A Response to Räsänen and Häyry’s Criticism of James Rachels’

Smith/Jones Example in His Article “Active and Passive Euthanasia”

Rick Garlikov

In their article “Fifty Years of Killing and Letting Die: On the Limits of Philosophical Bioethics” Joona Räsänen and Matti Häyry focus too technically on an insignificant minor characteristic of one argument in James Rachels’ “Active and Passive Euthanasia” and miss his main point.  Their argument is the following in the blue font – with my responses added in red font in the relevant places:

To illustrate Rachels' argument, consider the following, slightly adapted cases from Rachels. When you do, imagine that you know all of the following and nothing more—of any relevance to your ethical evaluation. [I presume this means these are all the facts you know about the two cases, not that you don't know much or anything about ethics.]

Killing. Smith will gain a large inheritance if his six‐year‐old cousin dies. One evening, while the child is taking a bath, Smith sneaks into the bathroom, drowns the child, and makes it look like an accident.

Letting Die. Jones will gain a large inheritance if his six‐year‐old cousin dies. One evening, while the child is taking a bath, Jones sneaks into the bathroom planning to drown the child. But, as Jones enters the bathroom, the child hits his head and falls face down into the water. Jones stands ready to kill the child if necessary. But the child dies on his own.

After presenting the above cases, Rachels then asked did either man behave better from a moral point of view? Smith killed the child, whereas Jones “merely” let the child die. That is the only difference between the cases. For instance, the people's motives were the same and the result of their actions/inactions was similar. So, did one of them act morally worse than the other? Rachels' answer is no.

If this ethical intuition is widely shared (as Rachels assumed it is – all that is required is for the reader to share the intuition and then the conclusion, not that either belief is ‘widely shared’), then, killing is not worse than letting die. If—and, according to Rachels, since—that is the case, then active euthanasia is no worse than passive euthanasia. This is because the only difference between active euthanasia and passive euthanasia is precisely the difference between killing and letting die—a morally irrelevant distinction.

However, the neglected problem with the argument is that Rachels takes the intuitions from the case where letting die is clearly morally impermissible—the case where Smith lets his cousin die in the bath—and uses the moral intuitions generated by this case as evidence for cases where letting die is morally permissible, such as passive euthanasia. We cannot reason from the conclusion that killing is no worse (than letting die) when it is impermissible to let die, to another conclusion that states that killing is no worse (than letting die) when it is permissible to let die.

While it is true that the Smith/Jones analogy argues from an impermissible (I’ll just call it ‘wrong’) act, that is neither neglected nor a problem for Rachels because it is not quite what his argument is.  And while they are right that there can be a moral difference between killing someone and letting them die, Rachels recognizes that and takes it into account in the fuller expression of his claim than they characterize here.  I will explain cases where there is a moral difference between killing and letting die – where one can be right while the other is wrong – but Rachels’ complete argument allows for that, and I am confident Rachels would accept that the moral differences I will point out do matter to make killing someone (outright) and letting them die have opposite moral value.  

But it will mean that either one can be right when the other is wrong, not just that whenever there is a difference, it will be in favor of letting die over actively killing.  I will show that there are cases, where letting die is right but killing is wrong; and that there are cases where, oppositely, killing is right and letting die would be wrong.  Rachels himself pointed out a latter such case.  Other than one place in the essay where  Rachels states his view in too abbreviated fashion, he is not claiming there is never a moral difference between killing and letting die, but is simply claiming that when there is such a moral difference, it is for a significant reason beyond ‘one is letting someone die’ and ‘the other is killing them’.  The difference between killing and letting die will then have, for example, different consequences or something else that determines whether an act is morally right or not.  Rachels mistakenly says that feature could be the intention of the person performing the act, but I will point out it needs to be something else.                                                                                                                                                  

Räsänen and Häyry also seem to me to unfairly attribute hubris to Rachels.  At the end of their article they write the following in the blue font – again with my responses added in red font in the relevant places:

In view of the goals that ethicists should pursue in the context of assisted dying, the failure of Rachels’ Bare Difference Argument – pointing out errors in one’s  misinterpretation of an argument do not show a failure of the person’s actual argument – shows that at least philosophical bioethicists should not try to pontificate on clinical cases based on made‐up conceptual differences.  Rachels didn’t commit that error.  The arguments by analogy used by ethicists should be more sensitive to context and should not neglect the pragmatic dimensions of the practices in which the individual actions, on which the analogical arguments draw, are embedded.  Rachels heeded that.  Philosophical bioethicists should, rather, aim at having a nuanced view of real‐life situations like assisted‐dying choices and their ethically relevant dimensions and at making these dimensions known to decision‐makers on all levels—bedside, ward, hospital, health care provision, and legislation.  Rachels was doing that.  The conclusion of such analyses can well be that matters remain contested—but if that is the reality, then bioethicists would overstep their professional roles by claiming otherwise.  Rachels did not overstep by offering, explaining, and supporting the point he was making.

What philosophical ethicists can and perhaps should do, however, is to make sure that the arguments presented are logically consistent and conceptually coherent—especially regarding agent's other commitments and beliefs.  I see no reason to believe Rachels didn’t do that or reasonably try to do it.  Ethicists with background in philosophy are very much needed for their critical outlook dissecting and systemizing skills that can help to clarify the discussions.   But when it comes to normative guidance, it is false to assert that philosophical ethicists know better than others what to do.  Rachels made no such claim.  And insofar as all the above simply means that bad philosophical reasoning and poor arguments should not govern or dictate medical practice, that is true, but it applies to the article “Fifty Years of Killing and Letting Die: On the Limits of Philosophical Bioethics” by Joona Räsänen and Matti Häyry too.

Specifically what they get wrong is that Rachels is not using what they call “The Bare Difference Argument” in the way they say, and it is not his only argument, particularly as they state it, for his claim that insofar as euthanasia is right in a given case or (in their terms) ‘permissible’, active euthanasia should be as permissible as passive in that case (with a certain stipulation or qualification), despite the American Medical Association’s statement to the contrary.

Now I will point out that there can be an ethical difference between passive and active euthanasia that Rachels does not discuss or perhaps notice, but it will not weaken his point, although there is one place in the essay he states in too abbreviated a way his main point and the abbreviated way is not a correct formulation nor a correct principle, although not for the reasons given by Räsänen and Häyry.  The incorrect or incomplete, too abbreviated formulation Rachels states is “I have argued that killing is not in itself any worse than letting die; if my contention is right, it follows that active euthanasia is not any worse than passive euthanasia”.  The correct formulation of his contention is that “I have argued that killing is not in itself any worse than letting die apart from a justified moral consideration/reason/principle to the contrary other than, or over and above the fact that, actively killing is not the same as passively letting die; if my contention is right, it follows that active euthanasia is not any worse than passive euthanasia when euthanasia is right [or ‘permissible’] in the first place, unless there is a specific condition that would make a moral difference, other than, or over and above the fact that, actively killing is not the same as passively letting die. [I will give a further explanation of this later along with examples of what would make a moral difference between the two kinds of euthanasia that I believe Rachels would accept as making a moral difference between passive and active euthanasia in those cases.]

Rachels says

…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.  [The last point here will need some amending and further explanation which I will give later in this essay, but is essentially correct, though not sufficiently complete.]

Rachels also says:

The decision to let a patient die is subject to moral appraisal in the same way that a decision to kill him would be subject to moral appraisal: it may be assessed as wise or unwise, compassionate or sadistic, right or wrong.

But he contends what I think is true that:

it is not the bare difference between killing and letting die that makes the difference in these cases [that is, cases of murder for profit or some other bad reason versus physician-assisted suicide for the supposedly good reason of ending the patient’s unnecessary, unredemptive, pointless suffering]. Rather, the other factors—the murderer's motive of personal gain, for example, contrasted with the doctor's humanitarian motivation—account for different reactions to the different cases.  [He is correct that other factors are what makes a difference between acts being right or wrong, but he is mistaken that the person’s intentions are those other factors.  A person’s intentions are relevant to his or her being a good or bad person, but not whether s/he is doing the right thing or not.  Many wrong acts result from a good person’s good, but misguided intentions; and there are rare cases where a right act is done for bad intentions and reasons. Räsänen and Häyry also consider intentionality to be a relevant issue though in different ways, but still it is not relevant to whether an act is right or not.  Even the doctrine of double effect does not turn solely on whether a bad consequence is intended or not because it does not permit known bad likely consequences that are not sufficiently compensated by the gains even if unintended.  For example, apart from special circumstances, you cannot knowingly kill or highly likely risk killing 10 innocent people in order to save one innocent person of equal value to the other individuals, even if your intention is just to save the one innocent person.]

The decision to let a patient die is subject to moral appraisal in the same way that a decision to kill him would be subject to moral appraisal: it may be assessed as wise or unwise, compassionate or sadistic, right or wrong.

This point negates another argument given by Räsänen and Häyry that if there is no difference between killing and letting die, then insofar as active euthanasia is wrong, so is passive, and that rather than both being right, they are both wrong.  They say that if “Rachels' original bare difference remains intact [it] testifies for the wrongness of euthanasia, also what he calls passive euthanasia. To see that, we only need to start the analysis from the other end.”

Of course, one must always be careful assertions of equality are not simply reversed or turned around and used against you.  A couple of old jokes point this out: 1) the man with an impaired arm in church imploring God to make his arms both be the same, so God impairs his good arm, or 2) the 60 year old couple who find a bottle on a sandy beach that, when they dust it off, frees a genie who gives them each one wish.  The wife is asked for her wish first, and she asks for great wealth that she specifies in detail.  The genie snaps his fingers and says “It is done.”  Then he asks the husband for his wish and the husband says “I wish she was 30 years younger than me.”  The genie snaps his fingers and says “It is done”, turns the man 90, and vanishes.  

Or consider Ronald Reagan’s answer during his presidential debate with Walter Mondale to the question about his age and whether he would be up to serving another term.  Reagan replied: “I will not make age an issue of this campaign. I am not going to exploit, for political purposes, my opponent's youth and inexperience”.   Or you have to beware of a challenge to your analogy, as in the vice presidential debate between Dan Quayle and Lloyd Bentsen, where when Quayle was asked about having sufficient experience to be vice president, he in part replied “I have as much experience in the Congress as Jack Kennedy did when he sought the presidency.”  That gave Senator Bentsen the opportunity to give the response that brought shouts and laughter from his supporters in the audience: “Senator, I served with Jack Kennedy. I knew Jack Kennedy. Jack Kennedy was a friend of mine. Senator, you're no Jack Kennedy.”  The last four words have served ever since as a response to someone who undeservedly compares himself with someone revered: you’re no Jack Kennedy.  

Rachels’ view is not that the equality only goes in one direction, but that it goes in both directions: if either form of euthanasia is wrong in a given case, so is the other, and if either case is right so is the other – unless there is some moral consideration/reason/principle to the contrary other than, or over and above the fact that, actively killing is not the same as passively letting die.  I will give such a difference I think Rachels would accept.  It then does not negate his principle when his principle is stated fully about what the difference has to be, rather than when it is stated in the abbreviated form that there is no moral difference.

I have already said that the intention of the person committing the act is not what makes the act right or wrong.  Here are some or all of the things that make an act right or wrong:

• overall value of the intrinsic consequences of the act in terms of benefit/burdens or goodness/harm

• deservingness of people benefiting from or burdened or harmed by the act

• fairness of distribution of the consequences (benefits/burdens or goodness/harm)

• fairness and reasonableness to the agent who would have to do the act

• incurred obligations

• violations of rights

• risk of unnecessary harm, particularly in a in a reckless, negligent, heedless, or irresponsible manner  (whether the harm happens or not)

• attempts to do intentional harm (whether successful or not)

But it takes further reasoning to explain how they should be applied in any given case or ethical problem -- further reasoning, for example, to show which act will give the best consequences to the most deserving people, further reasoning to explain who is deserving, further reasoning to explain what is the fairest way to distribute benefits and burdens, further reasoning to explain what is reasonable to expect of an agent who has to do the act, etc.  I have an ethical principle^[1] that is just a shorthand way of keeping track of all the kinds of components that need to go into making a moral decision or judgment, along with their prima facie order of priority.  If you don't consider all those things (and there may be some I have mistakenly omitted from my principle), you run a greater risk of having an incomplete consideration and erroneous conclusion.  For example, political debates often ignore the relevant factor which the opposing side is arguing is important.  The issue of taxes, for example, have two components at least -- fairness and benefit.  Some will argue that lowering taxes will actually raise more revenue by encouraging more trade, thus yielding greater revenue with a lower tax rate than from a higher one.  E.g., a 5% sales tax will yield more revenue from a billion dollars in sales than will a 10% sales tax that only allows $350,000,000 in sales. That becomes a factual issue then as to which tax rate will earn the most revenue, and it should be able to be decided empirically by testing.  But sometimes the issue of taxation is one of fairness, and it may, for example, be argued that sales tax is "regressive" costing poorer people a higher percentage of their income than wealthier people. But that argument leaves out the fact that often wealthier people contribute far more revenue in sales tax than do poor people (because they buy more) and that in many cases poor people benefit far more from the taxes paid by the wealthy than do the wealthy.  The wealthy may be paying for public schools, for example, that they don't need for their children's education but that they provide for families that do.  

Also, notice that even a dozen eggs is regressive, because the cost of them takes a higher percentage of the income of a poorer person than of a richer person, but we don't say the price of eggs is unfair.  But the point is that if one side in a political debate is simply saying higher taxes are unfair and the other side is saying that the rich can afford them and they are necessary to do all this good, neither side is systematically addressing all the relevant issues and they are merely shouting their own narrow considerations at each other. One is arguing fairness and the other is arguing utility, and neither side is addressing whether the tax is actually unfair or whether it will raise the most revenue and/or do the most good.  And they are ignoring whether fairness or utility is more important in this case, and why, if they do in  fact conflict. That is not a reasonable way to decide any ethical issue -- or any kind of issue, actually.

The principle I use was developed by going through all the philosophically known flaws in the historically important principles of ethics that are now often still conventionally used.  For example, egoism does not properly consider the rights and our obligations to others.  No forms of consequentialism (including act-utilitarianism) take into account promise-keeping, loan repayment, etc., and often they do not take into account the fair and proper distribution of benefits and burdens.  The Golden Rule does not take into account what another person wants or what might actually be best for him or her, but what you want for yourself -- which may not even be best or right for you.  The full development of my general ethical  principle is given and explained in my “Introduction to Ethics.”

Now it will turn out that in using my principle, not all the components will come into play in any given situation, or their application will be so obvious that the consideration only takes a fraction of a second.  E.g., in deciding whether to give some money (which you can easily afford to give) anonymously to one charity or another, where both are deserving, you would not usually consider what is fair to you in making that decision or what rights are involved, but would want perhaps to give the money to where it will do the most good.  There may be other considerations from the components of the principle, but not necessarily all of them.  In such cases, it is tempting and natural to think you are making a strictly utilitarian decision, but that is only because you already have seen the other kinds of factors don't apply or are neutral in the application.  But if you do it right, even if it boils down to which charity will be able to do the most good with the money, it was not a decision based only on utilitarianism from the beginning.  If it were, then if some other factor were to be important, your deliberations would not take it into account because utilitarianism takes nothing into account in deciding what is right other than what causes the greatest good.  E.g., suppose both charities could each do a lot of good with the money, but lots of people give to one of them and few people give to the other.  You might want to give to the second on grounds of fairly distributing benefits to the people whom the smaller charity would help.  The amount of good would be the same, but the value or fairness of the distribution is different.

There is a contemporary common error made by some philosophers and textbooks: saying that something would be right according to one ethical principle but wrong according to another, as if it doesn't matter whether the principles themselves are right or not.  But I hold that you can't any more reasonably say that "X is right if you take a utilitarian position" than you can reasonably say that Jeffrey Dahmer's actions in murdering and eating lots of innocent people was right if you take a cannibalism position or from the position of a vulture culture.  If utilitarianism is flawed or if cannibalism is flawed, then acts are not proved to be right by reference to them.

The Relevance of All This to Passive vs Active Euthanasia

I have written more extensively about euthanasia and “end of life” decisions in the following essays and will just refer to, or add, in short form some things here that are relevant to the Räsänen and Häyry article:

The Essential Goal of Medicine and the Moral Role of the Physician in Regard to Euthanasia

The Concept of the Right to Physician-Assisted Suicide

Determining, Declining, and Terminating Medical Treatments

Active Vs Passive Euthanasia: Moral Equivalence or Not?  Philippa Foot Vs James Rachels

The Concept and Ethics of Passive Euthanasia

A necessary, but not sufficient, condition for euthanasia to be right is that the patient wants to have it or would want to have it, and would let us know that if able to decide and communicate his/her decision.  The choice by the patient to have euthanasia is not sufficient because the patient could wrongly want to die or be willing to die sooner than necessary just as anyone contemplating ‘garden variety suicide’ over a temporary sad condition might.  No matter how short the time left, if there is a reasonable chance of experiencing something that would make the suffering worth (or more than worth) enduring, premature death might be wrong to voluntarily have.  (People permanently unconscious or otherwise unable to communicate with us, and infants whether born or unborn, are unable to let us know their wishes, and so in those cases we need to decide what they would likely want based on all possible evidence we can muster.)

But for purposes of this discussion, let us assume that the patient is willing to die, does want to die, or would want to die under his/her circumstances and that there is nothing that s/he will (likely) be able to experience that would make enduring the suffering worthwhile.  In other words, let us assume that it is right for the person to die prematurely – that is, before nature makes it impossible to continue to stay alive any longer under the current circumstances and state of medical knowledge; that is, before nature and/or physics and biology kill the person.

The question then is how best for them to die.  But that question also involves the means and the timing of the method used and what they prefer.  In particular, based on the reasoning in the Rachels/Foot essay above, does the person want to die immediately and quickly or slowly and more gradually over time.  That is somewhat of a false dichotomy because someone might want to die quickly, but not immediately because s/he is wanting to set the process of euthanasia (premature dying) in motion, but not have the actual death occur immediately (because, for example, they want to feel worse or ‘come to grips’ with death better or possibly even want to suffer a bit more first because they feel some suffering will be redemptive in some way, but not have to endure intolerable suffering or torment).  There are two ways to look at a case where the person does want passive euthanasia because they do want to hurry their death, but not make it immediate: 1) they do not want death right now,  so euthanasia that would cause death to occur now, whether passively or actively would then be wrong.  Or 2) They want to begin passive euthanasia that will let/help them die somewhat soon, but slowly or gradually.  And they want to distinguish that from actively taking a fast-acting poison in a few days' time.  It is not that they want to die quickly a few days from today, but that they want to die gradually with their life ending a few days from today.  If we are talking about, say, a four day process, it is not the four-day time of death (i.e., death on the fourth day from now) that matters to them, but the four day gradual process of dying that matters.

The distinction I am making is similar to one that occurs in the joke about the following.  In Genesis 6:3, it says “Then the LORD said, 'My spirit shall not abide in man for ever, for he is flesh, but his days shall be a hundred and twenty years’”, which leads to the blessing people sometimes give to others “May you live to be 120.”  But the joke version of it is the blessing that says “May you live to be 120, plus 3 days” where, when the person you are blessing asks “why the extra three days?” you answer “Because I don’t want you should drop dead all of a sudden.”  As some people [humorless ones] point out, though, of course you can still drop dead all of a sudden on the third day after turning 120.  And even if you die on your 120th birthday, it could be the result of a gradual deterioration from much earlier.  The speed at which you go from healthy to dead, or the time it takes to go from being healthy to being dead, is not by itself an indicator of the time of your death.  And vice versa, the time of your death is not by itself an indicator of when your health began to deteriorate in a way we consider that you began to die.  Knowing someone was dying for a year doesn’t tell you the date of their death any more than knowing someone died immediately of an acute stroke.  And, likewise, knowing someone died at 2:37am on a particular day doesn’t tell you when they began to die from the specific condition said to have been what they died from, or how long it took.  Moreover, of course taking this even further is the saying that from the minute we are born (or conceived) we begin to die, or the saying that ‘life is a sexually transmitted terminal condition’.  It is true for everyone that each day you live, you are closer to death and further from birth (and conception) than the previous day, even when we do not know which (midpoint) day begins to put you closer to your death than to your birth (or conception).

How you help them accomplish that in a reasonable way doesn’t matter to them and I think it should not matter to anyone else who legitimately considers euthanasia right in the first place in a given particular case.  Suppose, for example, they are on some sort of machine that is necessary to keep them alive, and that turning off the machine would let or make them die fairly quickly.  If they do not want to die fairly quickly but want to die somewhat slowly or gradually, though sooner than natural, it would be wrong for them to have passive euthanasia in the form of turning off the machine, but right for them to have a method that lets them die, say, over a four day period as they get weaker and weaker.  That could be A) through the withdrawing of  some other life-sustaining treatment, or it could be B) through a slow-acting poison of some sort that kills them.  The former would be passive euthanasia and the latter active euthanasia, but I don’t see  any moral difference between those two “slow-dying” methods in this kind of case.  I don’t think Rachels would either.  

But I contend, and think Rachels would agree, that there would be a moral difference between A) actively killing or passively letting the person die immediately, both of which would be wrong and B) actively killing or passively letting the person die gradually over, say, the four days, which might be right insofar as euthanasia is right at all in the first place.   What that means is if we consider a case where there is no kind of slow-acting poison available, Rachels and I would say slow or gradual passive euthanasia would be right, but fast-acting passive or active euthanasia would be wrong.  That is because of the moral consideration of doing what the patient wants his/her dying to be like, insofar as its having already correctly been determined that euthanasia is right or ‘permissible’.  I am pretty sure Rachels would accept that in such a case there is a moral reason that passive prolonged euthanasia is better than immediate active euthanasia.  However, I think he would say that if a gradually killing lethal injection of some sort that did not cause worse suffering as it worked were available, administering it would not be worse than the passive gradual, equally prolonged euthanasia because then both would meet the moral requirement of meeting the patient’s wishes in this case about how s/he wants her/his death to come, given it has also been already correctly been determined euthanasia is justified.

A Different Kind of Case Where Actively Killing Is Worse Than Letting Die

 Suppose someone is caught in a strong torrent of water, say, a rip tide in the ocean or a raging flood of river water through a rocky channel, and suppose you cannot swim and have no means to save them from drowning or being smashed upon large rocks further downstream – nothing you can throw to them to prevent their drowning or crashing on the rocks.  There is a sense in which you have to let them die, since either you cannot prevent it or it is too risky to even try to prevent it, because the attempt would just  likely add your death to theirs.  Insofar as that is “letting them die”, it is clearly morally superior to pushing them into the water and drowning them.  

I do realize that this might not be considered “letting” someone die in the same sense as choosing not to save them when you easily and safely could, as Jones could have easily saved the drowning six year old in the above example.  In this case your choosing to try to save them would not do any good for saving them, whereas in the bathtub case it would make all the difference.  Whereas someone might feel guilty in the rip tide or flood case for just having “let” the person die, others might say the person “didn’t ‘let’ them die; there was just nothing effective s/he could do.”  This is not dissimilar to the ambiguity about choosing to let them die versus not having a choice (or reasonable, viable option) to try to save them.  But there is a more significant point for this example.

Rachels’ Smith/Jones example works (or makes both men’s actions equally morally wrong) because Jones is omitting saving the child although he easily could have saved it, simply by bending down and lifting its head out of the water.  It is not like the rip tide/flood case.  And insofar as the condition in my general moral principle applies (all else being equal) – that one should do great good for others that comes at  little risk or cost to oneself, one has a moral obligation to do that.  But one has no moral obligation to sacrifice or risk sacrificing one’s life in a highly likely futile effort to do good for someone else.  At best, if there is even a slight chance of success, it would be a saintly, but not obligatory act, but if there is no chance, it would be a wrongful, needless, self-sacrifice.

Given that Rachels’ claim, when stated fully is that killing is no worse than letting die unless there is some specific moral difference between the two (i.e., something over and above the mere verbal distinction between ‘killing’ and ‘letting die’) which would make it worse, what is really happening in the Smith/Jones drowning cases is that Smith’s drowning the child was no morally worse than Jones letting the trial drown because Jones could easily and readily have saved the child and had a moral obligation to do it which he chose to ignore.  Räsänen and Häyry are correct that both letting the child drown and drowning it are equally impermissible [or, I would just say they are ‘equally wrong’, or simply ‘wrong’] and equally bad, but that is because there is no morally significant moral difference between the two (insofar as one does have an obligation to help others a lot at little or no risk or cost to oneself).  And Rachel’s fuller version of the bare difference argument takes that into account.

In the paper The Concept and Ethics of Passive Euthanasia I argue there are other kinds of cases where it would be morally right (or at least reasonable) to let someone die but wrong to kill them.  But that is because in those cases there will be a moral reason (that is, there will be moral elements) that make them morally different, not just verbally different. Rachels’ principle would allow passive euthanasia while preventing active euthanasia in such cases because there is more than a bare verbal difference in them.

Moreover, the bare difference argument is only one of four arguments Rachel’s gives for claiming letting die is no morally worse than killing (when one could readily keep someone alive, but simply chooses not to), and it is not meant to prove there is never a difference between letting someone die and killing them, but is meant to be an example of it.  I think it is an effective example because both acts, as Räsänen and Häyry point out, are (egregiously) “impermissible” [or I would just say ‘wrong’].

But what Räsänen and Häyry need to make their point that this fact matters is a case where letting something happen (through an act of omission) is right but making it happen (though an act of commission) is wrong for no other moral reason than the bare difference of letting happen versus making happen.  They try to do that with their examples of lying about the child’s art work versus not telling the child the truth about it and the physician’s lying about water safety versus omitting telling the truth about its lethality, but I cannot see that their claims are right in those cases, given that the mother and doctor both know (or at least believe) that their omitting the truth will have the same result as their lying.  I don’t see how a doctor’s not warning a person (who seeks their advice) from likely drinking deadly water is morally different from telling them it is safe to drink it.  As in “As a doctor, I wouldn’t say you shouldn’t let your child eat peanuts with other kids at the ballpark because of the deadly allergy you know he has to them. It is really up to you and what you want to do or think is right, particularly in his wanting to fit in with other kids.”  How could that possibly be okay for a doctor to say!

And the artwork case is even more nebulous, given that it is about what might or might not encourage or discourage a child from developing what they may or may not actually have a talent for if they pursue it further, but that is not yet developed enough to be recognized.

Also, it seems to me that the problem they raise with the two cases by Fiona Woollard of letting an already rolling boulder kill someone (versus pushing a boulder that will kill someone)^[2] in order to save two others is easily patched, but still will not help them. They say the problem with the example is “that while they are analogous with active euthanasia with one morally relevant feature (in both, letting die is permissible), they are disanalogous with other relevant features. For instance, in active euthanasia, we are not saving multiple people by killing one; we are ending the life of one patient to reduce their suffering and respect their autonomous choice to decide about their own life. Because of such disanalogies, it seems that the intuitions from Woollard's cases cannot be used as guidance for the euthanasia debate any more than the intuitions from Rachels' cases of two cousins.”  That would be easily remedied by simply making the two boulder cases about saving one severely injured person rather than two.  

The boulder cases are basically just versions of the famous ‘trolley problem’ and turn on the same issue – killing someone totally innocent to save others, versus killing someone who has put himself at risk in the same or similar way the people you are trying to save have put themselves at risk.  Even if you have a right (or even an obligation) to sacrifice one for many if they are all in equal circumstances, you don’t necessarily have the right or obligation to sacrifice innocent people to save people (even a greater number of people) who have unnecessarily put themselves in jeopardy.  

I myself would even go so far as to say people with responsibilities of having small children of their own should not put themselves in harm's way to rescue people who put themselves in harm’s way for no reason other than getting some sort of thrill out of a safe accomplishment.  That is, I think, for example it is wrong for parents of small children to try to save mountain climbers trapped in dangerous places on a mountain by a storm that was clearly forecast ahead of time and the mountain climbers knew that but dismissed or ignored the warning and the danger.  In other words, I think it wrong not only to kill or risk killing a totally innocent third person to save someone who put himself knowingly in harm’s way for no good reason, but I think it wrong even to voluntarily put oneself in harm’s way to save such a person.

Then there is this curious paragraph:

“To bring home the relevance of the moral (im)permissibility of the choice, considering another distinction, ignored by Rachels, could be useful. Forms of euthanasia conceptually include, in addition to active and passive, also direct and indirect. In the direct form, the physician or medical team typically administers a lethal drug that kills the patient. In the indirect form, the physician or medical team increases pain medication with the intent of alleviating pain and anguish but with the foreseen consequence of hastening the patient's death. Employing the doctrine of double effect,some have argued that ending the pain by ending the life intentionally is impermissible, whereas ending the life unintentionally (this is a debated point that does not concern us here) is permissible.”

But since their whole point is that in Rachel’s Smith/Jones example both acts are impermissible, they cannot themselves use a counter-example where both acts are also impermissible.  So, if ending a life knowingly but ‘unintentionally’ is impermissible, that point does, and should, concern them.

But also, the use of sufficient morphine or other drug to eliminate horrendous pain does not necessarily alleviate the emotional suffering from dying if the person remains conscious.  And if it renders the person unconscious until they die, it is not clear to me that is any different, morally or  otherwise, from active euthanasia.  “Don’t worry.  We are not going to kill you; we are just going to render you permanently unconscious” does not strike me as very comforting or reassuring if someone wants to continue to live.  Normally that includes their knowing they are still alive and experiencing thought and perceptions – knowing it at least part of the time, even if not when they are sleeping or temporarily otherwise unconscious.

And when Räsänen and Häyry say

“These points raise a broader worry about the role of philosophy in medical ethics. As the discussion of the permissibility of assisted dying continues, the perfect analogy with euthanasia is yet to be found”, 

they are making another significant error, for the Smith/Jones case is not an analogy for euthanasia, nor is it intended to be one, but is an example of letting someone die being just as morally wrong as killing them.  The Smith and Jones cases are somewhat analogous to each other, but not to euthanasia because neither is about mercy killing to prevent further suffering.

And philosophy is not simply about finding analogies or using only analogies as evidence for ethical claims.  Even if the Smith/Jones example were some sort of analogy for euthanasia, it is not Rachels’ only argument in his article.  Furthermore, analogies are not meant to match what they are analogous to in all ways, but in logically relevant ways.  Some fail to do that; others succeed, so you cannot just say analogies necessarily fail in philosophy or always constitute inadequate proof or poor reasoning.