KILLING AND LETTING DIE: IS THERE A MORAL DIFFERENCE BETWEEN PERFORMING ACTIVE EUTHANASIA AND LETTING A PATIENT DIE THROUGH WITHDRAWING LIFE PROLONGING TREATMENT?”

“The distinction between active and passive euthanasia is thought to be crucial for medical ethics…the idea 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 is endorsed by most doctors and…in policy statements and legislation” (Rachels 1975: 78).
The past few decades have witnessed rapid technological and social developments concerning end-of-life healthcare which have fundamentally altered the dying process. Accompanying these changes, (and arguably partially facilitative of them), are social, practical, legal and ethical concerns (Cartwright et al 2006: 256). Recent high profile “right-to-die” cases have served to heighten confusion within the general public and medical community surrounding euthanasia, particularly the distinction between “active” and “passive” forms (Moody 2002: 40). There has thus been a considerable amount of debate within the bioethical community concerning the distinction between “killing” and “letting die,” which in moral philosophy refers to the doctrinal difference between “acts” and “omissions.” As part of its fundamental code, the medical community embraces a moral division between “killing people” on the one hand, and “merely letting people die” on the other (Dines 1995:911), despite frequent assertions that the boundaries between these are becoming increasingly blurred and that the distinction does not stand up to close theoretical scrutiny (Moody 2002: 41, Dines 1995, Savalescu 2005, Keown 2003, Shaw 2002). Whether one believes that there exists a moral difference between “killing” and “letting die” rests on the specific philosophical line adopted in moral theorising. Generally, a consequentialist ethic stresses the significance of final consequences in determining moral difference between end outcomes of behaviour, whilst an absolutist, (de-ontological) perspective maintains that killing is prima facie wrong, and an innocent life should never be taken intentionally. Given that the primary concern within the medical reality is therapeutic outcomes, my line of argument supports the consequentialist viewpoint which holds that ultimately, the difference between performing active euthanasia and letting a patient die through withdrawing (or withholding) life-sustaining treatment lies apart from the moral responsibility that they carry. In some ways, strict insistence on a focus towards moral difference inherent within action and passivity in the euthanasia controversy clouds other significant issues for healthcare professionals, preventing them from squarely addressing life-terminating acts. As Moody states “it needs to be recognised and acknowledged that intentionally letting die, and helping to die by active means are morally and legally the same; they are both the intentional causation of death” (2002: 44).
Euthanasia is an extremely emotive issue, giving rise to complex discussions, and occasionally, even accusations (Leget 2006: 256). As with all such sensitive issues, there is considerable controversy over the terminology involved. The original meaning of “euthanasia” is derivative of the idea of a “good death,” “comfortable and free from pain and distress in the sense promoted in palliative care” and only in the nineteenth century did it grow to acquire the referent of “killing someone for their own benefit (Savalescu 2005: 14). In ethics literature on euthanasia there has been a widely accepted taxonomy which consists of two key distinctions using euthanasia as an umbrella term that may be subdivided; firstly between active and passive; and secondly, differentiating voluntary, nonvoluntary and involuntary forms which are dependent on issues autonomy and competent consent (Garrard and Wilkinson 2005 :64). “Passive” euthanasia involves refraining from doing anything to keep a patient alive, for instance, by refusing to perform surgery, administer antibiotics, or withholding life sustaining therapy. In contrast, the term “active” euthanasia designates taking some definite action designed to kill the patient, for example, injecting a lethal dose of potassium chloride (Dines 1995: 912). As Dines elaborates, “the formal expression of the active-passive distinction is usually known as ‘the doctrine of acts and omissions'” (1995: 913). The legislation surrounding euthanasia regards the failure to perform an act with certain foreseen bad consequences of that failure (i.e. death), is morally less reprehensible than to perform a different act which has the identical foreseen negative consequences. In other words, “it is worse to kill someone than to allow them to die” (Glover 1977 in Dines 1995: 913).
Stauch (2000:237) defends the principles which underpin present legislation surrounding euthanasia in the UK, aiming to show that the fundamental division of moral attribution is essentially sound. His argument in upholding a relevant difference between “killing” and “letting die” is premised on the infringement of the “principle of equality.” Utilising this philosophical tenet he claims that the refusal to characterise doctors’ conduct (in the context of withholding/withdrawing treatment) as an act, has a “perfectly defensible and principled basis” which derives from the use of “a wider and more plausible criterion of action than one of voluntary physical movement alone” (2000:238). This directs the focus of attention into a wider contextual schema, stating that what is significant is whether the cause of some given outcome forms “part of a causal set sufficient for such an outcome to follow” (Stauch 2000: 239). Stauch’s point rests on the fact that when medical practitioners “omit” to act, their failure is not merely a breach of duty, but “a deviation from a system of routine” and through attributing causal status to some necessary conditions, we may look to this to control the occurrence of such outcomes, and/or allocate blame to a human agent (2000: 240). By this reasoning, he asserts that it is justified (in cases where treatment is available to prolong life), to cite the failure of a doctor to treat as the cause of the patient’s death. An omission here is more than simply “not doing” as the language of action is linked to “the language of control” (Walton 1979: 4 in Begley 1998: 868). Something is classified as an omission within this line of thought when an agent could have brought about a state of affairs and was expected to do so.
However, he goes on to state that the “passive” doctor who allows a patient to die by failing or ceasing to provide medical assistance, allows for the completion of a pre-existing causal set for that outcome (that the patient will die, as they are in need of life-saving treatment). He contrasts this to the “active” agent who causes death through a specific action, where this behaviour is sufficient independently to instigate the same result (by activating a causal set) in combination with background conditions alone (Stauch 2000: 240). In summary, individual causal “authorship” of an omitting agent is important where there is a socially imposed duty to act. In the context of healthcare, acts and omissions are open to moral and legal redress, based on a duty of care (Montgomery 1997 in Snelling 2004: 354). According to Stauch, active euthanasia is considered problematic in a way that passive euthanasia is not, by merit of the “principle of equality,” which states that the life of every individual has an equal claim to a minimum respect by possessing a life of irreducible value and an agent who engages in active euthanasia fails to show respect for this. By engaging in active euthanasia, an agent assumes authorship over that other’s death, automatically assigning his own life an ontological priority. The example given to evidence this displays two circumstances involving active and passive euthanasia concerning a man dying of terminal cancer who has requested voluntary euthanasia by means of an advanced directive. In the first scenario, his wife asphyxiates him with a pillow whilst he sleeps (active euthanasia), and in the second, she fails to alert for a sudden need for a respirator as his condition worsens (passive euthanasia). Stauch (2000: 241) asserts that in the first example the wife assumes authorship over the death, violating the equality principle which makes this active euthanasia “killing”. In the second case, her action in itself is not sufficient to account for the man’s death, as he dies of the illness afflicting him, and thus she “lets him die,” which does not breach the equality principle and carries a variant moral weight. Stauch’s argument manifests the view that the distinction enforced by the law between active and passive euthanasia (“killing” and “letting die”) is “one which is both coherent and defensible at a fundamental level” (2000: 241). A related idea here is the belief that so-called passivity within the context of euthanasia fits into accepted ideas of “going along with nature” (Dines 1995: 912) and “not playing God.” However, this is not a suitable parameter for moral acceptability as many therapeutic measures to reduce suffering include intervention in “nature.”
Conceptually, Stauch’s theory draws on the definition of an act as the initiation of a causal process, whilst his idea of omission is more difficult to elucidate. Put simply, he follows Aquinas (in Snelling 2004: 352), in asserting that “omission means failing to do good, albeit not any good, but only the good that one ought to do.” He draws on an ontological perspective, preserving the “sanctity of life” principle by upholding a categorical injunction against killing (Moody 2002: 43). Many other theorists however, (Rachels 1975, Dines 1995, Begley 1998, Garrard and Wilkinsons 2005, Snelling 2004, Bishop 2000 and 2006, Keown 2003, Moody 2002), have claimed that this distinction is seriously flawed and has distorted the philosophical and legal landscape on which euthanasia and end of life decisions and policies are based. Though the standard medico-legal categorisation of euthanasia offers the possibility of finding “letting die” less morally objectionable, it has been continually attacked and critiqued as misleading, ambiguous and unhelpful (Garrard and Wilkinson 2005: 64). In the high profile case of Tony Bland it was suggested in court that the acts/omission distinction does not enjoy a moral foundation, and reliance on it has rendered the law “morally and intellectually misshapen” (Stauch 2000: 237, Keown 2003: 462, Moody 2002: 43). Rachels (1975: 79) points out that it is “very easy to conflate the question of whether killing in itself is worse than letting die, with the very different question of whether most cases of killing are more reprehensible than most actual cases of letting die.” Those authors who hold that the distinction between “killing” and “letting die” is defective (and ethically inconsistent), argue that though one learns to think of killing in a more negative light than letting die, this should not be the basis of an assumption that there is something inherent in the act of killing itself which makes it ethically worse than allowing to die. Rather, what is maintained is that the motive for conducting an act should account for differing moral judgment. (Rachels 1975: 80, Snelling 2004: 353, Begley 1998: 869, Dines 1995: 912). Thus their position contravenes Stauch’s absolutist stance shown above, as they assert that establishing the line of causality for death may be crucial from a legal standpoint, but it does not determine a true moral difference between “killing” and “letting die.”
One justification for this assertion is that the “sanctity of life” principle, premised on the idea that it is always wrong to end an innocent human life intentionally is continually facing cultural erosion. Having a life in itself is no longer enough, this life must be of a certain quality to make it a “worthwhile life” (Keown 2003: 461, Moody 2002: 43). This “quality of life” ethic ultimately renders the active-passive moral distinction redundant. Not only does it render all forms of euthanasia acceptable morally on the basis that they put an end to a life of suffering, pain and degeneration, but within this view, active euthanasia may also be more humane than passive. The process of being “allowed to die” may be relatively lengthy and extremely painful, thus prolonging a patient’s agony and poor quality of life, whilst active euthanasia by being administered a lethal injection is quick and painless. This makes it problematic to hold that passive euthanasia is morally less culpable than active as it often favours intermediate suffering (Rachels 1975: 78, Berry 2000: 372). The fact remains that in both active and passive euthanasia, the outcome within the medical reality is the same – death of the patient. Supporting this statement ethically requires a reflection on consequentialist thinking, which considers active-passive moral distinctions irrelevant, arguing that acts are right or wrong by virtue of their consequences (Snelling 2004: 350), and that if an act and an omission result in the same consequences, then their morality is therefore the same.
As healthcare ethics and legislative policy concerning euthanasia in the UK are dominated by an absolute position (founded on the concept that there is a distinction and “killing” is something we may never do, regardless of potential benevolent consequences) they disallow consideration of consequences, and resultantly have been accused of ethical inconsistency, accommodating in practice, what they deny in theory (Snelling 2004: 351). A primary concern of moral evaluation within the controversy over “killing” and “letting die” argument is that “a major factor which limits the usefulness of [these] concepts…is their partly evaluative nature” (Snelling 2004: 354). The evaluative components present explain why “killing” and “letting die” are not the same definitionally as acts and omissions, as the former can be assessed both positively and negatively dependent on situational factors, which means that an omission (such as withdrawing life-support treatment due to a prior motive, such as gaining inheritance from a dying relative) may be regarded in some circumstances as technically “letting die” but morally as killing (Snelling 2004: 355). The dinstinction between killing and letting die thus rests not on an inherent moral distinction between acts and omissions, but the intentions and motives of those involved. Morality is thus external to the acts themselves and ethical judgment should be reserved until an example is placed inside a wider context in which background factors are considered. As Sullivan explains (1977: 44 in Begley 1998: 869), “the traditional view is that the intentional termination of human life is impermissible, irrespective of whether this goal is brought about by action or inaction…is the action of refraining aimed at producing a death? Is the termination of life sought, chosen, or planned? Is the intention deadly? If so, the omission is wrong.” In light of other dynamics which are contributory to final outcome, such as motive and intention (direct and indirect), it is difficult to deny that “killing” and “letting die” (act and omission) carry equal moral responsibility (Begley 1998: 869). That we have to consider external factors to determine the judgment of an act ethically proves that in themselves, all harmful acts are not instrinsically worse, morally speaking, than all omissions (Rachels 1975: 79, Begley 1998: 869).
As has been mentioned previously, the establishment of “rightness or wrongness” is dependent on the justification upon which the action is based, and not on the type of action. Those who do claim that there is an inherent moral distinction refers to the presence of other morally important factors such as the role of intention as evidenced in the deontological position’s usage of the “doctrine of double effect.” The double effect principle is rooted in Christian moral theology (Snelling 2004: 355, Begley 1998: 870, Dines 1995: 912, Savalescu 1995: 12, Shaw 2002: 102), which attempts to draw distinctions between harms intended, and those that are not intended, but are nonetheless foreseen. Within the medical arena, treatments are often used in palliative care for certain therapeutic means, yet they may have other ends which arise apart from that intended. For example, a doctor may give a high dose of morphine, stating that their primary intention was beneficent -to relieve the pain of a patient with terminal cancer, yet they foresee that this medication may shorten life by depressing respiration (Savalescu 1995: 12). Healthcare professionals and ethicists appeal to this doctrine in order to differentiate between prohibited and permissible actions through a focus on intention. Yet the doctrine has been frequently criticised on account of the fact that it is virtually impossible to establish whether the “true” intention of an agent is that which they lay claim to, and to discern foreseen actions from those intended, and distinguish intended side effects from unintended (Moody 2002: 43). It allows the deflection of moral criticism by means of the flawed argument that there is an ethical difference between passive and active euthanasia, in that in the former the death is usually not directly intended.
Rachels (1975:80) suggests that whereas doctors have to discriminate between active and passive euthanasia to satisfy law, they should not give the distinction any added authority and weight by writing it into official statements of medical ethics. Within the context of the euthanasia debate, the view that failure to perform an act (“letting die”) is less morally reprehensible than performing an act with the same foreseen consequences rests upon a defective assumption that individuals are not as responsible for their inactions as their actions, which in turn, assumes that to be inactive is to take a neutral stance and to play no part in the outcome (Dines 1995: 913). Yet, as Dines elaborates, if the bad consequences of an act are foreseen, then to be inactive is not a neutral stance, it is to make a set choice “not to act” which affects the outcome of the patient’s death (1995: 913). Therefore, the active-passive dimension of the distinction between killing and letting die does not stand up to serious theoretical scrutiny, failing to provide a plausible basis for the moral evaluation of two courses of action, and failing to justify “letting die” as morally different from “killing” in terms of their use with reference to euthanasia. “Unworkable distinctions” (Otlowski 1997 in Miola 2000: 277) such as those between “acts/omissions” and “killing/letting die,” show the need for reform both in conceptual terms and in policy. This would allow a move away from debate stagnation in the doctrinal and hypothetical, and catalyze an acceptance of the imperative needs which emerge in the current medico-political climate concerning euthanasia, the growing support for the right to die (Fraser and Walters 2000: 122, Moody 2002: 40, Berry 2000: 374), and a review of lay and medical opinion concerning life-terminating decisions generally, whether they be classed as “acts” or “omissions,” “killing” or “letting die” (as in a medical context the end result is an invariable, the death of the patient). If a patient’s death is viewed as beneficial and morally justifiable in a particular case, then the difference between killing and letting die is irrelevant. Labelling a death as resultant of one or the other, does not determine which is better or worse, morally speaking, instead the central determinant of the morality of an act is motivation. Motive in a therapeutic context is most frequently the humanitarian impulse that characterises the medical objective, whether in active euthanasia, or withdrawing life-prolonging treatment, so, in conclusion, I see no moral difference between these two behaviours.