Penance and the Principle of Double Effect: The Ermenfrid Penitential and Moral Residue in Medical Dilemmas
Will Kuehnle, PhD Student, Ohio State University
Medicine demands that physicians routinely decide between morally repellent courses of action. When confronted by the tragic burden of their agency, medical practitioners often experience an intuitive response that involves, “feelings of anxiety, frustration, and depression,” which, when experienced repeatedly, “contributes to burnout and compromises the health and practice of professionals” (ten Have & Patrão Neves, 2021). George C. Webster and Françoise E. Baylis (2000) identified the continuing effects of such distress as “moral residue” and Robert Nozick refers to the same phenomena as leaving a “moral trace.” How to understand and manage moral residue is of the utmost importance as the medical field seeks to retain and educate physicians capable of confronting ethical challenges, the solutions to which seem beyond the limits of medicine. I intend to suggest a philosophical account of the moral residue produced by bioethical dilemmas, and to explore a therapeutic response modeled on the logic of a medieval penitential text.
Some proposals for identifying and discharging moral residue engage with it as a strictly psychological phenomenon. Examples of such proposals include increased bioethics education in medical school (Monteverde, 2016), reflective exercises focused on professional agency and autonomy (Cox, 2008), and systemic improvements in healthcare such that fewer occasions of moral compromise occur (Booth, 2020). Yet, each of these solutions fails because they interpret moral residue as a purely psychological or emotional response, rather than, as the term indicates, a moral reality. A philosophical account of moral residue is necessary in order to properly identify the forms of response that will suitably address the harm experienced by medical professionals in the form of their moral distress.
My paper will explore moral residue as an outcome of the doctrine of double effect. I will argue that moral residue is the product of two vulnerabilities in the principle of double effect: first, the tenuous distinction between intended and foreseen actions; second, the tolerance of an evil outcome. I will offer an interpretation of moral residue as the inevitable result of an act licensed by the principle of double effect. The allowance of a foreseen evil is not without moral consequence, even if the act itself is morally defensible. Rather than reject the principle of double effect as insufficient, I argue that this residue is intelligible within and subject to the moral logic of medieval penitentials. Inspired by the 11th century Ermenfrid Penitential, my paper will outline a penitential recourse for the discharging of moral residue. The Ermenfrid Penitential, composed in the wake of the Norman invasion of England and inspired by the principle of double effect and just war theory, recognizes the moral legitimacy of acts that lead to the death of human beings, while also enjoining soldiers to undergo penance for each life they took. My paper will contend that medicine ought to imitate this moral logic, simultaneously acknowledging the inevitability of moral residue and addressing it through moral means in the form of penance.
Some proposals for identifying and discharging moral residue engage with it as a strictly psychological phenomenon. Examples of such proposals include increased bioethics education in medical school (Monteverde, 2016), reflective exercises focused on professional agency and autonomy (Cox, 2008), and systemic improvements in healthcare such that fewer occasions of moral compromise occur (Booth, 2020). Yet, each of these solutions fails because they interpret moral residue as a purely psychological or emotional response, rather than, as the term indicates, a moral reality. A philosophical account of moral residue is necessary in order to properly identify the forms of response that will suitably address the harm experienced by medical professionals in the form of their moral distress.
My paper will explore moral residue as an outcome of the doctrine of double effect. I will argue that moral residue is the product of two vulnerabilities in the principle of double effect: first, the tenuous distinction between intended and foreseen actions; second, the tolerance of an evil outcome. I will offer an interpretation of moral residue as the inevitable result of an act licensed by the principle of double effect. The allowance of a foreseen evil is not without moral consequence, even if the act itself is morally defensible. Rather than reject the principle of double effect as insufficient, I argue that this residue is intelligible within and subject to the moral logic of medieval penitentials. Inspired by the 11th century Ermenfrid Penitential, my paper will outline a penitential recourse for the discharging of moral residue. The Ermenfrid Penitential, composed in the wake of the Norman invasion of England and inspired by the principle of double effect and just war theory, recognizes the moral legitimacy of acts that lead to the death of human beings, while also enjoining soldiers to undergo penance for each life they took. My paper will contend that medicine ought to imitate this moral logic, simultaneously acknowledging the inevitability of moral residue and addressing it through moral means in the form of penance.