Killing and letting die: the main Issues
Preamble
This project is an interdisciplinary collaboration between a philosopher involved in the field of bioethics and a sociologist who does reflexive analysis. It seeks to bring together knowledge of the philosophical field of bioethics, as summarized below, and knowledge about the interpretive ground of social action, in this case, physicians’ practice as a form of social action. The interviews seek to explore how physicians interpret and understand their own clinical practice, in light of the debates going on in the field of bioethics. Thus the project seeks to bring together two different fields of inquiry. The purpose of this post is to make accessible for a general audience the debates or issues in the field of bioethics. Needless to say, the very field itself can be challenged from the perspective of another field. This caveat should be kept in mind as you read this post.
Background
For quite a long time now doctors have been withdrawing life-support from patients who voluntarily and competently request this, even when they know that doing so will result in the death of their patient. Hardly anyone today seriously considers this practice to be wrong. But, in the field of bioethics, for many years the practice of withdrawing life-sustaining treatment (WLT) was distinguished from voluntary active euthanasia (VAE) on the grounds that VAE was a form of killing, while WLT did not involve killing but only allowing to die. It could be morally acceptable for a doctor to allow their patient to die, the argument went, but it was never morally acceptable to kill a patient. So, according to this line of thinking, WLT could (under certain circumstances) be morally acceptable, but not VAE.
Over the past five or six decades, many philosophers in this field have challenged this way of thinking, partly in relation to growing cultural support for VAE. They have argued, for various reasons, that the killing/letting die distinction does not support the claim that VAE, unlike WLT, is morally wrong. Some have attacked the distinction itself for being unclear. Others have accepted the distinction but have denied that it makes any moral difference whether a patient is “killed” or “allowed to die” in the senses of these words relevant to WLT and VAE. Either way, these particular philosophers argue that if we accept WLT as ethical action, then if we are consistent we have to accept VAE too.
The distinction between killing and allowing to die can be drawn in a few different ways. The purpose of this post is to summarize briefly how different philosophers have conceived of the distinction, and then to observe some of the back-and-forth of the bioethical debate over the distinction, as drawn in these different ways. Again, and especially from the perspective of the sociologist in this project, this is a very specific discursive field, a field that can be challenged in the way the terms of the debate are constituted. In other places, we have summarized the debate [Stumpf and Rogalski, forthcoming]. The main purpose here is to familiarize with the debate and the terms it uses in a very general way.
Commission versus omission
The first way to draw the distinction between killing and allowing to die is in terms of acting or doing versus omitting to act.
Some philosophers have drawn the distinction in terms of commission/omission; they see VAE as a direct and positive action - as positively doing something, but WLT as not doing something but only allowing an outcome to take place. To administer VAE, a doctor must act (for instance, they have to inject a lethal dose of potassium chloride into the patient’s bloodstream) to bring about death by stopping the patient’s heart. By contrast, when a patient is already dying from a terminal illness, and a doctor withdraws life-support (for example, removing a ventilator on which the patient is dependent for an adequate supply of oxygen), the doctor does not positively bring about their death but only allows the death to take place as a result of the underlying condition [Merkel, McLachlan].
Other bio-ethicists have objected to this formulation on several grounds. To name one: WLT involves positive actions too. A doctor has to do something (sometimes many things) in order to let their patient die; for instance they must remove a ventilator, stop a dialysis regimen, or issue a do-not-resuscitate order. But if WLT, like VAE, involves positive action (doing), then it can’t be distinguished from VAE using the doing/allowing distinction [McGrath]. A second problem is that you can kill someone by withdrawing their life-support. Imagine a patient is on life-support and an enemy sneaks into their room and turns off their life-support machine. The enemy has killed the patient by WLT [Brock]. But if so, we can’t distinguish WLT from VAE in a general way by claiming that VAE is doing and therefore killing and therefore wrong, but that WLT is not doing and so not killing and so not wrong. In other words, the link between killing and doing is not a necessary connection; one can kill by “allowing to die.” These objections generate counter-responses, pointing to an ongoing issue that remains unresolved.
People who support the commission/omission distinction can respond to the first objection in this way: Although WLT involves positive action, it does not involve action with respect to the death itself, but only with respect to the removal of barriers that were holding back death. (By contrast, VAE involves direct action with respect to the death itself, or doing something to bring about the death.) If acting to remove barriers that were holding back an outcome (death) is meaningfully distinct from positively doing something (killing), then the distinction may still hold. But if one can kill by removing a barrier to death, then the distinction will not, on its own, be morally relevant. Some proponents of drawing the distinction this way have acknowledged this, and have noted that the commission/omission distinction only makes a morally relevant difference in light of the differing moral obligations that obtain in relation to omissions and commissions.
In response to the second objection it can be pointed out that the doctor’s removal of life-sustaining treatment differs in important ways from that of the enemy [McGee]. The doctor acts in accordance with the patient’s wishes; the enemy acts against them. The doctor acts on the basis of an established professional care relationship with the patient as part of a socially recognized institution; the enemy does not and therefore acts without social authorization. The doctor’s intentions may differ from those of the enemy. And finally the doctor has an obligation to withdraw the treatment, and no longer has a duty to continue to provide treatment, but the enemy has an obligation not to interfere with socially and institutionally sanctioned treatment. One might argue that these differences combine to distinguish the enemy’s act of wrongful killing from the doctor’s legitimate act of allowing their patient to die by WLT. But one could also oppose this line of reasoning by pointing out that it is these differences (in voluntariness, relationship, intention, authorization, obligation) that make the moral difference between the two practices (if there is one), and not the mere fact that one is a commission and the other an omission [Isaacs].
Causation
The second account of the distinction ascribes a different causal role to an agent performing WLT from that ascribed to an agent carrying out VAE.
Some philosophers have also tried to explain a morally-relevant difference between VAE (seen as killing) and WLT (viewed as allowing to die) in terms of the differing causal roles involved. The basic idea is that when physicians perform VAE, they assume causal responsibility for the death of the patient (that is, they administer a drug that kills the patient). But when physicians perform WLT and allow the patient to die, not they but the underlying condition is causally responsible for the patient’s death [Stauch, McGee]. The implications of this position are that since it is wrong for a health-care professional to assume causal responsibility for a patient’s death, it means that VAE is morally wrong but WLT is not (necessarily) morally wrong.
Similarly to the omission/commission account above, the main objection with this line of thinking is that we seem to be able to cause death by WLT [Miller & Truog]. If a patient is dependent on life sustaining treatment, and physicians remove that treatment knowing they will die, then have not physicians knowingly done something that made the difference between their being alive or dead? The argument is that “causing x” is “doing something that makes x happen rather than y,” thus causing death by withdrawing treatment. In response to this problem, supporters of the causation account argue that causation as difference-making is not the most relevant notion of causation in the contexts of WLT and VAE [Bronner]. In such contexts, we know that removing life-sustaining treatment will be part of the causal story (it will make the difference), but what we want to know is whether the doctor violates the prohibition on killing patients by causing death actively, that is, by doing something to bring about death.
It is also relevant here to point out that we regularly refuse to call omissions causes. When someone could have been saved from dying, technically everyone’s failure to save them “makes the difference” between their being alive or dead. But we treat as causally relevant only failures by people who had both a duty to save them and the practical means to do so [Paterson]. So again, a notion of causation that goes beyond mere difference-making seems to be needed here.
Intention
The third account distinguishes VAE from (cases of legitimate) WLT in terms of what the agent intends to bring about.
Thirdly, some bioethicists have attempted to distinguish between WLT and VAE on the basis of intentions. The idea is that it is always wrong for a doctor to act intentionally to end their patient’s life, but that it is not wrong for a doctor to act in a way that results in their patient’s death so long as that death is not intended. On one view of intention, a doctor may know that WLT will very likely lead to death, and may even desire that the patient should die following WLT, and yet not intend the patient’s death because the death is not the goal of their action [Sulmasy]. They may withdraw treatment, for instance, in order to respect the patient’s wish and right to be free from burdensome and futile treatment. A simple test to discern the doctor’s intention is to ask whether they would consider themselves to have failed if the patient survived. The argument here is that, while it is possible to perform WLT without intending or aiming at the patient’s death, it is not possible to do VAE without intending their death [Paterson]. Intending death, from this bioethical view, is a key feature of what makes an action a case of killing. So all VAE involves killing, but WLT may or may not involve killing, depending on the intention with which it is carried out.
Other bioethicists working with a somewhat different conception of what “intentions” are have disagreed. If to intend an outcome is simply to desire that outcome, then there is empirical support for the claim that, in practice, many doctors intend their patient’s death in performing WLT [Miller and Truog; Brody]. In reply, one could argue that this only shows that many doctors do not in practice see the prohibition against intending their patient’s death as binding. Others have urged that agents are morally responsible for what they do whenever it is done with foreseeable and avoidable consequences [Begley]. Accordingly, since in performing WLT doctors regularly foresee and could have avoided the patient’s death, they are responsible for the death to the same extent as doctors are responsible for death in performing VAE. Those philosophers who understand intentions along the lines of a “commitment to act” will want such responsibility for death to attach only to cases where the agent aims at the patient’s death, either as an end (goal) or as a means.
Conclusion
Other philosophers have based the distinction between killing and letting die on other grounds besides commission/omission, distinct causal roles, or differing intentions. But the above are the main accounts of the distinction discussed in the bioethics literature. This post has attempted to explain what these accounts involve, and why some people think they support a moral difference between WLT and VAE, and why others have disagreed. As the philosopher in this project, I have tried to provide the means for someone unfamiliar with the debate to acquaint themselves with the main contours of this debated topic over which a great quantity of ink has already been spilled (see the bibliography below for a sampling of writings on the topic). I conclude by pointing out that the sociologist involved in this project believes an argument can be made that the field itself is problematic (see above) in that it is constituted by, as Wittgenstein would say, language that is on a holiday. For such sociologists, meaning is embedded in use, in this case in language of physicians engaged in clinical practice. Thus, the need for interviews with physicians.
Bibliography
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Brody B. Withdrawal of Treatment Versus Killing of Patients. In: Beauchamp TL, ed. Intending Death: The Ethics of Assisted Suicude and Euthanasia. New Jersey: Prentice Hall; 1996. p.90-103.
Bronner B. Two Ways to Kill a Patient. Journal of Medicine and Philosophy. 2018;43(1):44-63.
Isaacs TL. Moral Theory and Action Theory, Killing and Letting Die. American Philosophical Quarterly. 1995;32(4):355-368.
McGee A. Acting to let someone die. Bioethics. 2015;29(2):74-81.
McGrath S. Causation and the Making/Allowing distinction. Philosophical Studies. 2003;114(1-2): 81-106.
McLachlan H. The Ethics of Killing and Letting Die: Active and Passive Euthanasia. Journal of Medical Ethics. 2008;34(8):636-638.
Merkel R. Killing or letting die? Proposal of a (somewhat) new answer to a perennial question. Journal of medical ethics. 2016;42(6):353-360.
Miller FG, Truog RD. Death, dying, and organ transplantation: Reconstructing medical ethics at the end of life. New York, NY: Oxford University Press; 2012. Chapter 1, Withdrawing Life-Sustaining Treatment: Allowing to Die or Causing Death? p.1-25.
Paterson C. On “Killing” Versus “Letting Die” in Clinical Practice: Mere Sophistry With Words? Journal of Nursing Law. 2000;6(4):25-44.
Stauch M. Causal Authorship and the Equality Principle: A Defence of the Acts/Omissions Distinction in Euthanasia. Journal of Medical Ethics. 2000;26(4):237-241. https://doi.org/10.1136/jme.26.4.237
Sulmasy DP. Killing and allowing to die: Another look. The Journal of Law, Medicine & Ethics. 1998;26(1):55-64.
