Intended for healthcare professionals

Letters Morphine

Double effect is a myth leading a double life

BMJ 2007; 334 doi: (Published 01 March 2007) Cite this as: BMJ 2007;334:440
  1. Claud Regnard, consultant in palliative care medicine
  1. St Oswald's Hospice, Newcastle upon Tyne NE3 1EE
  1. claudregnard{at}

    Kelly Taylor's request to use morphine “to make her unconscious” under the principle of double effect is a puzzling choice.1

    Evidence over the past 20 years has repeatedly shown that, used correctly, morphine is well tolerated and does not shorten life or hasten death.2 Its sedative effects wear off quickly (making it useless if you want to stay unconscious), toxic doses can cause distressing agitation (which is why such doses are never used in palliative care), and it has a wide therapeutic range (making death unlikely). The Dutch know this and hardly ever use morphine for euthanasia.3

    Palliative care specialists are not faced with the dilemma of controlling severe pain at the risk of killing the patient: they manage pain with drugs and doses adjusted to each patient, while at the same time helping fear, depression, and spiritual distress. Doctors who act precipitously with high, often intravenous, doses of opioids may do so out of compassionate panic, but they are being misled into bad practice by the continuing promotion of double effect as a real and essential phenomenon in end of life care. Using double effect as a justification for patient assisted suicide and euthanasia on the grounds that it is already being done under the rubric of double effect is not tenable in evidence based medicine.4

    Whenever there is a demand to use morphine to render a patient unconscious, this should be refused, not just because of the law but because this approach is ineffective and risks causing more distress. In end of life care double effect is a myth leading a double life.


    • Competing interests: None declared.


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