urgently require a surgical act or other therapeutic treatment which would have as an accessory consequence, in no way desired or intended, but inevitable, the death of the fetus, such an act could no longer be called a direct attempt on an innocent life. Under these conditions the operation can be lawful, like other similar medical interventions granted always that a good of high worth is concerned, such as life, and that it is not possible to postpone the operation until after the birth of the child, nor to have recourse to other efficacious remedies."

"It is absolutely true that the Catholic Church bans abortion to save the life of the mother. However (and this is an extremely important point) the mother's life may be saved by a surgical procedure that does not directly attack the unborn baby's life. The most common dysfunctions that may set a mother's life against that of her unborn child's are the ectopic pregnancy, carcinoma of the uterine cervix, and cancer of the ovary. Occasionally, cancer of the vulva or vagina may indicate surgical intervention. In such cases, under the principle of the "double effect," attending physicians must do everything in their power to save both the mother and the child. If the physicians decide that, in the case of an ectopic pregnancy, the mother's life can only be saved by the removal of the Fallopian tube (and with it, the unborn baby), or by removal of some other tissue essential for the preborn baby's life, the baby will of course die. But this would not be categorized as an abortion. This is all the difference between deliberate murder (abortion) and unintentional natural death."

"The principle of the "double effect" also applies to sexual sterilization. If a woman must have a hysterectomy to remove a dangerously cancerous uterus, this will result in her sterilization, but is not a sinful act. However, if the purpose of the operation is not to heal or safeguard health, but to directly sterilize, then that act is intrinsically evil and is always a mortal sin."

"The legitimate defense of persons and societies is not an exception to the prohibition against the murder of the innocent that constitutes intentional killing. "The act of self-defense can have a double effect: the preservation of one's own life; and the killing of the aggressor.... the one is intended, the other is not.""