Assisted Dying: Physicians and Metaphysicians in the BMJ

There’s a slightly curious correspondence taking place in the BMJ at the moment that concerns assisted dying.  Des Spence started things moving with this short piece.  For the most part it is (sorry to say) a slightly pedestrian and simplistic overview of the state of the assisted dying debate.  One of the arguments against AD that he cites, for example, rests on the idea that it violates a doctor’s moral duty – which seems to me to be just the teeniest bit question-begging.  The rest of the anti- paragraph is a shopping list of the standards.  The next paragraph tells us that the pro-arguments are also strong, but he makes the mistake of claiming that it’s autonomy that does the work here.  It ain’t.  Not in respect of assistance.  I don’t violate your autonomy by not helping you to die.

So far, so workaday.  But a potentially interesting point is made next:

[A]ssisted dying is happening every day throughout the NHS. The doctrine of double effect means that doctors give large doses of morphine near the end of life. We know that this will hasten death, but we square this moral circle by accepting that we are relieving suffering. Doctors also widely withhold and withdraw treatment knowing that this will hasten death. Isn’t the reality that we are already actively engaged in assisted dying?

There’s an error here, too, I think: but it’s an interesting one.  Spence seems to be claiming that the DDE is a form of AD.  I’m not sure that this is correct.  The mistake seems to be that the DDE is seen as a means of exculpating (at least) and possibly justifying certain courses of treatment.  But that’s not actually what it is about.  Properly used, and assuming that’s a valid argumentative move (it’s not currently in favour, but I think that it could possibly have legs), the DDE does not justify or exculpate: it tells us that justification or exculpation may not be necessary in respect of certain harmful actions.  Bluntly, it’s a principle that says that the doctor who puts your broken arm in plaster doesn’t have to apologise for having prevented you going swimming, even though it would ordinarily be wrong to prevent someone going swimming and he knew that putting your arm in plaster would have precisely that outcome.  The DDE is, at root, a metaphysical principle that (for the most part) gets put to work in respect of applied ethics.  But because it’s a metaphysical principle, it can’t, on its own, tell us whether an action is permissible or impermissible: all it does is offer us a strategy for thinking about permissibility and impermissibility.

That’s worth repeating.  The DDE – at least as I see it – isn’t about right and wrong.  It’s about how we think about right and wrong.  It’s about implication, and about logic.  It’s about abstracts, and about the metaphysics of morals.

Having said this, it’s possible that assisted dying does happen quite a lot in the UK – maybe doctors do help people on their way more than they admit.  The DDE has nothing to do with this, and the idea that discussion of AD ought to be more frank about the reality of what goes on doesn’t seem to be wildly outré; so I’ll give Spence that much.  (Just for the sake of being absolutely clear, I understand assistance to refer to those cases in which Smith asks Jones to help him die; the permissiblity of AD is a matter of the permissibility of Jones agreeing to Smith’s request.  The DDE applies to those cases in which Jones’ actions may make Smith die irrespective of Smith’s desire to die; I think it’s stretching a point to call that assistance.) 

Maybe the debate among physicians is one that’s marked by a state of denial; and if it is, it’d perhaps be better to reframe the debate.


Spence’s piece generated a response from Claud Regnard and others, in which the death of the DDE is trumpeted.  Spence, they say,

raises the issue of double effect as a result of strong opioids. This is important because, if this effect exists, many doctors stand accused of the hypocrisy of not supporting assisted suicide while regularly hastening death.

Opioid overdose (whether deliberate or unintentional) can have serious adverse effects, including agitation. However, when opioids are correctly prescribed they do not hasten death and there is no need to invoke the doctrine of double effect to justify their use. Opioid dose requirements cannot be predicted so, to avoid adverse effects, doses should always be titrated to the individual. As for where the dividing line exists, this was finally resolved in a General Medical Council decision last year that clearly distinguished between safe and dangerous prescribing of strong opioids.  There are no circumstances in which the prescription of a lethal dose of opioid is necessary to control suffering, and therefore there is no need to invoke the doctrine of double effect.

Double effect with opioids is a perennial myth that has been used to defend unsafe prescribing.

Well, I’m not sure that there’s any hypocrisy involved – it could be a kind of false consciousness – but I take the point.  And I’m puzzled by how one might reconcile the claim that opioid dose requirements cannot be predicted with the claim that there are no circumstances in which the prescription of a lethal dose is necessary to relieve suffering; but I’m not a medic, so I’ll let that one pass.  It’s probably me that’s at fault there.  I’m a little wary of the appeal to the GMC’s authority, too. 

But what’s really noteworthy is this:

[W]hen opioids are correctly prescribed they do not hasten death and there is no need to invoke the doctrine of double effect to justify their use.

Again, we see the idea that the DDE can be invoked as an attempt to justify something; but that’s expecting too much of it.  The DDE is not a means of justifying an action; rather, it’s a rubric for telling us where to look for justification.  Administering the drug, or putting an arm in plaster, is just or unjust according to the intention behind the action; the correlative outcomes can potentially be discounted quite heavily if the DDE is sound.

And I’m also left wondering whether Spence and his respondees have missed a deeper point by getting tied up with the question of opioids.  Let’s allow that opioids, properly prescribed, need never bring about death.  Well, that leaves the DDE utterly untouched.  Indeed, if there’s no drug that need ever bring about death when properly prescribed, or – more radically – no situation of any sort in which we might bring about an undesirable outcome by virtue of an otherwise prima facie permissible action, that would make no difference at all to the validity of the DDE.  As I mentioned above: I think it’d still stand; a lot of others think that it’d still be a crock.  But you can throw all the practical examples you like at it: they’ll just keep bouncing off.

And that’s because, if you’re going to criticise the DDE, you have to stop being a physician and start being a metaphysician.

(Incidentally: I’m going away for a couple of days, and am unsure of my internet access.  Any comments might take a while to appear.)

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