Doctrine of Double Effect

If the first purpose of medicine —the restoration of health—could no longer be achieved there was still much for the doctor to do and
he was entitled to do all that was proper and necessary to relieve pain and suffering even if the measures he took might incidentally shorten life

R v Adams [1957] Crim LR 365 (Judge Devlin)

Doctrine of Double Effect

R v Adams [1957] Crim LR 365
R v Cox [1992] 12 BMLR 38
R. v Moor (David) [2000] Crim. L.R. 31 (Crown Ct)

John Adams was a GP, tried in the 1950s for the murder of the wealthy Mrs Edith Morrell, shed been dead for several years at that point, in looking after her before her death he prescribed ever increasing doses of morphine and heroin. When she died her son gave Adams her Rolls-Royce, and a chest of silver cutlery. This is after Adams had billed her estate over the equivalent of £40K. The reason I mention his case is he went to the courts saying that he never intended to shorten life, although he was aware his medicines could do so.

Notably with adams though, he inherited about 130 wills from his patients, and the detective who came forward with the prosecution even suggested he might have killed a prosecution witness!

Can you give someone medicines, knowing they will shorten their life?

Answer is it depends on why you gave them.

Can’t legally be with the intent of shortening life.

These are three cases that highlight this.

1991 Nigel Cox was a rheumatologist, who was looking after a woman named Lillian Boyes. She had worsening rheumatoid arthritis, and reportedly asked him repeatedly to end her life. He injected her with potassium chloride, deliberately with the aim of ending her life. He was arrested for attempted murder, convicted of it, and given a 12 month suspended sentence. The GMC didn’t take any further action, and he returned to work.

So cant treat with sole aim of ending life.

So we’ve got, you can’t give meds to end life if thats the only motive, you can do it to provide analgesia, (and maybe to inherit 130 wills!)

But then lastly it gets more confusing

So John Moor was a GP who worked in both community and the hospice. The case he was tried for about the death of George Liddell, an 85yrs widower with bowel cancer. There was a recognition by those looking after him that he was dying, and sore. More started him on a CSCI of diamorphine, and then later gave him a bolus of diamorph and chlorpromazine. He was tried for murder, after speaking with a journalist about another case, and said that he’d given loads of his patients diamorph overdoses to have a pain free death. He was acquited after just an hour of deliberation

Actus Reus vs Mens Rea

Acts/Omissions

it is perfectly reasonable for the responsible doctors to conclude that there is no affirmative benefit to Anthony Bland in continuing the invasive medical procedures necessary to sustain his life.
Having so concluded, they are neither entitled nor under a duty to continue such medical care. Therefore they will not be guilty of murder if they discontinue such care.

Airedale NHS Trust v Bland [1993] 1 All ER 821: Lord Browne-Wilkinson

I do not believe that there is a valid legal distinction between the omission to treat a patient and the abandonment of treatment which has been commenced,

Airedale NHS Trust v Bland [1993] 1 All ER 821: Lord Lowry

How can it be lawful to allow a patient to die slowly, though painlessly, over a period of weeks from lack of food but unlawful to produce his immediate death by a lethal injection, thereby saving his family from yet another ordeal to add to the tragedy that has already struck them? I find it difficult to find a moral answer to that question. But it is undoubtedly the law.

Airedale NHS Trust v Bland [1993] 1 All ER 821: Lord Browne-Wilkinson

“Our general principles do not rely on the concept of best interests of the incapable adult …. We consider that ‘best interests’ by itself is too vague

Report on Incapable Adults (Scot Law Com No. 151, 1995)

and would require to be supplemented by further factors which have to > be taken into account. We also consider that ‘best interests’ does not give due weight to the views of the > adult, particularly to wishes and feelings which he or she had expressed while capable of doing so. The > concept of best interests was developed in the context of child law where a child’s level of understanding may > not be high and will usually have been lower in the past. Incapable adults such as those who are mentally ill, > head-injured, or suffering from dementia at the time when a decision has to be made in connection with > them, will have possessed full mental powers before their present incapacity. We think it is wrong to equate > such adults with children, and for that reason would avoid extending child law concepts to them. Accordingly, > the general principles we set out below are framed without express reference to best interests.”

DNACPR

Tracey v Cambridge University Hospital NHS Foundation Trust

Tracey v Cambridge University Hospital NHS Foundation Trust and another [2014] EWCA Civ 822

Mrs. Tracey, diagnosed with terminal lung cancer, was admitted to hospital following a serious road accident. She required ventilation due to chronic respiratory issues but did not respond to treatment. On 26-27 February, Dr. Lavinio and Dr. Ford decided to withdraw ventilation and considered what to do in the event of a cardiac arrest. On 27 February, Dr. Lavinio placed a DNACPR notice in her notes without consulting her or her family. When her daughter Alison discovered this, she objected, leading to its cancellation on 2 March.

Mrs. Tracey’s condition later deteriorated, and on 5 March, a second DNACPR notice was placed after discussion with her family. She died on 7 March.

The Court of Appeal ruled that Article 8 of the European Convention on Human Rights (right to private and family life) applies to DNACPR decisions, as they directly affect how a person experiences the final stage of their life. DNACPR decisions impact autonomy, dignity, and quality of life, so there should be a presumption in favor of involving the patient, unless there are compelling reasons not to. The judgment highlighted several key failures in how Mrs. Tracey’s case was handled:

Vague or Euphemistic Communication is Insufficient
    The court found that Dr. Lavinio believed he had conveyed the DNACPR decision to Mrs. Tracey’s daughter, Alison. However, the language he used—such as saying Mrs. Tracey would “slip away”—did not fully communicate the gravity of the decision.
    The judgment emphasized that patients and families must be clearly informed about DNACPR decisions, and avoiding difficult conversations to spare distress is not an excuse.

Record-Keeping is Critical
    There was no documented evidence that Mrs. Tracey had been consulted about the first DNACPR decision, despite her previously expressing a desire to be involved in such discussions.
    The judgment rejected the argument that poor record-keeping explained this omission. Instead, it emphasized that DNACPR decisions must be properly documented, particularly when a patient’s views are known or when family members are consulted.

The Importance of Consultation
    Where possible, clinicians must involve patients in DNACPR decisions, and if they lack capacity, families should be consulted.
    The only exception is where consultation would cause physical or psychological harm to the patient—but the court warned that distress alone is not a valid reason to exclude a patient.
    The ruling noted that doctors should be cautious about assuming discussions would be too distressing, as this risks depriving patients of their right to be involved in decisions about their own care.

Breach of Article 8 Rights
    The court found that Mrs. Tracey’s Article 8 rights were breached, as the hospital did not demonstrate a valid reason for failing to involve her in the DNACPR decision.
    The ruling reinforced that patients have a right to be consulted about decisions that affect the final stage of their life, and any failure to do so requires clear justification.

Key Takeaways from the Judgment

✅ DNACPR decisions should be clearly communicated, avoiding vague or euphemistic language. ✅ Proper documentation is essential—failure to record discussions can undermine the legitimacy of decisions. ✅ Consultation with the patient should be the default, and where the patient lacks capacity, families should be involved unless there is a clear reason not to. ✅ Distress alone is not a valid reason to exclude a patient from the discussion. ✅ DNACPR decisions engage Article 8 rights, meaning patients should have a say in how they manage their final days.

What About On Nightshift At 03:00?

Winspear v City Hospitals Sunderland NHS Foundation Trust [2015] EWHC 3250 (QB) (Blake J)

Winspear Vs City Hospitals Sunderland NHS Foundation Trust

acts of the Case

Carl Winspear, a 28-year-old with cerebral palsy, epilepsy, and spinal deformities, was admitted to hospital with a chest infection. He lacked mental capacity under the Mental Capacity Act 2005 (MCA 2005).

During the night, a specialist registrar placed a DNACPR notice in Carl’s records without consulting his mother or any family member, intending to discuss it the next morning. The notice was not fully completed, missing key details. The registrar based the decision on Carl’s physical frailty and the perceived futility of CPR due to his spinal deformity.

Carl’s mother was unaware of the DNACPR decision until she visited the hospital the next morning. She strongly objected, stating that Carl had a reasonable quality of life. The DNACPR notice was subsequently cancelled, but Carl’s condition deteriorated, and he died later that evening.

His mother later brought a legal claim under the Human Rights Act 1998, arguing that the failure to consult violated Carl’s right to respect for private life under Article 8 ECHR. Judgment Summary

The Duty to Consult Applies to Patients Without Capacity
    The Court reaffirmed the principles established in Tracey, holding that DNACPR decisions engage Article 8 ECHR, even when the patient lacks capacity.
    Consultation with family or those caring for the patient is required under s.4(7) MCA 2005, unless it is not practicable or appropriate.

Failure to Consult was a Breach of Article 8 ECHR
    The registrar had time to consult Carl’s mother but did not attempt to do so. This was a procedural failure, making the decision unlawful under both Article 8(2) ECHR and s.4(7) MCA 2005.
    Consultation is not just a formality—it ensures that clinicians consider what the patient would have wanted, as well as the perspectives of those who know them best.

Record-Keeping and Communication Failures
    The DNACPR notice was incomplete, missing key details such as consultation records and a consultant’s counter-signature.
    The judgment emphasized that clear documentation is essential, particularly when excluding family from decision-making.
    The registrar’s vague plan to "speak to family in the morning" was insufficient, as DNACPR decisions require immediate consultation where possible.

Clinical Judgment vs. Legal Obligation
    The court acknowledged that clinicians make DNACPR decisions based on medical judgment, but this does not override the legal duty to consult where possible.
    The ruling clarified that distress to family members is not a justification for excluding them from discussions.

The Role of Section 4(7) MCA 2005
    The MCA imposes a duty to consult those close to the patient before making a best-interests decision unless impractical.
    Failure to comply with s.4(7) MCA means a doctor cannot rely on the legal protection of s.5 MCA, which normally protects clinicians acting in a patient’s best interests.

Key Takeaways from the Judgment

✅ DNACPR decisions engage Article 8 ECHR—patients (or, if they lack capacity, their family) must be consulted unless there is a strong reason not to. ✅ Record-keeping is critical—failure to document consultation makes a DNACPR notice vulnerable to legal challenge. ✅ A failure to consult when it is practicable makes a DNACPR decision unlawful under s.4(7) MCA 2005 and Article 8(2) ECHR. ✅ Medical judgment does not override legal obligations—family members must be involved unless there is a compelling reason not to. ✅ This case reinforces the Tracey judgment, confirming that patients who lack capacity should not be excluded from DNACPR discussions by default.

Parliament Ombudsman - End-of-life care: improving ‘do not attempt CPR’ conversations for everyone (2024)

Compassion In Dying

“The difference is humanity. It’s being willing to align yourself with a fellow human who’s in more trouble than you are.”

What Helps?

Doctors ‘owned’ decision
Doctors explained decision:
- Why CPR more harm than good
- What treatment you still get
Shared understanding of care
Space for questions
Pragmatic, Honest, Sensitive, Warm, Respect

Guidelines, Limitations, & Decision Making

Guidelines produced by professional bodies to facilitate decision-making are contradictory and of limited practical use in day-to-day decision-making.

Daniele Bryden - “Who To Admit To Critical Care” - Case Studies in Adult Intensive Care Medicine

Regulatory / Guidance

FICM - Care At The End Of Life (2019)

GMC - Treatment and Care Towards The End of Life (2010)

GMC - Decision Making and Consent (2020)

Communication is ethics. Ethics is communication.

General Principles & Shared Language

<

Other Resources

FICM - Midnight Laws

One Slide Summary

You Can Treat Symptoms Knowing They’ll Shorten Life
Withholding Treatment and Withdrawing Are The Same (Legally)
You Decide What Works, But Not What Matters
You Cannot Be Required To Provide Treatments (CPR) That Don’t Work
Decisions (DNACPR) Need Discussion - Day and Night
Dilemmas and Court Cases Come From Communication Problems
Patients Have Told Us What Helps:
Respect, Warmth, “Own Decisions”, Clarity + Honesty
If You Didn’t Document It Didn’t Happen
Ethical “Pillars” Are Just One Tool Among Many

Ethics and Law For ICM (Exams)

Doctrine of Double Effect

Doctrine of Double Effect

Doctrine of Double Effect

Actus Reus vs Mens Rea

Acts/Omissions

DNACPR

Tracey v Cambridge University Hospital NHS Foundation Trust

What About On Nightshift At 03:00?

Compassion In Dying

What Helps?

Guidelines, Limitations, & Decision Making

Regulatory / Guidance

General Principles & Shared Language

Other Resources

One Slide Summary