**6. Drugs double effects**

All medicines used in a treatment may cause unwanted symptoms. They are also called "adverse effects" or "adverse reactions". Side effects happen when a treatment causes a problem because it does more than treat the target issue. Side effects can range from mild to life-threatening conditions.

In end stage diseases, when symptoms like pain or breathlessness are a source of great suffering of the patient, the physician is compelled to prescribe powerful analgesics or sedatives and these medicines may cause an undesired double effect.

In case of an analgesic, besides alleviating the pain, they may depress the respiratory center and cause a respiratory arrest and ultimately the death of the patient.

A major doubt, at the light of ethical principles, is whether the double effect of a drug is acceptable or not?

The principle or doctrine of double effect, often abbreviated as DDE, is a set of ethical criteria which Christian philosophers, like Thomas Aquinas' in his work *Summa Theologica*, have advocated for evaluating the permissibility of acting when one's otherwise legitimate act (for example, relieving a terminally ill patient's pain) may also cause an effect that he would, otherwise, be obliged to avoid (sedation and a slightly shortened life) [11].

In his assessment, this set of criteria is justifiable if the following are true:

The nature of the act is itself good, or at least morally neutral.

The agent intends the good effect and does not intend the bad effect either to do good or as the end in itself.

The good effect outweighs the bad effect, in circumstances sufficiently grave to justify causing the bad effect, and the agent exercises due diligence to minimize the harm.

Resuming, the DDE is based on the idea that there is, morally, a pertinent difference between an "intended" outcome of an act and one that is foreseen by the actor but not deliberately planned to achieve his motive.

This doctrine has been criticized by the consequentialist, like John Stuart Mill, advocate of the utilitarian version of consequentialism. He argues that our moral analysis should ignore matters of motivation, which appeals to a distinction between intended and unintended consequences. In his opinion the scrutiny of motives will reveal a man's character, but utilitarianism does not judge character, only the rightness or wrongness of actions [12]. Thus, he concludes that the DDE should be rejected.

Analyzing and reflecting the DDE at the light of ethical principles, namely of beneficence and nonmaleficence, it is clear that there is a clash between the duty to suppress harm or suffering (do good) and, perhaps, the oldest of codes of conduct that reminds the physician that his main attitude towards the patient should be not to harm him (*primum non nocere*).

In my opinion, even in common jurisprudence there a clear distinction between intention and motive. The intention is the basic element for making a person

liable for the crime, which is commonly contrasted with motive. While intention means the purpose of doing something, motive determines the reason for committing an act.

If, there is no other way to suppress the suffering of the patient, than the prescription of an analgesic, should take in consideration the minimal dose to achieve the effect.

In this situation, it is my point of view that the procedure is morally acceptable even knowing that it might be a cause of respiratory arrest and death.

#### **6.1 Terminal sedation**

Terminal sedation, sometimes considered as an act of euthanasia, is a procedure wherein a patient is prescribed with a drug to induce sleep or unconsciousness until death occurs as result of the primary disease, while maintaining all other palliative medications. A typical example is a respiratory failure in end stage pulmonary fibrosis. In this stage, the breathlessness induces a suffering that a patient cannot tolerate. The only procedure is to sedate with a minimum effective dose that will induce the patient to lose his cognitive capacities but will preserve his organic functions. The drug prescribed has a short biological half-life. If, for any reason, the medication is brought to a standstill, the patient recovers in no time from his unconsciousness. Thus, this is not an irreversible procedure. Can this practice be considered as euthanasia? In my judgment it does not seems judicious to consider terminal sedation as an act of euthanasia.

### **7. Religious perspectives on end-of-life dilemmas**

Is there any special reason to include religious perspectives in a document on end-of-life ethical dilemmas? In other words, is there any space for religious overview in a field based in a scientific knowledge?

From my point of view there is every reason to entail religious perspectives in a reflection and discussion of end-of-life ethical dilemmas.

First and foremost, I will enumerate the arguments to entail religion in this discussion and in in a second section how the major religions overview these dilemmas.

It is evident that a human being has biological and cognitive functions. In an instance of biological suffering the response should come entirely from medicine, a science based on knowledge; however, in cognitive discomfort, the psyche also has a say.

According to Pew Research Center, 2015 in 2020, 98,1% of world population will be adherent of a religion, with Christianity with 31,2 and Islam with 24,1% occupying the first and second places, respectively (**Figure 1**).

These numbers display, in my opinion, that the religiosity of people cannot and should not be forsaken when analyzing the end-of-life ethical questions. On the other side, even unbelievers, atheists and agnostics can have spiritual concerns, a need in the human psyche to understand the ultimate meaning of our existence and values in life. Spirituality is intricately linked to religion. It is difficult to imagine someone professing a religion and not being spiritual, while the inverse is possible; it is not imperious for spirituality to be coupled to religion.

In mid-nineties, a new term, spiritual intelligence, was introduced by some philosophers, psychologists, and developmental theorists [13]. Spiritual intelligence relies on the concept of spirituality as being distinct from religiosity - existential intelligence. It is, therefore, reasonable to accept that in human suffering religion

**39**

*End-of-Life Ethical Dilemmas*

*DOI: http://dx.doi.org/10.5772/intechopen.93616*

to the bottom to understand the things.

principle of liceity of prescription [14].

of double effects.

**Figure 1.**

teenth century [15].

John Paul II) [16].

**7.1 Christian perspective**

stubbornness) [17].

living God, his Creator.

*7.1.1 The Roman Catholic Church*

important topics on end-of-life ethical dilemmas.

*World population 2015 by religion. Source: Pew research center.*

or spirituality and medicine are bound to intersect. To understand the concepts of ethics linked to the end-of-life dilemmas it is fundamental to question "Why?" Get

Another good reason to include religious perspective is the historical contribution that Catholic Church thinkers have given to the analysis and discussions of

In the previous section, we had a brief reference to saint Thomas Aquinas on his *Suma Theologica* when he advocated the intention, and not the result, in the doctrine

Almost seven centuries later, in 1957, Pope Pious XII in a speech addressed to anesthesiologists, accepted the proposition of double effects of drugs based on

Another important doctrine in end-of-life ethics, about the difference between ordinary and extraordinary means, was developed by three Spanish Dominican friars (Francisco de Vitória, Domingo de Soto and Domingo Báñez) in the seven-

Other thinking's of Catholic Church, namely regarding treatment stubbornness, were expressed in catholic Catechism and encyclicals (*Evangelium Vitae* by Pope

In the subset of this theme I will make a reference to the most practiced religions and their stand regarding end-of-life ethical dilemmas − treatment stubbornness,

According to the Catholic Catechism *"Discontinuing medical procedures that are burdensome, dangerous, extraordinary, or disproportionate to the expected outcome, can be legitimate; it is the refusal of "over-zealous" treatment*" (treatment

Regarding euthanasia the catechism says that an act or omission which, of itself or by intention, causes death in order to eliminate suffering constitutes a murder gravely contrary to the dignity of the human person and to the respect due to the

The position of Catholic Church in relation to nutrition and hydration through artificial means was clarified by Pope John Paul II when he stated that its

euthanasia, drugs double effects, and nutrition and hydration.

**Figure 1.**

*Bioethics in Medicine and Society*

ting an act.

the effect.

**6.1 Terminal sedation**

terminal sedation as an act of euthanasia.

view in a field based in a scientific knowledge?

the first and second places, respectively (**Figure 1**).

it is not imperious for spirituality to be coupled to religion.

**7. Religious perspectives on end-of-life dilemmas**

reflection and discussion of end-of-life ethical dilemmas.

liable for the crime, which is commonly contrasted with motive. While intention means the purpose of doing something, motive determines the reason for commit-

If, there is no other way to suppress the suffering of the patient, than the prescription of an analgesic, should take in consideration the minimal dose to achieve

In this situation, it is my point of view that the procedure is morally acceptable

Terminal sedation, sometimes considered as an act of euthanasia, is a procedure wherein a patient is prescribed with a drug to induce sleep or unconsciousness until death occurs as result of the primary disease, while maintaining all other palliative medications. A typical example is a respiratory failure in end stage pulmonary fibrosis. In this stage, the breathlessness induces a suffering that a patient cannot tolerate. The only procedure is to sedate with a minimum effective dose that will induce the patient to lose his cognitive capacities but will preserve his organic functions. The drug prescribed has a short biological half-life. If, for any reason, the medication is brought to a standstill, the patient recovers in no time from his unconsciousness. Thus, this is not an irreversible procedure. Can this practice be considered as euthanasia? In my judgment it does not seems judicious to consider

Is there any special reason to include religious perspectives in a document on end-of-life ethical dilemmas? In other words, is there any space for religious over-

From my point of view there is every reason to entail religious perspectives in a

First and foremost, I will enumerate the arguments to entail religion in this discussion and in in a second section how the major religions overview these

It is evident that a human being has biological and cognitive functions. In an instance of biological suffering the response should come entirely from medicine, a science based on knowledge; however, in cognitive discomfort, the psyche also

According to Pew Research Center, 2015 in 2020, 98,1% of world population will be adherent of a religion, with Christianity with 31,2 and Islam with 24,1% occupying

These numbers display, in my opinion, that the religiosity of people cannot and should not be forsaken when analyzing the end-of-life ethical questions. On the other side, even unbelievers, atheists and agnostics can have spiritual concerns, a need in the human psyche to understand the ultimate meaning of our existence and values in life. Spirituality is intricately linked to religion. It is difficult to imagine someone professing a religion and not being spiritual, while the inverse is possible;

In mid-nineties, a new term, spiritual intelligence, was introduced by some philosophers, psychologists, and developmental theorists [13]. Spiritual intelligence relies on the concept of spirituality as being distinct from religiosity - existential intelligence. It is, therefore, reasonable to accept that in human suffering religion

even knowing that it might be a cause of respiratory arrest and death.

**38**

dilemmas.

has a say.

*World population 2015 by religion. Source: Pew research center.*

or spirituality and medicine are bound to intersect. To understand the concepts of ethics linked to the end-of-life dilemmas it is fundamental to question "Why?" Get to the bottom to understand the things.

Another good reason to include religious perspective is the historical contribution that Catholic Church thinkers have given to the analysis and discussions of important topics on end-of-life ethical dilemmas.

In the previous section, we had a brief reference to saint Thomas Aquinas on his *Suma Theologica* when he advocated the intention, and not the result, in the doctrine of double effects.

Almost seven centuries later, in 1957, Pope Pious XII in a speech addressed to anesthesiologists, accepted the proposition of double effects of drugs based on principle of liceity of prescription [14].

Another important doctrine in end-of-life ethics, about the difference between ordinary and extraordinary means, was developed by three Spanish Dominican friars (Francisco de Vitória, Domingo de Soto and Domingo Báñez) in the seventeenth century [15].

Other thinking's of Catholic Church, namely regarding treatment stubbornness, were expressed in catholic Catechism and encyclicals (*Evangelium Vitae* by Pope John Paul II) [16].

In the subset of this theme I will make a reference to the most practiced religions and their stand regarding end-of-life ethical dilemmas − treatment stubbornness, euthanasia, drugs double effects, and nutrition and hydration.

### **7.1 Christian perspective**
