The Needle and the Plug: Is There a Difference Between Killing and Letting Die?

Many people believe there is a significant difference between withdrawing life-sustaining treatment and letting a terminally ill patient die (passive euthanasia) and actively causing a terminal patient’s death by, for instance, delivering a lethal injection (active euthanasia).

Even the American Medical Association (AMA) endorses the distinction. The AMA’s code of medical ethics states that a patient with decision-making capacity “has the right to decline any medical intervention or ask that an intervention be stopped, even when that decision is expected to lead to his or her death and regardless of whether or not the individual is terminally ill.” If a patient doesn’t have decision-making capacity, her surrogate decision maker may, in accordance with her wishes, decline the initiation of life-sustaining treatment or have such treatment stopped if it has already been started.

Active measures to end a patient’s life, however, are forbidden by the code. It says that doctors engaging in active euthanasia “would ultimately cause more harm than good” and that the practice is “fundamentally incompatible with the physician’s role as healer, would be difficult or impossible to control, and would pose serious societal risks.” Another strike against active euthanasia, according to the AMA, is that it “could readily be extended to incompetent and other vulnerable populations” (a rather odd concern given that it could be guarded against by limiting it to when it’s truly voluntary, as is the case for passive euthanasia).

But is active euthanasia morally worse than passive euthanasia if the goal for each is to relieve the patient’s suffering? In his classic 1975 article “Active and Passive Euthanasia,” published in the New England Journal of Medicine, the philosopher James Rachels argued that it isn’t.

In fact, Rachels contended, active euthanasia can be more humane than passive euthanasia. To demonstrate his point, he used the case of a man dying of incurable throat cancer. Even with continued treatment, the man’s going to die eventually. But he’s in excruciating pain, which can’t be successfully relieved, so he doesn’t want the treatment to keep him alive any longer. If he asks the doctor to end treatment, and the doctor obliges, the doctor’s withholding treatment would seem compassionate because the patient is suffering, his disease can’t be cured, and extending his suffering unnecessarily would be wrong.

However, as Rachels pointed out, if treatment were simply withdrawn, it would take longer for the man to die and he would suffer more than he would if he were actively killed by a lethal injection. “This fact,” Rachels argued, “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.” Claiming otherwise, he said, “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 prolong his life in the first place.”

Rachels also attacked the common belief that killing in itself is morally worse than letting die. He presented two cases that are exactly alike except one involves killing someone and the other involves letting someone die:

In the first, Smith stands to gain a large inheritance if anything should happen to his six-year-old cousin. One evening while the child is taking his bath, Smith sneaks into the bathroom and drowns the child, and then arranges things so that it will look like an accident.

In the second, Jones also stands to gain if anything should happen to his six-year-old cousin. Like Smith, Jones sneaks in planning to drown the child 4 in his bath. However, just as he enters the bathroom Jones sees the child slip and hit his head, and fall face down in the water. Jones is delighted; he stands by, ready to push the child’s head back under if it is necessary, but it is not necessary. With only a little thrashing about, the child drowns all by himself, “accidentally,” as Jones watches and does nothing.

Rachels argued there is no morally relevant difference between the two cases. “In the first place,” he said, “both men acted from the same motive, personal gain, and both had exactly the same end in view when they acted.”

As for arguments that the Smith and Jones cases are different from cases of euthanasia because they involve nefarious motives and obviously objectionable actions, Rachels said that the point is the same in euthanasia cases – the difference between killing and letting die is not a difference along which moral lines can be drawn:

If a doctor lets a patient die, for humane reasons, he is in the same moral position as if he had given the patient a lethal injection for humane reasons. If his decision was wrong—if, for example, the patient’s illness was in fact curable—the decision would be equally regrettable no matter which method was used to carry it out. And if the doctor’s decision was the right one, the method used is not in itself important.

So, what about arguments declaring that the difference between active and passive euthanasia is that in passive euthanasia the doctor doesn’t do anything to bring about the patient’s death?

It’s incorrect, Rachels argued, to say that in passive euthanasia the doctor doesn’t do anything to bring about the patient’s death. The doctor “does one thing that is very important: he lets the patient die.” Rachels granted that letting someone die is different from other actions in that it’s a kind action that is performed by way of not performing certain other actions, but he maintained that it is nonetheless a type of action.

“The decision to let a patient die,” he said, “is subject is subject to moral appraisal in the same way that a decision to kill him would be subject to moral appraisal: it may be assessed as wise or unwise, compassionate or sadistic, right of wrong.” And if a doctor deliberately let a patient die who had an easily curably disease, the doctor would be just as blameworthy for what he’d done as he would be for needlessly killing a patient.

It’s hard to argue that Rachels was wrong. In cases of both active and passive euthanasia, the motive, to relieve a terminally ill patient’s suffering, and the result, are the same. The method by which the result is brought doesn’t seem to matter. Though Rachels thought there was no morally relevant distinction between active and passive euthanasia, he never went so far as to say explicitly that to let someone die is to kill her.

The medical ethicist Dan Brock, on the other hand, argued just that with this case in his 1992 article “Voluntary Active Euthanasia,” published in the Hastings Center Report:

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-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?

Brock noted the important moral differences between the doctor’s behavior and that of the son: the doctor acted with the woman’s consent and the son didn’t; the doctor had good motives and the son didn’t; and the doctor occupied a role in which he was authorized to fulfill the woman’s wishes and the son didn’t.

So, the doctor’s act was justified, and the son’s act wasn’t. Yet in both cases, the woman is killed.

Whether you agree with Rachels and Brock or not, you have to admit that the conceptual and moral distinctions between active and passive euthanasia aren’t very sharp. In cases in which passive euthanasia is justified, it’s hard to come up with good reasons why active euthanasia is not also justified – whether compassion is delivered through a needle or the pulling of a plug doesn’t matter all that much.