Causation and Ethics

According to the classical Doctrine of Double Effect (DDE), there is a morally significant difference between intending harm and merely foreseeing harm. Versions of DDE have been defended in a variety of creative ways, but there is one difficulty, the so‐called “closeness problem”, that continues to bedevil all of them. The problem is that an agent's intention can always be identified in such a fine‐grained way as to eliminate an intention to harm from almost any situation, including those that have been taken to be paradigmatic instances in which DDE applies to intended harm. In this paper, we consider and reject a number of recent attempts to solve the closeness problem. We argue that the failure of these proposals strongly suggests that the closeness problem is intractable, and that the distinction between intending harm and merely foreseeing harm is not morally significant. Further, we argue that there may be a deeper reason why such attempts must fail: the rationale that makes the best fit with DDE, namely, an imperative not to aim at evil, is itself irredeemably flawed. While we believe that these observations should lead us to abandon further attempts to solve the closeness problem for DDE, we also conclude by showing how a related principle that is supported by a distinct rationale and avoids facing the closeness problem altogether nevertheless shares with DDE its most important features, including an intuitive explanation of a number of cases and a commitment to the relevance of intentions.

In this new book Moral Dimensions, T. M. Scanlon (2008) explores the ethical significance of the intentions and motives with which people act. According to Scanlon, these intentions and motives do not have any direct bearing on the permissibility of the act. Thus, Scanlon claims that the traditional Doctrine of Double Effect (DDE) is mistaken. However, the way in which someone is motivated to act has a direct bearing on what Scanlon calls the act’s “meaning”. One particularly important kind of “meaning” that an act can have consists in the ways in which it is appropriate for various people to blame the agent for the act. So the book ends with an extended analysis of blame and blameworthiness. As anyone acquainted with Scanlon’s work would expect, the book is full of extremely valuable insights. The discussion of blame in the last chapter (122–214) is of especially great and lasting importance. In these comments, however, I shall follow the common practice of concentrating on the areas on which I disagree with the work that I am discussing. In particular, I shall defend the DDE against Scanlon’s attack. This attack has three parts: first, he argues directly against the plausibility of the DDE (18–20 and 56–62); secondly, he offers an explanation of why moral thinkers might have been misled into accepting the DDE (20–28); and thirdly, he offers an alternative account of the main intuitions that philosophers have adduced in favour of the DDE – by arguing that we can do justice to these intuitions without appealing to the DDE (28–36). I shall not have time to answer the third part of Scanlon’s attack here. 1 Instead, I shall focus exclusively on the first two parts of his attack. First, however, I shall comment briefly on the question of how the DDE should be interpreted.

This article initially discusses reasons why Freud researchers turn to critical realism since this is what led me to compare causality in the two traditions in the first place. Three arguments on causality follow. First, it is argued that Freud's analyses of unconscious processes merit closer attention by critical realists, focusing on the relation between causal unconscious processes and rationality, and causal unconscious processes and social change. It may be objected that this does not concern the discussion of causality proper, to which I would reply that what we consider to be causally efficacious ultimately is relevant to our conception of causality. The second argument, which is the centrepiece, outlines Freud's conception of causality, his idea of overdetermination (complication of causes) and his treatment of motives and reasons as causes. His notions of causality are compared to those of critical realism. Freud's idea of retroactive causality is discussed in relation to delayed causality in critical realism and the idea of disembedded space-time components. Finally, Freud's concept of determinism and the related concepts of repetition and chance are discussed and compared to ubiquity determinism in critical realism and the distinctions between causal and non-causal correlations and necessary and accidental sequences of events. While the first argument concerns presuppositions for the discussion of causality in psychoanalysis and its relevance for critical realism, the third concerns implications and/or applications of the two views on causality. It is my contention that the second argument needs to be placed in context of the other two in order for the two conceptions of causality to be understood adequately and most revealingly compared.

The concept of causality is changing as human knowledge changes. Causality as an abstract notion has been traditionally studied in the field of metaphysics in philosophy. The Greek philosophers understood the time causality as explanation in general (Aristotle, 350 B.C.). The search for causes was a search for first principles, which were meant to be explanatory. In the more recent philosophy introduced by (Newton, 1687) was causality connected with determinism. The current experimental science reveals the non-deterministic notion of cause, which has to be also taken into consideration. The introduction of probability theory into all scientific disciplines allows to formalize and mathematize the wider conceived notion of cause.

The doctrine of double effect (DDE) can have two different functions, permissive and restrictive. According to the first function, agents are exculpated from the negative consequences of their actions, consequences that would be deemed illicit were they intentionally chosen. According to the second, agents are reminded that they are responsible, albeit in a distinctive manner, for the foreseeable damages that flow from their chosen actions. Aquinas has standardly been credited with a permissive version of DDE. I argue by contrast (drawing on the treatment of this issue in my Thomas Aquinas on War and Peace, Cambridge University Press, 2017) that the permissive version results from a misreading of Sum. theol. II-II, q. 64, a. 7. Other texts in the same work indicate that he embraced a restrictive version of DDE.

BackgroundPalliative sedation and analgesia are employed in patients with refractory and intractable symptoms at the end of life to reduce their suffering by lowering their level of consciousness. The doctrine of double effect, a philosophical principle that justifies doing a “good action” with a potentially “bad effect,” is frequently employed to provide an ethical justification for this practice.Main textWe argue that palliative sedation and analgesia do not fulfill the conditions required to apply the doctrine of double effect, and therefore its use in this domain is inappropriate. Furthermore, we argue that the frequent application of the doctrine of double effect to palliative sedation and analgesia reflects physicians’ discomfort with the complex moral, intentional, and causal aspects of end-of-life care.ConclusionsWe are concerned that this misapplication of the doctrine of double effect can consequently impair physicians’ ethical reasoning and relationships with patients at the end of life.

One of the most commonly referenced ethical principles when it comes to the management of dying patients is the doctrine of double effect (DDE). The DDE affirms that it is acceptable to cause side effects (e.g. respiratory depression) as a consequence of symptom‐focused treatment. Much discussion of the ethics of end of life care focuses on the question of whether actions (or omissions) would hasten (or cause) death, and whether that is permissible. However, there is a separate question about the permissibility of hastening or causing unconsciousness in dying patients. Some authors have argued that the DDE would not permit end of life care that directly aims to render the patient unconscious. The claim is that consciousness is an objective human good and therefore doctors should not intentionally (and permanently) suppress it. Three types of end of life care (EOLC) practices will be explored in this article. The first is symptom‐based management (e.g. analgesia); the second is proportional terminal sedation as a means of relieving suffering (also referred to as palliative sedation or continuous deep sedation); and finally, deliberate and rapid sedation to unconsciousness until death (a practice we call terminal anaesthesia in this paper). After examining the common arguments for the various types of symptom‐based management and sedation, we apply the DDE to the latter two types of EOLC practices. We argue that aiming at unconsciousness, contrary to some claims, can be morally good or at least morally neutral in some dying patients.

That a single action may have two ‘effects’, one of which is intended and the other not, because it is somehow ‘outside’ the agent's intention, was famously asserted by Aquinas in his Summa Theologiae and has since been turned into a full-blown ‘doctrine of double effect’ by casuists and moralists. Elizabeth Anscombe, in urging a return to Aristotelian ethics, regarded the doctrine as important for showing up difficulties in consequentialism. So does ‘double effect’ have roots in Aristotelian ethics and action theory? Aristotle's account of ‘mixed actions’ in NE 3.1 seems a good candidate for its provenance. That account indeed plays in some ways a similar role. But a careful interpretation reveals interesting differences, as Aristotle is concerned, not with the rightness of the agent's intention and will, but with whether the agent does what he wants, whether the agent's action proceeds from within, and what this implies about the agent's character.

This introductory chapter discusses the book's framework about moral responsibility. It argues that if fundamental laws of nature have irreducible indeterminacies associated with them, then being morally responsible should not “hang on thread”, or that people should not give up their views of being morally responsible and deeply different from animal. The chapter presents some articulation on the concept of moral responsibility. It states that the conditions of applying this concept are completely compatible with accepting any of its specific options. Some of the important themes such as Harry Frankfurt's cases and the principle of alternative possibilities are also explained.

This paper examines the doctrine of double effect as it is typically applied. The difficulty of distinguishing between what we intend and what we foresee is highlighted. In particular, Warren Quinn's articulation of that distinction is examined and criticised. It is then proposed that the only credible way that we can be said to foresee that a harm will result and mean something other than that we intend it to result, is if we are not certain that that harm will result. The ramifications of this are explored. The paper concludes with a moral evaluation of a variety of cases that have harmful outcomes. It is recommended both that we abandon the doctrine of double effect and that we cease to describe cases with harmful outcomes in a dishonest way.

ABSTRACTDrawing on two primary publications, I attempt to demonstrate that Morgan’s analysis of fair play in the doping wars, the treatment-enhancement distinction and the use of what he has called ‘emotional-psychological enhancement’ lends significant support to (1) the calls for fairness and respect in anti-doping strategies (and I would add in particular for athlete’s rights); (2) the calls for moral evaluation of ‘psycho-doping’ and its inclusion on the banned list; and (3) the calls for the consideration of the doping problem being reflective of ‘…a deep moral malaise’ where we have mistakenly sought ‘…a technical solution for what is wrongly perceived to be essentially a technical problem’ (Morgan 2007, 177). Further, through this analysis of Morgan’s work, I add an exploration of an inversion of the ‘Doctrine of Double Effect’ from medical ethics for its potential application to consideration of criteria for the evaluation of both the treatment-enhancement distinction and the banned list.

This essay defends a version of the Doctrine of Double Effect (DDE) – the doctrine that there is normally a stronger reason against an act that has a bad state of affairs as one of its intended effects than against an otherwise similar act that has that bad state of affairs as an unintended effect. First, a precise account of this version of the DDE is given. Secondly, some suggestions are made about why we should believe the DDE, and about why it is true. Finally, a solution is developed to the so‐called ‘closeness problem’ that any version of the DDE must face.

Aquinas’ conception of causality, especially when associated to the notions of creation and nature, grounds his cosmology as presented in the Summa contra gentiles . Two theses are central to this cosmology. The first claims that the divine causality bestows order upon the world. The second in turn maintains that the set of stars, the heaven, rules and moves the sublunar realm, which necessarily occurs due to divine causality. There is therefore an articulation conceived by Aquinas between the two theses. To show this articulation is the aim of this paper. For this, I investigate how Aquinas understands and associates the notions of causality, creation and nature in such a way that it guarantees both divine creation and the operation proper to natural beings, among which stands out the heaven, which, in virtue of continuous locomotion, sets the condition for the actualization of beings’ potentialities.

In this paper, I try to show how the clash between two different types of ethical theory—consequentialist and nonconsequentialist—affects moral and legal arguments for physician assisted suicide (PAS) and euthanasia (E). I begin by presenting a three-step argument for the permissibility of PAS and E, and then examine two possible criticisms of this argument. In conclusion, I consider how the possible further consequences of permitting PAS are dealt with by proponents of the two ethical theories.

These recommendations have been developed to improve the care of intensive care unit (ICU) patients during the dying process. The recommendations build on those published in 2003 and highlight recent developments in the field from a U.S. perspective. They do not use an evidence grading system because most of the recommendations are based on ethical and legal principles that are not derived from empirically based evidence. Family-centered care, which emphasizes the importance of the social structure within which patients are embedded, has emerged as a comprehensive ideal for managing end-of-life care in the ICU. ICU clinicians should be competent in all aspects of this care, including the practical and ethical aspects of withdrawing different modalities of life-sustaining treatment and the use of sedatives, analgesics, and nonpharmacologic approaches to easing the suffering of the dying process. Several key ethical concepts play a foundational role in guiding end-of-life care, including the distinctions between withholding and withdrawing treatments, between actions of killing and allowing to die, and between consequences that are intended vs. those that are merely foreseen (the doctrine of double effect). Improved communication with the family has been shown to improve patient care and family outcomes. Other knowledge unique to end-of-life care includes principles for notifying families of a patient's death and compassionate approaches to discussing options for organ donation. End-of-life care continues even after the death of the patient, and ICUs should consider developing comprehensive bereavement programs to support both families and the needs of the clinical staff. Finally, a comprehensive agenda for improving end-of-life care in the ICU has been developed to guide research, quality improvement efforts, and educational curricula. End-of-life care is emerging as a comprehensive area of expertise in the ICU and demands the same high level of knowledge and competence as all other areas of ICU practice.