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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). 

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. 

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