Double effect, in the bathtub.

Jennifer Fitz, as part of a longer discourse on lying, offers a novel explanation of the principle of double effect.  I think it's very approachable (and as far as I can tell, accurately represents Church teaching) so if this oft-misused principle has ever confused you -- please, check it out.

Hint:  The principle of double effect is not just a way of saying, "We can do something bad if we can think up a good enough reason."  Money quote:  "That's the clincher of double effect -- there are two effects."

Double effect (also called “parallel effect”) is actually one of the two principles that work together to keep our moral system sane.  The other is ‘ends don’t justify the means’, but that isn’t our topic today until way down below where I go out on a limb and guess things.  Back to Double Effect:

#1 Reason to love Double Effect: It lets you take a shower.

Because here’s what: Showers and bathtubs are super dangerous.  You could slip and crack your head open. And if the bathroom weren’t bad enough, you probably keep a stove and a water heater around the house, and perhaps even some kind of Vehicle of Death in your garage.  (Or, if you are a Luddite, a Pack Animal of Death for your transportation needs.)

Double effect says that you are allowed to have all this and more!  Because you aren’t actually trying to drown, scald or maim anybody.  Those are unintended consequences of your perfectly reasonable efforts to stay clean, fed, mobile, and so forth.   You’ll try to avoid those bad effects if you possibly can.

[What you can't do: If your enemy fails to drown in his bath, you can't hold him under.  In fact you can't even lay out the bath things and light a scented candle in an effort to lure him to his death.  You may only lead him to the tub for a legitimately good reason, such as to reduce the general stinkiness and discourage the spread of impetigo.  Or perhaps so that he might unwind after a long day driving. you. crazy.  But not to kill him. Barring circumstances we'll get to down the page.]

So that’s the use of double effect.  It lets us do something good, even if there is a some risk of something bad happening in the process.

Now unless you suffer from deep scruples, you probable don’t lay awake nights wondering if your really did the right thing, caving in and buying a water heater.  So where double effect gets famous is because it permits seriously dangerous action if there’s a genuine need for it.

You may not, for example, throw yourself in front of a bus in order to get that drat fly at last. (Even though the fly is germy and annoying, and you only want to give your beloved a peaceful picnic.  Good cause, good action, but the risks are disproportionate.  It’s a no-go.  Hope the bus gets the fly, and live to swat another day.)  But if it is to push your hapless child out of harm’s way, yes you may take the risk of your likely death in order to save the child.  You aren’t trying to die.  You hope to avoid dying.  Everyone will be much happier if a guardian angel steps up and takes care of things.

And that’s the clincher of double effect — there are two effects: There is one thing good you are trying to achieve, and one bad bad you hope to avoid. Even if the bad effect is 100% likely barring supernatural intervention, you can’t be trying to achieve the bad effect.

There's more -- go read the whole thing.  I think Jennifer's explanation is really helpful.  Double effect is a seriously hard-to-understand principle.  I think that's because there's a long separation in logic, and usually time and distance, between convincing yourself in the abstract that the principle of double effect is correct and morally right (which isn't so hard), and many of its applications, which can sometimes seem convoluted and (shall I say it?) jesuitical.    To navigate some of these situations, it's like you have to wander through a long, twisty tunnel.  At the beginning of the tunnel, the principle of double effect is well understood.  At the end of the tunnel, you see the conclusions it leads to.  The principle goes with you through the long, twisty tunnel, your only source of light, and it remains true all the time, but once you get to the end sometimes the conclusion is surprising and hard to understand.

Take one example:  the end-point of Catholic moral theology with respect to ectopic (tubal) pregnancy.  We wind up with what must seem a very bizarre conclusion:  

• A persistent ectopic pregnancy creates a life-threatening disorder from the point of view of the mother.  
• Yes, the out-of-place and growing embryo is a human being who deserves our protection. 
•  No, that doesn't mean that the mother doesn't get medical treatment, because she is also a human being who deserves our protection.  
• So yes, she can seek treatment for it, treatment which will end the pregnancy and inevitably kill the embryo.  
• But (assuming the mother wishes to remain true to Catholic moral understanding of life issues, and understands all this) she won't choose to use the drug methotrexate to end the pregnancy by killing the embryo, even though it is first treatment choice of many doctors and is probably physically the least dangerous option that doctors offer her, 
• and it may be she won't even choose the least-invasive surgical method, salpingostomy (incision in the fallopian tube) followed by killing the embryo by removing it and its amnion;
• but she can choose salpingectomy, which is the removal of the section of fallopian tube containing the misplaced embryo, 
• even though that removal inevitably results in the death of the embryo,
• which we knew all along was going to happen,
• and even though it would be objectively physically safer for the mother to undergo methotrexate or salpingostomy,
• and even though the salpingectomy will likely damage the mother's fertility.

I mean, if you don't have any understanding of the principle of double effect, this sounds nuts.  Even if you do have an understanding of the principle of double effect, it might still sound nuts.  You have to sit down and take time to connect all the dots to figure out how we got from here to there, or why it matters that we prefer one option to the other when the end result is a no-longer-in-danger mother and a dead embryo for all of them, and especially why "but the salpingectomy is more dangerous!" isn't a good enough reason to use one of the other methods, considering that the embryo is dead either way.

And yet, this is where double effect, properly understood, gets you.  If it isn't obvious, why not head over to Jennifer's blog and see if you can make the connections between her bathtub assailant and the unfortunate ectopic pregnancy problem?  If nothing else, the exercise illustrates why it's important for ordinary Catholics who desire to follow Church teachings -- whether they understand them or not -- to be confident that their local Catholic hospital faithfully follows it, and why the bishops have to guard that confidence even if it means getting bad press.

 

(UPDATE.   Edited slightly to avoid implying that salpingostomy is definitively considered illicit.  See first comment.)

Comments

[bearing]

(I should add that it is my understanding that there is some debate among orthodox theologians, who all recognize that methoxetrate treatement is illicit, about whether the middle-ground salpingostomy route is permissible or not. I happen to be convinced by the more morally conservative line of reasoning, and I trust I'd remain true to it if I ever were in the sad situation of having to deal with an ectopic pregnancy.)

[Jennifer Fitz]

Bearing, you a braaave lady bringing up ectopic pregnancy.

One thing I am unclear on: For the longest time, I was fairly certain that preterm live delivery, even so early in the pregnancy that the baby could not possibly survive, was a legitimate choice for proportionately serious reasons. (Such as certain death of the mother otherwise).

During the great Pheonix Hospital debates, someone told me that no, this was not a morally acceptable choice per the Church. (But, said by a person who disagreed with the church on that point.)

I would be interested to hear from someone who is knowledgeable on that particular question.

[Charlotte (Matilda)]

I tried to email you but it bounced back. I have a question regarding counting calories. Could you email me?
Thanks!

[bearing]

Jennifer, I consider this post not really about ectopic pregnancy, but more about the principle of double effect and the strange places it seems to lead us. I get tired of examples involving busloads of orphans crossing train tracks.

I'm unclear on that same thing, the preterm delivery, too. It's obvious that a baby may be delivered one week early for a proportionate reason. Two, six, ten weeks early... I don't see why there should be a bright line. (Let's assume hypertension or pre-eclampsia, something that is expected to get worse as the pregnancy progresses...) My thought is that you carefully monitor both baby and mother and do your best to take care of both, only acting when one of them reaches a critical point. Assuming the mother both wants the baby to live and wants herself to live, I think it would be safest to give her the best information possible about her condition and let her call the shots. I mean, that's what I would want if I were the mother.

[Delores]

Well... on ectopic: I have had 2.

The first one was while we lived in Abu Dhabi. I had never heard of one and it was hard to diagnose and they were not sure (at first) but all I was told was this: the baby CANNOT live, and I could very easily die. And I also knew that the Muslim country would not perform an abortion unless it were necessary. Well, at least I trusted that at the time. We were not catholic at the time. Eventually there was just too much concern, they went in and saw it was there and removed it. I have no idea how, other than that I kept my tube.

Which led to ectopic #2. We thought it might be, but were unsure and just waiting it out. That was a horrible time and we were catholic and I was just so unsure. But, the tube ruptured, so there was no real choice in the matter. In a way, to me the baby was already dead; but I could still live. I guess I feel like the decision was made for me.

But looking back on those two instances I realize how little 'moral theology' I had at the time. Would I have acted differently? I doubt it. I have always understood it that the ectopic baby will never live, so it is not like killing it; it is simply preserving the life of the mother -- they are doing good, but no harm. Perhaps I am oversimplifying, and I could easily be wrong.

For me the issue gets more fuzzy with situations like uterine cancer discovered when a woman is pregnant.

[bearing]

Delores, that's exactly why we need to be able to trust that our Catholic hospitals are on board with Church teaching -- because when an ordinary layperson seeks medical care, if they choose a Catholic institution *on purpose*, they should be able to trust that the staff will give them all the information they need, and that they will not violate the sanctity of life. (As a matter of medical ethics, I absolutely think it's fair, if there is a procedure that Catholic hospitals won't do for moral reasons, to explain that they don't do it and why. Ultimately it is the patient who makes the call whom to seek treatment from.)

Anyway, it is difficult to see why one leads to the other, although my experience has been that sitting down and thinking through it, the connections make sense.

Re: deadly uterine cancer discovered when a woman is pregnant, I was under the understanding that hysterectomy is permitted in that sad situation. You may remove the uterus to save the mother -- that's double effect -- but you can't schedule an abortion on Monday and a hysterectomy on Tuesday. So in a way it's not fuzzy at all, at least in the abstract. From the P.O.V. of the mother, of course -- who has the right to decide whether to risk her own life, as she may freely choose to do (cf. St. Gianna Beretta Molla) or whether to save it at the cost of her child's life, as she may freely choose to do -- it is not abstract at all....

[bearing]

... but about the procedure you had done in Abu Dhabi, like I said, as far as I know there is debate about whether the tube section has to be removed or whether the embryo can be removed licitly in that circumstance. (Certainly if the embryo is already dead it can be removed however works.)

[Delores]

But then I ask: what is the ultimate difference? If the tube is removed, the baby dies; if the baby is removed another way, the baby dies. Am I theologically incorrect in thinking along those lines? I would never support the drug-kill method, I guess that seems too direct.

I am guessing I had the salpingostomy since I kept my tube -- I was obviously unconscious at the time, and I don't think they asked my husband. My Dr. was a devout Muslim woman, assisted by her devout Muslim husband, and I guess I always figured (like I said) they would not do anything to harm a baby.

Curious: has an ectopic pregnancy ever been saved?

[Robin]

No fluff here; no sir. That's what I love about this blog.

My 14 yo loved the double effect explanations. And I'm still pondering the ectopic give drugs/take the baby/take the tube solution.

[bearing]

Another thing that I think can give some clarity about double effect is to stop focusing on all the people who could be suffering harm from the actions under consideration -- that is, to stop focusing on the ill pregnant woman and her baby, to stop focusing on the orphans on the train tracks or the assailant in Jennifer's bathtub -- and instead focus on the agent, the one who is actually on the point of DOING the critical act -- the one whose will ultimately has to decide to pull the trigger, throw the switch, prescribe a drug or wield a scalpel. They too have choices to make. Assume he does not consent to directly harm an innocent person. *Assume that one who intentionally harms an innocent person is himself grievously harmed* by taking that action. Look at it from the p.o.v. of the *doctors* of the ill pregnant woman, for example. If you assume that they harm themselves by the act of killing an innocent, and that they have a right to refuse to do it, does that clarify things at all?

[Delores]

Great point, Erin. So for the doctor, it does make a difference.