1. Preliminary Distinctions

(l) Voluntary, Involuntary, and Nonvoluntary Euthanasia

(Cf. James Rachels, "Euthanasia" - chapter 2 of Matters of Life and Death.)

Euthanasia is voluntary when it is requested by the person who undergoes it.

Euthanasia is involuntary when the person who undergoes it wants not to do so.

Euthanasia is nonvoluntary when the person who undergoes it is unable to indicate whether or not he or she wants to undergo euthanasia.

Comment

        Some writers use the expression "involuntary euthanasia" to mean what I shall refer to as "nonvoluntary euthanasia".

(2) Active Euthanasia versus Passive Euthanasia.

        There are two slightly different ways of drawing this second distinction, depending upon how one classifies the case in which one actively withdraws life support systems.  One way of drawing the distinction is in terms of:

    (i)  Acting versus doing nothing at all.

        According to this first way of drawing the distinction, active and passive euthanasia are distinguished as follows:

One has a case of active euthanasia whenever anything is done that contributes to the person's death.

One has a case of passive euthanasia only if nothing at all is done that contributes to the person's death.

        A different way of drawing the distinction between active and passive euthanasia is in terms of the following distinction:

    (ii)  The primary cause of death is human action versus the primary cause is some injury or disease.

        According to this second way of drawing the distinction, active and passive euthanasia are distinguished as follows:

One has a case of active euthanasia whenever the primary cause of death is human action.

One has a case of passive euthanasia whenever the primary cause of death, rather than being some human action, is some injury or disease.
 
 

2. Euthanasia and the Concept of Death

        There are case  where a life-support system could be used to maintain life processes in someone's body, but this is not done, or where a life-support system is being used, but then turned off, but where some people say that what one has is not a case of euthanasia, either active or passive, on the grounds that the person in question is really already dead.

Issue: What is the criterion of death?

Some Possible Criteria

(l) Irreversible cessation of heartbeat and respiration.

Problem:

        What was previously irreversible may not be irreversible today, given life support systems that can artificially maintain respiration and cardiac function.

(2) Irreversible cessation of spontaneous heartbeat and respiration?

Problem with (2):

        Consider the case of a person who is psychologically perfectly normal, and physically normal, except for needing an artificial heart.  Such a person is surely not dead.  Similarly for a person who is psychologically perfectly normal, but who needs some large device outside the body to maintain heartbeat and/or respiration.

(3) Irreversible loss of consciousness, based on death of the whole brain.

Comment:  This is the view that was advanced by the Harvard ad hoc Committee on the concept of death.

Decisive Tests: Absence of certain reflexes. Lack of response to what would normally be extremely painful stimuli.

Relevant, but not decisive tests: "Flat" (isoelectric) EEGs

(4) Irreversible loss of consciousness, but based upon UPPER brain death.

        Underlying idea:  If it is really the irreversible loss of consciousness that is crucial, and that determines whether an individual is dead, then upper brain death is the appropriate criterion, since upper brain death, on its own, is sufficient for irreversible loss of consciousness.

Test: "Flat" EEG provided that: (i) No drugs that depress the central nervous system are present; (ii) It is not a case of hypothermia.

Usually the EEG is measured at least twice, with an interval of 24 hours or so between measurements, to avoid problems due to (i).

Notice:  The upper brain may be destroyed, while the brain stem is intact, in which case spontaneous respiration and cardiac function will be present, since these are controlled by the brain stem. Hence a person who would be alive according to the traditional criterion, however it is interpreted, will be dead according to the upper brain death criterion.

An Objection to Both (3) and (4)

        While both whole brain death and upper brain death may be conditions that ensure that the person in question is dead, the reference to irreversible loss of consciousness that both involve is an error.  The reason is that consciousness could always in principle be restored to a given human body by means of a transplanted brain (or upper brain).

        What's crucial is not the destruction of those physical sates that underlie the general capacity for consciousness.  What is crucial is the destruction of those states that are the basis of personal identity - states such as memories and personality traits.  If those states were destroyed via selective damage to parts of the upper brain, then even if the capacity for consciousness were intact, the person who had previously existed would no longer exist.

Relevance of this to the Topic of Euthanasia

        Which account of death one accepts will affect what gets counted as a case of euthanasia.  If one accepts one of the brain-oriented accounts, then the "vegetable" cases in the narrow sense will not be cases of euthanasia, since one will be saying that the individual or person is already dead. The main cases of euthanasia will then be:

1.  Voluntary euthanasia.

2.  Nonvoluntary ("involuntary" according to the usage of many) euthanasia involving adults whose condition does not involve upper brain death - e.g. the Karen Ann Quinlan Case.

3.  Nonvoluntary euthanasia involving infants.
 
 

3.  The Moral Status of Euthanasia

        Most people accept passive euthanasia, both in the sense that (l) they think it is morally permissible, in appropriately delimited cases; and (2) they think it should be permitted by law.  Active euthanasia is much less widely accepted, and it is generally prohibited by law.

3.1  Fundamental Moral Issues

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

(2) If there is a significant difference, is it such as should be reflected in a difference in legal status?
 
 

3.2  Alternative Attempts to Justify the Claims that There Is a Significant Difference

(l)  Arguments that Attempt to Show that There Is an Intrinsic Difference

         The argument here can take two different forms, that it is important to distinguish.  Both claim that there is an intrinsic difference between (a) killing and (b) letting die - that is, a difference that exists independently of the consequences of each.  But according to the first approach:

(lA) The intrinsic difference does not turn upon theological premises.

According to the second approach, in contrast:

(lB) The intrinsic difference is dependent upon theological premises.

Comment:

        Arguments of type (lB) are really just the same arguments as those that arise in connection with theologically based arguments against suicide.

(2)  Consequentialist Objections to Active Euthanasia, but Not to Passive Euthanasia

        Consequentialist arguments come in two importantly different forms:

(2A)  Allowing active euthanasia is likely to lead, in individual cases, to undesirable consequences.

(2B)  The general practice of active euthanasia is likely to lead to other general practices that are highly undesirable.      (The "Wedge" argument, or "Slippery Slope" argument.)
 

4.  Discussion of Some Important Arguments of Type (1A)

Question:

        How might one support the claim that there is an intrinsic difference between killing and letting die - that is, a moral difference even if the consequences are the same in any given case - without appealing to religious arguments?

One Answer:  An Appeal to Moral Feelings or Intuitions?

Comment: This must be done in a critical and reflective fashion.

Crucial Question:   Do the two cases I'm considering - one of killing, the other of letting die - agree in all other morally relevant respects?

Point:  If they don't, the difference in one's feelings about the cases may derive from those differences, rather than from the fact that one is a case of killing, the other a case of letting die.

        There are two important cases, which I shall discuss, where an attempt has been made to keep other factors constant, including the individual's motive in acting or nor acting:

(l) James Rachels' case of the greedy person and his young cousin;

Comment:  Rachels' argument is an example of a very important type of ethical argument called the "bare difference argument".

(2) The diabolical machine case.

4.1  James Rachels' Case of the Greedy Person and his Young Cousin

       In his article "Active and Passive Euthanasia". James Rachels offers, in the following passage, an argument for the view that killing someone and letting someone die are, in themselves, morally on a par:

         "One reason why so many people think that there is an important moral difference between active and passive euthanasia is that they think that killing someone is morally worse than letting someone die.  But is it?  Is killing, in itself, worse than letting die?  To investigate this issue, two cases may be considered that are exactly alike except that one involves killing whereas the other involves letting someone die.  Then it can be asked whether this difference makes any difference to the moral assessments.  It is important that the cases be exactly alike, except for this one difference, since otherwise one cannot be confident that it is this difference and not some other that accounts for any variation in the assessments of the two cases.  So let us consider this pair of cases:

         "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 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.

         "Now Smith killed the child, whereas Jones 'merely' let the child die.  That is the only difference between them.  Did either man behave better, from a moral point of view?  If the difference between killing and letting die were in itself a morally significant matter, one should say that Jones's behavior was less reprehensible than Smith's.  But does one really want to say that?  I think  not."  (Applying Ethics, page 241)

        Rachels' argument is an instance of what is often referred to as the Bare Difference Argument, the structure of which is as follows:

(1)  The only morally significant differences between actions A and B is that action A has property P and lacks property Q, whereas action B has property Q and lacks property P.

(2)  The contribution that property P makes to the overall moral status of action A is just the contribution that property P makes when it is the only morally significant property that is present in some action.  That is to say, the situation is not one where other morally significant properties interact with property P so that the difference that its presence makes is either greater or less than it would otherwise be.

(3)  Similarly, the contribution that property Q makes to the overall moral status of action B is just the contribution that property Q makes when it is the only morally significant property that is present in some action.  That is to say, the situation is not one where other morally significant properties interact with property Q so that the difference that its presence makes is either greater or less than it would otherwise be.

(4)  Consequently, in view of (2) and (3), if the moral significance of property P were either greater than, or less than, that of property Q, then action A would have a different moral status from action B.

(5)  But this is not so: actions A and B are morally on a par.

(6)  Therefore properties P and Q have precisely the same moral significance.

        Rachels, in setting out the case of Smith and Jones, does not address the issues that correspond to steps (2) and (3) in the Bare Difference Argument schema just set out, and, as a consequence, his argument is incomplete.  But, while I shall not consider the matter here, I believe that (2) and (3) are both eminently reasonable in Rachels' case of Smith and Jones.  If so, Rachels' argument can be sustained, and he is right in concluding that the properties of killing someone and letting someone die have precisely the same moral significance.

4.2  The Diabolical Machine Case

        Another interesting case that may be helpful in thinking about the question of whether the distinction between killing someone and letting someone die is morally significant in itself is the following:

A very evil person has constructed a machine in which he has placed two people - John and Mary.  As things stand, if nothing is done, the machine will kill John, and Mary will emerge unharmed, whereas if a button is pressed, John will emerge unharmed, and Mary will be killed.  Would it be wrong for someone to flip a coin, and then to press the button if and only if the coin comes up heads?  If one did that, both John and Mary would each have a fifty percent chance of surviving.  But if killing someone is in itself more seriously wrong than merely letting someone die, then it would seem that it must be wrong to flip the coin, since if it would be wrong simply to press the button, then the grounds of that must be that doing so would be killing Mary, whereas not doing so would be merely letting John die.  But if this is so, then mustn't it also be wrong to do something that involves a fifty percent chance that one will wind up killing Mary .  But is it wrong to flip the coin to decide what to do?

4.3  The Case of the Resourceful Doctor

        There are also interesting arguments on the other side - that is, for the view that killing is, in itself, morally more wrong than letting die. - two of which I want to consider.

         The first is this.  Jenny, who is a doctor, has four very ill patients.  One needs a heart transplant; one needs a liver transplant; one needs a kidney transplant; and the final one needs a lung transplant.  Unfortunately, no organs are available, nor will any become available, and the situation is such that if no transplants are carried out, all four patients will die.

         An apparently hopeless situation.  But Jenny is very resourceful, and she notices both that all four patients are of the same blood and tissue type, and that she has a healthy patient - Bob - who also matches the four needy patients.  Jenny asks Bob if he would be willing to donate is organs to save the other four people, but Bob declines.  Jenny therefore kills Bob, and uses his organs to save the other four people.

         If killing and letting die were morally on a par, then surely it would have to be morally right to kill one innocent person to save four equally innocent people, and so Jenny's action would be morally right - indeed, highly praiseworthy.  But is it?  If not, then killing someone must in itself be morally more wrong than allowing someone to die.

        What is one to say about this argument?  One response is that any of the four patients who needed a transplant could have provided organs for the other three patients, since different organs are needed in each of the four cases.  So it might be argued that what Jenny should have done is to have used some random process to choose one of the four needy patients to serve as an organ donor for the other three.  But does this response go to the heart of the matter?  For mightn't many people still think that it would be wrong for Jenny to kill one person to save three others?

4.4  Trolley Cases

        In thinking about this, it may be helpful to consider another famous case that people have thought about in connection with the question of whether the distinction between killing someone and letting someone die is morally significant in itself:

         A trolley is on a track on the top of a hill.  The track leads down to the bottom of the hill, where it splits into two tracks, with a switch controlling which track the trolley moves onto at that point.  Two innocent people are tied to one track, and one innocent person to the other, and the position of the switch is such that, if the trolley were to start rolling down the track, and if the switch were not moved, it would proceed along the track to which two people are tied, and would kill both of them, whereas if the switch were moved, only the one person on the other track would be killed.

         Suppose now that the trolley does start rolling down the track, that you have no way of stopping it, of getting any of the three people off the tracks.  Suppose further that you know nothing about the three people involved - other than that they are all innocent of any serious wrongdoing, and so have no more reason to save any one person than any other.  The question now is this:  Is it morally permissible for you to move the switch, so that the two people who would have been killed are saved, while the one person who otherwise would not have been harmed is killed?

        Some people hold that the moral prohibition against killing is an absolute one, and so they hold that it would be morally wrong to move the switch so that one person dies, rather than two.  Indeed, on this view, it would not matter how man people were on the track that the trolley will move along if the switch is not moved: even if there were a million people or more, it would still be wrong to move the switch, because doing so would be directly killing an innocent person, and such an action is, it would be claimed, never justified.

        Few people would, I think, have those intuitions about the 'doomsday'-style counterexample.  But if one doesn't, the question that arises is whether it is morally permissible to switch the trolley even when there is only one person on each track - something that would be permissible if killing someone and letting someone die were in themselves morally on  a par - or whether there is some minimum number, n - where n is greater than one - such that it is morally permissible to shift the trolley only if the number of lives that one is thereby saving is equal to or greater than n.

        Here, however, let us suppose that there are four people on the track that the trolley will move along if not switched onto the track with the one person.  Then,  as regards numbers, the case is exactly comparable to the case where Jenny kills the one healthy patient to save the four patients who otherwise will die.  The question then is whether one's moral intuitions are the same in this trolley case as in the original, resourceful doctor case.

        Perhaps surprisingly, many people seem to view the cases differently, holding that Jenny's killing the one patient to save the other four is morally wrong, but that switching the trolley so that one person is killed, but four are saved, is morally permissible - or even morally obligatory.

        What is one to make of such intuitions?  One answer emerges if one considers a different type of case.  Here are two versions of it:

Version 1:  A trolley is rolling down the tracks, moving towards three innocent people whom it will kill if nothing is done.  Now, unfortunately, there is no switch.  But there is a very heavy person that one can move onto the track, and one knows from one's engineering studies that if the heavy person is placed on the track, then it is certain that that will stop the trolley, thereby saving three lives.

Version 2:  A trolley is rolling down the tracks, moving towards three innocent people whom it will kill if nothing is done.  Here, as in the original case, there is a switch that will enable one to move the trolley onto another track.  This other track, unfortunately, loops back around, so that if nothing stops the trolley, it will still kill the three people on the other part of the loop.  However, there is a very heavy person that the trolley will run into, and kill, and that collision will stop the trolley, saving the other three people.

        How do these two trolley cases differ from each other?  The answer is that, in Version 1, one has to do something to the person whose presence will stop the trolley - namely, move him onto the track - whereas, in Version 2, one does not have to move that person around.  Some people feel that this difference is important, although most people, I think, do not.

        The crucial question, however, is how these two trolley cases differ from the original case, and the answer is this.  In the original case, once the trolley has been switched onto the other track, the three lives are saved even if the single person who is thus put in danger manages somehow to get off the track.  In the revised versions 1 and 2, by contrast, if the single person gets off the track before the trolley runs into him, the trolley will continue along, and will kill the other three people.

        In the revised versions, then, the death of the single person is a necessary means to the saving of the other three, whereas in the original trolley case it is a consequence of saving the other three, but not itself a means that leads on to their being saved.

        Consider, now, the case of the resourceful doctor.  Here, too, the death of the one patient is a means of saving the other three.  Consequently, if one thought that killing the one person to save the three was permissible in the original trolley case, but not in the two revised trolley cases, or in the case of the resourceful doctor, then one would have an account of what the relevant difference is:

Suppose that there is a type of state of affairs, G, that is good, and another type of state of affairs, B, that is bad.  Suppose, further, that the following four things are all true:

(1)  One wants to bring about G;
(2)  There is no way of bringing about G without also bringing about B;
(3)  The goodness of G outweighs the badness of B;
(4)  One would prefer that B not occur.

Now compare the following three actions:

Action 1 involves intentionally bringing about G, knowing that G will necessarily cause B to occur;

Action 2 involves intentionally doing something that will give rise to two causal processes, one of which lead to G, and the other to B;

Action 3 involves intentionally bringing about B, knowing that B will necessarily cause G to occur.

The Principle of Double Effect then says that Actions 1 and 2 are morally permissible, but that Action 3 is morally wrong.
 

        The Principle of Double Effect is widely appealed to within Catholic moral theology, but has not generally been widely accepted outside of that tradition.  But if one thinks that saving the three people is permissible in the original trolley case, but not in the two revised versions, then it would seem that one has a good reason for embracing the Principle of Double Effect, since it is hard to see any other way of accounting for a moral difference between the original trolley case and the two revised versions.

        Suppose that one accepts the Principle of Double Effect .  Does that provide any basis for the view that while voluntary passive euthanasia is morally acceptable, voluntary active euthanasia is not?  It does not appear that it does, since it seems that the relevant causal structure is the same in both cases.  In the case of active euthanasia, one's positive action brings about the person's death and the person's death ensures that that person will not suffer any more from the disease in question.  Similarly, in the case of passive euthanasia, one's decision to withdraw a life support system, or one's simply doing nothing, causally brings it about that the person dies, and the person's death ensures that that person will not suffer any more from the disease in question.  The situation appears to be completely parallel.  But if it is, then the Principle of Double Effect cannot entail that the one action is morally wrong, and the other permissible.