Many people hold that there is an important
moral distinction between passive euthanasia and active euthanasia. Thus,
while the AMA maintains that people have a right "to die with dignity," so
that it is morally permissible for a doctor to allow someone to die if
that person wants to and is suffering from an incurable illness causing
pain that cannot be sufficiently alleviated, the AMA is unwilling to
countenance active euthanasia for a person who is in similar straits, but
who has the misfortune not to be suffering from an illness that will
result in a speedy death.
A similar distinction with respect to
infanticide has become a commonplace of medical thinking and practice. If
an infant is a mongoloid, or a microcephalic, and happens also to have
some other defect requiring corrective surgery if the infant is to live,
many doctors and hospitals believe that the parents have the right to
decide whether the surgery will be performed, and thus whether the infant
will survive. But if the child does not have any other defect, it is
believed that the parents do not have the right to terminate its life.
The rationale underlying these distinctions
between active and passive euthanasia, and between active and passive
infanticide, is the same: the idea that there is a crucial moral
difference between intentionally killing and intentionally letting die.
This idea is admittedly very common. But I believe that it can be shown to
reflect either confused thinking or a moral point of view unrelated to the
interests of individuals.
Two sons are looking forward to the death
of their nasty but very wealthy father. Tired of waiting, they decide,
independently of one another, to kill their father. The one puts some
poison in his father's whiskey, and is discovered doing so by his brother,
who was just about to do the same thing. The latter then allows his father
to imbibe the deadly drink, and refrains from administering an antidote
which he happens to have. The one son killed his father. The other merely
allowed him to die. Did the former do something significantly more wrong
than the latter?
My own view is that the actions are morally
equivalent, since I think that the following general principle-which may
be referred to as the moral symmetry principle-is sound:
Let C be a causal process that normally
leads to an outcome E. Let A be an action that initiates process C, and B
be an action that stops process C before outcome E occurs. Assume further
that actions A and B do not have any other morally significant
consequences, and that E is the only part or outcome of C which is morally
significant in itself. Then there is no moral difference between
performing action A, and intentionally refraining from performing action
B, assuming identical motivation in the two cases.
This principle implies that, other things
being equal, it is just as wrong intentionally to refrain from
administering an antidote to someone who is dying of poisoning as it is to
administer the poison, provided that the same
motive is operative in both cases. And,
more generally, it follows that the distinction between killing and
intentionally letting die is not in itself a morally significant one.
Some people find this
hard to accept. However, it has been my experience that those who are
inclined to reject the moral symmetry principle often do so because of a
failure to understand exactly what it does and does not imply. Let me
begin by considering an objection which, though badly confused, helps to
clarify the principle. The criticism in question claims that the moral
symmetry principle can be shown to be mistaken by the following
counterexample. It involves considering these two actions:
Action
M:
An individual refrains from giving
information to the enemy even though he knows that the enemy will torture
a child as long as he refuses to divulge the information.
Action N: An
individual tortures a child in order to induce the enemy to give him
information.
The contention is that
it is "surely monstrous" to view these two actions as morally
equivalent. The intuitive appeal of this position is obvious. Whether it
will stand up under critical reflection is quite another matter. The
crucial point, however, is that this example is just not relevant to the
moral symmetry principle. That principle states, very roughly, that it is
as wrong intentionally to refrain from interfering with a causal process
leading to some morally significant result as it is to initiate the
process. It does not assert that it is as wrong to refrain from
preventing someone else
from
initiating a causal process as it is to initiate it oneself. So it does
not imply that actions M and N are morally, equivalent.
One might try to argue
that although the moral symmetry principle does not imply that actions
such as M and N are morally equivalent, one can formulate a generalized
moral symmetry principle which does have this implication, and which ought
to be accepted by anyone who is willing to accept the original principle.
One can certainly formulate such a principle. The difficulty is to justify
the claim that anyone who accepts the original principle ought to accept
the generalization of it. For it would seem that if intentionally
refraining from preventing someone else from doing something and doing it
oneself are morally equivalent actions, then preventing someone else from
doing something and intentionally refraining from doing it oneself are
also morally equivalent actions.' But the intuitive feeling of most people
would surely be that the mere fact that when one prevents someone else
from doing something one is interfering with someone's action, whereas
when one merely refrains from doing something oneself one is not, is a
morally relevant difference. Thus there is a prima facie case against any
extension of the moral symmetry principle that would have the consequence
that intentionally refraining frorn preventing someone else from doing
something is morally equivalent to doing it oneself. I certainly do not
wish to assert that this prima
facie case
case cannot be
overcome. However, any argument that succeeded in overthrowing it would
ipso facto give one reason to reject the contention that it is "monstrous"
to treat actions M and N as morally equivalent.
What the objection to
the moral symmetry principle has in effect done is to confuse that
principle with
consequentialism
in ethics. If consequentialism is true, then so is the moral symmetry
principle. But the converse is emphatically not the case. It is very
important to realize that one can accept the moral symmetry principle
without committing oneself to a consequentialism position.
In order to reinforce my contention that
any moral difference between actions M and N, rather than counting against
the moral symmetry principle, merely reflects the fact that one's
obligation to prevent others from doing something may not be as great as
one's obligation to refrain from doing it oneself, consider actions that
are similar to h1 and N except that the
relevant effects are achieved
directly rather than by
influencing someone else's action:
Action
M*:
One is confronted with a machine that contains a child and
a military secret. The Machine is so constructed that unless one pushes a
button, the child will be tortured and the secret will be destroyed. If
one pushes the button, the child will emerge unharmed, but the secret
will be transmitted to the enemy. One refrains from pushing the button.
Action N*: One is
confronted with a similar machine. This time, however, it is so
constructed that unless one pushes a button, a secret will be transmitted
to the enemy, while a child will emerge unharmed. If one pushes the
button, the secret
will
be destroyed, but the child will be tortured. One pushes
the button.
Although the moral
symmetry principle does not quite entail that actions M* and N* are
morally equivalent, I believe that anyone who accepts that principle would
agree that there is no moral difference between M* and N*. Doubtless there
are some
philosophers
who would also characterize this view as "monstrous." And some
philosophers have tried to argue that there is, at least, significant
moral difference between acting and refraining from acting; however, all
the arguments that I have seen in support of this contention seem to me to
be either unsound or else not relevant to the claim that the distinction
is significant
in itself:
But what is one to say
about the feeling-which is admittedly fairly widespread-that there is a
morally significant difference between acting and refraining from acting?
I do not want simply to dismiss this feeling, even though I would maintain
that appeal to such "moral intuitions" does not constitute a good way of
arriving at sound moral principles. What I want to do is to try to show
how the feelings in question may rest upon certain confusions.
The place to begin is
by distinguishing the following two questions:
1. Is the distinction
between killing and intentionally letting die morally significant in it?
2. Are there other factors which make it
generally the case that killing someone is more seriously wrong than
intentionally letting someone die?
The answer to the second question is surely
yes. In the first place, the motive of a person who kills someone is
generally more evil than the motive of a person who merely lets someone
die. A person may let someone die out of laziness or apathy, and though I
would insist that such inaction is seriously wrong, it is surely not as
seriously wrong as the action of a person who kills someone else because
he wants him dead. Secondly, the alternative to letting someone die-saving
his life may involve considerable risk to the agent, or a very large
expenditure of society’s resources. This will rarely be true of refraining
from killing someone. Thirdly, if one person forms an action that normally
results in the death of a person, there is little likelihood that the
person will survive. While one merely refrains from saving someone’s life,
there is often a substantial chance that she will survive in some other
way.
These three factors-motive,
cost to the agent and/or society, and the probability that death will
result from one’s action or inaction-all tend to make it the case that an
attempt to kill someone will generally be more seriously wrong than
intentionally refraining from saving someone’s life. It is these factors
that make the difference, rather than the difference between killing and
letting die. People are right in thinking that killing is generally
morally worse than merely letting someone die. Where they go wrong is in
failing to notice that there are factors involved that can explain this
difference in perfectly satisfactory fashion. And, as a result, they
mistakenly conclude that the difference
between killing and letting die must be morally significant in itself.
Let the conclude my
case against the distinction by mentioning an example which isolates the
interfering variables, and thus raises in a vivid way the issue of whether
there really is any significant moral difference between acting and
intentionally refraining from acting. Imagine a machine containing two
children, John and Mary. I f one pushes a button, John will be killed, but
Mary will emerge unharmed. If one does not push the button, John will
emerge unharmed, but Mary will be killed. In the first case one kills
John, while in the second case one merely lets Mary die. Does one really
wish to say that the action of intentionally refraining from pushing the
button is morally preferable to the action of pushing it, even though
exactly one person perishes in either case? The best action, it would seem
to me, would be to flip a coin to decide which action to perform, thus
giving each person an equal chance of surviving. But if that isn't
possible, it seems to me a matter of indifference whether one pushes the
button or not.
If there is no
intrinsic difference between killing and intentionally letting die, where
does this leave the distinction between active and passive euthanasia?
There are two possibilities that need to be considered. The first is that
even if neither active nor passive euthanasia is wrong in itself, it may
be that legalizing the former would have undesirable consequences, as
Yale Kamisar and others have contended.' I do not think that this line of
argument is sound; however it is certainly one that deserves very serious
consideration.
The second possibility
is one that arises if one holds both that there is no intrinsic difference
between active and passive euthanasia and that euthanasia is,
nevertheless, wrong in itself, on the grounds, say, that a person does not
have a right to kill even himself in order to put an end to unbearable
suffering. Such a view would be compatible with the acceptance of passive
euthanasia in some cases, though not in all. For while one would be
committed to holding that passive euthanasia, like active euthanasia, was
wrong in it, there might be circumstances in which the former was morally
justified. The cost of keeping a person alive, for example, might be so
great that allowing him to die would be the lesser of' evils.
My response to this
second attempt to ascribe at least limited moral significance, albeit of a
derived variety, to the distinction between active and passive euthanasia,
is to reject the view that active euthanasia is wrong in itself. What I
should argue, ultimately, is that there must surely be some justification
for the institution of morality, some reason for society to accept moral
rules. And what reason more plausible than that the acceptance of a
certain set of moral rules accords better with the interests of people
than the acceptance of some other set of moral rules, or none at all? But
some moral rules that people accept, or have accepted, are clearly such as
do not serve the interests of individuals e.g. various sexual
prohibitions, such as that against masturbation. The prohibition of active
euthanasia seems to be another case of a moral point of view which does
not further the interests of individuals living together in society. Why,
then, has this moral point of view been accepted? The answer here, as in
the case of the traditional sexual outlook of Western society, is found in
the powerful influence of the Christian churches.' This historical point
deserves to be kept firmly in view when one is reflecting upon the
morality of euthanasia. Many otherwise thoughtful people somehow lose
sight of the fact that what they refer to as "moral intuitions" regarding
euthanasia sprang originally from a certain theological outlook, one that
is no longer taken seriously by most people who have taken the trouble to
examine its credentials carefully and impartially.
In conclusion, then, it
is far from clear that the commonly accepted distinction between active
and passive euthanasia is morally significant. This has been, admittedly,
a very brief survey of the relevant issues. In some cases I have been able
to do little more than touch upon them in
passing. However, I have tried to argue, in some detail, that the
distinction between killing and letting die is not morally significant in
itself. If this is right, then the reason that is most commonly offered
for holding that there is a morally significant difference between active
and passive euthanasia is in
fact unsound.