Abstract The traditional distinction
between active and passive euthanasia requires critical analysis. The
conventional doctrine is that
there is such an important moral difference between the two that,
although the latter is sometimes
permissible, the former is always
forbidden. This doctrine may be challenged for several reasons. First of
all, active euthanasia is in many
cases more humane than passive euthanasia. Secondly, the conventional
doctrine leads to decisions concerning life and death on irrelevant
grounds. Thirdly, the doctrine rests on a distinction between killing and
letting die that itself has no moral importance. Fourthly, the most common
arguments in favor of the doctrine are invalid. I therefore suggest that
the American Medical Association policy
statement that endorses this doctrine
is unsound. (N Engl J Med
292:78-80, 1975)
The distinction between active and passive
euthanasia is thought to be crucial for medical ethics. The idea is that
it is permissible, at least in some cases, to withhold treatment and allow
a patient to die, but it is never permissible to take any direct action
designed to kill the patient. This doctrine seems to be accepted by most
doctors, and it is endorsed in a statement adopted by the House of
Delegates of the American Medical Association on December 4, 1973:
The intentional termination of the life of
one human being by another -mercy killing - is contrary to that for which
the medical profession stands and is contrary to the policy of the
American Medical Association.
The cessation of the employment of
extraordinary means to prolong the life of the body when there is
irrefutable evidence that biological death is imminent is the decision of
the patient and/or his immediate family. The advice and judgment of the
physician should be freely available to the patient and/or his immediate
family.
However, a strong case can be made against
this doctrine. In what follows I will set out some of the relevant
arguments, and urge doctors to reconsider their views on this matter.
To begin with a familiar type of situation,
a patient who is dying of incurable cancer of the throat is in terrible
pain, which can no longer be satisfactorily alleviated. He is certain to
die within a few days, even if present treatment is continued, but he does
not want to go on living for those days since the pain is unbearable. So
he asks the doctor for an end to it, and his family joins in the request.
Suppose the doctor agrees to withhold
treatment, as the conventional doctrine says he may. The justification for
his doing so is that the patient is in terrible agony, and since he is
going to die anyway, it would he wrong to prolong his suffering
needlessly. But now notice this. If one imply withholds treatment, it may
take the patient longer to die, and so he may suffer more than he would if
noire direct action were taken and a lethal injection given. This fact
provides strong reason for thinking that, once the initial decision not to
prolong his agony has been made active euthanasia is actually preferable
to passive euthanasia, rather than the reverse. To say otherwise is to
endorse the option that leads to more suffering rather than less, and is
contrary to the humanitarian impulse that prompts the decision not to
prolong his life in the first place.
Part of my point is that the process of
being "allowed to die" can be relatively slow and painful, whereas being
given a lethal injection is relatively quick and painless. Let me give a
different sort of example. In the United States about one in 600 babies is
born with Down's syndrome. Most of these babies are otherwise healthy
-that is, with only the usual pediatric care, they will,
proceed to an otherwise normal infancy. Some, however, are born with
congenital defects such as intestinal obstructions that require
operations if they are to live. Sometimes, the parents and the doctor will
decide not to operate, and let the infant die. Anthony Shaw describes what
happens then:
...When surgery is denied (the doctor I
must try to keep the infant from suffering while natural forces sap the
baby's life away. As a surgeon whose natural inclination is to use the
scalpel to fight off death, standing by and watching a salvageable baby
die is the most emotionally exhausting experience I know. It is easy at a
conference, in a theoretical discussion, to decide that such infants
should be allowed to die. It is
altogether different to stand by in the nursery and watch as dehydration
and infection wither a tiny being over hours and days. This is a terrible
ordeal for me and the hospital staff - much more so than for the parents
who never set foot in the nursery.
I can understand why some people are
opposed to all euthanasia, and insist that such infants must be allowed to
live. I think f can also understand why other people favor destroying
these babies quickly and painlessly. But why
should
anyone favor letting "dehydration and infection Hither a tine
being over hours and days?" The doctrine that says that a baby may be
allowed to dehydrate and wither, but may not for given art injection that
would end its life without suffering, seems so patently cruel as to
require no further refutation. The strong language is not in. tended to
offend, but only to put the point in the clearest possible way.
My second argument is
that the conventional doctrine leads to decisions concerning life and
death made on irrelevant grounds.
Consider again the case
of the infants with Down's syndrome who need operations for congenital
defects unrelated to the syndrome to live. Sometimes, there is no
operation, and the baby dies, but when there is no such defect, the baby
lives on. Now, an operation such as that to remove an intestinal
obstruction is not prohibitively difficult. The reason why such
operations are not performed in these cases is, clearly, that the child
has Down's syndrome and the parents and doctor judge that because of that
fact it is better for the child to die.
But notice that this
situation is absurd, no matter what view one takes of the lives and
potentials of such babies. 1 f the life of such an infant is worth
preserving, what does it matter if it needs a simple operation? Or, if one
thinks it letter that such a baby should not live on, what difference does
it make that it happens to have an unobstructed intestinal tract? In
either case, the matter of life and death is being decided on irrelevant
grounds. It is the Down's syndrome, and not the intestines, that is the
issue. The matter should be decided, if at all, on that basis, and hot be
allowed to depend on the essentially irrelevant question of whether the
intestinal tract is blocked.
What makes this
situation possible, of course, is the idea that when there is an
intestinal blockage, one can "let the baby die," but when there is no such
defect there is nothing that can be done, for one must not "kill" it. The
fact that this idea leads to such results as deciding life or death on
irrelevant grounds is another good reason why the doctrine should be
rejected.
One reason why so many
people think that there is an important moral difference between active
and passive euthanasia is that they think killing someone is morally worse
than letting someone die. But is it? Is killing, in itself, worse than
letting die? To investigate this issue, two cases may be considered that
are exactly alike except that one involves killing whereas the other
involves letting someone die. Then, it can be asked whether this
difference makes any difference to the moral assessments. It is important
that the cases be exactly alike, except for this one difference, since
otherwise one cannot be confident that it is this difference and not some
other that accounts for any variation in the assessments of the two cases.
So, let us consider this pair of cases:
In the first, Smith
stands to gain a large inheritance if anything should happen to his
six-year-old cousin. One evening while the child is taking his bath, Smith
sneaks into the bathroom and drowns the child, and then arranges things
so that it will look like an accident.
In the second, Jones
also stands to gain if anything should happen to his six-year-old cousin.
Like Smith. Jones sneaks in planning to drown the child in Ills bath.
However, just as fie enters the bathroom Jones sees the child slip and hit
his head, and fall face down in the water. Jones is delighted; he stands
by, ready to push the child's head back under if it is necessary, but it
is not necessary. With only a little thrashing about, the child drowns all
by himself, "accidentally," as Jones watches and does nothing.
Now Smith killed the
child, whereas Jones "merely" let the child die. That is the only
difference between them. Did either man behave better, from a moral point
of view? If the difference between killing and letting die were in itself
a morally important matter, one should say that Jones's behavior was less
reprehensible than Smith's. But does one really want to say that? I think
not. In the first place, both men acted from the same motive, personal
gain, and both had exactly the same end in view when they acted. I t may
be inferred from Smith's conduct that he is a bad man, although that
judgment may be withdrawn or modified if certain further facts are learned
about him - for example, that he is mentally deranged. But would not the
very same thing be inferred about Jones from his conduct? And would not
the same further considerations also be relevant to any,
modification of this judgment? Moreover, suppose Jones pleaded, in his
own defense, "After all, I didn't do anything except just stand there and
watch the child drown. I didn't kill him; I only let him die." Again, if
letting die were in itself less bad than killing, this defense should have
at least some weight. But it does not. Such a "defense" can only be
regarded as a grotesque perversion of moral reasoning. Morally speaking,
it is no defense at all.
Now, it may be pointed
out, quite properly, that the cases of euthanasia with which
doctors are concerned are not like this at all. They do not involve
personal gain or the destruction of normal healthy children. Doctors are
concerned only with cases in which the patient's life is of no further
use to him, or in which the patient's life has become or will soon become
a terrible burden. However, the point is the same in these cases: the bare
difference between killing and letting die does not, in itself, make a
moral difference. If a doctor lets a patient die, for humane reasons, he
is in the same moral position as if he had given the patient a lethal
injection for humane reasons. If his decision was wrong if, for
example, the patient's illness was in fact curable the decision would be
equally regrettable no matter which method was used to carry it out. And
if the doctor's decision was the right one, the method used is not in
itself important.
The AMA policy
statement isolates the crucial issue very well; the crucial issue is "the
intentional termination of the life of one human being by another." But
after identifying this issue, and forbidding "mercy killing," the
statement goes on to deny that the cessation of treatment is the
intentional termination of a life. This is where the mistake conies in,
for what is the cessation of treatment, in these circumstances, if it is
not "the intentional termination of
the life of one human
being by another?" Of course it is exactly that, and if it were not, there
would be no point to it.
Many people will find
this judgment hard to accept. One reason, I think, is that it is very easy
to conflate the question of whether killing is, in it, worse than letting
die, with the very different question of whether most actual cases of
killing are more reprehensible than most actual cases of letting die.
Most actual cases of killing are clearly terrible (think, for example, of
all the murders reported in the newspapers), and one hears of such crises
every day. On the other hand, one hardly ever hears of a race of letting
die, except for the actions of doctors who are motivated by humanitarian
reasons. So one learns to think of killing in a much worse light than of
letting die. But this does not mean that there is something about killing
that makes it in itself worse than letting die. for it is not the bare
difference between killing and letting die that makes the difference in
these cases. Rather, the other factors the murderer's motive of personal
gain, for example, contrasted with the doctor's humanitarian motivation
account for different reactions to the different cases.
I have argued that
killing is not in itself any worse than letting die; if my contention is
right, it follows that active euthanasia is not any worse than passive
euthanasia. What arguments can be given on the other side? The most
common, I believe, is the following:
"The important
difference between active and passive euthanasia is that, in passive
euthanasia, the doctor does not do anything to bring about the patient's
death. The doctor does nothing, and the patient dies of whatever ills
already afflict him. In active euthanasia, however, the doctor does
something to bring about the patient's death: he kills him. The doctor who
gives the patient with cancer a lethal injection has himself caused his
patient's death; whereas if he merely ceases treatment, the cancer is the
cause of the death."
A number of points need
to be made here. The first is that it is not exactly correct to say that
in passive euthanasia the doctor does nothing, for he does do one thing
that is very important: he lets the patient die. "Letting someone die" is
certainly different, in some respects, from other types of action - mainly
in that it is a kind of action that one may perform by way of not
performing certain other actions. For example, one may let a patient die
by way of not giving medication, just as one may insult someone by way of
not shaking his hand. But for any purpose of moral assessment, it is a
type of action nonetheless. The decision to let a patient die is subject
to moral appraisal in the same way that a decision to kill him would be
subject to moral appraisal: it may be assessed as wise or un rise,
compassionate or sadistic, right of
wrong. If a doctor deliberately let a
patient die who was suffering from a routinely curable illness, the doctor
would certainly be to blame for what he had done, just as he would be to
blame if he had needlessly killed the patient. Charges against him would
then be appropriate. If so, it would be no defense at all for him to
insist that he didn't "do anything." He would have done something very
serious indeed, for he let his patient die.
Fixing the cause of
death may be very important from a legal point of view, for it may
determine whether criminal charges are brought against the doctor. But I
do not think that this notion can be used to show a moral difference
between active and passive euthanasia. The reason why it is considered bad
to be the cause of someone's death is that death is regarded as a great
evil and so it is. However, if it has been decided that euthanasia even passive euthanasia is desirable in a given case, it has also been
decided that in this instance death is no greater an evil than the
patient's continued existence. And if this is true, the usual reason for
not wanting to be the cause of someone's death simply does not apply.
Finally, doctors may
think that all of this is only of academic interest the sort of thing that
philosophers may worry about but that has no practical bearing on their
own work. After all, doctors must be concerned about the legal
consequences of what they do, and active euthanasia is clearly forbidden
by the law. But even so, doctors should also be concerned with the fact
that the law is forcing upon them a moral doctrine that may well be
indefensible, and has a considerable effect on their practices. Of course,
most doctors are not now in the position of being coerced in this matter,
for they do not regard themselves as merely going along with what the law
requires. Rather, in statements such as the AMA policy statement that I
have quoted, they are endorsing this doctrine as a central point of
medical ethics. In that statement, active euthanasia is condemned not
merely as illegal but as "contrary to that for which the medical
profession stands," whereas passive euthanasia is approved. However, the
preceding considerations suggest that there is really no moral difference
between the two, considered in themselves (there may be important moral
differences in some cases in their
consequences,
but, as I pointed out, these differences may make active
euthanasia, and not passive euthanasia, the morally preferable option).
So, whereas doctors may have to discriminate between active and passive
euthanasia to satisfy the law, they should not do any more than that. In
particular, they should not give the distinction any added authority and
weight by writing it into official statements of medical ethics.