Active vs. Passive Euthanasia: Analyzing Rachels' Argument

Introduction: Rachels and the Euthanasia Debate

In his 1975 article Active and Passive Euthanasia, James Rachels sets out a number of arguments explaining why the medical profession has misunderstood what it considers a moral difference between two types of treatment that Rachels asserts are really the same. Since this debate is still ongoing, a thorough assessment of Rachels' and his opponents' positions requires an educated perspective — one that can be gained by analyzing other relevant precedents and practices, many of which have changed since 1973, when the American Medical Association (AMA) announced the policy Rachels takes as his point of departure.

Without attempting to describe every argument for and against — many of which are strident or diffuse at best — considering the most important arguments will allow the rest to be set aside. These will give us the tools to evaluate Rachels' argument, which rests on the assertion that two acts are the same when they may in fact be materially different. Rachels' question remains 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, it is not for the reasons he presents, because either he missed the major points of discussion, or those points arose after his article was published.

Defining Active and Passive Euthanasia

Rachels claims tradition separates euthanasia into two categories — active versus passive — and cites an AMA policy statement in support, which he then attacks (1975). Rachels cites the AMA's definition of active euthanasia as "intentional termination of the life of one human being by another," while passive euthanasia is defined as "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 jurisdictions where different forms of suicide and euthanasia have actually been practiced in medicine under law — the Netherlands, Belgium, Luxembourg, Colombia, 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), a distinction with which many, though not 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 weight of informed opinion carries any force — and to make the AMA's 1973 definition, on which his argument rests, seem archaic. In one sense there is no such thing as passive euthanasia, but this is the definition Rachels sets out and the one examined below.

To restrict the scope of this potentially extensive discussion, this paper rules out physician-assisted suicide, in which the doctor provides medicine, equipment, or information that the patient chooses to self-administer (American Geriatrics Society). This practice comprises a growing segment of modern end-of-life care whether euthanasia is decriminalized or not (Lewis, 2009, pp. 132–33), but it 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 permissible to take any direct action designed to kill the patient" (1975, emphasis added). This paper limits its scope to Rachels' definition — that withholding treatment includes the cessation of life support, but not the provision of means to suicide — which occupies a more modern, sometimes more legal, but less clear-cut space between Rachels' dated binary opposition of active versus passive euthanasia.

Many real-world life-ending events bridge both definitions — for instance, when a practitioner must assist a patient beyond writing a prescription when the "patient is practically or contextually prevented from ending her own life" (Biggs, quoted in Michlowski, 2009, p. 311), which begins to shade into Rachels' notion of active euthanasia. These complications support the need for a more sophisticated argument. The AMA has changed the wording, if not the spirit, of its position on euthanasia since Rachels' article (AMA, 1996). Likewise, the medical field is filled with conflicting statements by professional associations with relevant authority over end-of-life care. Tucker and Steele (2007, p. 325) point to so many different definitions and terminologies that it becomes difficult to determine what to even call the acts Rachels bundles under "active and passive euthanasia" (1975). Similarly, the states where euthanasia, physician-assisted suicide, other-assisted suicide, and various "early death" options have been decriminalized offer a confusing and diverse array of definitions, conditions, restrictions, and sanctions that would require a professional bioethicist to sort out with authority.

Patient Autonomy as a Foundational Principle

The informed medical consumer must therefore look for common threads in order to derive a working definition of what Rachels described as a "doctrine ... accepted by most doctors" (1975). A close examination of the laws of the countries and U.S. states where active or passive euthanasia has been permitted reveals important similarities, even where those laws vary widely. Nearly universal across sources — and foremost in many of them — is 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 those conditions usually means prison time, granted the errant doctor is caught and prosecuted, which does not always occur (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 "beneficence" — the obligation to avoid harm, or "non-maleficence" (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 and carries the implication that every human has the right to self-determination, even over matters as profound as the time and method of their death. This implication underlies many assertions that what Rachels calls "passive euthanasia" is not the act of the physician, but rather of the patient, who chooses whether or not to continue to live.

Autonomy by definition requires that the patient be in an appropriately lucid, legally competent state of mind when the decision is made. Consequently, most jurisdictions where this practice is decriminalized withhold prosecution of a doctor who intentionally prescribes a lethal dose of medication only if that physician has satisfied a range of requirements — for example, imposing a waiting period, consulting other physicians, and in some cases consulting mental health specialists — beyond simply certifying that the medical condition is terminal. The Colombian Constitutional Court adopted a "rights-based approach" and became the first state to decriminalize voluntary active euthanasia on constitutional grounds, citing precisely this autonomy and the dignity it confers (Michlowski, 2009, p. 214).

Conclusion

The debate Rachels entered in 1975 has grown far more complex than his binary framework of active versus passive euthanasia can accommodate. While his central question — whether there is a morally meaningful difference between the two — remains unsettled, the most persuasive arguments for permitting life-ending decisions rest on considerations of autonomy, intent, and medical futility that he did not fully develop. The jurisdictions and professional bodies that have grappled most seriously with euthanasia have found the distinction between commission and omission meaningful enough to encode in law, even as they differ on its precise implications. Rachels was correct that the debate needed to be had; he was less successful in identifying the grounds on which it should ultimately be resolved.