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not the hastening of death that one knows can occur through respiratory depression. According to my Reformulated RDE, such a combination of intentions is coherent, plausible, and morally justifiable.

Although in such a case it might not seem immediately obvious, there are, in fact, two separable events, distinct in time and space: pain relief (intended) and respiratory depression (unintended). To see why these really are two distinct events, making the application of the RDE plausible, it is perhaps best to think about this case on a molecular level. The analgesic and respiratory depressant effects of morphine occur by the binding of morphine molecules at different subtypes of morphine receptors, populating different locations in the nervous system. The chemistry for each effect has a different time course (kinetics). Morphine achieves pain relief via µ1 receptors and respiratory depression via µ2 receptors. These molecular differences are manifested in the response of the patient to the drug. Pain relief occurs at lower doses and more rapidly than respiratory depression. Thus, while the effects are scattered throughout the body, conceptually this is still a Causal Forks Scenario (type II). So the claim that one intended pain relief and not respiratory depression is plausible and coherent.

However, since the event of death is also a potential cause of the event of pain relief, the skeptic might suggest that this could be construed as a type III scenario — an Alternative Causal Routes Scenario. Accordingly, one must ask whether the morphine case, so construed, would meet the conditions of Requirement 7 of the Reformulated RDE. I argue that even under this construal, the distinction between the foreseen and the intended would be plausible and coherent. ‘Death’ and ‘administering morphine’ do not pick out the same event. And neither do ‘analgesia’ and ‘death’ pick out the same event. The intention to administer morphine does not logically imply intending the death of the patient. Intending analgesia does not logically imply intending the death of the patient. The event of the death of the patient is certainly not a necessary causal condition for the event of pain relief. If it is not the doctor’s further intention that the patient should die, and it is not the case that he intends analgesia by way of the patient’s death, then the claim is at least plausible and coherent, and meets all of the conditions of Requirement 7 of the Reformulated RDE.

For the morphine case to be permitted, however, the remaining requirements of the Reformulated RDE must be met. This analysis turns out to be quite straightforward. A physician morally opposed to euthanasia has a conflict between a duty to relieve suffering and a duty not to kill (i.e. not to act with the specific intention in acting that a human being should die by way of that act except in cases of self-defense or rescue). In such cases, she may administer the morphine with the following provisos:

(1)the administration of morphine is one intentional act with the two foreseeable effects of pain relief and respiratory depression;

(2)injecting morphine is at least morally neutral;

(3)relieving pain is morally good and killing is morally bad;

(4)other means of pain relief such as non-steroidal anti-inflammatory drugs are no longer effective;

(5)no intervening agents are involved;

(6)she has the intention in acting of relieving pain and not depressing respirations and thereby hastening death;

(7)it is plausible and coherent for her to make this claim (as demonstrated by the above analysis), so one cannot rule out that she is sincere and rational in her report on her intentions;

(8)there is due proportionality, such as when the patient’s death is inevitable and the pain is great, so that fears of hastening the patient’s death seem overwhelmingly small when proportionately compared to the benefits of pain relief.

The act is then morally justified according to the RDE.

While space considerations prohibit analyzing more cases, the upshot is that under the Reformulated RDE, the tubal ectopic pregnancy, the cancerous gravid uterus, and the case of using lethal force in self-defense, all fall out of double effect analysis. Cases such as morphine for the dying, and almost any other clinical case that could be described as a treatment with a side-effect, fall within the scope of the Reformulated RDE.

CONSIDERAT ION OF POSSIBLE OBJECT IONS

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This is a considerable reworking of the RDE, and I can anticipate that objections will be raised. Here I consider seven objections, and will leave discussion of other potential objections to the thoughtful analysis of colleagues.

First, some might wonder if the RDE has been rendered superfluous. If a case such as the tubal ectopic pregnancy case must be justified by some other moral rule, perhaps the moral rule about killing that I offered is sufficient, and the RDE unnecessary. Those who have suspected that the RDE is merely correlated with other moral intuitions that actually do all the necessary moral work might be tempted to think this way. However, this is not the case.

A rule justifying killing only in self-defense or rescue would not cover the morphine case. The morphine case involves only one life, not a forced choice between at least two. So a rule that justifies direct killing only in cases of self-defense or rescue would not apply.

Nor would it do to recast the morphine case as the ‘rescue’ of the person who is dying. While clever, such a move would implicate one in an untenable dualism, claiming that the person was being threatened by some ‘other person’ (perhaps the

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person’s own body). And, clearly, the threat would not be a threat of death, but a threat of pain.

Similarly, the new rule prohibiting killing would not apply to a whole range of cases in which death is a side-effect, such as bone marrow transplantation for leukemia, in which the foreseeable risk of death is high, but not intended, but there is no ‘other party’ threatening death. Even cases such as the strategic bomber case would also still require the RDE, since the threat of harm posed to the bomber, her comrades, and her nation by the armaments factory (the intended target) would presumably not be imminent, and the schoolchildren next door (the unintended target) are not themselves the source of any threat. So, the RDE would be far from superfluous under my proposed reformulation.

Second, some might object that this reformulation is too complicated. Surely, with so many conditions and qualifications, one might suggest, there must be something suspicious about this theory. My argument against this is to remind readers that the purpose of ethical theory is to explain and justify morality. This is different from being a moral person or, more specifically, a moral clinician, and different from acting in a morally upright manner. If I am correct that the RDE is the theory that explains the concept of a side-effect, then clinicians act according to the RDE almost reflexively every day. Explaining what one means by a side-effect in a rigorous philosophical manner is a far more complex matter than having a common-sense working notion of a side-effect in clinical practice. One resorts to theoretical analysis if someone challenges the meaning of a common-sense notion such as the notion of a side-effect, or if someone objects to the application or plausibility of a moral rule such as the RDE with respect to a particularly difficult case.

Similar considerations apply to all sciences. Human bodies work according to the laws of biochemistry. One need not know all the theories of biochemistry in order to be a good doctor. But in exceptional cases one resorts to biochemistry to meet a particular clinical challenge or one explores biochemistry as a basic science in order to explain better what is common. No medical student would object to being taught about topoisomerases or enzyme kinetics ‘because it is too hard’. It is puzzling that anyone seriously interested in medical ethics would feel entitled to complain that medical ethics ‘is too hard’. This brings to mind Bernard Williams’s (Williams and Smart 1973: 149) critique of utilitarianism as having, in its reduction of all of morality to the simplicity of consequences, ‘too few thoughts and feelings to match the world as it really is’. If explaining biochemistry is complex, it seems reasonable to expect that the moral life of the human beings who arise out of these biochemical processes would be at least as complex.

A third anticipated objection is that this is all a religious theory that has no place in secular philosophical analysis. This objection is often repeated, or at least intimated, in the bioethics literature. However, it is also a puzzling objection. The RDE is a substantial topic of philosophical discourse. Nothing in my argument

depends upon acceptance of any scripture, the teaching of any church, pope, or bishop, or the dogma of any religion. That it has its origin with the writings of a saint is no argument that it is an inherently religious notion, any more than one can argue legitimately that all theoretical defenses of the immorality of adultery are inherently religious simply because one of the Ten Commandments prohibits adultery. It is a form of the ad hominem fallacy to attempt to detract from an argument merely by citing what one considers its (arguably!) suspect source.

In fact, a fourth anticipated objection is actually an additional counterargument to the third. Adherents to the traditional Roman Catholic formulation of the RDE might well object that the reformulation I am proposing is too radical a break with the Catholic tradition on double effect. I have suggested that the intention – foresight distinction, as it originated in the writings of St Thomas Aquinas, was misapplied from the beginning. While this might worry some Catholics, it also ought to suggest that the origins of the idea (whether Catholic or not) are irrelevant to my analysis and therefore no objection to it.

I do think that the idea of the intention – foresight distinction is of critical importance, and that we can credit Aquinas with first presenting it, even if I do not agree that it applies to the case to which he first applied it. I think this distinction remains crucial to Catholic moral thinking, and that contemporary philosophy of mind helps to clarify and support it. But if the RDE has been misapplied in Catholic thinking, that mistake needs to be corrected within Catholicism as well as in philosophy. And I hope that Catholic proponents of the RDE will be able to see how my analysis strengthens their own defense of this important moral rule.

A fifth anticipated objection is a variation on the fourth. Proponents of the RDE might accuse me of having so radically reformulated it that, in a parody of a phrase associated with the Vietnam War (and the phrase itself is a dark parody of sorts), ‘I had to destroy the RDE in order to save it’. There is no question that I have significantly restricted the use of the RDE by tightening the conditions for its rational application. But rendering a moral rule more rational can hardly be considered its destruction. Other attempts to reformulate this rule have changed its structure and moral tenor considerably more than mine. My reformulation simply makes the traditional formulation more stringent. If, as I believe is true, most of the objections to the RDE are raised by those who have found untenable the applications of the RDE that I also find untenable, then the proper metaphor is not that I have engaged in scorched earth warfare but that I have instead been pruning the vine. By pruning away branches of the RDE that are already dead, it is my hope that I will actually have breathed new life into this important moral rule and that, in its proper application, it will blossom.

A sixth anticipated objection is that the RDE, with its emphasis on intention, is not morally relevant. It is true, as I stated at the beginning of this chapter, that if one does not believe that intentions matter in the moral evaluation of human acts, the RDE will make no sense. Many, like Bennett, are skeptical about whether

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intentions actually exist. But these critics often, like Bennett, beg the question in a very serious way. Bennett (1995: 194) states, ‘What a person intends in φ ing is defined, therefore, by which of her consequential beliefs explain her φ ing and by which of her desires do so.’ Notice that he says ‘consequential beliefs’ and not ‘consequences’. If he defines intentions in terms of beliefs and/or desires, it is simply vacuous for him to argue that intentions can be reduced to beliefs and/or desires. In yet another curious example of one of the two major mistakes I have tried to correct in this chapter, namely that of paying insufficient attention to developments in philosophy of mind, Bennett cites Searle, but then proceeds to ignore everything Searle has to say about why intentions cannot be reduced to beliefs or desires. Bennett offers no reply to any of the arguments to the contrary noted above, such as Buridan cases, wayward causal chains, or the differences in the logical properties of beliefs, desires, and intentions. He also makes no mention of self-referential causation. Therefore, nothing he says should cast any doubt on the theory of intention I have presented.

Still, to accept the RDE, even if one concedes that intentions exist, one must be convinced that intentions mark a moral difference that cannot be accounted for purely by consequences. Space does not permit a full discussion here, but intentions make acts human and give acts a moral structure that must be evaluated if acts are to be evaluated as human and moral. At least two simple, initial lines of argument are available against the consequentialist alternative. First, one can point out that anyone who would dismiss the moral importance of how medical events come about, basing moral judgments solely upon the consequences, faces a monumental task. She must show that a formidable history of collective moral judgment has been ill-considered. Physicians, the US Supreme Court, and most plain persons continue to hold a belief that there is a moral difference between injecting 150 mEq of potassium chloride into the right ventricle of a dying patient and giving that same patient an injection of a dose of morphine sufficient to relieve the patient’s pain, and acting with that intention (Washington v. Glucksberg 1997; Vacco v. Quill 1997). The consequences of these two acts may be the same. I have argued elsewhere that the basis of the judgment that these acts are different depends upon intentions (Sulmasy 1998). It will not suffice, in the face of all that I have outlined about contemporary work in philosophy of action, simply to insist that intentions do not exist or to ‘prove’, via question-begging arguments, that everyone who believes these cases are morally different is misguided.

One can also offer counterexamples. I will offer a variation on one first proposed by Philippa Foot (1978). Suppose a physician were to have a limited supply of a life-saving drug and were suddenly to face five patients who needed it. Four of these patients would be highly likely to survive with a dose equivalent to 1/5 of the supply of the drug, while the fifth would be likely to survive only if given the total dose. If one were to give each patient a dose equivalent to 1/5 of the supply, foreseeing but not intending the death of the patient who needed a higher dose, one would

fulfill all of the conditions of the Reformulated RDE and the act would be morally permissible. However, suppose one were to face a situation in which there were no drug supply, but the drug could be made by sacrificing one of the five, grinding him up, and making a life-saving serum out of him — enough to save the other four. This plan would not meet the conditions of the Reformulated RDE, since it would violate Requirements 7(h) and 7(i). One could not plausibly and coherently claim that one did not intend the death of the individual sacrificed to make the serum. Only the crassest of utilitarians would see these cases as morally equivalent — always making the best of a bad lot. What marks the moral difference that people of reason and goodwill sense here is not the net outcome (which is exactly the same in both cases). The difference can be ascribed to the fact that in the latter case the death was intended as part of the doctor’s plan, while the death in the former case was foreseen but not intended.

Space limitations will not permit me to take up this debate in greater detail than I already have. Suffice it to say that the RDE matters in morality to the extent that intentions matter in morality.

Seventh, some objections might be based upon particular moral judgments about the cases that I discussed. For example, some might hold that euthanasia is not immoral, and therefore hold that killing a dying patient is not bad, and therefore conclude that the RDE does not apply to the morphine case. However, this sort of objection is not an argument against the RDE itself. Discussion would need to shift to arguments for and against the morality of acting with the specific intention in acting of making a human being dead by way of one’s act in order to relieve that person’s suffering. Even so, such a critic might not object to the role of intentions in morality in general and thus be persuaded by my reformulation of the RDE with respect to its application to cases in which it could be granted that the unintended side-effect actually would be bad, such as the foreseeable and uncontroversial badness of the hair loss that often accompanies cancer chemotherapy.

CONCLUSION

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I have presented a reformulation of the RDE that addresses what I consider two fundamental mistakes: the failure of ethicists (particularly bioethicists) to consider developments in the philosophy of mind in relation to the RDE and the misapplication of the RDE to a class of cases that has proven contentious. Critical to this reformulation of the RDE has been the introduction of various notions from philosophy of mind in order to tighten the conditions under which one can be considered plausible and coherent in a claim to foresee a certain bad outcome while not intending it. This reformulation precludes the cases that have seemed most incredible to critics, thereby lessening their objections. This reformulation

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also forces proponents of the RDE to reconsider the basis by which they can justify the acts that they mistakenly have thought to be justified by the RDE.

Elizabeth Anscombe (1970) once observed that the denial of the RDE ‘has been the corruption of non-Catholic thought, and its abuse the corruption of Catholic thought’. It is my hope that this chapter has helped to expurgate a little bit of that corruption.

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P O L I C Y

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