In traditional ethical analyses of end-of-life decision-making the concept of intention plays a crucial role. Through a review of qualitative research and clinically informed analyses of different end-of-life practices such as non-treatment decisions, aggressive symptom relief and palliative sedation, this chapter investigates the role intention plays in contemporary end-of-life practices. Qualitative studies put into doubt two common presuppositions about the intentions of health professionals: that these are directly accessible to the agent, and that they are unambiguous. Two rival interpretations of the findings, which take diametrically opposed views of the helpfulness of the concept of intention and the Principle of Double Effect, are outlined. Finally, by way of a theoretical account of intention, we present our own interpretation and the claim that it is indeed possible to practice excellent end-of-life care without having to intend (the hastening of) a patient’s death.
- End of life
This is a preview of subscription content, access via your institution.
Tax calculation will be finalised at checkout
Purchases are for personal use onlyLearn about institutional subscriptions
Woods and Graven offer a four-point definition of what they call the ‘Doctrine of Double Effect’: 1. The act itself must be of a permissible kind (morally good) or at least indifferent (morally neutral). 2. The agent may not positively intend the bad effect but may foresee it (and allow it to happen) but if there were a means to achieve the good effect without the bad effect then that would be the preferred option. 3. The good effect must be produced directly by the action, and not by the bad effect. The agent must not use a bad means to a good end, which is never allowed. 4. The good effect must be sufficiently important to compensate for the allowing of the bad effect. (See Chap. 12, this volume).
In October 2017, Ovid MEDLINE, PsycINFO and Embase were searched with relevant keywords, yielding 196 references. 131 articles were deemed irrelevant from the title, or were not in English, or were not full journal articles. The remaining 65 articles were assessed by abstract when available, resulting in 17 articles judged potentially relevant. These were evaluated in full text, and 11 articles were found to fit the search criteria. Further detail of the literature search is available on request to the first author.
The limits to the usefulness of the ‘counterfactual test’ has been noted in Shaw (2006; 201–204).
Anquinet, L., Rietjens, J. A., Van Den Block, L., Bossuyt, N., & Deliens, L. (2011). General practitioners’ report of continuous deep sedation until death for patients dying at home: A descriptive study from Belgium. European Journal of General Practice, 17, 5–13.
Anquinet, L., Raus, K., Sterckx, S., Smets, T., Deliens, L., & Rietjens, J. A. (2013). Similarities and differences between continuous sedation until death and euthanasia – Professional caregivers’ attitudes and experiences: A focus group study. Palliative Medicine, 27, 553–561.
Anscombe, G. E. M. (1963). Intention. Oxford: Basil Blackwell.
Aquinas, T. (1948). Summa Theologica. New York: Benziger.
Beauchamp, T. L., & Childress, J. F. (2009). Principles of biomedical ethics (6th ed.). New York: Oxford University Press.
Bennett, J. (1995). The act itself. Oxford: Clarendon Press.
Bosshard, G., Fischer, S., Van Der Heide, A., Miccinesi, G., & Faisst, K. (2006). Intentionally hastening death by withholding or withdrawing treatment. Wiener Klinische Wochenschrift, 118, 322–326.
Bratman, M. (1987). Intention, plans, and practical reason. Cambridge, MA: Harvard University Press.
Chappell, T. (2002). Two distinctions that do make a difference: The action/omission distinction and the principle of double effect. Philosophy, 77, 211–233.
Douglas, C., Kerridge, I., & Ankeny, R. (2008). Managing intentions: The end-of-life administration of analgesics and sedatives, and the possibility of slow euthanasia. Bioethics, 22, 388–396.
Douglas, C. D., Kerridge, I. H., & Ankeny, R. A. (2013). Narratives of ‘terminal sedation’, and the importance of the intention-foresight distinction in palliative care practice. Bioethics, 27, 1–11.
Fournier, V., Belghiti, E., Brunet, L., & Spranzi, M. (2017). Withdrawal of artificial nutrition and hydration in neonatal intensive care: Parents’ and healthcare practitioners’ views. Medicine, Health Care & Philosophy, 13, 13.
Jansen, L. A. (2010). Disambiguating clinical intentions: The ethics of palliative sedation. The Journal of Medicine and Philosophy, 35, 19–31.
Jansen, L. A., Fogel, J. S., & Brubaker, M. (2013). Experimental philosophy, clinical intentions, and evaluative judgment. Cambridge Quarterly of Healthcare Ethics, 22, 126–135.
Knobe, J. (2003). Intentional action and side effects in ordinary language. Analysis, 63, 190–194.
Magelssen, M., Kaushal, S., & Nyembwe, A. (2016). Intending, hastening and causing death in non-treatment decisions: A physician interview study. Journal of Medical Ethics, 42, 592–596.
Miller, F. G., Truog, R. D., & Brock, D. W. (2010). Moral fictions and medical ethics. Bioethics, 24, 453–460.
Nichols, S., & Ulatowski, J. (2007). Intuitions and individual differences: The Knobe effect revisited. Mind & Language, 22, 346–365.
Oderberg, D. S. (2000). Moral theory. A non-consequentialist approach. Oxford: Blackwell.
Onwuteaka-Philipsen, B. D., Van Der Heide, A., Koper, D., Keij-Deerenberg, I., Rietjens, J. A. C., Rurup, M. L., Vrakking, A. M., Georges, J. J., Muller, M. T., Van Der Wal, G., & Van Der Maas, P. J. (2003). Euthanasia and other end-of-life decisions in the Netherlands in 1990, 1995, and 2001. The Lancet, 362, 395–399.
Onwuteaka-Philipsen, B. D., Brinkman-Stoppelenburg, A., Penning, C., De Jong-Krul, G. J. F., Van Delden, J. J. M., & Van Der Heide, A. (2012). Trends in end-of-life practices before and after the enactment of the euthanasia law in the Netherlands from 1990 to 2010: A repeated cross-sectional survey. The Lancet, 380(9845), 908–915.
Papavasiliou, E. E., Payne, S., Brearley, S., & Euroimpact. (2014). Current debates on end-of-life sedation: An international expert elicitation study. Supportive Care in Cancer, 22, 2141–2149.
Pascal, B. (2001). Provincial letters. Eugene: Wipp and Stock.
Quill, T. (1991). Death and dignity. A case of individualized decision making. The New England Journal of Medicine, 324, 691.
Quill, T. E. (1993). The ambiguity of clinical intentions. The New England Journal of Medicine, 329, 1039–1040.
Rietjens, J. A., Voorhees, J. R., Van Der Heide, A., & Drickamer, M. A. (2014). Approaches to suffering at the end of life: The use of sedation in the USA and Netherlands. Journal of Medical Ethics, 40, 235–240.
Rys, S., Deschepper, R., Mortier, F., Deliens, L., & Bilsen, J. (2015). Bridging the gap between continuous sedation until death and physician-assisted death: A focus group study in nursing homes in Flanders, Belgium. American Journal of Hospice & Palliative Medicine, 32, 407–416.
Scanlon, T. M. (2000). Intention and Permissiblity: T. M. Scanlon. The Aristotelian Society Supplementary Volume, 74, 301–317.
Sercu, M., Pype, P., Christiaens, T., Derese, A., & Deveugele, M. (2014). Belgian general practitioners’ perspectives on the use of palliative sedation in end-of-life home care: A qualitative study. Journal of Pain & Symptom Management, 47, 1054–1063.
Shaw, J. (2006). Intention in ethics. Canadian Journal of Philosophy, 36, 187–224.
Sidgwick, H. (1907). The methods of ethics. London: Macmillan.
Sterckx, S., & Raus, K. (2017). The practice of continuous sedation at the end of life in Belgium. In D. A. Jones, C. Gastmans, & C. Mackellar (Eds.), Euthanasia and assisted suicide: Lessons from Belgium. Cambridge: Cambridge University Press.
Trankle, S. A. (2014). Decisions that hasten death: Double effect and the experiences of physicians in Australia. BMC Medical Ethics, 15, 26.
Van Der Heide, A., Onwuteaka-Philipsen, B. D., Rurup, M. L., Buiting, H. M., Van Delden, J. J., Hanssen-De Wolf, J. E., Janssen, A. G., Pasman, H. R. W., Rietjens, J. A., & Prins, C. J. (2007). End-of-life practices in the Netherlands under the euthanasia act. New England Journal of Medicine, 356, 1957–1965.
Van Der Heide, A., Van Delden, J. J. M., & Onwuteaka-Philipsen, B. D. (2017). End-of-life decisions in the Netherlands over 25 years. New England Journal of Medicine, 377, 492–494.
Woodward, P. (2003). Nancy Davis and the means-end relation: Toward a defense of the doctrine of double effect. American Catholic Philosophical Quarterly, 77, 437–457.
Editors and Affiliations
© 2020 Springer Nature Switzerland AG
About this chapter
Cite this chapter
Magelssen, M., Shaw, J. (2020). Intentions of Physicians and End of Life Care Team. In: Emmerich, N., Mallia, P., Gordijn, B., Pistoia, F. (eds) Contemporary European Perspectives on the Ethics of End of Life Care. Philosophy and Medicine, vol 136. Springer, Cham. https://doi.org/10.1007/978-3-030-40033-0_21
Publisher Name: Springer, Cham
Print ISBN: 978-3-030-40032-3
Online ISBN: 978-3-030-40033-0