In simple terms, the principle of double effect (PDE) invites one "to treat situations of human activity within which one is forced to deal with the occurrence of both good and evil as results of a moral decision and subsequent action."1 Catholic moral theology guides the individual with the use of PDE to take decision in conflict situation where good effect and bad effect happens simultaneously in a human act. This principle is rooted in the moral grounds of object, circumstances, and intention. PDE can be applied to a lot of issues, namely, sexual ethics, bioethics, business ethics, social ethics, political ethics, media ethics, environmental ethics etc. There are moral theologians2 and philosophers who have discussed its relevance and scope in bioethics. However, basing on the theories of utilitarianism, teleology, proportionality, and personalism they questioned its relevance in bioethical issues. In this context, taking the issue of living organ donation and transplantation we try to discuss its relevance in bioethics. In order to come to our conclusion we present its origin, the four conditions, criticism, and finally the relevance of PDE.
Moral theologians have discussed the principle of double effect with regard to its origin, meaning and importance.3 There are different opinions about the origin of the principle of double effect. According to J. Mangan, the application of the principle of double effect had been seen many centuries before the formulation of its conditions. Some cases in the Old Testament (e.g., the story of Eleazar in 1 Machabees, chap. 6) seem to be justified by the principle. However, before Aquinas one cannot find definite form. The historical origin of the principle can be seen in Summa Theologica II-II, question 64, article 7.4 The four conditions of the principle are the work of the 16th and 17th century moralists. The final modern version of the principle is presented by Jean Pierre Gury in 1850.5 Another opinion is by J. Ghoos. In his view, double effect does not come from Thomas' treatment of killing in self-defence. He argues that the exact form of the principle is the work of John of St. Thomas (1589-1644) in his De bonitate et malitia.6
There are four conditions in the PDE. Today we can see different formulations of PDE. A classical version the PDE runs thus: "1) The act (directly) performed is in itself good or at least indifferent. 2) The good accomplished is at least as immediate as the evil. 3) The intention of the agent is good. 4) There is a proportionate reason for causing the evil."7 Bernard Hoose presents the conditions as: "1) the act is good in itself or at least indifferent. 2) The good end does not depend upon the evil effect for its accomplishment. 3) Only the good is intended by the agent. It is his or her reason for acting. 4) There is a proportionate reason for causing the harm (the bad effect)."8 R. McCormick writies: "1) The action from which evil results is good or indifferent in itself; it is not morally evil. 2) The intention of the agent is upright - i.e., the evil effect is not sincerely intended. 3) The evil effect must be equally immediate causally with the good effect, for otherwise it would be a means to the good effect and would be intended. 4) There must be a proportionately grave reason for allowing the evil to occur."9 According to J. Mangan, "1) that the action is itself from the very object good or at least indifferent; 2) that the good effect and not the evil effect be intended; 3) that the good effect be not produced by means of the evil effect; 4) that there be proportionately grave reason for permitting the evil effects."10
Apart from the different forms of the conditions, today the discussion of the PDE can be viewed from four perspectives.11 1) As an interpretation of Aquinas: There is a dispute among the scholars about the origin of the principle in the teachings of Aquinas.12 Many authors also argue that the original form of the principle of double effect by Aquinas is not physicalistically limited.13 2) As a tool for manualist casuistry: The PDE is taken by many moralists as a framework for physicalism in manualist casuistry.14 3) As understood within the proportionalist methodology: According to Knauer, the PDE is considered as the "fundamental principle of all morality."15 Hence, the last condition of PDE is the early source of proportionate reason.16 4) As defended in relation to the new natural law methodology: This takes the PDE for its use as follows: firstly, "as a principle based moral theory, the doctrine of double effect functions in a much broader action-guiding role than it will for virtue ethics." Secondly, the PDE is seen as the way of intentionality. Here intention justifies one's action.17
There are criticisms raised regarding the application of the PDE to some cases. Scholars have analysed the conditions of PDE. With regards to the first condition, i.e., the action must not be morally evil, many authors argue that the act in itself be morally good or at least morally indifferent.18 Joseph Selling observes that the first condition "is speaking about the occurrence of any evil and its meaning is to exclude the direct placing of an act containing some evil from the very beginning."19 The PDE can be applied to certain problems "where the doing of a good may result in a foreseeable evil." But it cannot be applied to some "cases where evil is done directly."20
The second condition concerns "the immediacy of the effects." There cannot be any causal relationship from bad effect to good effect. For instance, sometimes good effect (taking sperm for testing) "would be caused [or produced] by the bad effect" (e.g. masturbation: pleasurable emission of seed outside marriage, which is seen as evil).21 In the opinion of David F. Kelly, the first two conditions are two ways of saying the same principle that "the end does not justify the means."22 He says that "the first two conditions constitute the framework for an emphasis on the physical end or purpose of each human "faculty" or biological function, considered in itself."23 So a physicalist modality and its application can be seen in medical ethical issues, particularly in the application of the first and second conditions.24 For instance, the reproductive faculty must be taken to its primary physical or biological end.
Furthermore, J. Selling analyses the core meaning of condition 2: "If all effects (good and evil) are more or less simultaneous, one can proceed with the consideration of intention and answer simply whether that intention is focused upon the performance of the act itself or upon the causation of its effects."25 But there arises a problem in the case of sequence of effects, for instance, "when act causes effect 1 which in turn causes effect 2, and so on."26 Here, condition 2 reveals that the assessment activity is complicated. In this context, one cannot point out the "intention on act or effects." But one looks at "which effect may be aimed at" when the intention is not directed on the act. Hence, according to Selling, in this situation PDE does not suffice and one needs another norm for the assessment.27
The third condition states that the agent does not intend the bad effect, or the intention of the agent is good.28 D. K. Chan makes the difference between intention and desire. "Intentions are the output of practical reasoning. They are subject to norms that govern reasoning. It is a requirement of clear-headed reasoning that side-effects that are believed certain to occur are taken into consideration in one's deliberation, and included in the scenario that one chooses and intends to bring about. Thus, one's foreknowledge of side-effects can 'force' one to intend the side-effect in the sense that one can be criticized for irrationality in not so intending. Intrinsic desires on the other hand serve as inputs into practical reasoning. They are usually formed over time in the process of character development. Thus, rationality constraints that apply to intention, such as the requirement of consistency, do not apply to desires. Neither is one guilty of irrationality in not desiring an effect that happens to accompany an action directed at one's ends, even if one acts in full expectation that the effect will occur."29 Besides, J. Selling analyses the difference between intention and voluntary. According to him, "the intention of the agent refers to the reason for doing anything. It is the whole purpose of my acting or bringing about an effectÉThere can be one and only one intention, the goodness or badness of which is the primary consideration in determining morality."30 Voluntary means: "Everything which comes into consideration in our moral evaluation everything which is foreseen, can be said to be voluntary or the result of an act of the will. This refers to the performance of an act as well as any consequences which may flow from an act and of which one is aware."31
The fourth condition states that there should be an adequate reason for allowing the bad effect.32 This condition is known as the principle of proportionality.33 Our main question is whether the principle of double effect could be applied to the case of living organ donation and transplantation?
The PDE can be applied to moral problems when its four conditions are met.34 It is applied in the classical example of a woman with a cancerous uterus. In this case, "the act-in-itself (removal of the uterus) causes, with equal immediacy, the good effect (removal of the cancer and the woman's health) and the bad effect (loss of reproductive function)."35 Here the first two conditions of the PDE are met. Besides, "[p]resuming the woman do not delight in her loss of fertility (third condition), and accepting the due proportionality of effects (fourth condition), the procedure is justified and double effect 'applies.'"36 However, if a woman finds that it is a disadvantage for her from the view point of future pregnancy, then the PDE is not applicable in this case. In this second case the act-in-itself is similar, however, "the good effect (the woman's health) is caused by means of the bad effect (loss of the reproductive function)." Thus, the second condition of PDE is not satisfied, and it is not justified.37
Furthermore, Bruno Schüller and Franz Scholz say that the PDE relies on a strict explanation of deontological norms.38 The Catholic tradition applies the PDE to the deontological norms.39 Besides, H. Tristram Engelhardt observes that PDE is a one-sided and incomplete approach. It fails to give therapeutic and theological considerations for physicians and patients.40
Joseph Selling analyses the meanings of the terms direct/indirect, intended/unintended, willing/permitting in the application of the PDE.41 He observes that one should note the inapplicability of the PDE to "cases of capital punishment, imprisonment, disciplining children or civil or ecclesiastical censure etc." In addition, PDE is not applicable to mutilation because it is a direct evil, which is "outside its competence."42 For instance, Selling argues that the medical development in organ donation and transplantation highlights the inadequacy of PDE. Here the removal of an organ from the donor is mutilation, which seems to be a moral problem. He says:
Curiously, this case cannot be made to fit into any of the other categories and its justification as a benevolent, non-obligatory (heroic), charitable act has all bit removed it from being classified as a moral "problem". Yet we should insist upon its moral relevance. There are situations in which the direct bringing about of an evil can be justified, the situation which need not be forced to conform to the principles of double effect, totally, or the lesser of two evils.43
In the observation of David F. Kelly, some authors consider mutilation or loss of function as indirect. Here the result of the act-in-itself is determined as one of simple removing.44 However, many authors see the act-in-itself as direct mutilation. It is morally justified according to the principle of totality. "[T]he act has been specified in such a way as to include the mutilating aspect in the act-in-itself. Nonetheless, double effect applies to similar cases with slightly different act-specifications, and in this sense is still influential in the analysis of the procedure at issue."45
For Peter Knauer, the error of the PDE is its physical relationship between good and evil.46 Similarly, Cornelius J. Van Der Poel says that one of the major difficulties with the PDE is its stress on the "physical effect in the judgement about the moral value of the human action."47 For instance, in the case of organ donation and transplantation, some moralists prohibit it because it is a direct mutilation, even if it helps other persons. However, physical surgery is only a part of the whole action of the transplantation.48 It also has a social and spiritual aspect.
David F. Kelly explains the defect of the principle of PDE in the ethical debate on organ transplantation. He says that in certain cases the PDE is taken to allow the "non-sterilizing mutilations." The act is removing the part of the body which involves mutilation. So the first and the second conditions of the PDE are applied. But there is no clarity here as "the notion of intention of the agent was confused with the 'object,' or direct act-in-itself. Seldom, if ever, was there any complete explanation of how an operation to remove a limb, for example, was only 'indirectly' a physical (first two conditions) mutilation."49 Laurence J. MacNamara observes that new progress in the field of organ donation and transplantation brings a new understanding to the concept of the "moral act," especially with regard to the "direct or indirect" dimension of the act.50
Joseph Boyle, one of the proponents of the PDE, maintains its relevance in bio-ethics. He observes: "double effect teaches us to respect the good in our actions just as God does, and reminds us that a more stringent rule would be too high a standard."51 For him, the PDE has an essential role in the Catholic tradition and in non-Catholic applied ethics, especially in the case of the morality of warfare and medical ethics, viz., abortion, euthanasia, withholding treatment, etc.52
We argue that though some scholars find limitations and demerits of the PDE in its application to certain cases, especially to the case of living organ donation, by understanding the mind of the church regarding mutilation, motive of the organ donation, paid organ donation etc, one can adequately evaluate the principle of double and its application to living organ donation and transplantation.
The emerging question is this: since organ donation is a major mutilation, is living organ donation an evil act in the documents of the church? We can clarify this from Veritatis Splendour. Even though we do not find direct mention of living organ donation and transplantation in Veritatis Splendour (no. 80), direct mutilation is considered as an intrinsically evil act. According to Torraco Stephen, whenever the Magisterium speaks of organ donation it simply speaks about charity as the motivating force behind it. Until VS, the Magisterium has not dealt with the specific act of mutilation involved in organ donation apart from its intention and circumstances. And even in VS, there are only passing remarks.53 The morality of major mutilation is justified in terms of charity, and the supernatural virtue of charity transcends the natural principle of totality.54 The point of Torraco Stephen is that "there is an aspect of organ donation that can be extremely helpful in gaining a deeper appreciation of the meaning of the intrinsically evil."55 For him, organ donation becomes an intrinsically evil act when it leads to the reduction of a human person to a form of marketplace parts. He quotes the ideas of Reneé Fox and Judith Swazey. They describe the development of organ transplantation from 1950 to the present time. They mention the problem of the giver i.e., the donor is not able to see the donated organs as "not-me" or "not-mine." Another problem is the commercialization of human organs, which dehumanizes the human body.56
In VS we cannot find any direct mention of organ donation and transplantation, but reference to the term mutilation in the list of intrinsically evil acts leads many moral theologians to debate the concept of living organ donation and transplantation. We can say that VS is not against living organ donation and transplantation. This highlights that the first condition of PDE is not against mutilation in the case of living organ donation and transplantation. The first condition does not favour this act if mutilation leads to the death of the donor or to other malpractices.
Church always justifies organ donation and transplantation based on charity in general. In the address on blood and organ donations of August 1984, John Paul II commended the National Association of Italian Volunteer Blood and Organ Donors for their spirit and initiative. He urged them "to promote and encourage such a noble and meritorious act as donating your own blood or an organ to those of your brothers and sisters who have need of it."57 The donation of blood and organs is a sign of generous inspiration of the heart. It is, at the same time, human and expresses Christian solidarity. This means the love of neighbour, which is rooted in the Gospel message of the new commandment, i.e., "love one another" (John 13: 34).58 In addition, in an address to a Congress on Renal Illness and Transplants (April 30, 1990), he speaks about the Church's main concern for renal illness and donations. The Pope asks the directors of Catholic institutions to encourage this generous act of organ donations: "Those who believe in our Lord Jesus Christ, who gave his life for the salvation of all, should recognize in the urgent need for a ready availability of organs for renal transplants a challenge to their generosity and fraternal love."59 Further, in his address to the participants of the first International Congress of the Society Organ Sharing (June 20, 1992), the Pope considered organ transplantation as a new way of serving the human family.60 In organ transplantation man/woman has found a way to give himself/herself, in blood and body. This gesture allows others to continue to live.61
Organ donation, says John Paul II, is a free and conscious decision either on the part of the donor, or that of someone who legitimately represents the donor. It is also a decision of giving without any remuneration. Really, donation concerns the well-being of another person. And this sincere gift of self-giving expresses our constitutive calling for love and communion.62 This gift is actually an authentic form of human and Christian solidarity.63 Similarly, John Paul II writes in Evangelium Vitae no. 86 that organ donation is an act of love when it is done in an ethical manner.64 For him, the death and resurrection of Jesus Christ establishes the supreme act of love. This extends a deep meaning to the donor's offering, which is saving the life of another person.65 According to John Paul II, generally, love (charity) constitutes the main element in organ donation and transplantation, especially in the case of the organ donor.66
If we apply the four conditions of PDE to living organ donation and transplantation, it is very clear that PDE is not against living organ donation and transplantation with the intention of the virtue of charity. The act itself is a virtuous act. It is charitable, and the first condition supports it. The second condition of the PDE can be seen from the perspective of good and bad effect. The donation of the organs gives chances to mutilation. We can say that in itself it is a bad effect. This means the donor has to suffer, discomfort, he/she cannot go for work etc. However, these particular side effects are tolerable and donation does not lead to the death of the donor. The surgery will be cured soon. The good effect is that donor helps the receiver in his/her critical stage. The receiver gets new life. This gives a spiritual and psychological satisfaction to the donor. If we interpret in this way, there is the immediacy of the good and bad effects in this procedure. And the intentions of the donor and the receiver are good. The donor has always the intention to help the other, who is in a critical stage. He or she has a virtuous intention. Similarly, the receiver also has a virtuous motive i.e. the relationship between the donor and the receiver. The receiver is not purchasing the organ from the donor, but he/she receives a gift from the other, which is the gift of life. Besides the fourth condition also supports living organ donation and transplantation. One can find proportionate reason for causing the evil. For example, the donation of the organ does not lead to the death of the donor. The donation of a particular organ does not affect the functional integrity of one's body. Moreover, the 1994 Directives, section no. 30 directly deals with living organ donation and transplantation. It reads thus:
The transplantation of organs from living donors is morally permissible when such a donation will not sacrifice or seriously impair any essential bodily function and the anticipated benefit to the recipient is proportionate to the harm done to the donor. Furthermore, the freedom of prospective donor must be respected, and economic advantage should not accrue to the donor.67
Though there is a physical harm to one's body, the functional integrity of the body is preserved here. This shows that there is only a proportionate harm to the donor.
PDE cannot be applied in the case of paid organ donation and donation of reproductive organs. With regard to the paid organ donation, the act itself is not good. The reason is that commercialization has a serious negative impact on many of the medical and ethical values intimately connected with organ transplantation.68 There should be free and voluntary consent from the donor. Donors should be informed about the risks in transplantation. However, commercialization may not fulfil these fundamental norms in organ transplantation.69 In reference to blood donation, John Keown notes that paid donation makes of human body a property.70 It regards the human body as property in which one does not find the subjective dimension of human person. Again, he argues that "the morally undesirable form of exploitation is the use of people for our own ends in ways that are detrimental to those people and/or that fail to respect their own autonomy."71 In his opinion, voluntary donation can solve the demand, which promotes altruism and solidarity, and paid donation is not essential.72 In addition, R. M. Titmuss comments: "no money values can be attached to the presence or absence of a spirit of altruism in a society. Altruism, in giving to a stranger, does not begin and end with blood (or other organs). It may touch every aspect of life and affect the whole fabric of values."73 Basing on this we argue that the first condition of the PDE is against paid organ donation. Moreover, the intention of the agent is not to help the person but to get the money. In order to get the money, one mutilates himself/herself, and there is no proportionate reason for causing the evil.
Similarly the donation of the reproductive organs also is not justified by the PDE. In this case, we can say that the act itself is not good. And from the second condition it is clear, there is no immediacy of the effect. When one donates the reproductive organs, one looses the reproductive function. Never he/she can recover it. Destroying the anatomy and function of normal tubes is a mutilation and therefore wrong in its very essence. It is forbidden by the commandment: "thou shall not kill," which is an act against human body. However, indirect sterilization does not involve any ethical problem. The main aim of the operation is to treat pathology.
In this article we have discussed different aspects of the principle of double effect and its relevance in bioethics. Though the four conditions of the principle were later developments, the concept of PDE, which is biblical, is very ancient. Taking different moral issues, theologians criticise its relevance. But from our analysis it is clear that PDE is relevant in moral issues, especially in the case of living organ donation and transplantation. It is useful in complicated issues, particularly when there are simultaneous good effect and bad effect happening in a moral act. In this situation the four conditions help the individuals to take an adequate decision in their moral act. PDE also gives a clear picture about the nature of the object, means or circumstances and the intention. PDE justifies virtuous act. It is true from the issue of living organ donation and transplantation. However, PDE does not justify evil acts, for example, paid organ donation and donation of reproductive organs. This highlights its relevance in bioethics.