World Congress Proceedings Vol. 3, Bioethics Evangelos Protopapadakis Why Letting Die Instead of Killing? Choosing Active Euthanasia on Moral Grounds ABSTRACT: Ever since the debate concerning euthanasia was ignited, the distinction between active and passive euthanasia – or, letting die and killing – has been marked as one of its key issues. In this paper I will argue that a) the borderline between act and omission is an altogether blurry one, and it gets even vaguer when it comes to euthanasia, b) there is no morally significant difference between active and passive euthanasia, and c) if there is any, it seems to favor active instead of passive euthanasia. Therefore, while the distinction between active and passive euthanasia might be meaningful in terms of description, if it is considered to be endowed with moral weight and used on purpose of justifying one type of euthanasia instead of the other, it becomes morally problematic and misleading. KEYWORDS: act, omission, euthanasia, active euthanasia, passive euthanasia All moral issues concerning the deliberate taking of the life of another person are always morally problematic and highly controversial. This means that, whatever are the reasons for supporting one or the other view, these reasons have to be strong and meaningful, and bolstered by sound arguments. Euthanasia – by this term I refer to the taking of the life of a terminal patient in extreme agony and intense suffering according to her persistent and informed request on the sole purpose of relieving her from intolerable pain1 – undoubtedly has some quite persuasive arguments on its side. Respect for patient's autonomy,2 for her so-called right to die3 and her right to privacy,4 treating her as an end and not solely as a means,5 opting for an allegedly 1 McLean, Sh., "End-of-life decisions and the law", Journal of Medical Ethics, 22:5 (1996), p. 262. 2 Nowell-Smith, P., "Euthanasia and the doctors – a rejection of the BMA's report", Journal of Medical Ethics, 15:3 (1989), p. 128. 3 Robertson, J.A., "Cruzan: No Rights Violated", Hastings Center Report, 20:5 (1990), p.9. 4 Humphry, D. & Wickett, A., The Right to Die – Understanding Euthanasia, Bodley Head, London, 1986, p. 68. 5 Bix, Br., "Physician Assisted Suicide and the United States Constitution", Modern Law 86 Evangelos Protopapadakis optimum balance between gains and losses,6 all these are good reasons why one would consider euthanasia as a moral option for herself and claim it, and others should either respect her claim, or resort to equally persuasive moral arguments in order not to. As a matter of fact, there are arguments equally strong and convincing in either sides of the debate, and this is why the debate is still an active one. When, however, the focus is shifted – from whether and under which circumstances is euthanasia morally justifiable – to the way it should be performed, there seems to be less controversy. Most ethicists agree that if euthanasia should be permitted, it should be performed passively and not actively. Allow me to focus a bit more on this distinction. Active euthanasia is performed usually by means of injecting the patient with a lethal drug. Of course there are other ways to actively take the life of the patient, but since a lethal injection is by far the most efficient, most humane and less dramatic one, it is favored in the majority of such cases.7 Passive euthanasia is usually achieved by withdrawing any life supporting means – such as the respirator, the external heart pump, the hemodialysis machine – by virtue of which the patient is being kept alive, or by withholding food and water.8 The active termination of the patient's life is usually denounced on moral grounds; it is considered to be killing, and thus morally unjustifiable.9 The withdrawal of life-supporting means, on the other hand, is assumed to be letting someone die, and thus not morally rejected.10 In the first case, this of active euthanasia, she who performs it actively intervenes with the patient's life and kills her; in the latter, that of passive euthanasia, she who inflicts death does so by omitting to intervene – she just 'let nature take its course' or 'the condition of the patient develop'11 – as far as the use of life-supporting machines is concerned, of course. Since killing someone is usually to morally harm or wrong her, but failing to prevent one's death is not per se wrongful, active euthanasia is considered to be as morally unjustifiable as killing is, while Review 58:3 (1995), p. 411. 6 Dyck, A.J., "Physician -Assisted -Suicide: Is it Ethical?", Harvard Divinity Bulletin, 21:4 (1992), p.17. 7 Munson, R., Intervention and Reflection: Basic Issues in Medical Ethics, Wadsworth Publishing Company, Belmont, 1983, p. 181. 8 Stewart, G.T., Curter, W.R. & Demy, T.J., Suicide and Euthanasia, Kregel Publications, Grand Rapids, 1998, p. 23. 9 Beauchamp, T.L., Intending death: The ethics of assisted suicide and Euthanasia, Prentice Hall, New Jersey, 1995, p. 3. 10 Beauchamp, T.L. & Childress, J.F., Principles of Biomedical Ethics, Oxford University Press, Oxford, 1994. 11 Baird, R.M., & Rosenbaum, S., Euthanasia: The moral issues, Prometheus Books, New York, 1989, p. 12. Why Letting Die Instead of Killing? 87 passive euthanasia is considered as morally neutral as failing to prevent the death of, let's say, the victims of a car accident somewhere in the world. This approach, however, in my mind remains arbitrary and morally unjustifiable. Acting and omitting to act according to common sense as well as in the eyes of the law usually fall under distinct categories. In ethics, however, this is not always the case.12 Consider a case in which A puts false charges for murder against you on purpose of having you convicted. Her act is blameworthy and morally unjustifiable, since she has purposefully lied in order to harm you. Now consider the case in which false charges are put against you by the state, charges that would immediately fall if B, the only person who would confirm your alibi, did so with no consequence whatsoever on her. However, B doesn't do this although she could with no personal cost at all, she again on purpose of having you convicted. In the first case A acts in order to wrong and harm you, while in the second B does nothing of the kind to prevent you being harmed. Nevertheless, B wrongs you no less than A does, and B's omission to testify for your innocence is equally blameworthy to A's actions intending to your conviction, since her intention was no different at all: both have proceeded in their actions (or omissions) with the intention to wrong and harm you. The same applies to euthanasia: intentionally letting one die when you can save her is no less morally blameworthy (or praiseworthy) than intentionally killing her. In both cases the intention of the agent, her purpose, and the results of her options are identical. The only thing that differs is the means she chooses to achieve her ends, to wit the death of the terminally ill and in terrible pain patient according to the latter's own free and informed will. In other words, in the case of euthanasia whether the moral agent acts or omits to act is only a matter of strategic planning, and not a moral one. The moral decision is the same for both options: in the best possible scenario, she who inflicts death has decided to relieve the patient of her hopeless agony. In my view, there is slight morally significant difference between active and passive euthanasia, if any. In addition to these, in the case of euthanasia – bearing in mind the way it is usually performed in both its possible scenarios – it is most of the times extremely difficult to tell action from omission.13 Take for example the lethal injection scenario on the one hand, and the withdrawal of the respirator on the other. It is very hard to tell why the first is deemed an action, while the second is not. It doesn't take to be an apt master of abstract meditation to conclude that injecting someone is as much performing an action as shutting down a machine. 12 Rachels, J., "Active and Passive Euthanasia," in Singer, P., (ed.), Applied Ethics, Oxford University Press, Oxford, 1986, p. 31. 13 Prado, C.G., & Taylor, S.J., Assisted Suicide: Theory and practice in elective death, Humanity Books, New York, 1999, p. 11. 88 Evangelos Protopapadakis Still, when it comes to euthanasia, shutting down a respirator is considered to be an omission, and not an action. The rationale usually brought forth is that the respirator is an artificial means of keeping someone alive, one that hadn't been invented, the patient would long have expired.14 In other words, attaching a patient to a machine is acting to keep her alive; disconnecting her, however, is omitting to act, in order to let nature take its course. This, of course, is no more of a justification for withdrawing the respirator than it is for denying a patient any other achievement of medical technology. Imagine a case, for example, in which the victim of a car accident in need of immediate surgery is denied this service with the rationale that surgeries in general are artificial means of interfering with one's life, and had surgical instruments not been invented and developed, she would have no access to such a service. Every human-invented instrument – including medical ones – surely didn't exist until someone created it, but this is no good excuse for refraining from using it when it has become available and we are able to make use of it. Anyway, if a doctor denied her patient access to the respirator in any other instance, she would promptly be accused for acting wrongfully and for neglecting her duty; in the case of passive euthanasia, however, the same decision is treated as refraining from acting. However, it is hard to find a morally compelling reason to accept this difference. Apart from these, in my opinion there are some good reasons to choose active over passive euthanasia in any case. Given that euthanasia is by definition a humanitarian response to a patient's agony, if one examines the way the patient expires in the case of each one of the two ways in which euthanasia is performed, it seems difficult to tell why passive euthanasia is considered to be a good death at all. As I mentioned above, passive euthanasia is usually performed by means of either withholding food or water, or by withdrawing life-sustaining machines. In the first case death comes slowly and in an indecent way out of dehydration or starvation, while in the second the patient dies out of suffocation (in the case she is disconnected from a respirator) or gradual intoxication (if she is detached from a hemodialysis machine), etc. In all cases, death comes in such agony and is being prolonged in such an unwanted degree, that makes one wonder why such a death is considered to be a good one, or at least a better ending than the inevitable 'natural' one. In contrast, active euthanasia – which is usually being performed by means of a lethal injection to the patient – guarantees an instant and an as less agonizing as possible death. The patient departs in a humane and descent way, according to her initial will. If this is so, then why passive euthanasia is usually favored over active one? I think only because its legal consequences for her who 14 Callahan, D., "Pursuing a Peaceful Death", Hastings Center Report, 23:4 (1993), p. 34. Why Letting Die Instead of Killing? 89 performs euthanasia are less dramatic in comparison to active euthanasia, if any.15 Opting for passive euthanasia is not at all securing an easy and good death for the patient; rather it is just a guarantee that the doctor who performs it avoids any consequence for her deed. It is not intended to serve the patient's best interests, but those of others who engage in it. Choosing passive instead of active euthanasia seems like doing the right thing (assuming that performing euthanasia is right at the first place) by resorting to the wrong means. Apart from this, it implies an unnecessary and hardly justifiable normative shift in one's moral approach towards euthanasia: in respecting her request for euthanasia the patient is being thought of as an end in herself; in choosing the means of fulfilling her request, the patient is dealt with as a mere means to somebody else's ends. Even for those who are not into the Kantian tradition, this seems to be somewhat inconsistent. So far I have argued that the distinction between purposeful action and purposeful omission is morally insignificant concerning euthanasia, and that active euthanasia – being a far more humane and descent way to depart – should be preferable on moral grounds, in particular as serving the patient's best interests and as an enduring indication that the patient is being treated not only as a means, but also as an end. It is only a logical step forward to argue that, since the distinction between active and passive euthanasia seems to be not only morally irrelevant, but also harmful to the only actual beneficiary of it, the dying patient, insofar as euthanasia is being debated as a moral issue, this distinction can only be misleading and confusing and, therefore, it should be abandoned.16 If euthanasia is morally justifiable, it should be such only because it stands for a humanitarian response to a fellow human's suffering, and not due to obscure and unsubstantiated moral excuses. REFERENCES Baird R.M., & Rosenbaum S., Euthanasia: The moral issues, Prometheus Books, New York, 1989. Battin M., "The Least Worse Death", Hastings Center Report, 13:2 (1983), pp. 13-16. Beauchamp T.L. & Childress J.F., Principles of Biomedical Ethics, Oxford University Press, Oxford, 1994. Beauchamp T.L., Intending death: The ethics of assisted suicide and Euthanasia, Prentice Hall, New Jersey, 1995. 15 Battin, M., "The Least Worse Death", Hastings Center Report, 13:2 (1983), pp. 13-16. 16 Rachels, J., "Active and Passive Euthanasia," in Singer, P. (ed.), Applied Ethics, Oxford University Press, Oxford, 1986, p. 35. 90 Evangelos Protopapadakis Bix Br., "Physician Assisted Suicide and the United States Constitution", Modern Law Review 58:3 (1995), pp. 404-411. Callahan D., "Pursuing a Peaceful Death", Hastings Center Report, 23:4 (1993), pp. 33-38. Dyck A.J., "Physician Assisted Suicide: Is it Ethical?", Harvard Divinity Bulletin, 21:4 (1992), pp. 16-17. Humphry D. & Wickett A., The Right to Die – Understanding Euthanasia, Bodley Head, London, 1986. McLean Sh., "End-of-life decisions and the law", Journal of Medical Ethics, 22:5 (1996), pp. 261-262. Munson R., Intervention and Reflection: Basic Issues in Medical Ethics, Wadsworth Publishing Company, Belmont, 1983. Nowell-Smith P., "Euthanasia and the doctors-a rejection of the BMA's report", Journal of Medical Ethics, 15:3 (1989), pp. 124-128. Prado C. G., & Taylor S.J., Assisted Suicide: Theory and practice in elective death, Humanity Books, New York, 1999. Rachels J., "Active and Passive Euthanasia" in Singer, P., (ed.), Applied Ethics, Oxford University Press, Oxford, 1986, pp.29-36. Robertson J. A., "Cruzan: No Rights Violated", Hastings Center Report, 20:5 (1990), pp. 8-9. Skegg P.D.G., Law, Ethics and Medicine. Studies in Medical Law, Clarendon Press, Oxford, 1984. Stewart G. T., Curter W. R. & Demy T. J., Suicide and Euthanasia, Kregel Publications, Grand Rapids, 1998. Dr Evangelos Protopapadakis Assistant Professor National and Kapodistrian University of Athens Athens Greece eprotopa@ppp.uoa.gr