Intended for healthcare professionals


When doctors might kill their patients

BMJ 1999; 319 doi: (Published 04 September 1999) Cite this as: BMJ 1999;319:639

Palliative care physicians always have their patients' best interests in mind

  1. Robert Twycross, Macmillan clinical reader in palliative medicine (
  1. Oxford University, Churchill Hospital, Oxford OX3 7LJ
  2. 20 Donnini Place, Gilesgate, Durham DH1 1ES
  3. Hill House, Lower Hillhead, Lerwick, Shetland ZE1 0EL
  4. Belfast City Hospital, Belfast BT7 2AB

    EDITOR—Gillon's editorial arising from the trial of Dr David Moor showed clear (and therefore forceful) analytical logic,1 but I found Doyal's contribution on the same topic was disturbing because it partly missed the point.2 Broadly speaking, the principle of double effect states that if measures taken to relieve physical or mental suffering cause the death of a patient it is morally and legally acceptable provided the doctor's intention is to relieve the distress and not to kill the patient. This is a universal principle without which the practice of medicine would be impossible. It follows inevitably from the fact that all treatment has inherent risks.

    Discussions of the principle of double effect tend to focus on the care of terminally ill patients and the use of morphine to relieve pain Regrettably, this gives the false impression that the use of morphine in this circumstance is a high risk strategy. When correctly used, morphine and other strong opioids are safe-safer than non-steroidal anti-inflammatory drugs, which are prescribed with impunity. The use of both classes of analgesic is justified on the basis that the benefits of pain relief far outweigh the risk of serious adverse effects. Indeed, clinical experience suggests that patients with cancer whose pain is relieved live longer than would have been the case if they had continued to be exhausted and demoralised by unremitting severe pain.

    Most people accept that a greater risk is acceptable in more extreme circumstances. It is axiomatic, however, that effective measures that carry the least risk to life will be used. Thus although it may occasionally be necessary (and acceptable) to render a patient unconscious, it remains unacceptable (and unnecessary) to cause death deliberately.

    In some quarters it is repeatedly stated that the principle …

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