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Table of Contents
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
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14. Doctrine of Double Effect
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The best medical practitioner is the one who can distinguish the possible from the impossible.
~ Herophilos
Double-Effect Dilemma
The Perplexing Case of the Double-Edged Scalpel
Dr. Evelyn Pierce, a highly respected oncologist, worked tirelessly to provide her patients with the best possible care. One day, she found herself in a perplexing situation that would test her knowledge and her ethical principles as a medical practitioner.
The patient, a pregnant woman named Maria, had been diagnosed with a life-threatening cancerous uterus. The medical standard of care required the removal of the uterus and fetus to save Maria's life. Dr. Pierce presented this information to Maria, explaining the diagnosis, prognosis, and benefits and burdens of the procedure. Maria, devastated by the news, gave her informed consent to undergo the surgery.
As Dr. Pierce prepared for the operation, she reflected on the doctrine of double effect, a medieval natural law tradition in Catholic moral theology. The doctrine states that an action is morally permissible if a good outcome is intended and a harmful effect is foreseen but unintended. While this principle might have justified her actions within Catholic theology, Dr. Pierce recognized that modern medical ethics required a more nuanced approach.
In accordance with the four principles of medical ethics—autonomy, beneficence, nonmaleficence, and justice—Dr. Pierce first considered Maria's autonomy by ensuring that she had given informed consent for the procedure. Next, she contemplated beneficence and nonmaleficence, striving to maximize Maria's best interests and minimize harm. Lastly, she took into account the principle of justice, recognizing that Maria had the legal right to access this life-saving treatment.
With these principles in mind, Dr. Pierce performed the surgery, saving Maria's life but resulting in the foreseen but unintended death of the fetus. The outcome was tragic, yet the procedure aligned with medical standards of care and the four principles of medical ethics.
The perplexing case of the double-edged scalpel highlights the limitations of the doctrine of double effect in contemporary medical practice. While the doctrine emphasizes the importance of a practitioner's good intentions, it fails to consider the consequences of their actions. The four principles of medical ethics, in contrast, hold practitioners legally, professionally, and morally accountable for their actions, independent of their intentions.
Through this academic murder mystery, medical students and healthcare providers can explore the complexities of ethical dilemmas and the importance of moving beyond the doctrine of double effect. By applying the four principles of medical ethics and engaging in the processes of specifying, weighing, and balancing, practitioners can navigate the challenging landscape of modern medicine while providing the best possible care for their patients.
Abstract
The doctrine of double effect is a medieval natural law tradition in Catholic moral theology which states that an action is morally permissible if a good outcome is intended and a harmful effect is foreseen but unintended. The moral permissibility of an action is determined by the intention of the agent rather than the consequences. The doctrine was created to justify certain actions within Catholic theology, but it precedes moral recognition of patient autonomy and only focuses on the intention of the practitioner. In modern medical ethics, the four principles of medical ethics (autonomy, beneficence, nonmaleficence, and justice) are used instead of the doctrine of double effect. The four principles are specified and balanced to determine accepted moral actions and hold practitioners legally, professionally, and morally accountable for the consequences of their actions, independent of their intentions.
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Think
[14:1] The doctrine of double effect has historically been defined by the medieval Natural Law tradition of Thomas Aquinas and by contemporary Catholic moral theologians as being:
If when doing something morally good it is also accompanied with a foreseen but unintended harmful effect, then the action is morally permissible if the intention was only for good.
[14:2] What is essential to notice is that the moral permissibility of action is determined solely by the agent’s intention rather than by the consequences of the actions. Using this type of moral analysis, if a person intended to make a significant economic gain (the good), with the foreseen but unintended consequence of polluting the environment (harmful effect), then using the doctrine of double effect that would make such actions morally permissible if the intention was only for good.
[14:3] The cynic’s snark reply is the old proverb:
The road to hell is paved with good intentions.
[14:4] However, the Catholic magisterium has found it necessary to have this doctrine so that the Church can justify moral actions which are impermissible within Catholic theology. One example that most rational agents would consider morally permissible and in line with the medical standards of care would be the intentional removal of a life-threatening cancerous uterus, even if its intentional removal would also result in the foreseen but unintentional death of a fetus. The doctrine of double effect was put in place precisely so that Catholics could justify such a procedure.
[14:5] However, it is essential to notice that the doctrine of double effect precedes any moral recognition of patient autonomy (informed consent). Rather the doctrine of double effect reflects the paternalistic medieval age, in which patient choice was not recognized. Because of this paternalism, the doctrine of double effect only focuses on the practitioner’s intent and does not recognize that it is the patient who has the authority to authorize the practitioner to perform the medical procedure.
[14:6] The field of medical ethics uses a different evaluative process of specifying and balancing the four principles of medical ethics to determine accepted moral actions. Specifying is analytically establishing how a general moral principle relates to a particular circumstance or situation. Balancing is the analysis of how two or more specified principles should be weighed and balanced for a particular circumstance or situation.
[14:7] Using the previous example of the life-threatening cancerous uterus, the principlistic approach would be the following:
Assess
Patient: 1) Autonomy
[14:8] Using the principle of patient autonomy (informed consent), the practitioner informs the patient with decisional capacity of:
- 1. The diagnosis of having a cancerous uterus.
- 2. The prognosis of the condition is life-threatening.
- 3. The medical standards of care is the removal of the uterus and fetus.
- 4. Benefits: saving the patient’s life.
- 5. Burdens: reasonable risks associated with having surgery, and the de facto abortion of the fetus.
The practitioner then needs to answer all patient’s questions and get informed consent authorizing the practitioner to perform the procedure.
Practitioner: 2) Beneficence & 3) Nonmaleficence
[14:9] Professional beneficence (do good) requires the practitioner to empathetically assess what medical standards of care options would maximize the patient’s best interests as determined by the patient’s reasonable goals, values, and priorities.
[14:10] Nonmaleficence (do no harm) is the obligation to mitigate harm to the patient. Since the fetus is part of the patient’s body, the patient can authorize medical treatment with or without regard to the fetus. In this case, the fetus might not come to term even if the procedure was not performed.
Public Policy: 4) Justice
[14:11] With the principle of justice (be fair) it is necessary to determine what available social resources and treatment options are legally permissible and available. If the procedure is legal, which it is, then the patient has the right to decide whether or not to have the cancerous uterus and fetus removed, the practitioner is obligated to maximize the patient’s best interests as determined by the patient's reasonable goals, values, and priorities, and public policy, as a matter of social justice, is obliged to provide the patient with medical access.
Weighing & Balancing
[14:12] Weighing and balancing determines the rank and order of specified moral principles. For this particular case, and because of regulatory state laws, the order of priority would be:
1. Public Policy (justice)
2. Patient Autonomy (informed consent), and
3. Practitioner Professionalism (beneficence & nonmaleficence).
[14:13] Using the four principles of medical ethics and specifying, weighing, and balancing circumvents any need for the medieval natural law tradition of the doctrine of double effect. In modern society, regardless of intentions, foreseen but unintended consequences will hold the practitioner professionally, legally, and morally accountable. Legally, medical malpractice is based on a deviation from medical standards of care due to the practitioner being negligent in an action or inaction that, as a consequence, results in harm to the patient. This legal, professional, and moral accountability is independent of the practitioner’s intentions.
Conclude
[14:14] The doctrine of double effect always focuses on the importance of the medical provider's beneficent (good) intentions. Under no circumstance is it ever permissible for a medical provider to have the intention of being maleficent (do harm) to the patient. Beneficent intent (do good), with an unfortunate double effect of harm, is accepted if it is in accordance with medical standards of care. However, if an action or inaction that deviates from medical standards of care is defined as negligent, and if, as a result, the action or inaction is accompanied with patient harm, then that action, regardless of intent, would be grounds for medical malpractice.
[14:15] In summary, while the doctrine of double effect emphasizes the importance of a medical practitioner’s good intentions, it does not account for the consequences of their actions. Modern medical ethics, using the four principles of medical ethics and the processes of specifying, weighing, and balancing, holds practitioners legally, professionally, and morally accountable for the consequences of their actions, regardless of their intentions. This approach is more comprehensive and better suited to address the complexities of modern medical practice.
(See also: 5. Assisted Suicide, 6. Capital Punishment - Executions, 11. Death With Dignity - Practitioner-Assisted Dying, and 17. Euthanasia)
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14. Review Questions
1. The doctrine of double effect establishes that the permissibility of an action is dependent on the consequences of the action, not the intention.
2. The doctrine of double effect is thoroughly paternalistic and does not recognize patient autonomy (informed consent).
3. Specifying and balancing the four principles of medical ethics has superannuated or surpassed any need for the doctrine of double effect.
4. If a practitioner can establish that their intention was solely for something morally good, that is, in the patient’s best interests, then that will legally absolve the practitioner from any foreseen but unintended consequences.
5. Although the intent of the doctrine of double effect was for good, that does not absolve the practitioner from legal jeopardy for foreseen unintended effects.
**
CORRECT! 🙂
[14:2] What is essential to notice is that the moral permissibility of action is determined solely by the agent’s intention rather than by the consequences of the actions. Using this type of moral analysis, if a person intended to make a significant economic gain (the good), with the foreseen but unintended consequence of polluting the environment (harmful effect), then using the doctrine of double effect that would make such actions morally permissible if the intention was only for good.
Wrong 😕
[14:2] What is essential to notice is that the moral permissibility of action is determined solely by the agent’s intention rather than by the consequences of the actions. Using this type of moral analysis, if a person intended to make a significant economic gain (the good), with the foreseen but unintended consequence of polluting the environment (harmful effect), then using the doctrine of double effect that would make such actions morally permissible if the intention was only for good.
CORRECT! 🙂
[14:5] However, it is essential to notice that the doctrine of double effect precedes any moral recognition of patient autonomy (informed consent). Rather the doctrine of double effect reflects the paternalistic medieval age, in which patient choice was not recognized. Because of this paternalism, the doctrine of double effect only focuses on the practitioner’s intent and does not recognize that it is the patient who has the authority to authorize the practitioner to perform the medical procedure.
Wrong 😕
[14:5] However, it is essential to notice that the doctrine of double effect precedes any moral recognition of patient autonomy (informed consent). Rather the doctrine of double effect reflects the paternalistic medieval age, in which patient choice was not recognized. Because of this paternalism, the doctrine of double effect only focuses on the practitioner’s intent and does not recognize that it is the patient who has the authority to authorize the practitioner to perform the medical procedure.
CORRECT! 🙂
[14:12] Weighing and balancing determine the rank and order of specified moral principles. For this particular case, and because of regulatory state laws, the order of priority would be:
1. Public Policy (justice)
2. Patient Autonomy (informed consent), and
3. Practitioner Professionalism (beneficence & nonmaleficence).
[14:13] Using the four principles of medical ethics and specifying, weighing, and balancing circumvents any need for the medieval natural law tradition of the doctrine of double effect. In modern society, regardless of intentions, foreseen but unintended consequences will hold the practitioner professionally, legally, and morally accountable. Legally, medical malpractice is based on a deviation from medical standards of care due to the practitioner being negligent in an action or inaction that, as a consequence, results in harm to the patient. This legal, professional, and moral accountability is independent of the practitioner’s intentions.
Wrong 😕
[14:12] Weighing and balancing determine the rank and order of specified moral principles. For this particular case, and because of regulatory state laws, the order of priority would be:
1. Public Policy (justice)
2. Patient Autonomy (informed consent), and
3. Practitioner Professionalism (beneficence & nonmaleficence).
[14:13] Using the four principles of medical ethics and specifying, weighing, and balancing circumvents any need for the medieval natural law tradition of the doctrine of double effect. In modern society, regardless of intentions, foreseen but unintended consequences will hold the practitioner professionally, legally, and morally accountable. Legally, medical malpractice is based on a deviation from medical standards of care due to the practitioner being negligent in an action or inaction that, as a consequence, results in harm to the patient. This legal, professional, and moral accountability is independent of the practitioner’s intentions.
CORRECT! 🙂
[14:13] Using the four principles of medical ethics and specifying, weighing, and balancing circumvents any need for the medieval natural law tradition of the doctrine of double effect. In modern society, regardless of intentions, foreseen but unintended consequences will hold the practitioner professionally, legally, and morally accountable. Legally, medical malpractice is based on a deviation from medical standards of care due to the practitioner being negligent in an action or inaction that, as a consequence, results in harm to the patient. This legal, professional, and moral accountability is independent of the practitioner’s intentions.
Wrong 😕
[14:13] Using the four principles of medical ethics and specifying, weighing, and balancing circumvents any need for the medieval natural law tradition of the doctrine of double effect. In modern society, regardless of intentions, foreseen but unintended consequences will hold the practitioner professionally, legally, and morally accountable. Legally, medical malpractice is based on a deviation from medical standards of care due to the practitioner being negligent in an action or inaction that, as a consequence, results in harm to the patient. This legal, professional, and moral accountability is independent of the practitioner’s intentions.
CORRECT! 🙂
[14:13] Using the four principles of medical ethics and specifying, weighing, and balancing circumvents any need for the medieval natural law tradition of the doctrine of double effect. In modern society, regardless of intentions, foreseen but unintended consequences will hold the practitioner professionally, legally, and morally accountable. Legally, medical malpractice is based on a deviation from medical standards of care due to the practitioner being negligent in an action or inaction that, as a consequence, results in harm to the patient. This legal, professional, and moral accountability is independent of the practitioner’s intentions.
Wrong 😕
[14:13] Using the four principles of medical ethics and specifying, weighing, and balancing circumvents any need for the medieval natural law tradition of the doctrine of double effect. In modern society, regardless of intentions, foreseen but unintended consequences will hold the practitioner professionally, legally, and morally accountable. Legally, medical malpractice is based on a deviation from medical standards of care due to the practitioner being negligent in an action or inaction that, as a consequence, results in harm to the patient. This legal, professional, and moral accountability is independent of the practitioner’s intentions.
14. Clinical Vignettes
1. Ms. Smith, a 72-year-old urban planner presents with a painful terminal illness and seeks relief from their suffering. The practitioner is faced with a difficult decision: they can prescribe a medication that will alleviate the patient's pain but may also hasten their death. According to the Doctrine of Double Effect, what is the practitioner's ethical responsibility in this situation?
2. Mr. Evans, a 62-year-old stockbroker comes to you with a complex medical condition and asks for your opinion on a treatment they have researched. The patient knows that the treatment may have unintended consequences, but they believe that the benefits outweigh the risks. You are familiar with the doctrine of double effect, which states that an action with both good and bad consequences can be morally justifiable if the practitioner's intention is good. Which of the following statements about the doctrine of double effect is most accurate?
3. Ms. Woods, a 48-year-old investment banker recognizes that the proposed treatment option may have unintended consequences, but they believe that the benefits outweigh the burdens. As a practitioner, you are familiar with the four principles of biomedical ethics: autonomy, beneficence, nonmaleficence, and justice. Which of the following statements about the four principles is most accurate?
4. Mr. Hassan, a 59-year-old financial analyst presents to their primary care practitioner complaining of chest pain and shortness of breath. The practitioner orders a battery of tests, including a stress test and an electrocardiogram (ECG), but fails to diagnose the patient with acute myocardial infarction (heart attack). The patient is sent home with a diagnosis of indigestion and instructed to follow up in a week. Two days later, the patient returns to the emergency room with severe chest pain and is diagnosed with a heart attack. The patient undergoes emergency coronary angioplasty and is recovering for several days in the hospital. What is the basis for a medical malpractice claim?
Option 1 medical standard of care: The practitioner provides a treatment that has been proven effective according to medical standards of care, but it may also have negative side effects for the patient.
Option 2 doctrine of double effect: The practitioner with good intentions deviates from medical standards of care, resulting in foreseen but unintended harm to the patient.
Which of the following options would the practitioner be considered to have committed medical malpractice if harm resulted from their decision?
CORRECT! 🙂
Explanation: According to the Doctrine of Double Effect, an action that has two effects - one good and one bad - may be permissible if four conditions are met: the action is intrinsically good or indifferent, the good effect is intended, the bad effect is not intended but merely foreseen, and the good effect outweighs the bad effect [14:1]. In this case, the practitioner's intention is to alleviate the patient's pain, which is an intrinsically good act. The hastening of the patient's death is an unintended but foreseen effect of the medication, and the good effect of relieving the patient's pain outweighs the bad effect of hastening their death [14:1]. Therefore, prescribing the medication is ethically permissible according to the Doctrine of Double Effect [14:1]. The option of refusing to prescribe the medication is not ethically justifiable as it would cause the patient unnecessary suffering [14:1]. The options of seeking a second opinion or consulting with a bioethicist may be appropriate, but they do not address the ethical responsibility of the practitioner in this situation [14:1].
Wrong 😕
Explanation: According to the Doctrine of Double Effect, an action that has two effects - one good and one bad - may be permissible if four conditions are met: the action is intrinsically good or indifferent, the good effect is intended, the bad effect is not intended but merely foreseen, and the good effect outweighs the bad effect [14:1]. In this case, the practitioner's intention is to alleviate the patient's pain, which is an intrinsically good act. The hastening of the patient's death is an unintended but foreseen effect of the medication, and the good effect of relieving the patient's pain outweighs the bad effect of hastening their death [14:1]. Therefore, prescribing the medication is ethically permissible according to the Doctrine of Double Effect [14:1]. The option of refusing to prescribe the medication is not ethically justifiable as it would cause the patient unnecessary suffering [14:1]. The options of seeking a second opinion or consulting with a bioethicist may be appropriate, but they do not address the ethical responsibility of the practitioner in this situation [14:1].
Wrong 😕
Explanation: The doctrine of double effect prioritizes the practitioner's intention and does not take into account patient autonomy and informed consent [14:5]. The doctrine of double effect is an ethical principle that is used to evaluate practitioner’s actions, independent of patient autonomy, that have both good and bad consequences [14:1]. It holds that an action is morally justifiable if the practitioner's intention is good, with no mention of the patient’s intention, even if the action has negative consequences [14:2]. In this case, the patient has researched a treatment that has potential negative consequences but believes that the benefits outweigh the risks. The doctrine of double effect does not take into account the patient's beliefs or values, and therefore patient autonomy and informed consent are not part of the evaluation [14:5]. The practitioner's intention is the most important consideration, and if the intention of the practitioner is to do good, then the action can be considered morally justifiable [14:1].
CORRECT! 🙂
Explanation: The doctrine of double effect prioritizes the practitioner's intention and does not take into account patient autonomy and informed consent [14:5]. The doctrine of double effect is an ethical principle that is used to evaluate practitioner’s actions, independent of patient autonomy, that have both good and bad consequences [14:1]. It holds that an action is morally justifiable if the practitioner's intention is good, with no mention of the patient’s intention, even if the action has negative consequences [14:2]. In this case, the patient has researched a treatment that has potential negative consequences but believes that the benefits outweigh the risks. The doctrine of double effect does not take into account the patient's beliefs or values, and therefore patient autonomy and informed consent are not part of the evaluation [14:5]. The practitioner's intention is the most important consideration, and if the intention of the practitioner is to do good, then the action can be considered morally justifiable [14:1].
CORRECT! 🙂
Explanation: The correct answer is: "The four principles have superannuated or surpassed any need for the doctrine of double effect." [14:1] The four principles of biomedical ethics - autonomy, beneficence, nonmaleficence, and justice - are widely used to guide ethical decision-making in healthcare. The doctrine of double effect is an ethical principle that pertains to actions that have both good and bad consequences and is a specific application of the principle of nonmaleficence, solely from the practitioner’s perspective. While the doctrine of double effect may be relevant in certain situations, the four principles are generally considered more comprehensive and applicable to a wider range of ethical issues in healthcare. [14:13] Therefore, the four principles have superseded any need for the practitioner centered doctrine of double effect.
Wrong 😕
Explanation: The correct answer is: "The four principles have superannuated or surpassed any need for the doctrine of double effect." [14:1] The four principles of biomedical ethics - autonomy, beneficence, nonmaleficence, and justice - are widely used to guide ethical decision-making in healthcare. The doctrine of double effect is an ethical principle that pertains to actions that have both good and bad consequences and is a specific application of the principle of nonmaleficence, solely from the practitioner’s perspective. While the doctrine of double effect may be relevant in certain situations, the four principles are generally considered more comprehensive and applicable to a wider range of ethical issues in healthcare. [14:13] Therefore, the four principles have superseded any need for the practitioner centered doctrine of double effect.
CORRECT! 🙂
Explanation: The basis for a medical malpractice claim in this situation is deviation from medical standards of care [14:13]. Medical malpractice occurs when a practitioner fails to meet the accepted standard of care, resulting in harm or injury to the patient [14:13]. In this case, the primary care practitioner may have deviated from the accepted standard of care by failing to diagnose the patient with a heart attack despite their symptoms and the test results, resulting in a delay in treatment and harm to the patient [14:1]. The other options are not relevant in this situation. The practitioner's intention and the doctrine of double effect are related to ethical decision-making, while patient non-compliance would only be relevant if the patient had failed to follow the practitioner's instructions or treatment plan [14:13].
Wrong 😕
Explanation: The basis for a medical malpractice claim in this situation is deviation from medical standards of care [14:13]. Medical malpractice occurs when a practitioner fails to meet the accepted standard of care, resulting in harm or injury to the patient [14:13]. In this case, the primary care practitioner may have deviated from the accepted standard of care by failing to diagnose the patient with a heart attack despite their symptoms and the test results, resulting in a delay in treatment and harm to the patient [14:1]. The other options are not relevant in this situation. The practitioner's intention and the doctrine of double effect are related to ethical decision-making, while patient non-compliance would only be relevant if the patient had failed to follow the practitioner's instructions or treatment plan [14:13].
CORRECT! 🙂
Explanation: The correct answer is, “Option 2, the doctrine of double effect” [14:1]. While the practitioner's intentions may be good, deviating from established medical standards of care is generally not ethically justifiable. The doctrine of double effect, an archaic ethical theory [14:1], fails to take into account the importance of patient autonomy and informed consent [14:5], which are highly valued principles in contemporary medical ethics. The focus should be on providing the most effective treatment for the patient while minimizing harm and upholding their autonomy. Therefore, it is essential for practitioners to follow established medical standards of care, that are in line with the patient's reasonable goals, values, and priorities [14:6], to ensure they are providing the most effective treatment for the patient while minimizing harm. Deviating from these standards can result in medical malpractice because of negligence and harm to the patient [14:13].
Wrong 😕
Explanation: The correct answer is, “Option 2, the doctrine of double effect” [14:1]. While the practitioner's intentions may be good, deviating from established medical standards of care is generally not ethically justifiable. The doctrine of double effect, an archaic ethical theory [14:1], fails to take into account the importance of patient autonomy and informed consent [14:5], which are highly valued principles in contemporary medical ethics. The focus should be on providing the most effective treatment for the patient while minimizing harm and upholding their autonomy. Therefore, it is essential for practitioners to follow established medical standards of care, that are in line with the patient's reasonable goals, values, and priorities [14:6], to ensure they are providing the most effective treatment for the patient while minimizing harm. Deviating from these standards can result in medical malpractice because of negligence and harm to the patient [14:13].
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14. Reflection Vignettes
1. Mr. John Smith, a 65-year-old retired carpenter, was admitted to the hospital with severe chest pain and shortness of breath. Mr. Smith has a history of smoking for over 30 years and has been experiencing a persistent cough and occasional hemoptysis for the past six months. His medical history is otherwise unremarkable, and he does not have any known allergies to medications. On examination, the practitioner noticed that Mr. Smith's respiratory rate was 30 breaths per minute, and his oxygen saturation was 88% on room air. The chest X-ray revealed a mass in the left lung, measuring approximately 8 cm in diameter, and the CT scan confirmed that the mass was malignant. The practitioner initiated treatment with supplemental oxygen, nebulizers, and intravenous pain medications, including opioids, to manage Mr. Smith's symptoms. However, despite aggressive management, Mr. Smith continued to experience significant pain and discomfort, which was affecting his quality of life. During the rounds, Mr. Smith expressed his desire to increase the pain medication dose, understanding that it could potentially hasten his death.
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
**
2. Mrs. Alice Jones is an 85-year-old woman with a history of advanced dementia, who was admitted to the hospital with aspiration pneumonia. She has been bedridden for the past year, and her oral intake has declined significantly over the past few months. She is now dependent on tube feeding for her nutrition and hydration. During the course of her hospitalization, Mrs. Jones developed severe pain and discomfort, despite receiving high doses of pain medication. The practitioner discussed the situation with Mrs. Jones's family and explained that increasing the pain medication could potentially hasten her death, given her advanced age and underlying medical condition.
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
***
