Human Values pp 236-251 | Cite as

Beyond Double Effect: Side-Effects and Bodily Harm



Much attention has been devoted by philosophers to the Principle (or Doctrine) of Double Effect (PDE) for which various formulations have been offered. While I believe that PDE is defensible — at least in some formulations — I want to argue that the relationship between intentions and side-effects needs some further thought. It is commonplace for defenders of PDE to point out that it does not give carte blanche for causing side-effects that are disproportionately harmful. It is less often noted that there are side-effects which, while remaining unintended, nonetheless have a central role in the description of certain kinds of act. Rather than being just a factor to be weighed against the good effects at which we are aiming, bad side-effects can generate an independent moral conclusion1 in conjunction with the long- or short-term intentions with which they are connected.


Ectopic Pregnancy Crew Member Double Effect Bodily Integrity Unborn Child 
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  1. 7.
    W. Quinn, ‘Actions, Intentions, and Consequences: The Doctrine of Double Effect’, in W. Quinn (ed.), Morality and Action (Cambridge: Cambridge University Press, 1993): 184–5.Google Scholar
  2. 8.
    Ibid: 186.Google Scholar
  3. 9.
    Ibid: 190.Google Scholar
  4. 11.
    J.L.A. Garcia, ‘Intentions in Medical Ethics’, in D.S. Oderberg and J.A. Laing (eds), Human Lives: Critical Essays on Consequentialist Bioethics (London: Macmillan, 1997): 179, n. 16. Quinn (op. cit: 186–7) mentions a similar case, but concludes that the marksman is not intending anything different from what he would intend if the human shield were not there.Google Scholar
  5. 14.
    See M. Moore, ‘Intentions and Mens Rea’, in R. Gavison (ed.), Issues in Contemporary Legal Philosophy: The Influence ofH.L.A. Hart (Oxford: Clarendon, 1987): 260–1.Google Scholar
  6. 15.
    “‘Closeness” can matter to what an agent intends (“psychological closeness”) because […] the fact that the mind can be brought to recognise a certain distinction of possible intentional contents does not imply that, on a given occasion, it utilizes that distinction in its actual practical deliberations and decision making’ (J.L.A. Garcia, op. cit: 165–6).Google Scholar
  7. 16.
    Ibid: 166.Google Scholar
  8. 18.
    This principle is relevant to healthcare allocation: patients do not have an inalienable right to retain a bed in an intensive care unit (for example) if this will deprive other patients of facilities to which they have a better claim. See, for example, A. Fisher and L. Gormally (eds), Healthcare Allocation: An Ethical Framework for Public Policy (London: The Linacre Centre, 2001).Google Scholar
  9. 22.
    John Finnis comments on a similar case (though one not involving consent): ‘The surgeon intends to and does deal with the body, i.e., the very person of the patient, as his own to dispose of. Though his choice is not, precisely, to kill or even, perhaps, to impair the functioning of the patient/victim — i.e., though death and impairment of function are side-effects — the surgeon’s choice is precisely to treat the bodily substance and reality of that other human person as if that person were a mere subhuman object. The moral wrong, on a precise analysis of the surgeon’s intent, is a form of knowingly death-dealing enslavement; one who inflicts death, even as a side-effect, in order to effect such an instmmentalisation of another has, in the fullest sense, “no excuse” for thus knowingly causing death. We should not complain if both law and common moral thought treat this as murder. But nor should we distort our understanding of intention so as to bring this within the category of murder supposed, too casually, to be limited to intent to kill (or seriously harm)’ (J. Finnis, ‘Intention and Side-Effects’, in R.G. Frey and C.W. Morris (eds), Liability and Responsibility: Essays in Law and Morals (Cambridge: Cambridge University Press, 1991): 60–1).Google Scholar
  10. 26.
    On the application to a different case of conflict — the case of conjoined twins — see H. Watt, ‘Conjoined Twins: Separation as Mutilation’, Medical Law Review 4 (2001): 237–45.Google Scholar
  11. 27.
    This view is defended in H. Watt, Life and Death in Healthcare Ethics: A Short Introduction (London: Routledge, 2000): 57–65.Google Scholar
  12. 30.
    See the discussion in J. Finnis, G. Grisez, and J. Boyle, “Direct” and “Indirect”: A Reply to Critics of Our Action Theory’, The Thomist 65 (2001): 21–9, 32, 39–41. The authors themselves defend craniotomy, on the grounds that the child’s death is not intended (but see note 22 for one author’s account of wrongful homicide without this intention).Google Scholar
  13. 34.
    For ethical analyses of different ways of managing ectopic pregnancies, including the use of MTX, see W. May, ‘The Management of Ectopic Pregnancies: A Moral Analysis’, in P. Cataldo and A. Moraczewski (eds), The Fetal Tissue Issue (Braintree: The Pope John XXIII Medical Ethics Research and Education Center, 1994): 121–47; A. Moraczewski, ‘Managing Tubal Pregnancies: Part I’, Ethics and Medics (June 1996): 3–4; A. Moraczewski, ‘Managing Tubal Pregnancies: Part II’, Ethics and Medics (August 1996): 3–4; G. Gleeson and C. Kaczor, ‘Is the “Medical Management” of Ectopic Pregnancy by the Administration of Methotrexate Morally Acceptable?’, in L. Gormally (ed.), Issues for a Catholic Bioethic (London: The Linacre Centre, 1999): 353–70; C. Kaczor, ‘Moral Absolutism and Ectopic Pregnancy’, Journal of Medicine and Philosophy 26 (2001): 61–74. Some have claimed that the aim in using MTX is not to attack the trophoblast’s normal functions, but to stop its abnormal invasion of the tube. However, implantation, even in the tube, is an exercise of an embryonic function, in that it is a life-preserving — even if ultimately futile — activity. The activity of the embryo is rather like breathing poisoned air. It is the exercise, though in an abnormal way, of a life-preserving function of the embryo. Such functions may not be deliberately attacked, even if, for environmental reasons, they cannot preserve life for long. In any case, it is not necessary to show that one intends to interfere with a function of the embryo to show that interference with the trophoblastic tissue is immoral. Rather, it is enough (I am arguing) to show that one intends to invade the embryo’s body in a way foreseen to do the embryo only lethal harm.Google Scholar
  14. 36.
    J.J. Thomson, ‘A Defense of Abortion’, Philosophy and Public Affairs 1 (1971): 47–66.Google Scholar

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© Helen Watt 2004

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