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

For a long time I have believed that insofar as there was any difference between active and passive euthanasia, active was better.  This is counter to the view of most physicians.  Philosopher James Rachels expresses  my own independently arrived at ideas about it very well in his 1975 paper "Active and Passive Euthanasia" [The New England Journal of Medicine, Vol. 292, No. 2].  But in her 1977 paper "Euthanasia" [Philosophy and Public Affairs 6(2) ] Philippa Foot argues that Rachels is mistaken and wrote "James Rachels believes that if the difference between active and passive is relevant anywhere, it should be relevant everywhere, and he has pointed to an example in which it seems to make no difference which is done."  She is speaking of Rachels' example of there being no moral difference between allowing a child to drown in a bathtub that one by chance sees it has slipped under the water, and pushing its head under the water to intentionally drown it.  Foot agrees that both are wrong and reprehensible acts, but she thinks it is for different reasons that in other examples or contexts do make a difference and that thus disprove what she says is Rachels' argument.

I am writing about this only because even though Foot's claim about Rachels' argument seems to me to be clearly mistaken, and her own argument irrelevant to disproving it, my considering her argument did allow me to discover one kind of case where passive euthanasia could be right while active euthanasia would be wrong, and though it is still irrelevant to Rachels' points and arguments, it is important to the overall issue of whether and when active or passive euthanasia is right or whether there is any moral difference between them different from what Rachels claims, in any context different from the one about which he was writing.

Consider Foot's example of where active euthanasia would be wrong but passive euthanasia would be right: "Suppose, for example, that a retreating army has to leave behind wounded or exhausted soldiers in the wastes of an arid or snowbound land where the only prospect is death by starvation or at the hands of an enemy notoriously cruel.  It has often been the practice to accord a merciful bullet to men in such desperate straits.  But suppose that one of them demands that he should be left alive?  It seems clear that his comrades have no right to kill him, though it is a quite different matter whether they should give him a life-prolonging drug. The right to life can can sometimes give a duty of positive service, but does not do so here.  What it does give is the right to be left alone."  Foot contends that the obligations of both charity and justice coincide in the bathtub case, which makes them both require keeping the child alive, but that in the battlefield case, charity would require using the merciful bullet whereas justice prohibits it if the man does not want to be shot and prefers being left alone.  However, neither charity nor justice, she says, requires that his life be further extended under the circumstances.  I think she is mistaken about a number of points, including the last one that there would be no obligation to give him life-sustaining or life-prolonging treatment/drugs under the circumstances in order to prolong his life and thereby also prolong his suffering.  To this last point, it seems quite obligatory to comply with a request he makes for, say enough water and rations to last a week if he were to survive that long, if you have the water and rations to spare.  Or it would be obligatory for the others to help get him, particularly if he wants, into a nearby shed where there is food and water he will be able to access on his own, and that you all are leaving behind anyway.

In the two different copies of Rachel's essay which I have, I do not see any place where Rachels' argues that if the difference between active and passive euthanasia makes a difference anywhere, it should make it everywhere, so even if there were cases where passive euthanasia would be right and active euthanasia would be wrong, it would not vitiate the sorts of cases Rachels described or his claim in the context he clearly has in mind.  If he made that claim somewhere else that Foot knows about, her argument would disprove its truth.  But then so would his own since he argues that in cases where there is a moral difference, normally active euthanasia would be better than passive, not the other way around usually claimed.  Foot is giving a case of involuntary euthanasia of the sort we normally call murder -- killing someone against his/her will even if supposedly for his/her own good-- and her claim about justice applies simply because of that.  Rachels is writing only about cases where euthanasia is already [correctly] determined to be right, and the next question then is whether it should be through active or passive means.  Rachels correctly points out that passive means of euthanasia will generally prolong the suffering and in many cases even worsen or intensify it.  In those cases, he argues that active euthanasia would be better and morally preferable, and that passive euthanasia would be the wrong form of euthanasia.  "...once the initial decision not to prolong his agony has been made, active euthanasia is actually preferable to passive euthanasia, rather than the reverse." [Emphasis mine.]    Later, he writes: "The reason why it is considered bad to be the cause of someone's death is that death is regarded as a great evil -- and so it is.  However, if it has been decided that euthanasia -- even passive euthanasia -- is desirable in a given case, it has also been decided that in this instance death is no greater an evil than the patient's continued existence.  And if this is true, the usual reason for not wanting to be the cause of someone's death simply does not apply." [Again, my emphasis.]  I would also point out that even though there is a moral difference between euthanizing an animal and euthanizing a person -- because it seems we are not robbing an animal of any hopes, dreams, plans, future goals it has worked for, particularly with deferred gratification, etc. -- we would still not generally use passive euthanasia even for a suffering animal that it has been determined needs to be euthanized, because that would be counterproductive and inhumane.  Veterinarians do not say things like "Your dog/cat is suffering in a way we cannot relieve and it is time for it to die, but we cannot just put it to sleep because active euthanasia is wrong, so I am going to give you a certificate that makes it legally permissible for you to stop feeding it without being charged with animal cruelty or abuse.  That way its suffering should be ended within three or four weeks."

It is at this point that I would like to bring in a further consideration of this whole matter, prompted by Foot's arguments in part. 

First, however, notice that I consider Rachel's arguments to be about those cases where euthanasia is right in the first place, and I thus added in quoting him that the determination that euthanasia is right is correct.  Rachels just talks about the determination being made, though I presume he thinks it is made correctly, but he does not specifically say that, and, the more important problem with that is his criteria in the second passage just above is a mistaken one for reasons that Foot points out in a different context, examining the problem with involuntary euthanasia, killing someone against their will, even if it would be in their best interest to be dead sooner rather than later, whether they know that or not.  Whether death is a greater evil than life or not, is not sufficient for determining that euthanasia is right or not, even in determining it for oneself.  Clearly it is not other people's place to kill you because they correctly know that you would be in some way better off dead than alive.  But I argue [in "The Right to Physician-Assisted Suicide"] that it is often a mistake even for a person to think it right to end his/her own life just because it has more bad than good in it.  Most, or at least many, lives have more bad than good in them, but the issue is not where the balance lies between 1) the amount and intensity of suffering on the one hand and 2) the amount and intensity of joy or satisfaction on the other, but is more about whether the amount of existing or likely to become existing good things makes, or would make, the amount and intensity of suffering worthwhile to the person or not.  So, even a person willing to die can be mistaken about its being right.  But if we assume that Rachels is talking about cases where it really is right for a person to hasten his/her death or have help terminating his/her life sooner than would happen naturally, then his argument is correct, and Foot is mistaken.

But that is not the quite the end of it, and Foot's army case, along with others, can help show what more is involved.

To say, even correctly, and even by the person him/herself, that life is no longer worth the suffering one will have to endure and so it is the proper time to die rather than prolonging and/or increasing the agony, does not necessarily give a precise time or manner in which one wants to die.  Generally the presupposition is that people ready and wanting to die, want it to be as quick and painless as possible.  But that is not necessarily true, as it might not be the case in Foot's military example, though it is difficult to tell because she does not indicate why the soldier does not want to be shot instead of being left behind.  It could be that he thinks he can be saved and treated humanely by the enemy; it could be that he thinks if he cooperates with them, they will keep him alive.  It could be that he thinks some miracle might save him.  In those cases, he has not determined or accepted that death is preferable.  He just thinks he might still avoid it.

But we can flesh out her example further.  Suppose he does want to die sooner rather than later, but that he doesn't consider the bullet better than starvation, and that he also wants some time to "come to better grips" with dying.  I have said about myself in the past, that I don't want to die in a plane crash caused by a malfunction at 35,000 feet that lets me know we are going to crash -- because it doesn't allow me enough time to come to grips with dying at that point in my life, but gives too much time to agonize about, and fear, it.  The soldier may prefer to die from starvation or cold than from a bullet, and he may even prefer to endure torture rather than the bullet, even though there will be more pain involved.  But he may also not be at the point where he welcomes death, which he might be when he is weaker and feels worse and is more ready and willing for it.  Pain is not the only or necessarily even main measure of suffering or quality of life. 
[I have read that Freud, for example, passed up taking morphine as he was dying, because he preferred clear thinking with pain to drug fog even with pain relief.  I think I would be that way because I personally hate drug fog that makes me drowsy and prevents me from thinking clearly, so I do not even take antihistamines that will cause it.  I had one sleeping pill one time in the university infirmary and do not understand why anyone would ever willingly experience the effect which it had on me -- making me 'out of it' in a drug haze the whole next day.  Yes, I went to sleep with it that night, but the sleep, though long, was not refreshing, and I was essentially then half asleep for the whole next day and a half.  I hated it.  And if that is the effect it has on everyone, I cannot understand anyone's wanting to have it by taking barbiturates for the feeling.]
So if we consider it wrong to kill someone who doesn't want to die, it seems only reasonable to also consider it wrong to let or help someone die in a manner which s/he does not want to die or in an immediate time frame that doesn't allow the proper acceptance yet.  In such a case, passive euthanasia could be right where active is not.  Or passive euthanasia could  be "active" enough for the patient (or soldier).

Rachels point is still taken, however, if he was writing about using using euthanasia at that point where life is no longer worth living and where living longer is unendurable and has no redeeming qualities -- the point where the person justifiably wants to die and is ready to die.  That is not the point where the soldier in Foot's example was, regardless of the reason.  It is at that point that continued life from passive euthanasia -- the withdrawal of life-sustaining treatment, with its attendant short run increase of amount and intensity of suffering,  as opposed to an acceptable (to the patient and the person administering it) form of active euthanasia would be wrong, according to what I believe is Rachels' basic argument and to my argument about this.  But if the person is not quite to that point, but wanting to get to that point through passive euthanasia, because they do want to die fairly soon but they also want to be more willing to die and want to be at the point where they are more accepting of their death, then passive euthanasia with its attendant diminution of strength and of desire to continue living, would be better and right.

This work is available here free, so that those who cannot afford it can still have access to it, and so that no one has to pay before they read something that might not be what they really are seeking.  But if you find it meaningful and helpful and would like to contribute whatever easily affordable amount you feel it is worth, please do do.  I will appreciate it. The button to the right will take you to PayPal where you can make any size donation (of 25 cents or more) you wish, using either your PayPal account or a credit card without a PayPal account.