The Double-Effect Death-Spiral… and the Way Out!

Eamonn Clark

There are a number of pressing problems in Catholic moral theology, especially in bioethics. One of them is the right understanding of the so-called “Principle of Double-Effect,” (PDE) or whether this is really a legitimate principle at all in the way it is normally expressed. Now that Dr. Finnis has both parts of his series on capital punishment out, let’s put on our moralist hats and get to work.

I’ll spare you all the ins and outs of the history of the problem – Fr. Connery’s wonderful book on abortion in the Catholic moral tradition deals with this in some relevant detail – but will give you the gist of the recent discussions so that we can dive into John Finnis’ articles. I too will write in two parts, I think…

The 19th century saw the problem of “craniotomy” come up, and this is a decent and to me, most familiar way to dive into the problem of PDE. (Craniotomy is crushing the skull of an inviable fetus, in this case with an eye to extracting the child to save the mother.) Archbishop Kenrick of Baltimore wrote his morals handbook and forbade the operation, Cardinal Avanzini of Rome anonymously opined in favor (page 308-311) of the procedure in his journal (which would become the Acta Apostolicae Sedis), and Cardinal Caverot of Lyon (the city pictured above, coincidentally) petitioned the Holy Office for an official response. Needless to say, there was some controversy.

In response to Caverot’s dubium, the Holy Office (the precursor to the CDF) decided in favor of Kenrick’s position. But it did so cautiously, saying that the procedure “cannot be safely taught.” It did not exclude definitively the liceity of the procedure in itself.

Let’s fast-forward to today’s iteration of the old camps, of which there were and still are precisely three…

The “Grisezian” Position:

Doctors Grisez, Finnis, and Boyle were major proponents of the liceity of craniotomy in the 20th century and into the 21st. Grisez lays out his argument in several places, including in his magnum opus (entirely available online), The Way of the Lord Jesus. It is worth quoting the relevant passage in its entirety:

“Sometimes the baby’s death may be accepted to save the mother. Sometimes four conditions are simultaneously fulfilled: (i) some pathology threatens the lives of both a pregnant woman and her child, (ii) it is not safe to wait or waiting surely will result in the death of both, (iii) there is no way to save the child, and (iv) an operation that can save the mother’s life will result in the child’s death.

If the operation was one of those which the classical moralists considered not to be a “direct” abortion, they held that it could be performed. For example, in cases in which the baby could not be saved regardless of what was done (and perhaps in some others as well), they accepted the removal of a cancerous gravid uterus or of a fallopian tube containing an ectopic pregnancy. This moral norm plainly is sound, since the operation does not carry out a proposal to kill the child, serves a good purpose, and violates neither fairness nor mercy.

At least in times past, however, and perhaps even today in places where modern medical equipment and skills are unavailable, certain life-saving operations meeting the four conditions would fall among procedures classified by the classical moralists as “direct” killing, since the procedures in question straightaway would lead to the baby’s death. This is the case, for example, if the four conditions are met during the delivery of a baby whose head is too large. Unless the physician does a craniotomy (an operation in which instruments are used to empty and crush the head of the child so that it can be removed from the birth canal), both mother and child eventually will die; but the operation can be performed and the mother saved. With respect to physical causality, craniotomy immediately destroys the baby, and only in this way saves the mother. Thus, not only classical moralists but the magisterium regarded it as “direct” killing: a bad means to a good end.

However, assuming the four conditions are met, the baby’s death need not be included in the proposal adopted in choosing to do a craniotomy. The proposal can be simply to alter the child’s physical dimensions and remove him or her, because, as a physical object, this body cannot remain where it is without ending in both the baby’s and the mother’s deaths. To understand this proposal, it helps to notice that the baby’s death contributes nothing to the objective sought; indeed, the procedure is exactly the same if the baby has already died. In adopting this proposal, the baby’s death need only be accepted as a side effect. Therefore, according to the analysis of action employed in this book, even craniotomy (and, a fortiori, other operations meeting the four stated conditions) need not be direct killing, and so, provided the death of the baby is not intended (which is possible but unnecessary), any operation in a situation meeting the four conditions could be morally acceptable.”

We can see the attractiveness of the Grisezian position. It removes the uncomfortable conclusion that we must allow two people to die rather than save one. However, it simultaneously introduces an uncomfortable conclusion: that we may ignore the immediately terrible results of our physical exterior act in favor of further consequences of that act due to the psychological reality of our intention, in this case contingent on even further action (viz. actually extracting the child after crushing the skull – presumably, a surgeon may perform the craniotomy and then simply leave the child in the womb, thus failing to save either life).

Hold on to that thought.

The “Traditional” Position:

I put the word “traditional” in scare-quotes because it is the position which follows the cautious prohibition of the Holy Office, but it is not very old and is merely probable opinion. It is taken by a good number of moralists who are “conservative” and “traditional” in other areas. And it doesn’t have a modern champion the way Grisez was for the pro-craniotomy camp.

Folks in this school often make more or less good critiques of the Grisezian position, zeroing in on the lack of the appreciation for the immediate physical effects which flow from an external act. How is it that crushing a child’s skull does not equate with “direct killing”? It seems that such an action-theory, as proposed by Grisez, Finnis, and Boyle (GFB) in their landmark essay in The Thomist back in 2001, is utterly at odds with common sense. The plain truth then, is that craniotomy, just like ripping the organs out of someone healthy to save 5 other people, functions based on consequentialism.

This position, however, must bite two bullets. First, there is the sour prescription to let two people die when one could be saved. Second, it throws into confusion the topic of private lethal self-defense… Doesn’t shooting a person in the head also directly kill in order to save another’s life? GFB made this point in their Thomist essay, and, in my opinion, it is their strongest counter-argument. It pulls us back to the fundamental text in the discussion, q. 64 a. 7 of the Secunda Secundae, whence supposedly cometh PDE.

Hold on to that thought too.

The Rights-Based Position:

The final position for our consideration comes most recently from Fr. Rhonheimer, who seems to be at least in part following Avanzini. Basically, the argument goes like this… In some vital conflicts, like the problematic pregnancy at issue, one has two options – save one life, or allow two deaths. Everyone has a right to life, but in cases where we find acute vital conflicts, it sometimes makes no sense to speak of rights. The case in which a person in a vital conflict (the child) will not even be born is one such example. Therefore, while the child retains the right to life, it makes no sense to speak of this right, and so it does not bear on the decision of whether to perform an act which would end in the child’s death if it will save the mother.

Leaving aside the problem of the language of rights in moral discourse (see McIntyre’s scathing critique in After Virtue), we can simply observe that this is a position which does not evidently derive from virtue-ethics but is made up wholesale out of a desire to appease an intuition. Rhonheimer, as far as I recall, does not even attempt to integrate his position into the broader framework of moral theology. In sum, the damning question is, “Why precisely does acute danger to others and shortness of life remove the necessity to respect the bodily integrity/life of a person?” To me, it seems little more than an appeal to intuition followed by foot-stomping.

I credit Fr. Rhonheimer for making an attempt to present a different solution, and certainly, not all of his work is this problematic. But we are presently concerned with this particular topic. Anyway, I suggest that this is not a serious position for further consideration.

A Brief Synthesis

I recently wrote my STB thesis on moral liceity with respect to “per se” order, which is to say that those acts with “per se” order form the fundamental unit of moral analysis upon which the whole question of “object” vis-a-vis “intention” turns. I look at Dr. Steven Long’s truly excellent groundwork in his book The Teleological Grammar of the Moral Act, but I expose what I found to be some ambiguities in his definition and presentation of what exactly constitutes per se order. Skipping over all the details, let me quickly show how problematic the first two foregoing positions are and then give a rundown of the basic solution and its integration with respect to capital punishment. (It is Finnis’ articles on the death penalty which brought us here, remember!)

There are 3 dilemmas we have already mentioned: the central problem is craniotomy. At the two poles are the “transplant dilemma,” with one healthy patient and 5 critical patients in need of new vital organs, and the standard case of private lethal self-defense (PLSD), such as shooting a person in the head in order to stop his lethal attack.

The Grisezian position ably explains the craniotomy and PLSD. Nowhere – and I have looked pretty hard – do NNL theorists explore the implications of their action-theory (such as presented by GFB in their article) with respect to something like the transplant dilemma. One could easily appropriate the language of Grisez’s passage in TWOTLJ to accommodate such an obviously heinous action as ripping out the heart, lungs, kidneys, liver, etc. of a healthy man to save 5 others. (It should be noted that the individual’s willingness to give his body over to such an act, while good in its remote intention, is totally inadmissible. I think basically all Catholic moralists would agree with this.) To rip out the man’s vital organs could certainly be described as “reshaping the body” or something similar to Grisez’s description of craniotomy as “reshaping the skull.” After all, the surgeon need not intend to kill the man – he could simply foresee it happening in view of his means to save these other men.

GFB evidently miss the point in their Thomist article, as they claim a causal equivalence between craniotomy and procedures done on a person for that person’s own sake, on page 23: “It is true that crushing the baby’s skull does not of itself help the mother, and that to help her the surgeon must carry out additional further procedures (remove the baby’s body from the birth canal). But many surgical procedures provide no immediate benefit and by themselves are simply destructive: removing the top of someone’s skull, stopping someone’s heart, and so forth.” We can see, then, that the principle of totality is undervalued by GFB and those who follow them. Serious damage done to a person must at least help that person. Any help to other persons is secondary, and I would argue per accidens rather than per se… One human substance is always related accidentally to another human substance.

The traditional approach more or less throws the teaching of St. Thomas into a cloud of ambiguity. By stating that the craniotomy is illicit because of the directness of its physical causation, the language in q. 64 a. 7 becomes unintelligible. We have to see the whole thing:

“Nothing hinders one act from having two effects, only one of which is intended, while the other is beside the intention. Now moral acts take their species according to what is intended, and not according to what is beside the intention, since this is accidental as explained above (II-II:43:3; I-II:12:1). Accordingly the act of self-defense may have two effects, one is the saving of one’s life, the other is the slaying of the aggressor. Therefore this act, since one’s intention is to save one’s own life, is not unlawful, seeing that it is natural to everything to keep itself in ‘being,’ as far as possible. And yet, though proceeding from a good intention, an act may be rendered unlawful, if it be out of proportion to the end. Wherefore if a man, in self-defense, uses more than necessary violence, it will be unlawful: whereas if he repel force with moderation his defense will be lawful, because according to the jurists [Cap. Significasti, De Homicid. volunt. vel casual.], ‘it is lawful to repel force by force, provided one does not exceed the limits of a blameless defense.’ Nor is it necessary for salvation that a man omit the act of moderate self-defense in order to avoid killing the other man, since one is bound to take more care of one’s own life than of another’s. But as it is unlawful to take a man’s life, except for the public authority acting for the common good, as stated above (Article 3), it is not lawful for a man to intend killing a man in self-defense, except for such as have public authority, who while intending to kill a man in self-defense, refer this to the public good, as in the case of a soldier fighting against the foe, and in the minister of the judge struggling with robbers, although even these sin if they be moved by private animosity.”

Without launching into a critique of the Cajetanian strain of commentary which ultimately gave rise to the crystallized formulation of PDE which pervades most moral discourse on vital conflicts, I will again follow Long and say that the “rules” of PDE really only work if one already knows what one is looking for. In this respect, PDE is like the moral version of St. Anselm’s ontological proof for God’s existence – it is nice to have in a retrospective capacity, but it is not actually that helpful as an explanatory tool.

As we have seen, GFB take Thomas to mean that one does not “intend” to kill the aggressor, just as the surgeon does not “intend” to kill the child in the craniotomy. The traditional school does not have as clear of an answer – it seems forced to say, somewhat like Fr. Rhonheimer, that the rules just “don’t apply,” yet without a convincing explanation. After all, the principle of totality does not bear on the slaying of one person for the sake of another, even in the case Thomas addresses. Furthermore, because it appears that it is only due to the death of the aggressor that the attack is stopped, thus implying “intentional killing” as a means, how do we explain St. Thomas’ position?

We can note a few things in response. First, it is in fact not death which stops the attack initially – it is the destruction of the body’s capacity to continue attacking, which itself is the cause of death. The separation of the soul and body (which is what death is) need not be the chosen means or the intended end. In every single case, the aggressor is incapacitated before dying, and such incapacitation is what is sought. (This is at least part of what makes Finnis’ argument about “unintentional killing” in war plausible.) Second, the child stuck in the womb is a radically different kind of threat than the rational aggressor. Third, Thomas is quick to turn the discussion to public authority, as a kind of foil. All of this is quite significant and points to an answer.

To the first point… It is true that the private citizen can’t have the death of the aggressor as a goal, meaning, death can’t be what is sought as a means or as an end. He doesn’t need to do anything to the soul-body composite as such, he only needs to do something to the body’s ability to be used as a weapon.

To the second point… A gunman in an alley is a very different sort of threat than a child growing in the womb. There seem to be two classes of threats – non-commutative, and commutative. The non-commutative threats are those which result from principles not in themselves ordered towards interacting with the outside world, viz., the operations of which are without a terminus exterior to one’s own body. These would be the material principle itself of the body (the act of existing as a body), and the augmentative and nutritive faculties of the vegetal soul. So a person falling off a cliff, or a child growing in the womb, are not acting on the outside world… Threats which proceed from the animal or rational appetites, however, are indeed acting externally. The crazed gunman who is not morally responsible and the hired hand are both trying to do something to another person, whereas the child growing in the womb is not. So perhaps different kinds of threats allow for different kinds of defense.

To the third point… Without a full exploration of the famous “self-defense” article quoted above, Thomas is eager to explain that public authority can kill intentionally – evidently meaning it can be the end of one’s act rather than just the means. (“Choice” refers to means, “intention” refers to ends – they are only equivocally applied in the inverse senses in scholastic morals.) Here’s where it gets weird.

Because the soul-body composite is its own substance (a living human being), the act of killing a person (regardless of one’s psychology) destroys that substance insofar as the world of nature is concerned. (We leave aside the interesting questions of  the survivalism vs. corruptionism debate among Catholic philosophers.) It forms a per se act – that is to say, there is nothing further which can come from this action which will be per se an effect. This is because, as I argued in my thesis, per se order exists only within the substance chosen to be acted upon. Per se effects are those effects which necessarily occur in the substance an agent acts on which come from the agent’s act itself, given the real situation of the substance. So to destroy a substance necessarily ends the per se order. At the end of per se order there is the intended effect – such as debilitation (which is only logically distinct from self-preservation and therefore is not a separate/remote/accidental effect – what it is to protect oneself simply is to remove a threat) or death. Of course, this intended effect can itself be part of a chain of intended effects which function as means with relation to some further end. If I defend myself in order to live, but I want to live for the sake of something else (like acquiring wealth), then there is a chain of intended ends which function as means. The necessary process of moral evaluation, however, is to look for the per se case of action and examine whether it is rightly ordered in itself.

We have seen with the transplant dilemma that it is wrongly ordered to damage one innocent person’s body lethally with the good aim of helping many others. The answer to the craniotomy seems to be the same… The child does not have an unjust appetite, he has a rightly ordered vegetal/material appetite which is inconvenient to others, so he may not be attacked, unless that attack also proportionately helps him and is chosen in part for that reason. (Such a case might really exist – for example, an inviable fetus is causing the womb to rupture… It’s foreseen that delivering the child will both save the mother and allow the child to live longer than he would have otherwise, even though exposure to the outside world will be the cause of his death. It certainly seems that this would be permissible given the principle of totality.) Finally, we reach the case of PLSD… There is no principle of totality at work here, even though the intended effect of self-preservation is immediately achieved with the debilitation which causes death. Rather, the normal rule of totality is indeed suspended. This is because of the kind of threat which the aggressor poses – it is a threat to the commonwealth due to a disordered external appetite.

Because “it is natural to everything to keep itself in ‘being,’ as far as possible,” and “one is more bound to take care of his own life than another’s,” it stands to reason that in a case in which there is public disorder due to the external act of a person, that person becomes the rightful recipient of correction at the hands of those whom he threatens, without his own good being a barrier to protecting the good of oneself or the community. The blows to the aggressor, we can see, actually help him – they keep him from being a bad part of society. And the private citizen’s duty is indeed to protect the commonwealth insofar as he is a part… This would include a kind of “natural delegation” to dispense with individual totality for the sake of communal totality – he is at liberty to risk the good of the one person (while, remember, he actually does something good to the aggressor by rectifying his disordered exterior act) for the sake of the commonwealth. The private defender may not try to kill the aggressor, but he may knowingly cause it with no benefit to the aggressor beyond keeping him from being harmful. Even though death is a per se effect, the defensive act is legitimate – the private defender acts like a miniature public official in this urgent situation, without psychologically taking death itself as an end.

This plugs in very nicely with Thomas’ vision of capital punishment… Stay tuned for part 2, though I’m sure a lengthy tome like this won’t be too necessary, given that a response from Dr. Feser is likely forthcoming, due in no small part to having been called out personally by Dr. Finnis.

Interesting times indeed.