70\u2005Systematic review on the doctrine of double effect within palliative care

Abstract

Background The Doctrine of Double Effect (DDE) suggests pursuing a morally good action, despite foreseeable bad side-effects (including death) is still ethical, providing the bad side-effects weren’t intended (within set circumstances). Consequently, DDE is a means of freeing doctors to prescribe morphine for pain at the end-of-life without misplaced legal fears. However, increasingly the role for DDE in Palliative Care is being questioned. Our aim was to collate the current arguments for and against a role for DDE in Palliative Care, to provide an updated position. Methods A systematic literature review was performed on DDE in Palliative Care. Peer-reviewed publications included if; English; abstract (to confirm applicability); from last 5 years (2013–2018). 10 full papers were analysed and key arguments summarised. This qualitative data was combined, addressing the research question. Results Persuasive support both for and against DDE in Palliative Care was identified. Positives; legal prerequisite (realising treatment morbidity/mortality); important moral ‘tool’ (doctors require ‘good intentions’); and expert clinical support (championing DDE). Negatives; unnecessary (no legal/clinical need); not applicable (distancing by palliative care); misinforms (fuels misplaced opioid fears); paternalistic (about staff, not patient-centred); unusable (complex, and intent/motive untestable); risks diversion from tailored dosing (poor practice, even if well-meaning); not a blanket ‘doctrine’ (or an ‘untouchable’ defence if misprescribe opioids). Discussion The literature remains divided on current importance of DDE. DDE has inherent philosophical value with historical impact and current support. However, DDE’s applicability in Palliative Care is unclear (because appropriate symptom control doesn’t cause death); inconsistencies refute the presumed need (DDE is not needed to ‘protect’ prescribers in chemotherapy-related neutropenic sepsis deaths); and DDE allows potential harm (unintentionally providing a medical defence if deliberately administer a fatal opioid overdose)… sufficient to undermine DDE’s current value. ‘Best practice’ appears a better tenet to guide doctors.