Killing vs. letting die: Is there a moral difference?

Euthanasia, hot topic? Yes. Controversial? Yes. Broadly misunderstood? I believe so.

Euthanasia is typically understood as ending a life in order to relieve pain or suffering. Sometimes it’s equated to mercy killing and sometimes when a physician supplies life ending drugs to the patient for them to use it is called physician-assisted suicide. Up until Friday, Feb 6/2015, euthanasia has been a relatively quiet issue in Canada. Other countries like Belgium, Switzerland and Germany and some US states (ie. Oregon, Montana) have embraced assisted suicide as a legal right of someone in grievous, unending pain.

5755763742_5a97254bf6_ocreative commons licensed ( BY-SA ) flickr photo shared by opensourceway

On Friday, a unanimous vote by 9 judges resulted in the following statement:

We do not agree that the existential formulation of the right to life requires an absolute prohibition on assistance in dying, or that individuals cannot ‘waive’ their right to life. This would create a ‘duty to live.[1]

Whether there truly is a duty or a right to live will have to wait for another post but the issue at hand is clear: the Supreme Court of Canada no longer believe that it should be prohibited to take one’s own life…depending on the circumstances. In other words, people should have the right to autonomy over their own death when they are in severe and irremediable suffering, whether physically or psychologically.

As a nurse working in the Intensive Care unit of a busy hospital, this hits home. I have watched people die. I have helped people die. Have I caused people to die? Herein lies a sometimes vague yet vast difference. The difference does not depend on the outcome (both result in death) and it does not depend on the method (both can use the same drugs and treatments). The difference depends on the intention of killing vs. letting die.

Is this an intellectually dishonest differentiation? Some say that letting someone die is akin to passive euthanasia. Our withdrawal of extraordinary therapies (morally optional therapies like placing the patient on a ventilator) results in the person’s death. The use of the term passive is no longer commonly used, as withdrawal of treatment is a very active and deliberate act.[2] These same people may call our use of treatments to end life, active euthanasia. They say that in both situations we are causing the death of a person. I disagree with this use of language and more than that, I want to make a case for the major difference between killing and letting die.

An example will be useful here. Suppose a man buys a dog but refuses the recommended pet insurance that he would need to save the dogs life should the dog need any significant amount of veterinary care. The dog ends up being diagnosed with cancer of the brain which requires expensive chemotherapy treatment. Of course, lacking pet insurance, the man cares for the dog at home and eventually, it dies. Would anyone charge this man of killing his dog? More likely, we would attribute cancer as the causative agent of the dog’s death. The dog died of cancer. Of course in many situations, people decide to euthanize their pets that have terminal illnesses and in this case we would say that the dog had cancer and he “put him down.” A noticeable difference? I think so.

Another example could be useful for audiences who accept the truth of God’s existence and his goodness in the presence of evil. Why does God allow evil? This hot topic lends a great example of an all good being allowing evil for the purposes of free will among other things. Yet we use the language “allows” rather than causes. Why is this? It is clear that God himself commits no morally evil acts. See 1 John 3:5, John 19:4 and others. We could say that because God allows evil, he is responsible for its existence. In a way, yes, he is in control and therefore responsible. Yet we do not generally consider that God has committed moral evil even though he allows it.

In essence, when we remove life sustaining (extraordinary) treatments or withhold them altogether, we are not intentionally causing death to come. Just as the man does not intentionally cause the dog’s death and just as God does not intentionally cause evil, our omission of action is in a general sense responsible for a person’s death, but not our personally responsible. The dog’s death is caused by cancer as evil is caused by our sinful hearts. Both the man and God are morally free from responsibility in these cases. Likewise, when we remove life support, both the patient and the medical team wish the patient to live out the rest of their days without unwanted, invasive medical treatments. In most cases the patient does not want to die but comes to the realization that death is imminent.

In the special cases of patients who require pain medication in amounts high enough to put them to sleep or in doses that will hasten their death by depressing their respiratory function, the unintentional side effect of hastening death is secondary to pain control (the law of double effect). Death may come more quickly but providing these comfort measures becomes morally acceptable as death is not the intent of the action. Terminating life support is seen as morally permissible as the natural death or disease process takes the life of the person, not the medical team. Likewise, in the commonly used example of a man who actively drowns a child vs. a man who sees a child drowning and remains passive, not attempting to save him, intent is central. It is not the action that determines the morality of the issue but the man’s intent. Even though he is passive, he is still responsible because he intends the child to drown.

Contrast this with the intentional euthanasia or assisted suicide as purposeful acts intended to end a person’s life. A long held moral truth by most is that the killing of an innocent person is wrong. This dates back to Exodus 20:13 wherein the Ten Commandments prohibit humans from killing each other. As well, in the Christian worldview, it is not a person’s right to decide the timing of one’s death (Hebrews 9:27). The special exceptions of killing in war time and in the situations of self defense are particular to the context and not applicable here. Many in the secular world agree that killing of an innocent person is wrong, hence the punishment by law for murder.

Lest people accuse me or others who disagree with the active and intentional killing of those requesting euthanasia as cruel, I want to remind those not familiar with medicine that comfort measures (pain control, fluids for hydration, regular hygiene for comfort and dignity) are generally not to be withheld in end of life. This would constitute intentional suffering and even torture. Something to note as well is that modern pain control is often sufficient to remove significant suffering in end of life and make palliation (rather than euthanasia) bearable.

So is there a difference between killing and letting die? Excellent resources to help answer this question are Scott Rae’s Moral Choices and Kelly Madland’s post A Good Death.

 

[1] http://www.theglobeandmail.com/news/national/supreme-court-rules-on-doctor-assisted-suicide/article22828437/

[2] J.P. Moreland disagrees with me here and continues to use passive euthanasia to equate to withdrawal of treatment while affirming that intention is key. See his blog here http://www.str.org/articles/active-and-passive-euthanasia#.VNkePPnF-_g