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The doctrine of double effect
  1. Jen Browne,
  2. Mariana Dittborn,
  3. Joe Brierley
  1. Paediatric Bioethics Centre, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
  1. Correspondence to Dr Joe Brierley, Paediatric Bioethics Centre, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK; joe.brierley{at}

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An 8 month old infant was found to be unresponsive at home by his mother. Despite, initial signs of life the infant was in full asystolic cardio-respiratory arrest on arrival to A&E. There was no past medical history of note and they had been well on the day of presentation. Full resuscitation was carried out, with return of spontaneous circulation at 30 min. The infant was transferred to PICU for ongoing management. Despite multiple investigations, no cause was found for the cardiac-arrest, with brain MRI sadly revealing a severe hypoxic-ischaemic injury. Sedation and ventilation were weaned off, but the infant did not demonstrate independent respiratory effort. Following discussion with both parents, a decision was made to withdraw life-sustaining treatment. The infant was extubated on an infusion of morphine and midazolam, dying soon afterwards.

The PICU trainee felt distress; she intended to alleviate suffering, but did morphine and midazolam hasten the infant’s death?

This vignette has been drawn from authors’ experiences and does not represent a real case.

This case vignette is taken as a representative scenario where the ‘Doctrine of Double Effect’ (DDE) might be used to alleviate the paediatric intensive care unit (PICU) trainee’s distress. In this piece, the authors’ aim to describe the widely known DDE and demonstrate that it is no longer needed to ethically justify good end-of-life practices and the delivery of compassionate and excellent palliative care.

‘Primum non-nocere—first do no harm is a fundamental principle on …

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  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.