A Defence of Active Euthanasia

Written by Scarlet Rose

Edited by Alfred Tyrrell

The distinction between active and passive euthanasia is fundamental to medical ethics and criminal law. Active euthanasia is understood as a physician actively ending a patient's life to relieve suffering, for example through lethal injection, whereas passive euthanasia involves a physician withholding life-sustaining treatment. In most countries, active euthanasia is illegal. Per the American Medical Association established in 1973, ‘the intentional termination of the life of one human being by another- mercy killing- is contrary to that for which the medical profession stands.’ This sentiment is still upheld today with active euthanasia widely seen as violating criminal laws that reject the right to kill others and also undermining the role of medical professionals who are trained to save lives. However, passive euthanasia is permissible in most hospitals, with its justification grounded in the belief that a physician facilitating a patient’s forgoing of life-sustaining treatment does not constitute killing them but is simply allowing them to die. This is the ‘killing and letting die’ distinction which many philosophers have used to defend passive euthanasia and condemn active euthanasia. Nevertheless, I argue that this distinction fails and therefore active and passive euthanasia should be regarded as morally equal. 

Crucially, the killing and letting die distinction posits that passive euthanasia, such as the absence of a ventilator, directly kills no one, whereas a lethal injection does. Despite the use of a ventilator helping to counteract death occurring, removing it is ‘an indirect cause of death but will not kill directly’, as argued by H.V McLachlan. In passive euthanasia it is the terminal illness that is seen as killing the patient, previously prevented by artificial intervention. Therefore, removing it simply allows nature to take its course. This distinction between active and passive euthanasia lies in the difference between ‘acting’ and ‘omitting,’ with it not being morally permissible for a physician to act to bring about death as this opposes a physician's obligation to not kill patients. Most criminal laws forbid killing others, but it is morally acceptable to refrain from acting in order to bring about death. 

One problem with this is that whether an action is seen as ‘killing’ or ‘letting die’ is not always contingent on the action itself. For instance, two scenarios from D.W Brock demonstrate this: 

Case 1: A terminally ill patient, dependent on her respirator, requests to be removed from it and her physician enacts this. 

Case 2: The greedy son of the patient mistakenly believes she will never request this and wanting his inheritance, removes her respirator.

In legal investigations, the son’s claims that he ‘merely let her die’ would not hold: he would be deemed a murderer. Although both agents perform the same action-removing the ventilator- in case 1, the patient’s death is caused by her illness, whereas in case 2 she is killed. Although there is a moral difference in regards to patient consent and the son not being a trained physician, why is the cause of the patient’s death attributed to her illness in ethical circumstances but attributed to the actions of the agent in unethical cases? Arguably whether something is an action of ‘killing’ should not be dependent on the ethical context: it may be an ethical or unethical killing but a killing nonetheless. 

Additionally, in circumstances of passive euthanasia where a physician merely refrains, I believe this constitutes action. When you refrain from doing something, you deliberate about what you ought to do and then make the choice to withhold action. For instance, regardless of whether a physician deliberately ends a patient's life through lethal injection, or whether they deliberately decide to not give a patient life-sustaining treatment, both are deliberate ‘actions’ that bring about the same result. This is clear in two scenarios given by James Rachels: 

Case 1: Smith will gain a large inheritance if he kills his younger cousin. While the child is taking a bath he drowns him. 

Case 2: Jones is in the same situation but it is unnecessary for him to kill the child as he drowns on his own accord. He sits back and watches the child die. 

Although Smith killed the child and Jones simply let him die, there is no moral difference between the two agents as they had the same intention and caused the same outcome. Even though Jones ‘indirectly’ killed the child, he made a deliberate decision to not intervene and thus he cannot relinquish moral responsibility. He actively put himself in a position that would bring about the child’s death. Therefore, being a passive agent does not constitute inaction if you have deliberately put yourself in this passive situation. An agent deliberately putting themselves in a position where they know they will indirectly kill, is no different to an agent putting themselves in a position where they know they will directly kill: they both bring about a killing and have orchestrated it this way. 

Moreover, the AMA states it is wrong for a physician to perform active euthanasia, as ending a patient's life opposes their primary duty of saving lives. However, if actively killing patients is unethical due to its infringement on this, it follows that a passive approach—not preventing patients from dying—also contradicts a physician's fundamental role. Both active and passive euthanasia involve a physician facilitating the ending of a patient’s life, and thus if active euthanasia is not permissible on these grounds, I argue the same should be extended to passive euthanasia. 

To close, I believe active and passive euthanasia are morally equal and thus if passive euthanasia is legal in most countries, then this should be extended to active euthanasia. Primarily, I have argued this by showing that passive euthanasia is not seen as ‘killing’ merely because killing is morally unacceptable in most countries, so in order for it to be permissible it must be called ‘letting die’. However, if the same actions took place in alternate contexts it would be deemed killing. I do not believe the action of killing itself should change in different contexts (may be seen as ethical or unethical but is still a killing), thus the ‘killing and letting die’ distinction is an inadequate way of defending passive euthanasia while simultaneously criminalising active euthanasia. Furthermore, ‘refraining’ in passive euthanasia still constitutes action. I believe deliberately refraining from acting is morally equal to directly acting, as a physician is intentionally placing themselves in a position where they know their inaction will bring about the death of their patient. Finally, if the AMA opposes active euthanasia because it violates a physician’s role of saving lives, a physician preventing the preservation of a patient’s life in passive euthanasia also undermines this. Hence, the two forms of euthanasia are arguably morally equal, in both intention, action, and outcome. Thus, it appears contradictory for most countries to permit one and not the other.