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Active and passive euthanasia

Active euthanasia

Active euthanasia occurs when the medical professionals, or another person, deliberately do something that causes the patient to die.

Passive euthanasia

Passive euthanasia occurs when the patient dies because the medical professionals either don't do something necessary to keep the patient alive, or when they stop doing something that is keeping the patient alive.

• switch off life-support machines
• disconnect a feeding tube
• don't carry out a life-extending operation
• don't give life-extending drugs

The moral difference between killing and letting die

Many people make a moral distinction between active and passive euthanasia.

They think that it is acceptable to withhold treatment and allow a patient to die, but that it is never acceptable to kill a patient by a deliberate act.

Some medical people like this idea. They think it allows them to provide a patient with the death they want without having to deal with the difficult moral problems they would face if they deliberately killed that person.

There is no real difference

But some people think this distinction is nonsense, since stopping treatment is a deliberate act, and so is deciding not to carry out a particular treatment.

Switching off a respirator requires someone to carry out the action of throwing the switch. If the patient dies as a result of the doctor switching off the respirator then although it's certainly true that the patient dies from lung cancer (or whatever), it's also true that the immediate cause of their death is the switching off of the breathing machine.

• in active euthanasia the doctor takes an action with the intention that it will cause the patient's death
• in passive euthanasia the doctor lets the patient die
  • when a doctor lets someone die, they carry out an action with the intention that it will cause the patient's death
• so there is no real difference between passive and active euthanasia, since both have the same result: the death of the patient on humanitarian grounds
• thus the act of removing life-support is just as much an act of killing as giving a lethal injection

Is active euthanasia morally better?

Some (mostly philosophers) go even further and say that active euthanasia is morally better because it can be quicker and cleaner, and it may be less painful for the patient.

Acts and omissions

This is one of the classic ideas in ethics. It says that there is a moral difference between carrying out an action, and merely omitting to carry out an action.

Simon Blackburn explains it like this in the Oxford Dictionary of Philosophy:

But the acts and omissions doctrine doesn't always work...

The killings in the bath

The philosopher James Rachels has an argument that shows that the distinction between acts and omissions is not as helpful as it looks. Consider these two cases:

• Smith will inherit a fortune if his 6 year old cousin dies.
• One evening Smith sneaks into the bathroom where the child is having his bath and drowns the boy.
• Smith then arranges the evidence so that it looks like an accident.

• Jones will inherit a fortune if his 6 year old cousin dies.
• One evening Jones sneaks into the bathroom where the child is having his bath.
• As he enters the bathroom he sees the boy fall over, hit his head on the side of the bath, and slide face-down under the water.
• Jones is delighted; he doesn't rescue the child but stands by the bath, and watches as the child drowns.

According to the doctrine of acts and omissions Smith is morally guiltier than Jones, since he actively killed the child, while Jones just allowed the boy to die. In law Smith is guilty of murder and Jones isn't guilty of anything.

However, most people would regard any distinction between their moral guilt as splitting hairs.

Suppose Jones defends himself by saying:

Would we be impressed?

An objection to this analogy

You might argue that we can't compare the case of a doctor who is trying to do their best for their patient with Smith and Jones who are obvious villains.

Of course you can't. But if you don't find the difference between killing and letting die persuasive in the Smith/Jones case, you shouldn't find it effective in the case of the well-meaning doctor and euthanasia.

The importance of intention

The Smith/Jones case partly depends on us paying no attention to the intentions of Smith and Jones. But in most cases of right and wrong we do think that intention matters, and if we were asked, we would probably say that Smith was a worse person than Jones, because he intended to kill.

Consider this case (and yes, it's a fantasy, doctors don't behave like this):

• Brown is rushed into hospital after being stabbed.
• He arrives in casualty. Although he is bleeding heavily, he could be saved.
• The only doctor on duty wants to go home, and knows that saving Brown will take him an hour.
• He decides to let Brown bleed to death.
• Brown dies a few minutes later.
• Brown's mother arrives, and on learning what has happened screams at the doctor, "You killed my son!"
• The doctor replies, "No I didn't. I just let him die."

No-one would think that the doctor's reply excused him in any way. In this case letting someone die is morally very bad indeed.

And if the lazy doctor defended himself to Brown's mother by saying, "I didn't kill him. The dagger in his heart killed him," we wouldn't think this an adequate moral argument either.

You can probably invent many similar examples.

But there are cases where letting someone die might not be morally bad.

Suppose that the reason the doctor didn't save Brown was that he was already in the middle of saving Green, and if he left Green to save Brown, Green would die. In that case, we might think that the doctor had a good defence against accusations of unethical behaviour.

Further reading

James Rachels, 'Active and Passive Euthanasia'. The New England Journal of Medicine, Vol. 292, pp 78-80, 1975

Preferring active to passive euthanasia

This section is written from the presumption that there are occasions when euthanasia is morally OK. If you believe that euthanasia is always wrong, then this section is not worth reading.

Active euthanasia is morally better because it can be quicker and cleaner, and it may be less painful for the patient.

Doctors faced with the problem of an incurable patient who wants to die have often felt it was morally better to withdraw treatment from a patient and let the patient die than to kill the patient (perhaps with a lethal injection).

But some philosophers think that active euthanasia is in fact the morally better course of action.

Here's a case to consider:

• A is dying of incurable cancer.
• A will die in about 7 days.
• A is in great pain, despite high doses of painkilling drugs.
• A asks his doctor to end it all.
• If the doctor agrees, she has two choices about what to do:
  • The doctor stops giving A the drugs that are keeping him alive, but continues pain killers - A dies 3 days later, after having been in pain despite the doctor's best efforts.
  • The doctor gives A a lethal injection - A becomes unconscious within seconds and dies within an hour.

Let's suppose that the reason A wants to die is because he wants to stop suffering pain, and that that's the reason the doctor is willing to allow euthanasia in each case. Active euthanasia reduces the total amount of pain A suffers, and so active euthanasia should be preferred in this case.

To accept this argument we have to agree that the best action is one the which causes the greatest happiness (or perhaps the least unhappiness) for the patient (and perhaps for the patient's relatives and carers too). Not everyone would agree that this is the right way to argue.

We can look at this situation is another way:

• Causing death is a great evil if death is a great evil.
• A lesser evil should always be preferred to a greater evil.
• If passive euthanasia would be right in this case then the continued existence of the patient in a state of great pain must be a greater evil than their death.
• So allowing the patient to continue to live in this state is a greater evil than causing their death.
• Causing their death swiftly is a lesser evil than allowing them to live in pain.
• Active euthanasia is a lesser evil than passive euthanasia.

But this still won't satisfy some people. James Rachels has offered some other arguments that work differently.

Do as you would be done by

The rule that we should treat other people as we would like them to treat us also seems to support euthanasia, if we would want to be put out of our misery if we were in A's position. But this isn't necessarily so:

• A person might well not want to be killed even in this situation, if their beliefs or opinions were not against active euthanasia.
• There are many examples of people who have accepted appalling pain for their beliefs.

Only rules that apply to everyone can be accepted

One well-known ethical principle says that we should only be guided by moral principles that we would accept should be followed by everyone.

If we accept that active euthanasia is wrong, then we accept as a universal rule that people should be permitted to suffer severe pain before death if that is the consequence of their disease.