October 1995 XVII/2
"NO GREATER LOVE"
Anyone familiar with medical ethics is aware of the principle of double effect. The example used most frequently to illustrate this principle concerns a woman who is pregnant, but is also found to have a cancerous uterus. May the woman undergo therapy to remove or suppress the cancer, even though the infant in her womb may die as a result of the therapy. The answer to this question is in the affirmative. The woman, with the help of medical personnel, seeks a legitimate goal, namely to prolong her life. She intends to overcome the cancer and seeks therapy. Usually surgery or chemotherapy will accomplish this goal. As a result of surgery or chemotherapy, the fetus dies. The death of the fetus is an unintended effect and therefore not morally culpable. The death of the fetus is not desired but cannot be avoided if the mother is to overcome the cancer.
Recently two pregnant women with cancer dramatically reversed this scenario. Both women, knowing their lives were in danger, decided to forego cancer therapy until after their babies were born. They both died shortly after giving birth. Whether they would have died within a short time, even if they had undergone radiation and chemotherapy immediately, is not the issue. Rather the main issue is that their children were saved as a result of delaying therapy.
In 1993, Barbara Barton was given two pieces of news. (1) She was pregnant with twins, and also had chronic granulocytic leukemia. Her best chance to live, the doctors told her, was to start aggressive cancer treatment immediately, which would result in an indirect abortion of the fetuses. Mrs. Barton postponed the bone marrow transplant to protect the fetuses. Carrying the pregnancy to full term would mean she would have little chance of survival herself. A friend stated: "She saw the babies as a sign. The babies meant more to her than anything." The twins were born on July 13, 1994. A few weeks later, Barbara developed a fever, indicating her disease had worsened. Seven months later, after undergoing bone marrow therapy, she died.
The case of Clemintina Geraci Winn is similar. (2) Three months pregnant, doctors told her that her cancer was spreading. She could fight the cancer aggressively, causing the death of the baby, or take less hazardous drugs and carry the baby to term. She choose the latter course. By the time she gave birth the cancer had metastasized throughout her spine, liver and brain. Clementina spent her last days making video tapes for her son to watch as he grows up. On the tapes she told him about their Italian grandparents, about her favorite music, about her dream for him. She died March 6, 1995, at Washington Hospital Center, and her four month old son slept peacefully as she was buried a few days later.
From an ethical perspective, both women had a choice between two goods. Either they could seek to prolong their own lives through cancer therapy which would result in the death of their babies, or they could prolong the life of their babies by foregoing cancer therapy until the babies were born. Both goods, prolonging their own lives and preserving the lives of the babies could not be accomplished simultaneously. A choice of one good over the other had to be made. The choice they made resulted in their own deaths. Was this an actual or implicit choice of suicide? Were they doing something evil to achieve a good result? In order to understand clearly the nature of the moral options open to the two women, let us examine more closely the moral reasoning known as the principle of double effect.
Often we choose to do something morally good, which results not only in the good which we intend, but also in a harmful result which we do not intend. The harm results because we cannot achieve both goods at the same time. If possible, we would avoid causing the harmful result, but it is so closely entwined with the beneficial result, that the beneficial result cannot be accomplished without causing the harmful result as well. Because the harmful result is beyond our true desire, it is not intended, that is, it is not freely chosen. Usually, the unwanted effect is foreseen. Thus, the women in question knew they were shortening their own lives. To intend this, with full freedom and deliberation would be morally wrong. It would be choosing suicide. But they were not morally responsible for shortening their lives because they had no alternative once they decided to choose the good of prolonging the life of their babies.
A clear example of double effect is depicted in the play, A Man for All Seasons by Robert Bolt. (3) In 1535, Sir Thomas More is commanded by King Henry VIII to swear allegiance to the King as religious head of the Catholic Church in England. If he refuses he faces death. More has two goods he would like to preserve; his own life and allegiance to the Pope as head of the Church. But given the command of Henry VIII, he cannot achieve both goods. After much soul searching, he refuses to take the oath and is beheaded in the tower of London. In a way, he is responsible for his own death, because he chose a good that was not compatible with prolonging his own life. But his own death was not something he chose directly. It was a foreseen but indirect result of the choice of a greater good; being true to his religious faith.
The principle of double effect underlies the manner in which we are able to live with the moral decisions of every day life. For example, many people are opposed to excessive military spending. When they pay their taxes, which they realize is a morally good action, they know that a portion of their taxes will be devoted to military spending. Should they refuse to pay their taxes foreseeing that much of the money they contribute to the common good will be used for purposes which at best or morally questionable? No, it is possible for them to express disapproval of this use for their taxes, thus making it clear that the use of tax money is beyond their direct intention when they pay their taxes. The various good causes to which their taxes will be directed are the direct intention of their effort. Notice this is not a case of "doing more harm than good." Rather it involves expressing a distinct division between what is intended directly.
Some object to the moral analysis known as double effect, maintaining that if one knows a harmful effect will result from one's actions, then one is morally responsible for that effect. This viewpoint does not appreciate the power and meaning of intention in human affairs. It is possible to be the physical cause of a result but not the moral cause of the same result. Only if the choice of the evil is direct are we morally responsible for an evil result. The opponents of this double effect analysis of human action often neglect to speak about the good that is truly intended and to which the harmful effect is inextricably connected. Moreover, they do not differentiate between being a physical cause of a particular result and being a moral cause of a result.
Reflecting upon the actions of Barbara and Clementina, we are struck by the generosity of these two women, and the depth of love that motherhood engenders. In our materialistic world, where "everything has a price," it is edifying to reflect upon the depth of a mother's love. Each person has a strong natural desire to prolong life. But the love of these mothers for their children led them to sacrifice their own good, for the good of their children. What motivated each mother to determine that prolonging the life of her child was a greater good than prolonging her own life? Reading the accounts of their last days, it seems that neither woman ever "explained" her actions. Thus, there was not a rigid logical reasoning process which led either one to forego aggressive cancer therapy in order to protect the life of the babies. Clementina's husband, David Winn, said he expected nothing else from his wife: "She did it because it was the right thing for her to do." As Barbara died, a friend stated: "She was very matter-of-fact and didn't shed a single tear. The best made decisions arise not only from a reasoned analysis of what is "right" in the ethical sense, but also from a love of the good. As Thomas Moore stated when his daughter declared that it would be unreasonable for him to be witness to the truth if it would result in his death: "Finally Meg, it's not a matter of reason; finally, it's a matter of love.
Kevin O'Rourke, OP
1. "A Mother Sacrifices Life so Twins Can be Born," New York Times, February 9, 1995.
2. "Cancer Fells Woman Who Saved Son," Washington Post, March 14, 1995.
3. Robert Bolt. A Man For All Seasons, Vintage Books, 1962.
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