Ethical questions regarding end-of-life care may seem to be a recent phenomenon based on late-breaking developments in biomedical technology. However, such cases have existed since the advent of Western medicine over two thousand years ago under Hippocrates (c.460-370 B. C.), the father of medicine. The ancient Hippocratic Oath attributed to him states in part, “I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect.” Cases such as that of Terry Schiavo, a Florida woman forty years of age said by some to be in a “persistent vegetative state” for nearly fourteen years, are illustrative of this dilemma that has been faced by medical personnel, ethicists, legislators, courts, government leaders and society for millenia. Ms. Schiavo had no advanced directive to indicate her wishes and her family is currently in disagreement over whether her life should continue to be sustained through medical intervention via a feeding tube or allowed to die of starvation since there is said by some to be little hope of recovery. Persons like Terry Schiavo, Karen Ann Quinlan and Jack Kevorkian have become household names in recent years as this debate has reached the American public in the news. The ethical issues regarding euthanasia (Greek for “good death”) are complicated. Those in favor of euthanasia say that there is no moral distinction between killing and letting die, while those opposed to aspects of euthanasia say that there is a moral distinction between the two. The U. S. Supreme Court, in its rejection of challenges to the constitutionality of laws which prohibit physician-assisted suicide, cited this distinction in explicit terms, but did not explain or defend it. In contrast, the Second Circuit of the U.S. Court of Appeals had previously stated that there was no distinction, reasoning that, if it were so, it would discriminate between those on life support who would be allowed to end their lives by removing such support, and those not connected to life support who would be denied similar access to death. Scripture indicates that killing of any kind apart from capital punishment, just war and self-defense are immoral, so it is important to make distinctions between modes of death both morally and legally.
Definitions and Principles
It is important to define terms for purposes of this discussion. Euthanasia is divisible into at least four categories: 1) voluntary passive euthanasia, in which the physician abides by the patient or patient’s family’s refusal of extraordinary means or withdrawal of treatment; 2) involuntary passive euthanasia, also called physician assisted suicide, in which the physician provides the medical means for the person to kill him/herself but does not cause the death directly; 3) voluntary active euthanasia, in which the physician causes the death of the person by medical means with rational consent of the patient/family; and, 4) involuntary active euthanasia, in which the physician causes the death of the person without the patient’s/family’s consent. See chart below. The first is commonly referred to as “letting die” while the other three are variously referred to as “killing.” However, even the first is controversial, and some would consider it killing as has occurred in the aforementioned Schiavo case which involved removal of treatment via a feeding tube.
Chart 1. Forms of Euthanasia
- Refusal of treatment; no extraordinary means or heroic treatment
- Withdrawing of treatment primarily on defective neo-nates, incompetent patients, and those in a persistent vegetative state
- Induce death with consent; mercy killing of hopeless cases with pain
- Induce death without consent; mercy killing; incompetent; deformed neo-nates
The principles involved in cases of euthanasia include autonomy, non-maleficence, beneficence and double effect. Autonomy is the right of a person to make decisions concerning his or her own life, e.g., the right to forego resuscitation or terminate life-support. Beneficence is the obligation to help those in need, e.g., to prevent the death of a patient, while non-maleficence is the duty to do no harm, e.g., not prolonging a patient’s suffering through extraordinary means if the patient has issued a “do not resuscitate” order. The principle of double effect is the justification of a harmful effect from a procedure if the harmful effect is an incidental byproduct or unforeseen event, not the direct intended effect, e.g., the administration of morphine to a terminal patient to relieve pain in spite of the fact that it may hasten death.
Some choices in this regard on the part of the patient have always received legal and ethical sanction. These include a patient’s refusal of life-support technology, such as a respirator or artificial nutrition, or a patient’s request that it be withdrawn. The administration of drugs primarily for pain relief when the secondary effect may cause death also has received legal and ethical sanction for many years.
Distinctions Between Killing and Letting Die
In Scripture, the life of a human being is considered sacred because all people are created in the image of God, and the killing of innocent life is prohibited. “Whoever sheds man’s blood, by man his blood shall be shed, for in the image of God He made man” (Gen 9:6). “You shall not murder” (Exo 20.23). “Keep far from a false charge, and do not kill the innocent or the righteous, for I will not acquit the guilty” (Exo 23.7). For a Christian, death is the last enemy (1Cor 15.27), yet we live and die to the Lord, not alone (Rom 14.7-8). In fact, to die is gain (Phil 1.21). However, the Christian should not seek the premature death of himself nor that of another. The time of death is in the hands of God. “There is an appointed time for everything. And there is a time for every event under heaven– A time to give birth and a time to die” (Eccl 3:1-2). However, every case of “mercy killing” in Scripture is seen in a negative light: 1) those who either killed themselves or had themselves killed by others; 2) the command against murder includes the murder of self; 3) suffering does not render a life meaningless or valueless; and, 4) our lives are not our own, not at our own disposal.
In the ethical debate, “killing” is generally defined as causing someone to die. “Letting die” is generally defined as allowing someone to die of “natural causes.” The following scenarios are typical examples of the difference between killing and letting die outside the medical field. Scenario 1: If a man is swimming in a pool and another man drowns the first man, that would constitute killing. Scenario 2: If a man is drowning in a pool and another man tries to save him but is prevented by circumstances beyond his control, even if it was to save his own life or the life of another, that would constitute justifiable letting die. Scenario 3: If a man is drowning in a pool and another man who stands to gain a great deal from the first man’s death does nothing to help, even though it is in his power to do so without causing any harm or danger to himself, that would arguably constitute unjustified letting die because the intent was the same as that of killing. The American Medical Association distinguishes cases of unjustified killing from cases of justified letting die. Justified actions in medicine are confined to (passive) letting die (item 1 on page 1). “Mercy killing” (items 2, 3 and 4 on page 2) is always unjustified. According to the AMA, a physician has the right to stop treatment if the case meets all three of the following conditions: 1) The life of the body is being preserved by extraordinary means; 2) there is irrefutable evidence that biological death is imminent; and, 3) the patient and/or family consents. Physicians are bound to the duty of beneficence (to do good and prevent harm) and non-maleficence (to do no harm) in the Hippocratic Oath, so are prohibited from killing, but are not morally bound to aggressively preserve life in every case. The AMA House of Delegates has stated that the “cessation of treatment is morally justified when the patient and/or the patient’s immediate family, with the advice and judgment of the physician decide to withhold or stop the use of extraordinary means to prolong life when there is irrefutable evidence that biological death is imminent.” This authorizes some instances of allowing to die by withholding or stopping treatment but excludes killing. Even if the distinction between killing and letting die is morally irrelevant in some cases, it is not always morally irrelevant as some proponents of “mercy killing” allege. The most important arguments for the distinction between killing and letting die depend on a distinction between acts and practices. Justifying one act in a particular case is easier to do than to justify a general practice. To allow “mercy killing” as a practice can lead to a number of serious consequences: 1) abuse – presuming a “request” from the comatose or demented; 2) error – some will die unnecessarily because of uncertainties of medicine; 3) slippery slope – voluntary euthanasia will lead to involuntary euthanasia for those who cannot consent; 4) distrust – the patient will lose trust in the doctor whom he knows can kill; and, 5) coercion – elderly, handicapped and dying may feel subtly or directly encouraged to request euthanasia. The opponents of euthanasia allow for acts of letting die under certain circumstances because they make a distinction between acts of letting die that are morally justified and those that are not.
Those who favor euthanasia in most forms generally agree that there is no moral distinction between killing and letting die. For example, philosopher James Rachels writes,
“the bare difference between killing and letting die does not, in itself, make a moral difference. 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.”
Rachels compares two scenarios in which a child drowns in a bathtub. In both cases an older cousin is involved in the drowning, both with the same motive to inherit a large sum of money if the child dies, but performing different acts. In the first, the older cousin (Smith), actively drowns the child. In the second, the older cousin (Jones), intends to drown the child, but upon entering the bathroom, sees the child accidentally fall into the tub hitting his head and passively watches while the child drowns. In the first case, Smith actively drowns the child. In the second case, Jones passively watches him die. The result is the same. Though in both scenarios the older cousin is culpable, the mere difference between active and passive involvement is morally irrelevant according to Rachels, since the motivation and the result is the same. Therefore, he says, the AMA is inconsistent in its policy concerning the withholding of end-of-life treatment. They should allow active as well as passive euthanasia. Another euthanasia proponent, Patrick Hopkins, asserts that removal of a machine is not a passive act. He says human organs are very much like machines. In fact, some organs can be replaced or assisted by machines internally. Turning off or removing a machine attached on the outside is no different than turning off or removing a machine on the inside, e.g., blowing out the computer chip in a person’s pacemaker. The case can only be made if one makes a moral distinction between machines and bodies. Therefore, he concludes, if removal of a machine is not a passive act, but rather is active, then it is not morally distinct from other active means of ending a life. Similarly, Michael Tooley argues in favor of no moral distinction from the moral symmetry principle when he writes, “…it is as wrong intentionally to refrain from interfering with a causal process leading to some morally significant result as it is to initiate the process. It does not assert that it is wrong to refrain from preventing someone else from initiating a causal process as it is to initiate it oneself.” This principle implies that, all things being equal, it is just as wrong to intentionally refrain from administering an antidote to someone who is dying of poisoning as it is to administer the poison, provided the same motive is operative in both cases. Thus it follows that the distinction between killing and intentionally letting die is not morally significant. In sum, proponents of euthanasia contend that a patient’s request for a fatal medication is analogous to a patient’s refusal of life-sustaining medication.
These arguments fail in several ways. First, euthanasia is not a truly autonomous act. It always involves another person left behind to cope with the responsibility, guilt, morality and remorse. Second, building into medical practice an explicit exception licensing physicians to kill their patients to relieve severe pain is not necessary. The physician may be able to relieve pain short of killing. Much progress has been made in recent years in pain management. We should not build a social or professional ethic on borderline situations and extreme cases. There are ways to “accept” acts of killing in exceptional circumstances without altering the rules of practice, e.g., guilty by reason of temporary insanity. Third, much of their argument is based strictly on “rights” language which is about the extent to which the principle of autonomy may be exercised. It sees moral problems only in terms of competing interests, e.g., “my rights” vs. “your rights.” Virtue ethics, on the other hand, asks questions about the effect of our moral choices on our character: who are we going to become if we follow this path of action? Fourth, Rachels seems to make no distinction between intentions. He focuses only on acts. To him, if the acts are the same, the morality is the same because the outcome is the same. This is wrong. If two persons perform the same act, one intending to kill and the other not intending to kill, there is a moral difference according to Scripture. Those who committed unintentional killings in Old Testament Judaism were protected from acts of vengeance in cities of refuge, while those who committed murder were put to death. Fifth, the intent in euthanasia is to cause the patient’s death. By contrast, most patients who desire to discontinue treatment do not want to die, but to live out their remaining time without dependence on medical technology.
First, it is important to make a distinction between killing and letting die. Those who see no distinction between the two seem to do so to justify hastening the death of those who are suffering severe pain or lingering with a low quality of life, but are not dependent on machines from which they might be removed. Though this is regrettable, it does not justify killing innocent life. Establishing a practice of allowing physicians to terminate life or to provide the means for others to terminate their own lives is morally wrong and will lead to a host of even worse consequences.
Second, though it is important to make a distinction between killing and letting die, the acceptance or rejection of the distinction does not necessarily determine moral conclusions about particular cases. There are some cases of letting die that are immoral. It is not as simple as determining whether it is a case of killing or letting die to determine an action’s morality. We must distinguish between unjustifiable killing and justifiable letting die. To do so requires following the principles found in Scripture, much care, much wisdom, and much courage on the part of legislators, judges, pastors, ethicists, physicians, families and individuals. The times ahead will likely become more complicated and more challenging for all of these in our technology-oriented society. May we be found faithful as a society to follow the righteous paths laid out for us in God’s Word regarding end-of-life issues such as this so that we might not incur his wrath but might experience his blessing.
Beauchamp, Tom L. and James F. Childress. Principles of Biomedical Ethics. New York: Oxford University Press, 1979.
Emanuel, Ezekiel. “Whose Right to Die?” The Atlantic Monthly. Vol. 279, No. 3, Mar 1997, 73-79, in http://www.theatlantic.com/issues/97mar/emanuel/emanuel. htm.
Frame, John M. Medical Ethics: Principles, Persons and Problems. Phillipsburg, NJ: Presbyterian and Reformed, 1988.
Hopkins, Patrick, D. “Why Does Removing Machines Count as “Passive” Euthanasia?,” Hastings Center Report, 27:29-37 My-Je 1997.
Orr, Robert, David Biebel and David Schiedermayer. More Life and Death Decisions: Help in Making Tough Choices About Care for the Elderly, Euthanasia, and Medical Treatment Options. Grand Rapids: Baker, 1990, reprint 1997.
Pojman, Louis P. Life and Death: Grappling with the Moral Dilemmas of Our Time. Boston: Jones and Bartlett, 1992.
Rachels, James. “Active and Passive Euthanasia,” in May, Applied Ethics, pp. 589-593: http://www.montgomerycollege.edu/faculty/~bsoderbe/public_html/rachels.text.
__________. “Active and Passive Euthanasia,” The New England Journal of Medicine, Vol. 292, January 9, 1975, 78-80, reprinted in http://web.acc.qcc.cuny.edu /SocialSciences/ppecorino/DeathandDying_TEXT
Rae, Scott B. Moral Choices: An Introduction to Ethics, 2d ed. Grand Rapids: Zondervan, 2000.
Sulmasy, Daniel P. “Killing and Allowing to Die: Another Look,” Journal of Law, Medicine & Ethics. Vol. 26, No. 1, 1998, 55-64, in
Thomasma, David C. and Glenn C. Graber. Euthanasia: Toward an Ethical Social Policy. New York: Continuum, 1990.
Tooley, Michael. “An Irrelevant Consideration: Killing versus Letting Die,” http://web.acc.qcc.cuny.edu/Social Sciences/ppecorino/DeathandDying_TEXT/ Tooley.htm
Westley, Dick. When It’s Right to Die: Conflicting Voices, Difficult Choices. Mystic, CT: Twenty-Third Publications, 1990.