The Death of Socrates, by Jacques-Louis David (1787)

The late philosopher James Rachels published one of the most salient pieces on the euthanasia (E) debate in 1975 in The New England Journal of Medicine titled “Active and Passive Euthanasia.” Here is a brief outline of his argument.

The distinction between active euthanasia (AE) and passive (PE) is thought crucial. This is mistaken. Why?

AE is preferable to PE because it reduces suffering.

Rachels understands saving all defective newborns or destroying certain ones (if they have Down’s syndrome (DS) or congenital defects for example), but he doesn’t understand allowing them to die slowly and painfully.

Given the distinction, life & death decisions are made on irrelevant grounds. For example, intestinal blockage (IB) allows us to let a DS baby die, but wo/ the IB we would have to kill it. But the blockage is irrelevant. The issue is whether the DS baby should live. The distinction between AE and PE make this situation absurd—it leads to us thinking IB was important.

Killing is not worse than letting die. Consider 1) Smith drowns his cousin for money; and 2) Jones lets his cousin drown for money. It doesn’t seem there is any moral difference between the 2 cases. Similarly, whether you kill or let die for a good motive—say to relieve suffering—the act is right or wrong independent of how you brought death about. In both cases, the intent or motive is primarily to terminate life (and relieve suffering or costs).

We tend to think killing is worse than letting die because usually bad guys kill and physicians let die. But this doesn’t mean that there is something intrinsic to killing which is worse than letting die.

Counter-argument – In PE the physician does nothing and the disease kills the patient. In AE the physician does something to kill the patient.

Rachel’s Response – 1) Physicians do do something when they allow people to die—they let them die. That is a type of action. 2) It is bad to cause someone’s death because death is ordinarily thought bad for them. But if death has been deemed preferable, then bringing about death is no longer bad. 3) MDs may have to go along with the law, but the distinction between active and passive euthanasia cannot be defended philosophically.

Comment – This is one of the most air-tight and flawlessly reasoned pieces I have read in the medical ethics literature. And my sense is that this argument is increasingly winning the day.

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