Active and Passive Euthanasia

In his 1975 article "Active and Passive Euthanasia," James Rachels sets out a number of arguments why the medical profession has misunderstood what they consider a moral difference between two types of treatment that Rachels asserts are really the same. Since this debate is still raging today, a thorough assessment of Rachels' and his opponents' positions requires an educated perspective that can be gained analyzing other relevant precedents and practices, many of which have changed since 1973 when the American Medical Association (AMA) pronounced the policy Rachels takes as exegesis. Without setting out to describe every argument pro and con, many of which are strident or diffuse at best, considering the most important will overshadow the ones we omit. These will give us the tools to evaluate Rachels' argument, which rests on an assertion that two acts are the same when they may in fact be materially different. Rachels' question is still unsettled: Some people agree with him; some still disagree; many of his arguments appear deeply flawed; and if his argument that there is no moral difference between withholding care and active euthanasia is gaining traction in the world, it is not for the reasons he presents in support, because either he missed the major points of discussion, or those arose since his article.

Rachels claims tradition separates euthanasia into two bins, active vs. passive, and cites an AMA policy in support, which he then attacks (1975, n. pag.). Rachels cites the AMA definition of active euthanasia as "intentional termination of the life of one human being by another," where passive euthanasia is "cessation of the employment of extraordinary means to prolong the life of the body when there is irrefutable evidence that biological death is imminent" (AMA 1973, cited in Rachels 1975). The few states where different forms of suicide and euthanasia have actually been practiced in medicine under law, the Netherlands, Belgium, Luxembourg, Columbia, Oregon and Washington, have all found a substantive difference between the act of ending another's life, and that of allowing one's own life to end (Chambaere, Bilsen, Cohen, Onwuteaka-Philipsen, Mortier, & Deliens, 2010, p. 895), with which many but hardly all relevant professional associations agree. The difference between commission and omission (Manning, 2005, p. 13) is significant but subtle enough to confuse Rachels if the bulk of informed opinion bears any weight, and to make the AMA's 1973 definition his argument is based upon seem archaic. In one sense there is no such thing as passive euthanasia, but this is the definition Rachel sets out, which I explore below.

Therefore, to restrict the scope of this potentially extensive discussion, I will try to rule out 'physician-assisted suicide' where the doctor provides medicine, equipment or information the patient chooses to self-administer how they will (American Geriatrics Society). This practice comprises a growing segment of modern end-of-life practice whether euthanasia is decriminalized or not (Lewis, 2009, p. 132-33), but lies outside a strict reading of Rachels' definition of passive euthanasia where the "idea is that it is permissible, at least in some cases, to withhold treatment and allow a patient to die, but it is never per-missible to take any direct action designed to kill the pa-tient" (1975, emphasis added). I limit myself to Rachels' definition that withholding treatment includes cessation of life support, but not provision of the means to suicide, which occupies a more modern, sometimes more legal, but less clean-cut space between Rachels' dated binary opposition of active vs. passive euthanasia. Many real-world life-ending events bridge both definitions, if a practitioner has to assist the patient beyond writing the prescription when the "patient is practically or contextually prevented from ending her own life" (Biggs, quoted in Michlowski, 2009, p. 311), which starts to shade into Rachels' active euthanasia. These complications support the need for a more sophisticated argument. My orders, however, were to describe rather than to repair, so I allow Rachels to define the parameters. I also want to avoid a 'straw man' argument debunking something Rachels didn't actually say.

This definition is central to the discussion of active, passive or other euthanasia because there are so many, I have to focus on Rachel's to achieve coherence. The AMA has changed the wording, if not the spirit, of their position on euthanasia since Rachel's article (AMA 1996). Likewise the medical field is littered with conflicting statements by professional associations with relevant purview over end-of-life care. Tucker and Steele (2007, p. 325) point out so many different definitions and terminologies that it becomes difficult to decide what to even call the acts Rachel bundles under "active and passive euthanasia" (1975). Likewise the states where euthanasia, physician-assisted suicide, other-assisted suicide and a menu of possible "early death" options have been decriminalized, proffer a confusing, diverse array of definitions, conditions, restrictions and sanctions that would take a professional bioethicist to sort out with authority.

So, the informed medical consumer must look for similarities, in order to derive a working definition of what Rachel blithely described as a "doctrine...accepted by most doctors" (1975). A close consideration of the laws of the countries and U.S. states where euthanasia active or passive has been allowed finds similarities, even though those laws vary widely. Nearly universal across sources, and foremost in many of them, is the respect for the "autonomy" of every individual (British Medical Association 2001, p. 9). The primacy of this concept of human self-determination carries significant consequences and conditions for medical practitioners, failure to comply with which usually means prison time, granted the errant doctor is caught and then prosecuted, which does not always happen (Lewis, 2009, p. 137).

In the chapter "Medical Ethics and Professional Standards," the British Medical Association (BMA) defines "autonomy" as the second most important moral value doctors must enact in practice, subordinate only to the "medical duty of 'beneficience' or the obligation to avoid harm, 'non-maleficience'" (BMA 2001, p. 9). Autonomy is the "individual patient's ability to make informed choices about what happens to his or her body" (BMA 2001, p. 9). This 'autonomy' component recurs throughout the literature I discuss and carries the implication that every human has the right to self-determination, even over issues as pressing as their own time and method of death. This implication lies at the bottom of the many assertions that what Rachels calls "passive euthanasia," is not the act of the physician, but rather of the patient, who chooses or not to continue to live.

Autonomy by definition carries a requirement that the patient be in an appropriately lucid, legally competent state of mind when that decision is made. Therefore most states where this practice is decriminalized withhold prosecution of a doctor who intentionally prescribes a lethal dose of medication if that physician administers a number of tests, for example imposing a waiting period and consulting other physicians and in some cases mental health specialists, above and beyond certifying that the medical condition is terminal to varying degrees. We find this autonomy fundamental to human rights in practice in several different ways below. The Colombian Constitutional Court adopted a " rights-based approach" and became the first state to decriminalize voluntary active euthanasia on constitutional grounds because of this autonomy and the dignity it bestows (Michlowski, 2009, p. 214).

The presence of incurable, terminal health conditions, or the probability of death with and without treatment, is another condition recognized as justifying early termination of life by those who condone such practice (Lewis, 2009, p. 128). Some states do not require this limiting factor if the patient is in extremes of pain or has other profound medical complications (Lewis, 2009, p. 128), but this "medically futile" requirement (Lewis, 2009, p. 128) is cited alongside patient competence in definitions of appropriate ending of life by agencies and professional associations as diverse as the Oregon Department of Human Services; the legislatures of Belgium and Holland; and the Supreme Court of Columbia. The result is an emerging consensus in the group of practitioners and attending professionals that individuals have an inalienable right to self-determination given the mental competence to exercise that; therefore infringing on that right is outside the authority of any other individual (within the rubric of law), even a physician, especially where there is extreme pain "caused by terminal illness or injury" (Lewis, 2009, p. 128) usually up to the point of unconsciousness, which sometimes triggers euthanasia given the other conditions.

This injury or illness condition becomes operative on the border between physical and mental health, where euthanasia is still rarely legalized for complaints of "existential suffering," which is apparently requested often enough to have earned its own category, the so-called "tired of life" justifications (Lewis, 2009, p. 128). Likewise, the attending physician is usually considered to have an obligation (Lewis, 2009, p. 134), sometimes a mandate (Michlowski, 2009, p. 185), to educate the patient about alternatives such as "palliative care" (pain relief) or sedation, but the ultimate choice of options remains up to the competent individual. The Belgian legislature reluctantly refrained…