title: Decisions that hasten death: double effect and the experiences of physicians in Australia.
abstract: BACKGROUND
  In Australian end-of-life care, practicing euthanasia or physician-assisted suicide is illegal. Despite this, death hastening practices are common across medical settings. Practices can be clandestine or overt but in many instances physicians are forced to seek protection behind ambiguous medico-legal imperatives such as the Principle of Double Effect. Moreover, the way they conceptualise and experience such practices is inconsistent. To complement the available statistical data, the purpose of this study was to understand the reasoning behind how and why physicians in Australia will hasten death.
  
  
  METHODS
  A qualitative investigation was focused on palliative and critical/acute settings. A thematic analysis was conducted on semi-structured in-depth interviews with 13 specialist physicians. Attention was given to eliciting meanings and experiences in Australian end-of-life care.
  
  
  RESULTS
  Highlighting the importance of a multidimensional approach, physicians negotiated multiple influences when death was regarded as hastened. The way they understood and experienced end-of-life care practices were affected by politico-religious and cultural influences, medico-legal imperatives, and personal values and beliefs. Interpersonal and intrapsychic aspects further emphasised the emotional and psychological investment physicians have with patients and others. In most cases death occurred as a result of treating suffering, and sometimes to fulfil the wishes of patients and others who requested death. Experience was especially subject to the efficacy with which physicians negotiated complex but context-specific situations, and was reflective of how they considered a good death. Although many were compelled to draw on the Principle of Double Effect, every physician reported its inadequacy as a medico-legal guideline.
  
  
  CONCLUSIONS
  The Principle of Double Effect, as a simplistic and generalised guideline, was identified as a convenient mechanism to protect physicians who inadvertently or intentionally hastened death. But its narrow focus on the physician's intent illuminated how easily it may be manipulated, thus impairing transparency and a physician's capacity for honesty. It is suggested the concept of "force majeure" be examined for its applicability in Australian medical end-of-life law where, consistent with a multidimensional and complex world, a physician's motivations can also be understood in terms of the emotional and psychological pressures they face in situations that hasten death.
authors.affiliation: Centre for Health Research, School of Medicine, University of Western Sydney, Campbelltown, Australia. s.trankle@uws.edu.au.
authors.forename: Steven A
authors.initials: SA
authors.lastname: Trankle
mesh_terms: D000328:Adult; D016223:Advance Directives / Q000331:legislation & jurisprudence; D001291:Attitude of Health Personnel; D001315:Australia; D003422:Critical Care / Q000941:ethics*; D003657:Decision Making; D034723:Double Effect Principle; D004645:Empathy / Q000941:ethics*; D005260:Female; D006801:Humans; D033182:Intention; D008297:Male; D008875:Middle Aged; D010166:Palliative Care / Q000941:ethics*; D010817:Physician-Patient Relations; D010820:Physicians / Q000941:ethics* / Q000331:legislation & jurisprudence / Q000523:psychology; D036301:Qualitative Research; D012067:Religion; D017236:Suicide, Assisted / Q000941:ethics* / Q000331:legislation & jurisprudence / Q000523:psychology; D035521:Supreme Court Decisions; D011795:Surveys and Questionnaires; D013727:Terminal Care / Q000941:ethics* / Q000331:legislation & jurisprudence / Q000523:psychology; D014481:United States; D028761:Withholding Treatment / Q000941:ethics* / Q000331:legislation & jurisprudence