Is the Prohibition of Active Euthanasia Inconsistent if we Regard Passive Euthanasia as Morally Permissible?

When it comes to Euthanasia, it is often at a first glance quite evident to see an intrinsic difference between actively ending a life, and passively allowing that life to cease. Yet if we consider these physical actions and their foreseen consequences in light of moral intuition, humanitarian impulse and the causal chain of events leading up to these actions and the death of a person, it can be understood that in many cases, there is no deviation between acts and omissions, whether intrinsically or at all.

It is important here to define the term euthanasia; for this discussion Holland’s definition is appropriate; ‘Intentionally producing or hastening a patient’s death for the benefit of that patient’ (Holland, 2003, p85). The only ways I shall be concerned with euthanasia under this definition is in a voluntary and non-voluntary sense. Considering involuntary euthanasia will introduce myriad problems, most notably the distinction between involuntary euthanasia and outright murder, into which there is not space here to delve.

A significant point to consider the General Medical Council’s paper entitled The Role of Doctors, which states that it is a doctor’s duty to ‘respect patient’s dignity and privacy’ (GMC, 1999, p1) and that ‘Doctor’s must always be prepared to explain and justify their decisions (p8).

Regrettably, there are myriad cases in which legislation clashes with the doctor’s moral duty and intuition, thereby disabling the doctor from respecting ‘patients’ dignity’. For many of these cases, the explanation and justification doctors give will lamentably be legally as opposed to morally based, making this a gross miscarriage of justice to patients who have needlessly suffered solely to keep medical staff on the right side of legislation which recurrently contradicts moral intuition.

For a case in point, consider Rachels’ illustration in which some children with Down’s syndrome ‘are born with congenital defects such as intestinal obstructions that require operations if they are to live. Sometimes, the parent and the doctor will decide not to operate, and let the infant die’, by slowly deteriorating through starvation. Yet for all that, ‘standing by and watching a salvageable baby die is [a] most emotionally exhausting experience’ (Rachels, 1975, p30), and it is cases like these that utterly exemplify how so many medical cases ‘run contrary to the humanitarian impulse’ (Rachels, 1975, p30) and moral intuition.

It is hardly demanding to perceive active euthanasia in this and similar circumstances as physically repulsive, yet simultaneously morally attractive. Peter Singer alludes; ‘our present attitudes date from the coming of Christianity…since we are created by God, we are his property’ (Singer, 1979, p89). Viz. to actively kill a Down’s syndrome child with intestinal obstructions would be an act contrary to God’s will, or at best in conflict with the notion of the sanctity of human life.

This view lies on the mistaken suggestion that a physical censurable act to initiate the premature death of the patient is requisite for active euthanasia, whereas there is no such censurable act needed forpassive euthanasia. Yet taking a step back from the observable physical action of, say, prescribing a lethal injection, we see that the decision to prescribe the lethal injection is the choice- the censurable act- that brings about the consequence of the persons death. As Williams says, ‘this is a point about cause, not…about action’ (Williams, 1995, p58); so, if that choice were not made, the patient would remain alive and suffering, rendering the choice the cause. On a par with this, deciding to withdraw or withhold treatment is the choice- the censurable act– that causes the end of a life. If this decision were not made, the patient would still be living.

It is true that in active euthanasia the doctor would be discontinuing a causal chain of events, but how is initiating a less sufferable chain of events wrong? If we trace the original ‘natural’ causal chain back far enough, we could say that a newsagent who sold cigarettes five or ten years ego could be considered an initiator of a new causal chain, ultimately leading to the patient’s death (either by cancer or lung disease,or euthanasia). In this case, the newsagent’s moral culpability could equate to that of the doctor, with the differentiation being only in the length of the causal chain initiated. Thus, it seems that initiating a new causal chain (active euthanasia), is not where culpability lies. If it were, we could hold the newsagent just as responsible as the doctor, which we do not.

Therefore, if culpability lies not in the physical act, nor the initiation of a causal chain, but in internal decision making, then killing and letting die are prima facie morally symmetrical  (a view Tooley holds), for we cannot locate a difference between them. Tooley’s ‘full claim is: there’s moral symmetry between killing and letting die, but the typical presence of extraneous factors that make the actual instant of killing morally worse than letting die have led us to the conceptual error that killing is intrinsically worse than letting die’ (Holland, 2003, p92). These extraneous factors are motive, cost and certainty of death, and it is within these culpability lies, for ‘in most relevant real-life cases, extraneous factors do make killing worse than letting die’ (Holland, 2003, p92). So, in the case of the Downs syndrome child, the motive of both killing and letting the child die are the same; arguably, to curtail future suffering. The certainty of death is guaranteed in either case. The only differentiation between active and passive euthanasia here is in the cost. Through passive euthanasia, both the child and the nurses incur a huge cost in physical and emotional pain respectively, whereas if active euthanasia were permissible, this cost would be reduced, illustrating how in this case, active euthanasia is more morally preferable.

However, although motive seems to be entirely internal to the agent (the doctor), cost and certainty of death seem external. In Holland’s example of a boy drowning in a river (Holland p92), the passerby that fails to help is said to be less morally culpable because the possibility of someone else helping, and the possible risk to himself. This seems odd. The external fact that someone else might help should have no bearing on someone else’s moral culpability. The vague, completely external possibility of this aide in no way reflects on a person or their choice. If someone was being murdered, and a passerby interfered and saved said person, this in no way makes the potential murderer less culpable for their acts. Culpability should remain internal, and should not be influenced by wholly external factors that seem to be able to render a person less culpable solely by chance (as it seems to in Tooley’s account). Thus, a small clarification of Tooley’s argument, which he may have already had in mind, is that it is the internal consideration of and deciding to act or not act in light of these extraneous factors that hold culpability. So, if the passerby merely decided not to help the boy, without taking into account and hoping for the appearance of someone else to help, and walked on by, they should be more culpable than if they reflected on the possibility of someone else helping and then acted in light of this, say, by looking for someone else to help. Thus, we find culpability not in extraneous factors themselves, but in examining how and whether a person took into account these factors, and whether they made the appropriate decision to act or not act in light of this, thereby making culpability entirely internal to the agent (the doctor), instead of bringing into account external, variable, chance-based factors.

Williams is another philosopher who holds ‘the much discussed distinction between doing and allowing seems not to be a distinction at all’. He says; ‘allowing something to happen is, typically, itself an action, though it is one that…can be performed by not doing anything’ (Williams, 1995, p60). ‘Not doing anything’ here is slightly misleading, for making a decision is doing something. Merely because it cannot be physically seen, it still involves cognitive processes that will have implications further down the line. Williams’ idea can be more clearly understood in terms of counterfactual-causation1, or, ‘the causal powers of not doing’ (Williams, 1995, p57), which structures conditionals in the form “If A had not occurred, then B would not have occurred”, i.e. “If Dr Smith had not decided to withdraw treatment (instead of prescribing a lethal injection), Patient A would not be dying painfully and slowly”. This significant metaphysical argument for causation seems to apply aptly here, and signifies how non-physical action- passive euthanasia- (as well as active euthanasia) can logically be shown to be the actual cause of a very real effect: the death of a patient.

Looking at Rachels’ Smith and Jones’ example like this will shine further light. The analogy goes; both Smith and Jones stand to gain a large inheritance if their six year-old cousin dies. In one case, Smith drowns the child to gain the inheritance. In another case Jones has full intentions to drown the child, but when he enters the bathroom, the child slips and drowns in the bath, while Jones waits close by ready to hold the child’s head under the water if he/she regains consciousness. ‘Smith killed the child; whereas Jones ‘merely’ let the child die…Did either man behave better, from a moral point of view?’ (Rachels, 1975, p32).

Rachels, who has a similar view to Williams, sees both killing the child and letting the child die as physically different but equally blameworthy. Viz. Although they are different acts, they are morally symmetrical. Both Smith and Jones made the decision to not alter their physical actions (though they could have), to allow the child to survive. They both made a decision, and the direct foreseen consequence of that decision was the death of the child. It is these mental actions that- as Williams would say- counterfactually caused the child’s death. Viz. if both Smith and Jones had not done what they did, the child would not be dead. The only differentiating principle is that Smith initiated a causal chain; Jones allowed an existing one to continue, but, as has already been argued, through Tooley’s, and William’s and my own thoughts; this is not where responsibility lies. Both men had equal power to alter the outcome of situation, yet consciously decided not to exercise this power because of the extraneous factor of their motive. It is this deciding to act or not act to alter the situation based on motive that seems to hold culpability, as it is this that counterfactually caused the death.

Applying this line of thought to more typical cases of euthanasia, such as a patient taking completely burdensome drugs that maintain life at an unbearably low standard, will clarify things. If the patient stopped taking the drugs, they would slowly and painfully die. If they continue to take the drugs, they will continue to live life without any real dignity or quality. Here, passive euthanasia goes against our ‘humanitarian impulse’, and goes against the doctor’s duty to maintain their patients’ dignity. Active euthanasia is contrary to the law, but seems more merciful, and maintains dignity, while remaining physically repulsive and emotionally distressing to the initiator.

  • In the case of passive euthanasia, the doctors’ mental decision to withdraw treatment to enable the patient to die slowly and painfully (a foreseen consequence of the decision) would be the primary act that counterfactually causes the patients’ death. Viz, without that decision being made and acted upon, the result would not have occurred, thus the result was dependant on that decision.
  • In the case of active euthanasia, the doctors’ mental decision to actively end the patient’s life quickly and painlessly would be the primary act that causes the patient’s death. If the doctor had not made the decision to prescribe such actions to himself, the patient would still be suffering. The lessened suffering of the patient was dependant on the doctor making the decision to actively end the patient’s life.

In both cases, the doctor is equally responsible for the death of the patient, for his decision, which would likely have been unwittingly based on considerations of Tooley’s extraneous factors, is what caused the patient to die in the way they did. To go back to the point mentioned earlier, it is not the extraneous factors themselves that contribute to the doctor’s culpability; it is the consideration of these factors. For if the doctor justifiably believed the patient was guaranteed to die anyway, yet this was in fact not the case, the actual extraneous factor (that the patient will in fact live) would render the doctor more responsible than he in fact is. Therefore, it is the doctor’s consideration of what he understands the extraneous factors to be, not the actual extraneous factors themselves, which contribute to culpability. So, in both cases, the doctor possesses the power to alter the physical situation. The patient is going to, and wants to, die. Active and passive euthanasia have been shown to be symmetrical, which means the remaining questions is whether the doctor should act mercifully and deliver a coup de grace to his patient, which seems more humane, or should he use his power to effectively leave his patient to succumb to ‘nature’ (which, as was previously shown, may not be nature at all, but the unfortunate end of a causal chain initiated possibly many years ago by, say, a newsagent). In both cases, it is his mental act that will be the cause of the method of the patient’s death, and so it is his responsibility to choose, based on extraneous factors, the least sufferable option for the patient.

At this point, religious arguments could be introduced against active euthanasia. For, as Singer says, ‘since we are created by God, we are his property ‘, so, through active euthanasia, with interfere with God’s will, whereas through passive euthanasia, we in a sense leave God’s will unscathed; but recall; both active and passive euthanasia are ‘intentionally producing or hastening a patients’ death’. Both alter the lifespan of the patient. In both cases we can be seen to be interfering with God’s will, so why, in light of this papers’ arguments should Christians put negative emphasis primarily on active euthanasia, when both active and passive euthanasia cause the patient’s death?

Another religious argument is from the sanctity of human life. Many Christians believe that ‘to deliberately end a life, even one of a terminally ill patient, is destroying a life God has made’ (RE:Quest, 2009), and the idea that life is sacred, or holy, is what makes such an act wrong.  But, as has been said, in both active and passive euthanasia, the doctor is making the decision to deliberately end the patients life, thus both should be ruled out. Alternatively, we should continue prescribing the patient drugs indefinitely to preserve this sacred life. Then again, would doing this not be interfering with God’s will? Also note; nowhere in the Bible does it specify what is meant by ‘life’. Does it mean to merely be breathing, or ‘alive’, or does it imply some minimum quality of life? As Abraham Lincoln said, “In the end, it’s not the years in your life that count. It’s the life in your years.” (Courier Journal, 2009) It seems easy to see a life only in the second sense to be what some might call sacred. In which case, euthanasia can be justified on religious grounds when a patient’s life is no longer above this minimum quality threshold. These lines of thought obviously need more attention, but by understanding active and passive euthanasia as morally symmetrical, religion must either accept both or reject both. Rejecting both seems irrational as it involves indefinitely prescribing drugs to ill patients, thus suggesting that both should be accepted. There will obviously be further argumentation from religion, but I believe that rational arguments such as those put forth here should triumph over religious arguments which seem to beg more questions of them than they do of others.

If we assume these religious arguments can be overcome, I hope to have shown, by aligning both Tooley’s and Williams’ ideas, that active and passive euthanasia are morally symmetrical based on conscious decision making made with reference to extraneous factors. Culpability lies not in initiating a new causal chain or allowing a previous one to continue. It is the decision, based on considerations of extraneous factors to allow a foreseen consequence to occur (either actively or passively) that is where responsibility lies because the consequence in both cases is counterfactually dependant on this very decision.

Thus, it seems highly inconsistent for us see passive euthanasia as permissible while prohibiting active euthanasia. It has been argued that in some cases active euthanasia is morally preferable, based on the considerations of extraneous factors and the fact that in such cases only passive euthanasia is permissible seems absurd. In each case, the decision has been made to curtail the life of the patient, so why prohibit one and not the other?

Reasons against active euthanasia other than the religious ones mentioned are those similar to the slippery slope argument which leads to the idea that we would lose trust in doctors if they were allowed to actively end a life. But these are problems with application, not with the inherent morality of such issues, the latter of which is being discussed here.

In sum, a doctor deciding to withdraw treatment to bring about the death of a patient cannot be morally differentiated from a doctor deciding to prescribe a lethal dose of drugs to hasten the death of a patient. In both cases, the decision and the following acts seem morally equivalent (extraneous factors being understood as equal) as the consequence depends on that decision.


    Holland, S. 2003: Bioethics, Cambridge: Polity Press
    Lee, B. 2009: Space, Time and Causality Lectures. University of York
    Lewis, D. 1973: Causation. The Journal of Philosophy, Vol 70, No 17, (Oct 11th 1973), pp556-567
    Rachels, J. 1975: Active and Passive Euthanasia. New England Journal of Medicine, 292, 78-80
    Singer, P. 1979. What’s wrong with killing? In Practical Ethics. Cambridge University Press (p83-109)
    Tooley, M. 1980: An Irrelevant Consideration: Killing Versus Letting Die. In B. Steinbock (ed.), Killing and Letting Die. New York: Forham University Press, 56-62
    Williams, B. 1995: Acts and omissions, doing and not doing. In Making Sense of Humanity and Other Philosophical Essays, 1982-1993, Cambridge: Cambridge University Press
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