Discussion Group Report

"The distinction between active and passive euthanasia is widely thought to be of great moral importance," says the January 9, 1975, edition of The New England Journal of Medicine in introducing two articles advocating opposing points of view on this subject. "For instance most doctors believe that, although it may sometimes be permissible to withhold treatment and let a patient die, it can never be permissible to directly kill the patient."

James Rachels challenges this doctrine while Thomas 0. Sullivan upholds it.

Rachels argues that active euthanasia may be more humane than passive euthanasia, that the conventional doctrine leads one to make life-or-death decisions on morally irrelevant grounds, and that the distinction between killing and letting die makes no moral difference. Take the familiar case of the patient who is dying of incurable cancer of the throat and is in terrible pain, which can no longer be satisfactorily eliminated. He is certain to die within a few days, even if present treatment is continued, but he does not want to go on living for those days, since the pain is unbearable. Under the present doctrine the doctor may simply withhold treatment, since it would be wrong to prolong his suffering needlessly. But simply withholding treatment may mean it will take the patient longer to die, and so he may suffer more than he would if a lethal injection were given.

Or there is the case of the baby with Downs syndrome who, as happens with some such babies, is born with a congenital defect such as an intestinal obstruction that requires an operation to save the baby's life. Sometimes the parents and the doctor decide not to operate and let the infant die. It is a terrible emotional ordeal for a doctor and the hospital staff to stand by and watch as dehydration and infection wither a tiny being over hours and days. Moreover, the decision about whether to save such a baby's life is being decided on irrelevant grounds. It is the Down's syndrome, and not the intestines, that is the issue.

What about the possibility of abuse of patients through euthanasia? In the first of two possible cases, Smith stands to gain a large inheritance if anything should happen to his six-year-old cousin. Smith enters the bathroom while the child is bathing, drowns the child, and then arranges things to make it look like an accident. In the second, Jones also stands to gain from the child's death. He sneaks into the bathroom planning to drown the child. Hut as he approaches him, the boy slips, hits his head, and falls face down in the water. Jones stand by and lets him drown "accidentally." "Smith killed the child, whereas Jones merely let him die," says Rachels. Did either man behave better from a moral point of view? Sullivan argues that Rachels has misinterpreted the traditional doctrine on euthanasia, which he says does not depend on the distinction between killing and letting die. Rather it forbids the intentional termination of life, whether by killing or letting die. "The withdrawal of extraordinary means of life support need not involve the intention to terminate life, even if death is foreseen."

"We are hardly obliged to assume the Jones-like role Rachels assigns the defender of the traditional view. We have the option of operating on the Downs' baby and saving its life...that is precisely the course of action most defenders of the traditional position would choose." Rachels' distinction between active and passive euthanasia is mere jargon; the AMA resolution on euthanasia does not state or imply the distinction Rachel attacks. That it does not seems clear from the fact that the resolution speaks approvingly of ceasing to use extraordinary means of saving the patient in certain cases. The contrast is between ordinary and extraordinary means. Paul Ramsey in The Patient As a Person defines the former as "all medicines, treatments, and operations which offer a reasonable hope of benefit for the patient and which can be obtained and used without excessive expense, pain, and other inconveniences." Extraordinary means are those which do not meet this definition.

The traditional view is that the intentional termination of human life is impermissible. Is the intention deadly? If so the act or omission is wrong. A physician's unwillingness to use extraordinary means may be prompted, not by a determination to bring about death, but by other motives, for instance, his realization that further treatment may offer little hope of reversing the dying process and/or be excruciating, as in the case when a massively necrotic bowel condition in a neonate is out of control." The doctor who does what he can to comfort the infant but does not submit it to further treatment or surgery may foresee that the decision will hasten death, but it certainly doesn't follow from that fact that he intends to bring about death.

"I fully realize that there are times when those who have the noble duty to tend the sick and the dying are deeply moved by the sufferings of their patients, especially of the very young and the very old, and desperately wish they could do more than comfort and companion them. Then, perhaps, it seems that universal moral principles are mere abstractions having little to do with the agony of the dying. But of course we do not see best when our eyes are filled with tears."