The rule of double effect--a critique of its role in end-of-life decision making.

According to the ethical principle known as the “rule of double effect,” effects that would be morally wrong if caused intentionally are permissible if foreseen but unintended. This principle is often cited to explain why certain forms of care at the end of life that result in death are morally permissible and others are not.1–9 According to the rule, administering high-dose opioids to treat a terminally ill patient's pain may be acceptable even if the medication causes the patient's death. In contrast, the rule does not authorize practices such as physician-assisted suicide, voluntary euthanasia, and certain instances of forgoing . . .