continuing to see their son in this exceptionally distressing condition and would,
finally, be able to mourn the loss they had suffered two years before. That is not a
negligible benefit, by any means, and if, whatever happened, nothing more could
be done to harm or benefit Bland himself, it seems right to let the choice of out-
come be decided by what would most benefit those closest to him.
But it is interesting to compare the case of Tony Bland with that ofRv.Cox
1992). Dr Nigel Cox was found guilty of attempted murder in 1992 for admin-
istering a lethal dose of potassium chloride to a patient, Lilian Boyes who, dying
and in acute pain, had pleaded with him to help her die. It is indeed, hard to see
how, on the face of it, this case is to be distinguished from that ofBland,without
invoking the distinction between active and passive euthanasia. The remarks of
Lord Justice Butler-Sloss in the Court of Appeal hearing ofBlandwould seem to do
just that:
`The position of Dr Nigel Cox, who injected a lethal dose designed to cause
death, was different since it was an external and intrusive act and was not in
accordance with his duty of care as a doctor. The distinction between Mr Bland's
doctors and Dr Cox was between an act or omission which allowed causes
already present in the body to operate and the introduction of an external
agency of death.' [21]The Guardian's leader writer called that position a philosophical nonsense' 20 November 1992) and maybe it is, if taken at face value. What is not true is that there is no other morally relevant distinction to be drawn between the two cases. What follows should not be seen as implying any criticism of Dr Cox who, it would seem, was placed in an extremely difficult situation and, in all good faith, was probably doing what he believed was the only thing he could do to help Ms Boyes. But whether Cox's decision was the right one in the circumstances, the explanation for its rightness must be different from the explanation of the rightness of withdrawing treatment from Tony Bland. The source of this distinction is an old notion, thought by many to be now discredited, calledthe principle of double effect'. It should, I think, be seen not as
arule for resolving moral problems but as a guide which can clarify what is at issue
in particular cases. It relies on a distinction between what one intends and what
one merely foresees as a result of one's actions. The principle suggests that,
whereas one is fully responsible for what one intends to do, one is not responsible
for foreseen but intended effects of one's actions, provided that:
1) what is done must be, at the least, morally permissible;
2) what is intended must include only the good and not the bad effects of what
is done;
3) the bad effects must not be themeanswhereby the good is brought about;
4) there must beproportionalitybetween the good and bad effects of what is
done.
Whereas Dr Cox must have intended Lilian Boyes' death as the only way, as he saw
it, of sparing her further pain and suffering, the medical team treating Tony Bland
intended to spare him further suffering or at least to spare his relatives, given that
Tony Bland himself may have been aware of nothing at all) whilst foreseeing that
The Critically Ill Patient 221