In the Service of Human Life
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Applied Bioethics in stylized text
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In the Service of Human Life

Double Effect Explained

In the world of philosophy, there are more than a few heavyweights that hail from the Catholic Intellectual Tradition. These deep thinkers pioneered new ways of approaching life’s great questions. The morality of the Church colors these viewpoints in a way that esteems the human person and seeks its ultimate good. Even non-Catholics will recognize names like Thomas Aquinas, Duns Scotus, Augustine, and the more modern GK Chesterton. What makes their contributions so significant is that, while rooted in faith, they’re broadly applicable. One of these offerings is Aquinas’ Principle of Double Effect.

You may have heard an example of this principle before.You and some friends go exploring in a cave. While trying to leave, one of your friends becomes stuck in the narrow entrance blocking your way. You can’t move them and you’re all trapped inside with no possible escape or rescue coming. Would it be ethical to use the dynamite that you brought along to blow a wider hole, even though it may fatally wound your friend?

It’s not unusual for a single action to have two effects. Hitting a grand slam in the World Series inspires the player who cranked the ball out of the park and demoralizes the pitcher who threw too good of a pitch. The same is true in medicine. A new regimen of prescription drugs for a patient can cure an ailment while at the same time generating some unpleasant side effects. Their seizures may stop, for example, but they may be constantly nauseous.

What happens, though, when one of the effects is a moral good, and the other is a moral evil? How do we ethically parse that scenario in a way that maintains respect for the patient and keeps a medical decision within the boundaries of an ethical code?
Aquinas offers his Principle for just this situation. The Stanford Encyclopedia of Philosophy summarizes Aquinas’ criteria in this way:

- The act itself must be morally good or at least indifferent.
- 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.
- 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.
- The good effect must be sufficiently desirable to compensate for the allowing of the bad effect

In other words, the action being taken must not be morally evil on its own, the person taking the action must intend the good result, the good result must not come from an evil means, and the good result must be proportional.

In order for a decision to have the justification of double effect, all four criteria must be satisfied. Failure on any one point is an ethical failure on the question.

One of the medically acceptable uses of abortion is in cases where the mother’s life is at risk. Thankfully, medical advances have made these situations statistically insignificant. Even still, what about a pregnant woman who is facing a medical condition that threatens her life? She elects to have an abortion. Intending to save her own life, the abortion also has the effect of ending the life of her child. Does the Principle of Double Effect validate her decision as ethical?

Her decision fails all four of the criteria. First, abortion is the intentional act of killing a person. That is neither morally good nor is it indifferent. Second, the bad effect of abortion is inseparably linked to her desire to preserve her own life through the abortion. Third, the good effect is produced solely through the abortion. It’s using evil means to achieve a good, which is unacceptable. Finally, the preservation of the life of the mother is in no way compensation for the death of the child.

Now, if that same mother needed to start a course of treatment not possible while pregnant, she could elect to have her pre-term child delivered by cesarian section and admitted to the Neonatal Intensive Care Unit (NICU). NICU technology has advanced to the point where even a child born at 22 weeks has a chance of survival. If she delivered the child, and started treatment, and her child for whatever reason did not survive, the Principle of Double Effect may validate her decision as ethical. A full analysis would be required, but it’s very possible that her decision was ethical, even if it resulted in a negative outcome.

Patients benefit from a rigorous ethical inquiry into their treatment options. The Principle of Double Effect is among the best tools that any patient, physician, or ethicist can use to choose the right course in a difficult situation.

Disordered

The human person is a miracle in the created order. From the first moment of life, as a singular cell with a single copy of its own, unique, unrepeatable code of DNA, a person stands apart from all other creatures. A fusion of generations of genetic mutations, every person represents a truly new creation.

Sadly, the process of human development is fraught with complications. Many lives end in the earliest days of gestation. Others don’t make it to term. Too many children die in their first days of life, a result of complications from birth or because of structural defects. It’s no easy task to repeat the code of DNA countless times, to divide cells and grow organs, build systems, and then get them all working together.

Part of what it means to be human is to deal with deficiencies. The human body is complex and there are myriad of genetic bugs passed from generation to generation. Each one of us, in our uniqueness, struggle with dysfunctions and deficiencies. Every system and organ in our body present opportunities for things to go wrong. Some are genetic, others environmental, and still others a result of our own choices.

Despite the disorders and dysfunctions, we remain human. No matter our age, whether in our first moments after conception, or celebrating our 101st birthday, we retain our humanity. We retain our unique status in the world, a one time occurrence, having never been before, and never to be repeated again.

Some dysfunctions are minor, and others are life altering. From diabetes to renal disease, congenital heart defects to bipolar disorder, industrial accidents to injuries on the battlefield; our circumstances shape our lives. Some disorders require institutionalization, others require structural changes to our bodies, and most require some lifestyle adjustments. Nothing diminishes or reduces our humanity. Not the loss of a limb in a tragic car accident or a required daily dose of an antipsychotic medication.

Ethical norms, whether codified in law or not, demand a liberal application of respect to the human person. Mentally ill or political prisoner, newly conceived or terminally ill, intellectually disabled or addicted to opioids, every patient, every person, has a life worthy of respect and protection.

Our dysfunctions and disorders do not define us, nor do they dictate the level of care and attention that we deserve. Acute illness or chronic condition, we all have lives worthy of living because of who we are. Our life is a gift to our family, our community, and our world. And there is no condition, no change of status, no action that can ever diminish that gift.

Dying with Dignity

Do you have a right to die on your terms? It’s a question that many people are asking. Ethicists, physicians, public policy experts, even legislators are debating that right on its merits. This is as much a moral question as it is a legal one.

The law is more than bipolar on when ending someone’s life is acceptable. You individually cannot murder anyone, with or without cause. But you can in cases of self-defense. A physician or a mother may kill a child in development up to a certain gestational age. A physician who overprescribes medication can be charged with murder. The State can execute a convicted criminal who has committed a certain offenses. These distortions illustrate why we can’t be confident in relying upon law alone as our moral and ethical guide. The law seeks to do what is just, ethics seeks to do what is right.

The public debate over euthanasia is couched around the idea of “dying with dignity.” Proponents want you to think that the limits that they place in law today are sufficient to protect the rights of the individual and the patient. These limits may require a waiting period, a certain negative prognosis, or multiple consultations before the fatal prescription is written. They hold that there is a right to die on your own terms and that it’s going to be used in so few cases that we shouldn’t spend much time dwelling on the underlying ethics. Safe, legal, and rare. Sound familiar?

It’s a clever argument to frame euthanasia as a personal and dignified choice for the patient to make, even though in reality it destroys the dignity of the human person. Legalizing euthanasia implicitly means that there are some people whose lives have no meaning or worth. They’re disposable and they will not be missed. We’d rather they be dead than alive.

The proposed guidelines, even those enacted in law, are open-ended. Any law or policy is subject to shifting public policy and opinion over time. Medicine is an imprecise science, and so even to restrict euthanasia to the terminally ill leaves room for error. It’s that same margin for error that gives credence to the argument to end the death penalty. Death is a permanent state. Just as many death row convicts are exonerated through new evidence each year, terminally ill patients are sometimes given an improper diagnosis, respond positively to experimental treatments, or beat the time estimates placed on their lives.

In reality, legalizing euthanasia is a Trojan horse designed to codify a perversion of a truly dignified death. Once enshrined in law, outlawing the practice would be considerably more difficult.

We all share a desire to die peacefully, and many of us approach our own mortality with fear. We fear the unknown and we let that fear cause us to act irrationally. You have a right to die of natural causes, not a right to take your own life at a time and in the method of your choosing. Every person possesses an inherent dignity that is totally separate from any utility that they may provide to their family, community, or society writ large.

An authentically dignified death is one in which the person is loved and respected. It’s when all ordinary means of care are exhausted, and a patient is given comfort care until their natural death. A dignified death is one in which the patient knows that they have worth because of who they are, not because of what they offer. A dignified death protects the patient in their weakest moments, allowing no harm to come to them. A dignified death is one of natural causes, not direct intervention.

The end of ones life can be filled with considerable pain and suffering. It can also come without warning or in a period of great bliss and joy in their lives. Regardless of the circumstances surround one’s death, you have the right to die with authentic dignity, of natural causes, and not a moment sooner.

Basic Transplant Ethics

The Boneyard is a magical place for pilots and aviation enthusiasts. When the Department of Defense retires an aircraft, it’s flown out into the Arizona desert and parked on a massive military base. Surveying the rows of thousands of aircraft, you get a sense of the history of military aviation in the United States, and the amazing stories that behind these planes.

It’s not just airplanes from the 1950s and 1960s parked in the Boneyard, but even models that are still flying. Early models of the F-16, or example, rest at the Boneyard, preserved in the arid climate. While some of the planes at the Boneyard may be recalled to active service, most won’t. They are a resource to operational flying units. When a part breaks, the maintenance crew can call down to the Boneyard and ask for a canabalized part. This is particularly helpful if the needed part is no longer in production. Technicians will review the Boneyard inventory, find the part on one of the parked planes, remove it, and ship it to the squadron. This cost effective technique allows for older, non-flyable planes to continue to add value beyond scrap metal.

The progress that we’ve made in the field of human organ transplantation is remarkable. Gravely ill people are able to receive organs that give them a new lease on life. In most cases, organ transplants are an ethically valid procedure. Organ donations can be made by a still living person or by a recently deceased one. Donating organs is ethically valid if there is consent on the part of both parties, if the donation is done with the intent to prolong the life of the receiver, if the donation won’t cause immediate harm or death to the donor, and if the organs are assigned to patients within the established guidelines of prioritization.

The danger that organ donation presents is that it can be perverted easily. These perversions take an ethically good technology and create a grave moral evil. A less common perversion would be the intent. If the donor wants to give up an organ for an irrational reason, that would make the transplantation unethical. This would be something like a person hates a particular organ and wants it removed. Again, not very common.

Informed consent presents the second major perversion, and this one is more common than any of us would like to think. Organs that are stolen by individuals, or governments, and transplanted, even if they save someone else’s life, are done so unethically. Harvesting organs from political prisoners, through medical experimentation, or any other associated ghoulish activity is decidedly unethical, again, regardless of the outcome.

Finally, any organ donation that would create direct and immediate harm to the donor, or even death, would be unethical. This would include a donor’s heart, both lungs, both kidneys, eyes, or any other complete organ that’s required for life or whose removal would constitute a harm to the donor. Organs that are removed from a donor who is still alive, whose heart is still beating, are markedly more useful than those removed from a recently deceased donor. Even just a few minutes can make the difference between an organ being viable for transplantation. However, despite this medical fact, the integrity and dignity of the human person demands that they be seen and treated as a person, not a retired airplane sitting in the desert waiting to give up all of its most valuable parts.

Our code of ethics provides the guardrails by which we ensure that technologies and procedures created for good ends remain that way. The human body has many parts that can be useful to preserving the lives of others, but they can only be used ethically if they are freely given and the dignity of both patients is protected.

Embryonic Gene-Editing

News of the birth of the world’s first gene-edited babies made headlines worldwide. Born in a Chinese hospital, Dr. He Jiankui edited the embryo’s DNA in an attempt to make the twins resistant to HIV. Their mother is HIV-negative, but their father is HIV-positive. This put the twins at high risk for contracting HIV while in utero.Read Article