Journal of medical , I979, 5, 143-144 J Med Ethics: first published as 10.1136/jme.5.3.143 on 1 September 1979. Downloaded from

Analysis: an introduction to ethical concepts

Acts and omissions his patient, one must take into consideration whether the question involved is an act or omission'4. Colin Honey Kingswood College, Crawley, A doctor may more readily omit to render aid to a Western Australia stranger than to his own patient. But he may also omit to perform certain procedures more justifiably than others. A closer examination of acts and At first sight it seems reasonable to say there is an omissions at this point requires consideration of the important difference between, on the one hand, principle of double effect and the distinction actively causing harm or injury to a person and, on between ordinary means and extraordinary means. the other, omitting to prevent harm from occurring. There is a difference between failing to resuscitate Ordinary and extraordinary means an aged terminally-ill patient who has arrested and Ordinary means, it is held, must always be adopted actively killing a similar patient who shows no signs -where any obligation exists to act-whereas of imminent death. Or at least it has seemed to many extraordinary means need not. Pope Pius XII that such a difference is obvious: the validity of the employed this distinction in his allocution to distinction has been challenged (most recently by anaesthetists on 24 November I957. He considered Jonathan Glover') as being a distinction without a

the use of a respirator to be discretionary orcopyright. difference-since the consequences in both cases are extraordinary. In doing so he employed the principle identical. in a technically ethical rather than clinical sense. In From Aristotle via Thomas Aquinas and Roman ethical discourse 'ordinary' does not just mean 'that Catholic moral theology has come the distinction which is readily available and known to be effective': between act and omission. A recent statement ofthe it may mean rather that which would not 'impose on formal principle is the following: the patient undue suffering or expense, or, it may be, To act intentionally ('at will') is to bring about or an undue distortion of his personality or a barrier in prevent a change in the world (in nature). By this his relationships with his kin, a lessening of his http://jme.bmj.com/ definition, to forebear (omit) action is either to leave human capacity, and all without reasonable hope of something unchanged or to let something happen.2 benefit'.6 Such an understanding of the distinction permits a wider discretion than a purely clinical The implication is plain. You cannot be held judgment would. In the rapidly-moving world of responsible for things you did not do. But it is not medical practice and technology today's 'extra- quite as simple as that. ordinary' is tomorrow's commonplace. While it may To fail to operate on a baby with a tracheal not be quite true to say that patients in hospital no esophageal fistula would normally be tantamount to longer die, they simply fail to respond to resuscita- on September 30, 2021 by guest. Protected : but if the baby is severely deformed the tion attempts, it is becoming almost daily more case is less clearP. A major objection to the principle nearly true. This has led the Education of acts and omissions has been the claim that what- Council in New York to employ in their Living Will ever distinction there is between an act and an the terms "artificial means or 'heroic measures' " in omission it is not a morally relevant distinction. It an attempt to make their meaning clear. may be argued that the only humane options are to If the distinction between clinical and ethical operate or actively to hasten death: the worst course meanings of 'ordinary' holds good the terms of the is to allow such a child to wane and die from lack of debate are clarified but the problem of deciding is nourishment. Such extreme cases do strain the less straightforward. A perfectly 'ordinary' operation distinction and raise the question whether there is a to clear a blocked esophagus may constitute a difference in principle between acting to harm and pointless intervention when the prospective life of failing to act to help. the patient is considered. On the other hand it may The distinction between acts and omissions is not serve to alleviate the awesome responsibility a only important in ethical discourse. It also has clinician may feel to discover and employ whatever important legal implications. George Fletcher artificial means or heroic measures are currently observes that 'in analysing the doctor's legal duty to available. '44 Colin Honey J Med Ethics: first published as 10.1136/jme.5.3.143 on 1 September 1979. Downloaded from

Double effect first case (but feared) and what was deliberately enacted in the second. To be fair we must observe If it can be morally and legally justifiable sometimes that the intention in both cases was, in some sense, to omit to bring about inherently good effects, is it the comfort and safety of the victim. Campbell's ever permissible actively to bring about bad effects ? objection holds against any attempted black-and- The principle of double effect allows such acts white caricature. under certain carefully defined conditions. Formally It remains possible for the utilitarian or conse- stated the principle runs thus: quentialist to stress the identity ofpractical outcome. Doing an action that has a bad effect is permissible The question of whether there is any more to ifthe action is good in itself, the intention is solely to morality than that is outside our present scope, but produce the good effect, the good effect is not it is at least a controversial position. For those whose achieved through the bad effect, and there is concern is also with conformity to moral principles sufficient reason to permit the bad effect.7 or the distinctions may be crucial. In practical decision-making there remains an On this principle it would be possible to justify the important difference between acts and omissions. administration of analgesics to a terminally-ill No amount of philosophical discussion obscures the patient which had the incidental, but foreseen fact that it is a common-sense guide in many cases. consequence of shortening his life. But each of the But there are complexities, too-and the distinction conditions is important. The intention must be to cannot thoughtlessly be applied in all cases. produce solely the good effect, even though it is Nevertheless, for ordinary moral thinking it may foreseen that the bad effect will very probably also prove to be a valuable rule-of-thumb. occur. It is the distinction between intention and foreknowledge which causes difficulty. A V References Campbell challenges the distinction on the ground 'Glover, J (I977). Causing death and saving lives, that the foreseen bad effects are 'a result ofhis action Harmondsworth, Penguin. which he foresaw, and therefore for which he is Paper 2 (I978) Is there a morally significant difference responsible'.8 Within the casuistic framework from between killing and letting die ? Prolongation of life.copyright. which it derives (Aristotelean-Thomism) the London. The Linacre Centre for the Study of distinction makes technical sense. It is challenged on Ethics ofHealth Care. two grounds: Campbell's objection to the fineness of 8McCormick, RA (i974). To save or let die. Journal of the distinction and the utilitarian objection to the the American medical association, 8, I72-I76, identity ofoutcomes. Perhaps the following example reprinted in Contemporary issues in ed, will serve to meet these objections in part. Beauchamp, T L and Walters, L R (I978). If I were to go to the aid ofa road-accident victim Encino and Belmont, California, Dickenson. and decide that in the thick fog he stood no chance of 4Fletcher, G P (I967). Prolonging life: some legal http://jme.bmj.com/ survival unless I could get him offthe road, and if I considerations. Washington law review, 42, 999-IOI6, reprinted in Beauchamp and Walters, were then to shift him fully realising the attendant op cit and in Euthanasia and the right to death ed. risk of injury from moving him, and if as a result he Downing, A B (I969) London, Peter Owen. did, in fact, die of such injuries, would it be correct 'Pius XII (1957). Allocution to doctors and students, to say I had intended his death? Or that I was Acta apostolicae sedis, XXXXIX, n. I7-I8. responsible for it ? On the principle of double effect 6Duncan, A S, Dunstan, G R and Welbourn, R B (eds) it would not. The action was itself The inten- good. (I977). Dictionary of medical ethics, p 252 London, on September 30, 2021 by guest. Protected tion was only to produce a good effect. The good Darton, Longman & Todd. effect was not achieved through the bad effect. The 7Paper i (1978). The principle of respect for human life. risk involved in not moving him was sufficient to Prolongation oflife London, The Linacre Centre for justify the bad effect (ie the possibility of his being the Study ofEthics ofHealth Care. injured in the shift). "Campbell, A V (I975). Moral dilemmas in medicine, 2nd The action of moving the victim is viewed quite edition, p I03. Edinburgh, Churchill Livingstone. differently from, for example, a doctor arriving on the scene and deciding that since he will probably Further reading die in pain whether or not he is shifted the best course would be to end his life huimanely with an Foot, P (I967). The problem of abortion and the injection. The question is, should it be viewed so doctrine of double effect. Ox.ford review, 5, 5-I5, differently? It could be argued that there are two reprinted in Moral problems, ed. Rachels, J (I975), important differences: in the second case there is a New York, Harper and Row. Rachels, J (I975). Active and passive euthanasia. The higher probability-a virtual certainty-of death New England journal of meNcine, 292, 78-80, resulting, so the consequences are not strictly reprinted in Contemporary issues in bioethics ed. identical; and there does seem to be a clear distinc- Beauchamp, T L and Walters, L R (1978). Encino tion possible between what was only foreseen in the and Belmont, California, Dickenson.