Is there a moral difference between passive and active euthanasia?
General Reference (not clearly pro or con)
Michael Manning, MD, Catholic priest, in his 1998 book Euthanasia and Physician-Assisted Suicide: Killing or Caring?, explained in the chapter "Killing vs. Allowing to Die" that:
"This is an extremely important distinction in the euthanasia debate. Generally speaking, opponents of euthanasia maintain that there is a clear moral distinction between merely allowing to die and actually causing or deliberately hastening someone's death. For some it is a crucial moral discernment; for others, it represents either casuistry [excessively subtle reasoning intended to rationalize or mislead] or moral fiction."
Is there a moral difference between passive and active euthanasia?
Daniel Callahan, PhD, Director of International Programs at the Hastings Center, wrote in his 1995 article "Vital Distinctions, Mortal Questions: Debating Euthanasia and Health Care Costs" that appeared in the book Arguing Euthanasia that:
"The distinction between killing [active euthanasia] and allowing to die [passive euthanasia] is still perfectly valid for use... The distinction rests on the commonplace observation that lives can come to an end as the result of (a) the direct action of another who becomes the cause of death (as in shooting a person), or as the result of (b) impersonal forces where no human agent has acted (death by lightning or by disease)...
At the center of the distinction between killing and allowing to die is the difference between physical causality and moral culpability. On the one hand, to bring the life of another to an end by an injection is to directly kill the other--our action is the physical cause of death. On the other hand, to allow someone to die from a disease we cannot cure (and that we did not cause) is to permit the disease to act as the cause of death."
Ezekiel J. Emanuel, MD, PhD, Chair of the Department of Clinical Bioethics at the National Institutes of Health, wrote in his 2000 article "A Time to Die: The Place for Physician Assistance," in the Journal of Health Politics, Policy and Law:
"Frequently, people indicate that their support for euthanasia and physician-assisted suicide (PAS) is based on the fact that they would not want to live 'hooked up to machine' or 'when it's hopeless:' Advocates of euthanasia and PAS encourage such thinking when they elide the moral and legal distinctions between intentionally ending a life through an intervention, such as an injection of muscle relaxants, and stopping medical treatments...
In June 1997 the U.S. Supreme Court made quite clear that these actions are legally distinct. There is a constitutional right to refuse medical treatments and even have a proxy exercise that refusal, while, by a vote of 9 to 0, the Court clearly stated that there is no constitutional right for either euthanasia or PAS. There is also a moral distinction. The safeguards we think appropriate and necessary for permitting euthanasia or PAS are not necessary for terminating medical care... Such differences in safeguards bespeak different moral evaluations about stopping medical interventions and actively injecting a patient with a life-ending drug. "
Thomas Fuchs, MD, PhD, Associate Professor of Psychiatry at the University of Heidelberg, wrote the following in his 1998 article "The Notion of 'Killing'. Causality, Intention, and Motivation in Active and Passive Euthanasia" that appeared in the Journal Medicine, Health Care, and Philosophy:
"We may discern a relevant difference between killing and letting die on the level of causality, namely if we consider the biological dimension... Only on this biological...level are we able to obtain the proper notion of killing: It is an impact extraneous to the organism, produced by the action of another person, and causing immediately lethal damage. 'Letting die', on the contrary, means to give way to an ongoing inner-organismic process of disintegration, without supporting or substituting vital functions. Therefore the extubation [removal from a ventilator] of an incurably ill patient, though a physical action with subsequent death, is not killing in its proper meaning. Only by active euthanasia does the physician become the actual agent and cause of death... The extubation does not produce the effect of death; it only influences the time of its occurence."
The American Medical Association (AMA), in its 2006 "Decisions Near the End of Life" policy statement, distinguished between passive and active euthanasia:
"Our AMA believes that: (1) The principle of patient autonomy requires that physicians must respect the decision to forgo life-sustaining treatment of a patient who possesses decision-making capacity. Life-sustaining treatment is any medical treatment that serves to prolong life without reversing the underlying medical condition. Life-sustaining treatment includes, but is not limited to, mechanical ventilation, renal dialysis, chemotherapy, antibiotics, and artificial nutrition and hydration...
(4)Physicians must not perform euthanasia or participate in assisted suicide."
James Rachels, PhD and Professor at the University of Alabama at Birmingham, in his 1975 article "Active and Passive Euthanasia" that appeared in The New England Journal of Medicine, argued:
"The distinction between active and passive euthanasia is thought to be crucial for medical ethics... However, a strong case can be made against this doctrine...
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. To say otherwise is to endorse the option that leads to more suffering rather than less, and is contrary to the humanitarian impulse that prompts the decision not to prolong his life in the first place.
Part of my point is that the process of being 'allowed to die' can be relatively slow and painful, whereas being given a lethal injection is relatively quick and painless...
... It is not exactly correct to say that in passive euthanasia the doctor does nothing, for he does do one thing that is very important: he lets the patient die. 'Letting someone die' is certainly different, in some respects, from other types of action - mainly in that it is a kind of action that one may perform by way of not performing certain other actions. For example, one may let a patient die by way of not giving medication, just as one may insult someone by way of not shaking his hand. But for any purpose of moral assessment, it is a type of action nonetheless. The decision to let a patient die is subject to moral appraisal in the same way that decision to kill him would be subject to moral appraisal. "
Patrick D. Hopkins, PhD, Professor of Philosophy at Millsaps College, wrote in his 1997 article, "Why Does Removing Machines Count as 'Passive' Euthanasia?" that appeared in The Hastings Center Report:
"In the case of euthanasia...removing a machine is no different (functionally, morally metaphysically) from removing a biological bodily organ if both systems are performing the same role. Both are cases of disrupting some bodily process. If this disruption leads to death, then both are cases of killing...
Unnecessary suffering only seems to have weight when it is appealed to against technology, against artificiality, a common enough invocation in arguing to free patients from the 'trap of technology'... Even if the patient is in pain, has no chance for recovery, or has lost cognitive functions, no appeal to unnecessary suffering, no appeal to our being inhumane will currently, legally permit us to free this person from the trap of nature.
But if we are cruel in refusing to let nature free patients from the trap of technology, we are both cruel and conceptually blind when we refuse to let technology free patients from the trap of nature... When we remove machines playing these functional roles from hurting and hopeless patients, we kill those 'trapped by technology.' But this is not a bad thing. It is bad when we refuse to grant people trapped by nature the same benefit. "
Dan W. Brock, PhD, Professor of Medical Ethics at Harvard Medical School, argued in his Mar. 1992 article "Voluntary Active Euthanasia" that appeared in The Hastings Center Report:
"The belief that doctors do not in fact kill requires the corollary belief that forgoing life-sustaining treatment, whether by not starting or by stopping treatment, is allowing to die, not killing. Common though this view is, I shall argue that it is confused and mistaken.
... Consider the case of a patient terminally ill with ALS disease. She is completely respirator dependent with no hope of ever being weaned. She is unquestionably competent but finds her condition intolerable and persistently requests to be removed from the respirator and allowed to die. Most people and physicians would agree that the patient's physician should respect the patient's wishes and remove her from the respirator, though this will certainly cause the patient's death. The common understanding is that the physician thereby allows the patient to die. But is that correct?
Suppose the patient has a greedy and hostile son who mistakenly believes that his mother will never decide to stop her life-sustaining treatment and that even if she did her physician would not remove her from the respirator. Afraid that his inheritance will be dissipated by a long and expensive hospitalization, he enters his mother's room while she is sedated, extubates her, and she dies. Shortly thereafter the medical staff discovers what he has done and confronts the son. He replies, 'I didn't kill her, I merely allowed her to die. It was her ALS disease that caused her death,' I think this would rightly be dismissed as transparent sophistry [subtly deceptive reasoning] - the son went into his mother's room and deliberately killed her. But, of course, the son performed just the same physical actions, did just the same thing, that the physician would have done. If that is so, then doesn't the physician also kill the patient when he extubates her [removes the respirator]?
... Both the physician and the greedy son act in a manner intended to cause death, do cause death, and so both kill."