The Moral Acceptability Of Passive Euthanasia

This paper will discuss the moral permissibility and acceptability of passive euthanasia, especially with regard to active euthanasia. The aim of the paper is to argue for the thesis that passive euthanasia is morally acceptable under certain conditions. I will present a defense of this thesis by defining its terms, distinguishing the various forms of euthanasia, especially between active and passive, as well as voluntary and non-voluntary euthanasia. I will cite concrete cases and also consider various factors that may affect the euthanasia decision, such as the pain and suffering of the patient. The arguments will be evaluated from utilitarian perspectives, taking into account the views of Kant and Aristotle.

Strictly speaking, “the term ‘euthanasia’ refers to actions or omissions that result in the death of a person who is already gravely ill.” (Moreno). There are two important features of euthanasia. First, that euthanasia involves the deliberate and premeditated act, of taking away a person’s life; and, second, that it is an act of mercy, which is taken for the sake of the person whose life is unbearable from pain or has an incurable disease. This notion of mercy distinguishes euthanasia from most other forms of taking life. Euthanasia is a controversial concept, which evokes heated moral, medical, legal, and social debates. The term has both positive and negative connotations: the fundamental idea is, that a suffering person will be relieved by means of an act of mercy, but at the same time there are numerous abuse cases where people have been killed or murdered under the euthanasia pretext.

There are various forms of euthanasia. Although the topic of this paper is the discussion of moral acceptability of passive euthanasia, it is important to distinguish between active and passive forms of euthanasia: actively causing a person to die (for example by intentionally giving some medication) or passively allowing them to die by withdrawing or withholding their treatment, or taking away something they need to survive. Typical examples of passive euthanasia are switching off life-supporting machines, such as feeding tubes, respirators, or not carrying out life-extending operations and treatments or not giving life-extending drugs. Another categorization of euthanasia is along voluntariness or by consent: voluntary and non-voluntary euthanasia are both in the patient’s interest, freeing him/her from unbearable suffering. The difference between the two lies in the patient’s ability to make the decision. In the case of voluntary euthanasia (which is also often referred to as assisted suicide) the terminally ill patient is mentally competent and makes the decision about terminating his/her own life. In the case of non-voluntary euthanasia (which is also often referred to as mercy killing) the patient is not mentally competent to make a decision about his/her fate (for terminal brain damage or coma, for example) and a proxy, the guardian or physician makes the decision on his/her behalf. Finally, involuntary euthanasia – though not in the focus of this paper – needs to be mentioned as a conceptually different form of euthanasia. In this case euthanasia is administered without the consent, and against the will of the person.

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In the following I will compare and contrast passive and active euthanasia, discuss whether there is a moral difference between them, and mount a defense of the thesis, that in most cases there is no real moral difference between helping someone die and letting someone die. I will also argue that there is a more profound moral difference between voluntary and non-voluntary euthanasia, and there need to be clear guidelines to ascertain that no one gets killed against his/her wishes. By explaining that there is, in fact, no relevant moral difference between omissions and acts, I will prove that active euthanasia is not immoral and is fundamentally no different than passive euthanasia, and in some cases passive euthanasia is more moral than active. The utilitarians emphasize that when deciding an acts morality we should only consider the consequences (Mill). To validate this point, first, we may argue, that it is not exactly correct to say that omission is a non-act (Rachels). Letting the patient die is also an act. There is an active decision of not to perform certain other life-saving actions. However, whether it is considered an act or not, the outcomes are the same, thus regarding morality they should be approached in the same way. From a moral perspective pulling the plug of the respirator, withdrawing the feeding tube or withdraw a life sustaining treatment is an act itself, which means, that omission is also an act itself. Thus passive euthanasia is subject to moral appraisal in the same way that active euthanasia, a decision to directly act would be subject to moral appraisal. Since utilitarians are only concerned with the consequences of an action, not with the motives or the action itself, there does not seem to be any reason to distinguish between active and passive euthanasia, since they both lead to the same ultimate conclusion (the death of the patient). If we consider the amount of happiness or pain that either form of euthanasia creates, however, one may even argue, that withholding a treatment (passive euthanasia) may take the patient longer to die, and so lead to more suffering, than if more direct actions would be taken (active euthanasia). This suggests, that – from a utilitarian perspective – once an initial decision not to prolong the patient’s life and agony has been made, active euthanasia would actually be preferable to passive euthanasia, because it would decrease overall pain.

If we examine the difference between passive and active euthanasia from a deontologists (Kant’s) point of view we can come to a similar conclusion. One of his basic insights is that morality is a matter of motives and intentions, and not a matter of consequences (Kant). If we accept that the intent of an action determines morality rather than the effects, omissions would be subject to the same moral evaluation as acts, since the underlying motives would be similar (to end the patient’s suffering). This argument also suggests that there is no morally relevant difference between act and omission, that is, between active and passive euthanasia. In fact, if we proceed with this argument and develop the logic that morality is a matter of intentions further, we can conclude, that passive euthanasia leads to more suffering rather than less, and is contrary to the motivation that prompts the initial decision of not to prolong the patient’s life and agony. Thus, active euthanasia is not only not morally inferior to passive euthanasia, but may indeed be preferable.

(Current) So far we have looked at the possible differences between the various forms of euthanasia and came to conclude, that, although there are some valid arguments from the causality perspective, and also the current practices worldwide might allow passive euthanasia, but not, or only very rarely allow active euthanasia, we see no major moral distinction between the two forms. From a utilitarian perspective they both lead to the same conclusion, and we even terminate that in some cases active euthanasia may be preferable to passive form, because it brings less suffering to the patient. We have, however, came to conclude that there is a more significant distinction between voluntary and non-voluntary euthanasia, since in the latter the patient’s will may or may not be carried out which can lead to potentially ‘killing’ someone who either wouldn’t have wanted to be ‘killed’ in this way.

The subject of euthanasia is filled with room for interpretation. In the analysis above we have proved that there are various and contradictory approaches, and it seems to be difficult to come to a conclusion about the moral rightness of euthanasia. A different approach could be to study the concept of euthanasia case by case and determine the ethical values and the major factors that need to be considered in an attempt to establish some criteria for moral acceptability. In the next part of this paper I will discuss the various factors that influence the euthanasia decision through some concrete cases and evaluate their moral acceptability.

Human life itself is commonly taken to be a cardinal good for people, often valued for its own sake. But when a competent, terminally ill patient decides that the best life possible for him/ her with treatment is of such bad quality that it is worse than no further life at all, than continued life is no longer considered a benefit. Human life should not be degraded by reducing the quality of life for the sake of artificially extending the quantity of life. When a person has no quality of life any more because of unbearable pain, then they should not be forced to live, they should be able to choose to die, because at one stage continued attempts to cure are not compassionate any more. However a deontologist would disagree with this argument. Kant emphasizes that it is persons duty to live, even if you have an untreatable illness. You have to act from duty and not give in to the easier path and chose euthanasia. The following example shows how it is possible to think this way and deny euthanasia: “I no longer accept this enduring pain, and this protruding eye that nothing can be done about,” Chantal Sebire 52 years old French schoolteacher said. ” I can’t take this anymore.”… “I want to go out celebrating, surrounded by my children, friends, and doctors before I’m put to sleep definitively at dawn.” When she was offered the possibility of passive euthanasia she objected: that passive form of euthanasia was “neither dignified, humane, or respectful of me or my children.” From these lines we can see how Sebire insists that she stays alive, since it is her duty. In this context euthanasia should be a natural extension of patients’ rights to life’ allowing them to decide the value of life and death.

Through the next example we will see some difficulties we can come across when trying to enforce non-voluntary euthanasia. Current medical ethics seem to implicitly legitimize or legally accept passive euthanasia in many parts of the world with the moral argument of letting nature (the underlying disease) take its course, and accepting that human active (medical) intervention would simply lengthen this process unnecessarily (Moreno, 1995). This seems to be acceptable if that is what the patient wants (voluntary) or would have wanted (non-voluntary). Of course, the case of voluntary euthanasia is more straightforward: the patient is conscious and can actively give consent and confirm his/her wishes. In the case of non-voluntary euthanasia, however, when the patient is unconscious and incompetent, the decision makers must rely on former statements or comments of the patient where they had indicated they would not want to live ‘hooked up to a machine’ or ‘when it is hopeless’. An example is the well known and much debated Eluana Englaro case. The Italian woman had been in coma for irreversible brain damage that she had suffered in a car accident at the age of 20. For 17 years she was in a vegetative state, while her father, ultimately successfully, fought for passive euthanasia (having her feeding tubes removed), saying it would be a dignified end, and this is what her daughter would have wanted. His argument was that her daughter had visited a friend in coma before her own accident, and stated „she did not want the same thing happen to her if she was in the same state” (CNN.com, 2009). In absence of such former statements, the consenting proxy (guardian or physician) must rely on their own judgments and that has the possibility to lead to – as it is called – slippery slopes. This also brings up the problem of involuntary euthanasia, when euthanasia is administered without the consent, and against the will of the person. In our example how can we be sure that the father is telling the truth? Or is he only saying this to help his own suffering?

It is also important to see how the physician’s role is crucial. It is them who know the patient’s condition well, who have access to drugs who have specialized knowledge or appropriate methods, and it is also them who can provide emotional support for the patient and the family. Equally importantly, it is also the physician who has been directly and intimately connected with and responsible for the person’s care, and who the patient typically trusts. The physician’s role is controversial too. One approach is that euthanasia is fundamentally incompatible with the physician’s role as healer. This is one of the main arguments of the anti-euthanasia movements, which often cite the Hippocratic Oath, that clearly states: “I will neither give a deadly drug to anybody who asked for it” (Hippocratese) This explicitly forbids killing patients. However, we must understand that Hippocrates did not explicitly say that doctors must preserve life at all costs. Also, we may argue the real word-by-word relevance of the Oath to modern medicine and to the current rights of patients and doctors. The Oath can also be interpreted as a duty of the physician to alleviate pain and suffering. If there is no other option, the doctor, in fulfilling this duty, should be allowed to actively end the patient’s life.

Throughout this essay we have had a look at the different types of euthanasia, and how different moral approaches accept them. We managed to conclude that morally there is no difference between passive and active euthanasia, and in some cases active euthanasia would even be advantageous. We also saw how it is hard to come up with a universal law how to judge euthanasia, since each case is extremely different and there are a lot of perspectives that have to be considered. Therefore when deciding on the moral acceptability of euthanasia we have to view each case separately and then with regard to each theory decide on it’s morality.