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Joseph Boyle, Professor of Philosophy, St. Michael's College, Centre for Bioethics,
University of Toronto, Toronto, Ontario, M5S 1J4, Canada
The first condition of DDE has been the focus in recent discussions
and disputes about the doctrine and its applications. The distinc-
tion between what is brought about intentionally and what is
brought about as a side effect, and the claim that in the case of
actions which cause certain harms this distinction marks an
important moral difference - the difference between what is
always impermissible and what might be morally permissible -
raise difficult and controversial issues.
Twenty years ago there was substantial skepticism among
philosophers about whether the distinction between what an
agent intends and what the agent brings about as a side effect
DIFFICULTIES
serve the purposes of those who decided to save others' lives. But
these harms to certain individuals are within the agent's power to
prevent. So, they are side effects, and not reasonably evaluated by
absolute prohibitions against inflicting harms.
Still, it seems odd to many to consider as harmful side effects of
one's choices things which one does not actually cause, and this
sense of oddity increases when one considers the reverse side of
this idea, namely, that an agent can intentionally harm someone
without causing the harm, merely by wanting the harm to occur
and choosing not to prevent it. Baruch Brody thinks that this
possibility unnecessarily complicates the ethics of decision
making about the termination of life saving treatment. For this
possibility implies that "either a great deal of killing is morally
permissible or that we are required to treat a very large number of
terminally ill patients so as to avoid killing them" (Brody, 1988,
p. 25). He prefers a strictly causal theory of killing, which avoids
these complications.
But Brady's disjunction is incomplete. Defenders of DDE will
hold that there is another possibility besides keeping people alive
so as to avoid killing them and killing them intentionally by
omission. The traditional understanding of the doctrine of ordi-
nary and extraordinary treatments provides that possibility.
According to this view, one can choose to omit life preserving
treatments not only for the sake of ending the patient's life but for
the sake of avoiding various burdens of the treatment. Thus, if it
were true that the only way to avoid intentionally killing people
would be to continue to treat them, then we would be obligated
by a norm absolutely prohibiting intentional killing by causing
death or by omission to treat an implausibly great number of
patients, but treating people is not the only alternative to intention-
ally killing them.
This approach to the ethics of terminating treatment is more
complicated than Brady's strictly causal approach, but it is not
clear that the causal approach is therefore preferable. If one
supposes, as Brody appears to suppose, that there is no absolute
prohibition against intentional killing by omission, then the
intentional approach of DDE and the ordinary and extraordinary
treatments doctrine is bound to give the wrong results, and
indeed is not needed or justified. But rejecting this normative
belief of the Catholic tradition does little to justify Brady's alterna-
NOTES
1
This formulation implies that traditional Catholic formulations in terms of
three or four conditions are, strictly speaking, superfluous. See Boyle, 1980,
p. 532 for an explanation of why, given their concern about casuistical applica-
tion, traditional moralists found it useful to formulate DDE in theoretically
superfluous ways.
2
See Ashley and O'Rourke, 1981, pp. 227-238, 276-284, 375-387 for a contem-
porary Catholic statement of many of these issues. See also Grisez and Boyle,
1979, Chapter 12, for a systematic account of those among them which relate to
the ethics of killing.
3
A curiosity of Quinn's approach is worth noting. He is convinced that it would
destroy the natural application of DDE if one were to allow that the craniotomy
does not violate the first, intentional condition of DDE. Yet he is not troubled by
the fact that his revision of DDE excludes other natural applications which are
used as standard examples, such as the difference between using analgesics
which shorten life for the sake of easing pain and the use of the same or other
analgesics with the intention of shortening life. The grounds for regarding one
application as essential and others as dispensable are not clear.
4
In his famous discussion of killing in self-defense, which is widely regarded as
the first statement of DDE, Thomas Aquinas provides only one sentence by way
of justification of the distinction between intentionally harming and harming as a
side effect - the cryptic remark that "moral acts receive their species according to
what is intended" (Summa Theologiae, 2-2, q. 64, a. 7, trans, author). Neither he
nor the tradition elaborates this idea. But there is a hint within the more recent
tradition which points in the direction of the argument I begin here. This part of
the tradition does not sharply distinguish between justification and excuse, and
tends to express DDE in terms that suggest it to be a principle of excuse. That, of
course is a mistake (Boyle, 1980, pp. 529-530). But it suggests what is true and
important for the justification of DDE, namely, that the character of one's
responsibility for side effects is different from that for what one intends. It is also
worth noting that there is a deep, theological precedent for the distinction: part
of the Catholic solution to the problem of evil is that God does not intentionally
bring it about but only accepts it as a side effect.
5
The absolute prohibitions against intentionally harming persons which
characterize the Catholic moral tradition have been defended, and not simply on
the basis of a divine command theory (Finnis et ah, 1987, pp. 281-294). The
defense of these moral absolutes by Catholics does not presuppose moral
principles very different than those Donagan endorses (Donagan, 1977, pp.
57-66). For one natural interpretation of the Kantian principle of respect for
rational creatures implies that they never be intentionally harmed in certain
ways. Donagan's non-absolutist interpretation is not obviously better, and
requires an enormously complex and intuitive procedure for determining when
the norms prohibiting harming people at will are applicable (pp. 66-74).
6
I thank John Finnis, John Hartley and Elmar Kremer, who read an earlier draft
of this paper, and both corrected a number of mistakes and suggested improve-
ments. The main ideas of this paper are the result of countless discussions with
Germain Grisez; the justification of the DDE presented here emerged in one of
these discussions, and was first stated in Finnis et al. (1987, p. 292).
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