Humanist Perspectives: issue 152: Active and Passive Euthanasia

Active & Passive Euthanasia
Is there a moral distinction?
by Bob Lane

I started to write “the Sue Rodriguez case has reminded us all…” and then I realized how wrong that is. It is not the Sue Rodriguez ‘case’ — it is Sue Rodriguez who has reminded us all of our own mortality and our need to think carefully about the kind of society we want to live and to die in. I knew Sue Rodriguez only through the media, heard her speak so eloquently and painfully in support of what she believed in, watched as her strength was sapped by the devastating disease (amyotrophic lateral sclerosis), and was moved by her clear thought and her bravery as a person facing death. Here was a woman who acted on her beliefs with courage and tenacity and whose grace has enriched us all.

She challenged us to think about the difference between what our laws of the land say and what our people say. Her death, and her life, says to us ‘think carefully about these matters of life and death for they are not academic and distant but are a necessary part of everyone’s existence.’

Is there any difference between killing and letting die?

Sue Rodriguez and Karen Ann Quinlan have done more than ethicists, doctors, and moralists to rivet public attention on the legal and moral aspects of euthanasia. In 1994 Sue Rodriguez chose to die. In 1975 Karen Ann Quinlan, for reasons still unknown, ceased breathing for several minutes. Failing to respond to mouth-to mouth resuscitation by friends she was taken by ambulance to a hospital in New Jersey. Physicians who examined her described her as being in “a chronic, persistent, vegetative state,” and later it was judged that no form of treatment could restore her to cognitive life. Her father asked to be appointed her legal guardian with the expressed purpose of discontinuing the respirator which kept Karen alive. After some delay the Supreme Court of New Jersey granted the request. The respirator was turned off. Karen Ann Quinlan remained alive but comatose until June 11, 1985, when she died at the age of 31.

These cases and others like them demand that we think carefully through a number of conceptual issues. What is a person? What is death? How does the difference between active and passive function in arguments for and against euthanasia? Is there any difference between killing and letting die?

The question of personhood bears on euthanasia as on abortion debates. What criteria should be used to determine personhood? Is it just a matter of species? That is, are all and only biological humans persons? That does not seem right because for the theist, it must be the case that God or gods, angels and so forth are also persons in the moral sense. Further, if we do discover some alien race on a distant planet would their lack of a certain dna string be sufficient to say that they were not persons, capable of making decisions and acting on them? And in fact, here on our own planet is there not a strong argument for treating the Great Apes as persons, as a recent book advocates? The importance of this conceptual issue is just that if we could establish the criteria for personhood then those qualifying enjoy the same rights as any other patient. It seems right to say, for example, that the person Karen Ann Quinlan died sometime in 1975 though her body survived until 1985.

It used to be that death meant the termination of breathing. Later physicians defined death as a total stoppage of the circulation of blood. This definition served well until recent technology made it possible to sustain respiration and heartbeat indefinitely, even when there is no brain activity. The need for still viable organs for transplantation has resulted in a refined definition based on brain wave activity.

It has long been held that the distinction between active and passive euthanasia is crucial for medical ethics. The idea is that although it may be permissible in some cases to withhold treatment and allow a patient to die, it is never permissible to take any direct action to bring about that death. North American Medical Associations base their ethical conduct on this distinction, as in this statement by the American Medical Association: “The intentional termination of the life of one human being by another … is contrary to that for which the medical profession stands … 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.”

This so-called distinction between active and passive was challenged by the philosopher James Rachels in a paper first published in 1975 in the New England Journal of Medicine. In that paper Rachels challenges both the use and moral significance of that distinction for several reasons. First, he argues, active euthanasia is in many cases more humane than passive; second, the doctrine leads to decisions concerning life and death being made on irrelevant grounds; and third, the doctrine rests on a distinction between killing and letting die that itself has no moral significance. Rachels urges doctors to reconsider their views. He writes:

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 this request.

Suppose the doctor agrees to withhold treatment… The justification for his doing so is that the patient is in terrible agony, and since he is going to die anyway, it would be wrong to prolong his suffering needlessly. But now notice this. If one simply withholds treatment, it may take the patient longer to die, and so he may suffer more than he would if more 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.

Is killing someone worse than letting them die? Rachels asks us to consider these two cases: In the first Smith will gain a large inheritance if anything should happen to his young cousin. One evening while the youngster is taking a bath, Smith sneaks into the bathroom and drowns the child, and then arranges things so it will look like an accident. In the second parallel case, Jones will gain a large inheritance and plans to drown his cousin, but as he enters the bathroom Jones sees the child slip and hit his head and fall face down in the water. Jones watches and does nothing. Now, Smith killed the child while Jones ‘merely’ let the child die.

Rachels’ question: 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?”

If the crucial issue in the euthanasia debate is the intentional termination of the life of one human being by another, then how can it be consistent to forbid mercy killing and yet deny that the cessation of treatment is the intentional termination of a life? What is the cessation of treatment if it is not the “intentional termination of the life of one human being by another”? The so-called distinction between active and passive does not provide a useful moral distinction.

I believe that there are some circumstances when euthanasia, including active euthanasia, is the morally correct action. I also understand that there are real concerns about legalizing euthanasia because of fear of misuse and/or overuse and the fear of the slippery slope leading to a loss of respect for the value of life. We do need to proceed with caution. We need full and open discussion, improvements in research, the best palliative care available, and above all we need to think about the topic together. Our best approach at this time may be to modify the laws to include motivational factors as a legitimate defense. Just as homicide is acceptable in cases of self-defense, assisting in taking a life should be considered acceptable if the motive is mercy. Obviously, strict parameters would have to be established that would include patients’ request and approval, or, in the case of incompetent patients, advance directives in the form of a living will or family and court approval.

Bob Lane is a retired philosophy professor and frequent contributor. This article is taken with permission from a longer essay of his in the book Assisted Suicide edited by Karen F Balkin and published by Greenhaven Press in January 2005.

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