Is there a significant moral difference between active and passive euthanasia?

Euthanasia, the deliberate ending of a life for the benefit of the person, is often divided into ‘active’ and 'passive’ categories. Definitions vary widely, but generally include some variant of the difference between 'killing’ someone and 'letting them die’. If a doctor injects a terminally ill patient with potassium chloride to end their life, he has taken an active action towards their death. Alternatively, if he merely allows an IV drip to run out, he has only aided the death by passive omission. A popular opinion is that active euthanasia must be wrong and “inherently undesirable” , whatever the opinion held of other forms. We might trace this back to Kantian deontolotogy, for whom killing was always and absolutely wrong. This essay will argue that, despite such intuitions towards a significant difference, no such gulf exists on the moral plane. (I am primarily concerning myself with the ethics of voluntary euthanasia. If found to be unethical, it seems likely that its involuntary and non-voluntary cousins would fall by proxy.)

In philosophical discussion, the more general consideration of the act/omission debate has led many to find important differences between the two notions. Callahan discusses  the majority metaphysical view, that the self and the external world are crucially separate. This allows the rest of the empirical world to maintain its own “causal dynamism”  distinct from our own, and appears to deny any attempt to blur the act/omission distinction. However, effective as it may be for the general debate, I believe it has flaws if applied directly to the consideration of hospital-situated euthanasia. Generally we will discuss patients who are terminally-ill, in extreme pain, or both; people relying almost totally on their physician to maintain their existence. In this situation, the doctor cannot best be described as one actor among many, floating in the metaphysical soup. His relational position is more akin to that of a 'God’ figure, with near-complete control over the patient’s continued livelihood. With the power and responsibility afforded to him, it would be unfair to consider the failure to refill an IV drip from the above example as merely an 'omission’, as it more accurately takes the form of a conscious act.  This highlights the intense difficulty in even defining the difference between active and passive euthanasia.

A popular refrain is to appeal to a certain term, 'nature’, which has been long relegated from other disciplines. This serves a multitude of uses, mainly for those seeking to highlight the moral failings of active euthanasia. 'Natural’ has antonyms of 'artificial’, 'fake’ and 'freakish’, giving it a particularly positive connotation. Indeed, Hopkins argues we have made 'nature’ “ontologically distinct” , affording a moral neutrality to anything found in, or pushed into, its grasp. Therefore, passive euthanasia is often preferred, not due to cogent analysis, but the association with nature affording a “moral simplicity” , a form of “moral laziness” . Are these claims to 'nature’ fair? For one, the assertion that the 'natural’ exists in today’s medicine should be questioned. The very debate we are engaged in, over euthanasia, has largely come about because of advances in the medical sciences. Humans who would have long since succumbed to viruses or diseases in any other century are now seeing their 90th and 100th birthdays, aiding a particular rise in late-onset chronic disorders. Even children and young adults involved in crashes, who would have been given up on only a few decades ago, are now brought back to life even as their bodies are broken. In short, other than for those advocating a return to cave-dwelling, the existence of 'natural’ life is exceedingly dubious .

A popular worry against active euthanasia is that it requires making quality-of-life decisions, twinning an unacceptable “medical paternalism”  with disgustingly consequentialist considerations of the value of human life. However, I would argue that such considerations are already the accepted norm. Even in countries where euthanasia is outlawed, there are allowances for doctors to end life-saving treatment when any improvement in condition is infeasible. When not aided by media campaigns, long-term coma sufferers are often 'turned off’ after a period of months or years, when it becomes clear that a miraculous recovery isn’t a reasonable expectation. These events, provoking little public attention, involve exactly the same consequentialist considerations of cost and benefit that some argue are 'introduced’ by active euthanasia, i.e. is the continuation of this life worth living? When we conclude that the answer is 'no’, we already allow the coma patient to die, which is surely euthanasia in all but name.

Hopkins brings up a different point regarding our intuitive appreciation of the 'natural’. When photographed for the media, coma sufferers are often shown as small, emaciated bodies connected to huge machines, giving the impression of an entirely artificial existence. However, perhaps that sense of the synthetic is merely initial. Sufferers of various chronic heart defects are fitted with an entirely artificial device to maintain their life beyond its otherwise natural existence, known as a pacemaker . Many of the patients fitted with such a device are entirely dependent on it, and would soon enter cardiac arrest without its assistance. However, we don’t consider their existence any less 'real’ or 'worthwhile’ than someone relying on the chemical pacemaker they were born with. To revisit the example of the photograph, how would our consideration change if the iron lung were not a huge contraption, reminiscent of some industrial past, but a device the size of an A4 pad, inserted into the existing lungs to maintain air transfer? If someone led a fulfilling life with such a device attached, it would be appear nonsensical to consider their life 'artificial’, which infers that our understanding of  what constitutes 'natural’ is far from clear. Indeed, Hopkins argues that we are unnecessarily “fetishising the biological” , ignoring the functionalist realisation  that what matters is the operation of an organ, not its chemical make-up.

Another term which often pops up when considering euthanasia is 'cruelty’, used by all sides of the debate. As mentioned, we currently perform what could be considered passive euthanasia, by letting coma victims “starve” to death on a “saline solution”  when their continued existence is considered to be the more painful option. However, if reducing suffering is our goal, surely active euthanasia would often be the moral superior? A potassium chloride injection for a long-term coma sufferer will ensure painless death in under two minutes, which seems preferable to weeks of literally wasting away. One alternate consideration here, while not strictly of the moral realm, is that the strict safeguards required to allow active euthanasia in current societies  would almost certainly cancel out the aforementioned benefits. Indeed, under those circumstances, passive starvation could likely be the quicker option.

One important issue for the moral status of euthanasia, and indeed a great deal of contemporary ethics, is the question of autonomy. The Kantian idea that “inherent human dignity”  gives each of us some right to personal self-determination is currently a well-accepted view, but its conclusions for euthanasia are not entirely clear. The most obvious statement, that we should follow the patient’s wishes, is often impossible when they cannot communicate, or their age or mental development has left them unable to give a cogent preference. In that case, preferring autonomy gives us no further insight into how to proceed. Even if we strictly consider voluntary euthanasia where a preference has been given, problems abound. For example, who’s autonomy are we interested in? Clearly we should focus on the patient, but humans are inherently social animals. We are a member of numerous communities of family, friends and acquaintances, all of whom are affected by our decision. Is strict, single-person autonomy even desirable here?

To consider the other side of this issue, can one consider a patient’s wishes to be truly autonomous? Any rational person would surely weigh up numerous factors, including the strain on health resources of their continued existence, or the “stress to the family”  of watching a slow and undignified death. This is not simply an issue of avoiding the coercion of family members wanting rid of the patient , but asking whether any rational patient could be expected to consider only his interests. If that isn’t the case, is the decision truly autonomous? A third strand is to consider the autonomy of another major actor, the doctor. As mentioned previously, healthcare professionals are given great power to act on behalf of the sick. But, if we consider the patient’s best interest to pass away, should the doctor be forced to administer such an end? Surely there is an issue of supporting the autonomy of the patient, only to greatly harm the autonomy of the doctor. Many physicians would consider assisting with euthanasia to go against the basic tenets of their Hippocratic oath, and an American study found that 24% of doctors  who have done so later regretted their decision. One solution could be to make the administering of euthanasia an opt-in activity, but this could simply increase the psychological stress for those willing to undertake the responsibility. Another is to introduce a timing system such as in Israel , where the final act is actually undertaken mechanically, but it seems unlikely that this would radically change the perceived location of emotional guilt

I have so far considered mainly arguments which point to the moral equivalence of active and passive euthanasia. There are of course some which point in the opposite direction, but I believe them to generally not be moral in nature. One which I’ve already mentioned is the Kantian concern, that killing is simply wrong in and of itself. An answer is that, unless you follow a particularly narrow conception of 'killing’, our hospitals are already involved with terminating the lives of numerous patients. Another argument, perhaps the most popular, is an amorphous set grouped under the phrase 'the slippery slope’. These broadly hold that, once active voluntary euthanasia for terminally-ill patients in extreme pain is permitted, the requirements will gradually trickle away until we have, by one dystopian reading, involuntary euthanasia for all. The power of this argument is essentially the same as any other 'slippery slope’ argument, resting on the degree to which one movement makes the next more likely (i.e. are we on a slope) and views of future society (i.e. can the slope be stopped).

I believe that this may be a difficult issue, but it “cannot be impossible”  to overcome. Our openness to voluntary active euthanasia in 2009, which sis almost certainly higher than in any other year of recorded history, seems directly attributable to the changes in medical and other technologies which time have brought us. I do not believe that, as some would hold, we are now more 'pro-euthanasia’ due to some lower value placed on the value of human life. Indeed, it seems hard to explain why the last century saw such a huge expenditure of social resources on healthcare improvements, if we are really becoming less concerned with the “sanctity of life” . Perhaps it is more accurate to say that we consider life no less sacred, in fact possibly more so, but modern technology has allowed for variants of 'life’ which barely deserve the term.

I have considered a number of the main issues regarding euthanasia. My conclusion is that, while active and passive euthanasia may well differ in the legal, political and other arenas, they remain morally indistinguishable.