Morphine: too much or too little

In my Tuesday, November 25 blog, I detailed my opposition to physician-assisted suicide.  Lively and interesting comments followed with a broad range of views and observations.  A few of the comments reflected some misunderstanding of basic concepts in hospice and palliative medicine.  Therefore, in the spirit of encouraging erudite and engaged conversation, I present here the definition of a key concept, The Principle of Double Effect.

Whatever one’s beliefs about end-of-life and suicide, all can agree that pain control is vital.  Physicians have been accused, and rightly so, of being hesitant to give adequate doses of medications, especially narcotics.  Patients are equally guilty of resisting pain control, often because of false beliefs regarding side effects.  As a result, even though we all know pain control is important, there are times when it is not achieved.

It is true that the higher the dose administered of a pain medication, the more likely serious side effects.  While most of the time pain medications are safe and can be given with a minimal risk at very high doses, such as might be used in a patient with advanced cancer, it is possible for narcotics to cause drops in blood pressure, decreased breathing and can, rarely, lead to death. The balance between the benefits of narcotics and their side effects is important to understand and is at the core of the Principle of Double Effect.

First, written 850 years ago by St. Thomas Aquinas in the sentinel work of philosophy, Summa Theologiae, and nearly universally supported by Western ethical theory, The Principle of Double Effect, as it relates to pain control, says; if the Primary Goal is to control pain, if there are side effects, even death, then the treatment is morally and ethically acceptable.  In other words if a patient is dying of head and neck cancer and is in horrible pain, and if in order to control the pain it takes so much narcotic that the patient’s breathing is reduced that, while sad, is ethically acceptable.  However, the reverse may not be acceptable.  Many doctors, patients and philosophers would say that leaving a person with horrible pain to suffer in order to avoid using narcotics is unacceptable and unethical.

It is critically important to understand the difference between death from narcotics, which might occur under the Principle of Double Effect verses death from euthanasia.  The goal of a narcotic (or other treatment) under Double Effect is to allow the patient to live without pain.  Thus, the primary action is to provide a good, to heal suffering.  The primary goal of a narcotic (or other treatment) as used for euthanasia or physician assisted suicide is to kill.  In the first case, harm is rare and not the intent, in the second death is the intent and happens every time.

Particularly in palliative or hospice care, we must be aggressive as needed to control pain.  The Principle of Double Effect allows doctors, families and patients to focus on that which is most critical, quality of life.  It is a paradox that when we fail to provide aggressive comfort care, untreated suffering makes patients literally, “want to die.”  It should always be our goal to control pain and thereby make it possible to live.



  • Kristine
    Jim, this is an excellent explanation of a complex ethical principle. As a Catholic Clinical Ethicist, explaining the difference between achieving appropriate pain control and euthanasia to patients, families, and often physicians, is something I do on a regular basis. Thank you!
  • Liz
    Perhaps, the Double Effect is more about the quality of the process of dying? Liz
    • James Salwitz, MD
      Absolutely. Double effect helps give the freedom to provide treatment to live life well during difficult times. jcs
  • [...] Morphine: too much or too little Share this:EmailMoreTwitterFacebookLinkedInTumblrGoogle +1DiggPinterestRedditStumbleUponLike this:LikeBe the first to like this. [...]
  • [...] I just read two very insightful posts that Andrew of posted/reblogged.  The first was under the heading “Why not choose death” and the second “Morphine too little or to much?” [...]
  • D Someya Reed
    I disagree that this is a complex ethical principle. It is merely justification based on the intent of the giver. What I find extremely troubling is that I have discussed it with countless hospice workers, including RN's and across multiple states and not one has claimed to have ever heard of it let alone define it. In an industry where it would most likely be used and/or abused, why are there so many who claim to have no knowledge of this? If they honestly don't know then do we have the right people staffing this industry? Incidentally, the most common response among hospice workers about morphine (Roxanol, liquid form)..."You cannot give too much morphine" and "It's a myth that morphine affects blood pressure or breathing."
    • James Salwitz, MD
      I think this area of healthcare has indeed expanded so fast that we are lagging in education and training. It is something we really need to push. With the movement of many nurses to become APN certified in HPM, it should help. jcs
  • You have no idea of the mental suffering a person goes thru for months and even years when they are bedridden, have no life and just want the suffering (mental as well as physical) to end. There is no way can anyone can know beyond a doubt that meds will alleviate the pains, exhaustion & suffering that a person goes thru knowing they are dying (at least not until you yourself die). My father and my spouse going through this has proven to me that all doctors and so called Christian beliefs about just making them comfortable is a total lie. The no euthanasia stance is just another way for medical professionals to make more money (if not then do it for free lol) & belivers to play God by thinking "they" know what or how a dying person feels. No one knows what God wants and to say you do is being totally blinded by your own personal beliefs (you to think you are God). We as Gods creation have been given the ability to take care of the matters in front of us and to have compassion for other people's suffering and yet we do not use what God has given us to improve the suffering people are going thru during the dying process. If we do not use this knowledge then maybe we should quit using our abilities (medical) to stop any suffering as that is not what God wants. Why do interfere with Gods plans for us when we get a common cold. This is just so much bull (everything done is either for money or recognition of how smart people think they are - including this blog

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