346    PART V  •  READINGS

withdrawing treatment, acts and omissions, and to refuse treatment. They claim there is no principled
intending the patient’s death versus foreseeing it. basis for insisting that a patient endure a protracted
Although those arguments continue, what allows and burdensome death by refusal of treatment and
meaningful debate is that at some common-sense, depriving the patient of the option of a faster death
observable level, we actually do know which prac- in the patient’s control by physician-assisted suicide.
tice is which. This leads to a second argument, that physicians
have a duty to make assisted suicide available. This
argument rests on physician duties of beneficence
and nonmaleficence (ie, physician duties to care for
patients and do no harm to them). The claim here is
ARGUMENTS IN FAVOR OF in part empirical, that patients seeking assisted sui-
PHYSICIAN-ASSISTED SUICIDE cide are suffering pain, discomfort, and burdens that
can be relieved only by assisted suicide. A related
claim is that physicians who have brought patients
Advocates for legitimating physician-assisted sui- to the brink of death through the rigors of treatment
cide rest their arguments chiefly on patients’ rights (life-sustaining and otherwise) but then deny re-
of autonomy and liberty, physicians’ duties to treat quested assistance with suicide wrongfully abandon
symptoms, such as pain and discomfort at the end those patients [68].
of life, and the claim that killing (or helping the pa- Beauchamp and Childress [69] make a weaker
tient kill himself or herself) is not morally worse than claim, that physicians are not obligated to assist sui-
allowing to die. Not all arguments for legitimating cide but that they may be permitted to do so in some
physician-assisted suicide or euthanasia call for out- circumstances. They articulate a set of criteria nec-
right legalization. One proposal, for example, would essary to justify assistance, including an informed,
create an affirmative defense of ‘‘mercy killing’’ to a voluntary, and durable request made by a competent
criminal prosecution for homicide [67]. patient, together with rejection of the alternatives,
American bioethics and law have a long history in the context of an ongoing doctor-patient relation-
of championing a patient’s moral and legal rights ship. They thus focus on the nature of the patient’s
of autonomy and liberty. There is wide consensus request, the physician’s motives, and the act’s con-
in ethics, law, and clinical care that those rights en- sequences to decide if such aid in dying is justified.
title the patient to refuse unwanted life-sustaining At the same time, they recognize that creating a rule
treatment. The question is whether those rights also allowing physician-assisted suicide requires not only
create an entitlement to a willing physician’s assis- that some cases of it be justified, but that a widely ap-
tance in committing suicide. plied rule and its likely consequences be acceptable.
The Supreme Court has rejected the claim that Beauchamp and Childress [69] are among a
the United States Constitution protects such a legal number of authors rejecting the persuasiveness of
right. Debate continues, however, on whether a distinctions between killing and allowing to die. Such
moral right exists and whether individual states challenges to the distinction between killing and al-
should follow Oregon’s lead and create a right pro- lowing to die have often been animated by Rachels’s
tected by statute. [70] argument that the actions of a greedy relative
Supporters of a right to assisted suicide argue that who allows a cousin to drown so he can inherit are
the right to refuse unwanted treatment is best un- no worse than if he killed the cousin to inherit. How-
derstood as part of a broader right to decide how to ever, in both of Rachels’s scenarios, the relative in-
die. They maintain that this is a fundamental part of tends and strives to produce his cousin’s death; there
choosing what happens to your body and the trajec- is no other goal driving him. Yet in effectuating a pa-
tory of your life. They argue that rights of autonomy tient’s wish to forgo treatment, the physician is striv-
and liberty are weak if they are only negative rights ing to respect the patient’s right to bodily integrity
 W olf   •   Physician-Assisted Suicide      347

and authority to exclude unwanted bodily invasion. no universal health care insurance, and health care
Further, death may or may not eventuate, depending more often rendered by a physician with little or no
on the clinical situation. Thus, Rachels’s argument is prior relationship with the patient [75–78].
open to challenge and remains controversial. The Oregon data may thus be more readily
Much as some advocates for physician-assisted generalized to the rest of the country than the Dutch
suicide have challenged on philosophical grounds data, but remain sparse. In 6 years of reported
the distinction between honoring refusals of life- experience, physicians have written 265 lethal
sustaining treatment and assisting suicide, others prescriptions, and 171 patients have used these
have recently challenged the distinction by claim- prescriptions to commit suicide [27]. However, the
ing that some practices deemed acceptable under Oregon data rely on physician reports, and physicians
the prior rubric are difficult to distinguish from more in Oregon (as in the Netherlands) may underreport or
active aid in dying, such as euthanasia. They point may report compliance with the rules when the rules
in particular to what some call ‘‘terminal sedation’’ have been violated. As some commentators have
[64–66]. Though the term is used inconsistently, it pointed out, what is not reported in Oregon we have
frequently refers to sedation to unconsciousness plus no way to know [79].
termination of artificial nutrition. However, when a
patient with decisional capacity or incompetent pa-
tient’s surrogate properly authorizes termination of
artificial nutrition as an exercise of the right to be
free of unwanted bodily invasion, and sedation to ARGUMENTS AGAINST
unconsciousness is clinically warranted and properly PHYSICIAN-ASSISTED SUICIDE
consented to, it is difficult to see this as equivalent to
lethal prescription or injection. The fact that a prac-
tice predictably brings on death does not determine Key arguments against legitimating physician-
whether it is licit or not; that distinction hinges on the assisted suicide are that the traditional rejection of
underlying patient rights, patient or surrogate autho- this as part of the physician’s role is important to the
rization, and physician motives. integrity of the medical profession; that legitimating
Finally, empirical data from the Netherlands and the practice will lead to error, abuse, and negative
now Oregon have fueled competing assessments. consequences for patients; and that the practice is
Though some claim the Dutch data show a viable actually not clinically necessary to provide humane
practice of assisted suicide and euthanasia, others have care at the end of life.
expressed concern over data showing significant vio- Many commentators have expressed deep concern
lations of the Dutch requirement of voluntary, compe- that the traditional Hippocratic injunction to physi-
tent patient consent [60,71]. This is most obvious in cians to refuse to assist suicide and perform eutha-
data showing euthanasia of children and incompetent nasia remains essential to the ethical integrity of the
adults [13,56,57,71–73]. Further, data showing that a medical profession [80–83]. Physicians routinely
substantial number of Dutch physicians fail to comply wield power over life and death almost unmatched
with the reporting rules, thus thwarting effective over- by others in our society. A commitment to use those
sight, have raised questions about how any regime of powers only to comfort and heal, avoiding use of
assisted suicide and euthanasia can be effectively con- those powers to intentionally cause death, helps orient
trolled [14,58,74]. In reality, there is a broader debate the profession toward beneficence and nonmalefi-
about the applicability of the Dutch experience to the cence. Thus, avoiding assisted suicide and euthanasia
United States context. Significant differences between becomes part of a larger ethical commitment to do
the two countries suggest that the problems plaguing no harm. Psychologically, a prohibition on assisting
the Dutch experience would be worse in the United suicide and performing euthanasia may help prevent
States, with a far larger and more diverse population, physicians from acting out ambivalence toward the
348    PART V  •  READINGS

dying patient by deliberately ending that patient’s life were an MD a license to prescribe lethal medication,
[84]. Practically speaking, the prohibition may help it would be unrealistic to assume such perfection.
avoid erroneously or abusively taking life. Physicians are human beings. They make mistakes.
One response to these arguments has been that In the United States, they often do not know their pa-
a modern physician is committed not only to care tient well and may not appreciate what concerns are
and cure but to respect patient autonomy. Thus, it is contributing to a patient’s request for assisted suicide
argued, a physician should respect and assist the vol- or the range of options that exist for addressing those
untary and competent choice of a patient, even if the concerns.
patient chooses suicide or euthanasia. The problem In a country of tremendous disparities in health
with this argument is that a physician is not morally status, access to care, and quality of care, there is
obligated to do everything a patient wants; to hold substantial concern that physician-assisted suicide
otherwise would reduce the physician to the patient’s would be subject to significant error and abuse [76].
puppet and suggest there is no ethical limit to what a Over 40 million Americans entirely lack the health
physician may do. Patients may request unapproved care insurance necessary to cope with serious illness
or inappropriate medications, nontherapeutic and [87,88]; others may face limited and unappealing
even injuring procedures, and experimental proce- choices in dealing with illness or disability, including
dures that pose excessive risk. In all of these cases, a limited choice of setting. One may cogently argue
the physician’s job is not simply to accede to the that what these individuals need is access to good
patient’s request. The physician has duties that may care and supportive settings, not a lethal prescription.
include saying no. Individuals with disabilities may properly worry that
The more specific question, then, is, What are they are especially vulnerable to error and abuse
the physician’s duties at the end of life? Many com- [89]. Too often, their quality of life may be underval-
mentators have argued that a physician has duties ued. It may be far easier for clinicians to respond to a
to respect a patient’s right to be free of unwanted disabled individual’s situation with a lethal prescrip-
invasive treatment and to meet a patient’s need for tion than to address the underlying problems and to
pain relief and palliative care, but that these do not open options.
translate into a duty to deliberately cause the pa- Finally, those opposing physician-assisted suicide
tient’s death through lethal prescription or injection argue that the practice is not necessary to provide
[85,86]. A physician is morally and legally obli- humane care at the end of life. They point out that
gated to respect a patient’s right to refuse treatment, many of those advocating physician-assisted suicide
even if the foreseeable consequence of honoring the mistakenly argue that the practice is needed to address
refusal is likely to be death; that much is widely pain. Yet as long as physicians can provide aggressive
agreed. A physician caring for a patient at the end pain relief and palliative care, including sedating to
of life is also obligated to strive competently to re- unconsciousness if necessary, pain is not the primary
lieve pain and provide palliation, even if the pain argument for physician-assisted suicide. Data reveal
relief required carries a foreseeable risk of hasten- that most patients interested in assisted suicide are not
ing death; that, too, is widely agreed. The argument motivated by pain [27–29,31,44]. Instead, concerns
is that there is an important distinction between (1) about losing autonomy, dignity, and control, as well as
respecting the right to forgo treatment and meeting depression and helplessness, loom large. Physicians,
the need for pain relief with the goal of caring and of course, are not all-powerful deities who can simply
(2) supplying lethal medication or injection to de- remove all of those concerns; some of these are part
liberately end life. of the human condition and the reality of death. But
A related set of arguments points to the likely con- the literature suggests that physicians skilled in care at
sequences of permitting physicians to assist suicide. the end of life, with good hospice options to offer and
Those who favor assisted suicide often assume that a skilled team can usually provide what Emanuel and
they can design a process free of error and abuse, but Emanuel call a ‘‘good death’’ [90].
 W olf   •   Physician-Assisted Suicide      349

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(CA)7 University of California Press; 2002. p. 162–3. September 29, 2004.
85.  Gert B, Culver CM, Clouser KD. An alternative to 89. Siegel MC. Lethal pity: the Oregon Death with
physician-assisted suicide: a conceptual moral analysis. In: Dignity Act, its implications for the disabled, and the
Battin MP, Rhodes R, Silvers A, editors. Physician-assisted struggle for equality in an able-bodied world. Law Inequal
suicide: expanding the debate. New York: Routledge; 1998. 1998;16(1): 259–88.
p. 182–202. 90.  Emanuel EJ, Emanuel LL. The promise of a good
86. Pellegrino ED. The false promise of beneficient death. Lancet 1998;351(9114):SII21–9.
killing. In: Emanuel LL, editor. Regulating how we die: the 91.  Foley KM. Competent care for the dying instead of
ethical, medical, and legal issues surrounding physician- physician-assisted suicide. N Engl J Med 1997;336(1):53–8.

DISCUSSION QUESTIONS
1.  How, exactly, are patients’ rights of autonomy and liberty supposed to support a moral right to
physician-assisted suicide? Do you find that argument convincing? Why or why not?
2.  Wolf sketches three arguments for a moral right to physician-assisted death. Which of these arguments
support only physician-assisted suicide? Which also support euthanasia?
3.  How is the physician’s special obligation to “do no harm” related to the arguments that Wolf
sketches against physician-assisted suicide?
4.  Based on the data and arguments presented in Wolf’s paper, do you think that allowing physician-
assisted suicide and/or euthanasia would lead to “error, abuse, and negative consequences for pa-
tients”? If so, is that a compelling reason to prohibit either or both of those practices?

JAMES RACHELS (1941–2005)

Active and Passive Euthanasia

James Rachels was Professor of Philosophy at the University of Alabama at Birmingham.

He wrote on a wide range of topics in applied ethics but is perhaps best known for his widely
used textbooks on moral philosophy. In this paper, Rachels argues that there is no moral
From The New England Journal of Medicine, James Rachels, “Active and Passive Euthanasia,” 292, pp. 78–80. Copyright © 1975
Massachusetts Medical Society. Reprinted with permission from Massachusetts Medical Society.
 R achels   •   Active and Passive Euthanasia      353

difference between killing someone and letting someone die. Therefore, he argues, there is
no good reason to believe that active euthanasia is morally forbidden while passive euthana-
sia is morally permissible.

GUIDING QUESTIONS
1.  What moral claim is Rachels criticizing in this paper?
2.  What point is Rachels trying to make with the examples of the patient with throat cancer and the
baby with Down’s syndrome?
3.  What is the thought experiment involving Smith and Jones intended to show? How is this related to
the main argument about active and passive euthanasia?
4.  How does Rachels respond to the objection that in passive euthanasia, “the doctor does not do any-
thing to bring about the patient’s death,” but in active euthanasia, he or she does?

The distinction between active and passive euthana- is unbearable. So he asks the doctor for an end to it,
sia is thought to be crucial for medical ethics. The and his family joins in the request.
idea is that it is permissible, at least in some cases, to Suppose the doctor agrees to withhold treatment,
withhold treatment and allow a patient to die, but it is as the conventional doctrine says he may. The justifi-
never permissible to take any direct action designed cation for his doing so is that the patient is in terrible
to kill the patient. This doctrine seems to be accepted agony, and since he is going to die anyway, it would
by most doctors, and it is endorsed in a statement be wrong to prolong his suffering needlessly.
adopted by the House of Delegates of the American But now notice this. If one simply withholds treat-
Medical Association on December 4, 1973: ment, it may take the patient longer to die, and so he
may suffer more than he would if more direct action
The intentional termination of the life of one human were taken and a lethal injection given. This fact pro-
being by another—mercy killing—is contrary to that
vides strong reason for thinking that, once the ini-
for which the medical profession stands and is contrary
tial decision not to prolong his agony has been made
to the policy of the American Medical Association.
active euthanasia is actually preferable to passive
The cessation of the employment of extraordinary
euthanasia, rather than the reverse. To say otherwise
means to prolong the life of the body when there is
is to endorse the option that leads to more suffering
irrefutable evidence that biological death is imminent is
the decision of the patient and/or his immediate family. rather than less, and is contrary to the humanitarian
The advice and judgment of the physician should be impulse that prompts the decision not to prolong his
freely available to the patient and/or his immediate family. life in the first place.
Part of my point is that the process of being “al-
However, a strong case can be made against this doc- lowed to die” can be relatively slow and painful,
trine. In what follows I will set out some of the rel- whereas being given a lethal injection is relatively
evant arguments, and urge doctors to reconsider their quick and painless. Let me give a different sort of ex-
views on this matter. ample. In the United States about one in 600 babies
To begin with a familiar type of situation, a pa- is born with Down’s syndrome. Most of these babies
tient who is dying of incurable cancer of the throat are otherwise healthy—that is, with only the usual
is in terrible pain, which can no longer be satisfacto- pediatric care, they will, proceed to an otherwise
rily alleviated. He is certain to die within a few days, normal infancy. Some, however, are born with con-
even if present treatment is continued, but he does genital defects such as intestinal obstructions that
not want to go on living for those days since the pain require operations if they are to live. Sometimes, the
354    PART V  •  READINGS

parents and the doctor will decide not to operate, and should not live on, what difference does it make that
let the infant die. Anthony Shaw describes what hap- it happens to have an unobstructed intestinal tract?
pens then: In either case, the matter of life and death is being
decided on irrelevant grounds. It is the Down’s syn-
When surgery is denied [the doctor] must try to keep the drome, and not the intestines, that is the issue. The
infant from suffering while natural forces sap the baby’s matter should be decided, if at all, on that basis, and
life away. As a surgeon whose natural inclination is to use not be allowed to depend on the essentially irrelevant
the scalpel to fight off death, standing by and watching a question of whether the intestinal tract is blocked.
salvageable baby die is the most emotionally exhausting
What makes this situation possible, of course, is
experience I know. It is easy at a conference, in a theo-
the idea that when there is an intestinal blockage, one
retical discussion, to decide that such infants should be
allowed to die. It is altogether different to stand by in the can “let the baby die,” but when there is no such defect
nursery and watch as dehydration and infection wither a there is nothing that can be done, for one must not
tiny being over hours and days. This is a terrible ordeal “kill” it. The fact that this idea leads to such results as
for me and the hospital staff—much more so than for the deciding life or death on irrelevant grounds is another
parents who never set foot in the nursery.1 good reason why the doctrine should be rejected.
One reason why so many people think that there
I can understand why some people are opposed to all is an important moral difference between active and
euthanasia, and insist that such infants must be al- passive euthanasia is that they think killing someone
lowed to live. I think I can also understand why other is morally worse than letting someone die. But is it?
people favor destroying these babies quickly and pain- Is killing, in itself, worse than letting die? To investi-
lessly. But why should anyone favor letting “dehydra- gate this issue, two cases may be considered that are
tion and infection wither a tiny being over hours and exactly alike except that one involves killing whereas
days”? The doctrine that says that a baby may be al- the other involves letting someone die. Then, it can
lowed to dehydrate and wither, but may not be given be asked whether this difference makes any differ-
an injection that would end its life without suffering, ence to the moral assessments. It is important that the
seems so patently cruel as to require no further refuta- cases be exactly alike, except for this one difference,
tion. The strong language is not intended to offend, since otherwise one cannot be confident that it is this
but only to put the point in the clearest possible way. difference and not some other that accounts for any
My second argument is that the conventional doc- variation in the assessments of the two cases. So, let
trine leads to decisions concerning life and death us consider this pair of cases:
made on irrelevant grounds. In the first, Smith stands to gain a large inheri-
Consider again the case of the infants with Down’s tance if anything should happen to his six-year-old
syndrome who need operations for congenital defects cousin. One evening while the child is taking his
unrelated to the syndrome to live. Sometimes, there is bath, Smith sneaks into the bathroom and drowns the
no operation, and the baby dies, but when there is no child, and then arranges things so that it will look
such defect, the baby lives on. Now, an operation such like an accident.
as that to remove an intestinal obstruction is not pro- In the second, Jones also stands to gain if any-
hibitively difficult. The reason why such operations are thing should happen to his six-year-old cousin. Like
not performed in these cases is, clearly, that the child Smith, Jones sneaks in planning to drown the child
has Down’s syndrome and the parents and doctor judge in his bath. However, just as he enters the bathroom
that because of that fact it is better for the child to die. Jones sees the child slip and hit his head, and fall
But notice that this situation is absurd, no matter face down in the water. Jones is delighted; he stands
what view one takes of the lives and potentials of by, ready to push the child’s head back under if it is
such babies. If the life of such an infant is worth necessary, but it is not necessary. With only a little
preserving, what does it matter if it needs a simple thrashing about, the child drowns all by himself, “ac-
operation? Or, if one thinks it better that such a baby cidentally,” as Jones watches and does nothing.
 R achels   •   Active and Passive Euthanasia      355

Now Smith killed the child, whereas Jones “merely” “mercy killing,” the statement goes on to deny that
let the child die. That is the only difference between the cessation of treatment is the intentional termina-
them. Did either man behave better, from a moral point tion of a life. This is where the mistake comes in, for
of view? If the difference between killing and letting die what is the cessation of treatment, in these circum-
were in itself a morally important matter, one should stances, if it is not “the intentional termination of the
say that Jones’s behavior was less reprehensible than life of one human being by another?” Of course it
Smith’s. But does one really want to say that? I think not. is exactly that, and if it were not, there would be no
In the first place, both men acted from the same motive, point to it.
personal gain, and both had exactly the same end in Many people will find this judgment hard to
view when they acted. It may be inferred from Smith’s accept. One reason, I think, is that it is very easy to
conduct that he is a bad man, although that judgment conflate the question of whether killing is, in itself,
may be withdrawn or modified if certain further facts worse than letting die, with the very different ques-
are learned about him—for example, that he is men- tion of whether most actual cases of killing are
tally deranged. But would not the very same thing be more reprehensible than most actual cases of letting
inferred about Jones from his conduct? And would not die. Most actual cases of killing are clearly terrible
the same further considerations also be relevant to any, (think, for example, of all the murders reported in the
modification of this judgment? Moreover, suppose Jones newspapers), and one hears of such cases every day.
pleaded, in his own defense, “After all, I didn’t do any- On the other hand, one hardly ever hears of a case
thing except just stand there and watch the child drown. of letting die, except for the actions of doctors who
I didn’t kill him; I only let him die.” Again, if letting die are motivated by humanitarian reasons. So one learns
were in itself less bad than killing, this defense should to think of killing in a much worse light than of let-
have at least some weight. But it does not. Such a “de- ting die. But this does not mean that there is some-
fense” can only be regarded as a grotesque perversion of thing about killing that makes it in itself worse than
moral reasoning. Morally speaking, it is no defense at all. letting die, for it is not the bare difference between
Now, it may be pointed out, quite properly, that the killing and letting die that makes the difference in
cases of euthanasia with which doctors are concerned these cases. Rather, the other factors—the murder-
are not like this at all. They do not involve personal er’s motive of personal gain, for example, contrasted
gain or the destruction of normal healthy children. with the doctor’s humanitarian motivation—account
Doctors are concerned only with cases in which the for different reactions to the different cases.
patient’s life is of no further use to him, or in which I have argued that killing is not in itself any worse
the patient’s life has become or will soon become than letting die; if my contention is right, it follows that
a terrible burden. However, the point is the same in active euthanasia is not any worse than passive eutha-
these cases: the bare difference between killing and nasia. What arguments can be given on the other side?
letting die does not, in itself, make a moral difference. The most common, I believe, is the following: “The
If a doctor lets a patient die, for humane reasons, he is important difference between active and passive eu-
in the same moral position as if he had given the pa- thanasia is that, in passive euthanasia, the doctor does
tient a lethal injection for humane reasons. If his deci- not do anything to bring about the patient’s death. The
sion was wrong—if, for example, the patient’s illness doctor does nothing, and the patient dies of whatever
was in fact curable—the decision would be equally ills already afflict him. In active euthanasia, however,
regrettable no matter which method was used to carry the doctor does something to bring about the patient’s
it out. And if the doctor’s decision was the right one, death: he kills him. The doctor who gives the patient
the method used is not in itself important. with cancer a lethal injection has himself caused his
The AMA policy statement isolates the crucial patient’s death; whereas if he merely ceases treatment,
issue very well; the crucial issue is “the intentional the cancer is the cause of the death.”
termination of the life of one human being by an- A number of points need to be made here. The first
other.” But after identifying this issue, and forbidding is that it is not exactly correct to say that in passive
356    PART V  •  READINGS

euthanasia the doctor does nothing, for he does do one Finally, doctors may think that all of this is only of
thing that is very important: he lets the patient die. “Let- academic interest—the sort of thing that philosophers
ting someone die” is certainly different, in some re- may worry about but that has no practical bearing on
spects, from other types of action—mainly in that it is their own work. After all, doctors must be concerned
a kind of action that one may perform by way of not about the legal consequences of what they do, and
performing certain other actions. For example, one may active euthanasia is clearly forbidden by the law. But
let a patient die by way of not giving medication, just as even so, doctors should also be concerned with the
one may insult someone by way of not shaking his hand. fact that the law is forcing upon them a moral doctrine
But for any purpose of moral assessment, it is a type of that may well be indefensible, and has a considerable
action nonetheless. The decision to let a patient die is effect on their practices. Of course, most doctors are not
subject to moral appraisal in the same way that a deci- now in the position of being coerced in this matter, for
sion to kill him would be subject to moral appraisal: it they do not regard themselves as merely going along
may be assessed as wise or unwise, compassionate or sa- with what the law requires. Rather, in statements such
distic, right or wrong. If a doctor deliberately let a patient as the AMA policy statement that I have quoted, they
die who was suffering from a routinely curable illness, are endorsing this doctrine as a central point of medi-
the doctor would certainly be to blame for what he had cal ethics. In that statement, active euthanasia is con-
done, just as he would be to blame if he had needlessly demned not merely as illegal but as “contrary to that for
killed the patient. Charges against him would then be ap- which the medical profession stands,” whereas passive
propriate. If so, it would be no defense at all for him to euthanasia is approved. However, the preceding con-
insist that he didn’t “do anything.” He would have done siderations suggest that there is really no moral differ-
something very serious indeed, for he let his patient die. ence between the two, considered in themselves (there
Fixing the cause of death may be very impor- may be important moral differences in some cases in
tant from a legal point of view, for it may determine their consequences, but, as I pointed out, these differ-
whether criminal charges are brought against the ences may make active euthanasia, and not passive eu-
doctor. But I do not think that this notion can be used thanasia, the morally preferable option). So, whereas
to show a moral difference between active and pas- doctors may have to discriminate between active and
sive euthanasia. The reason why it is considered bad passive euthanasia to satisfy the law, they should not do
to be the cause of someone’s death is that death is any more than that. In particular, they should not give
regarded as a great evil—and so it is. However, if the distinction any added authority and weight by writ-
it has been decided that euthanasia—even passive ing it into official statements of medical ethics.
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 NOTES
if this is true, the usual reason for not wanting to be 1.  Shaw A: ‘Doctor, Do We Have a Choice?’ The New
the cause of someone’s death simply does not apply. York Times Magazine, January 30, 1972, p54.

DISCUSSION QUESTIONS
1.  Do you find the thought experiment involving Smith and Jones convincing? Why or why not?
2.  Why, according to Rachels, do people think that killing is worse than letting die? Do you find his
explanation convincing? Why or why not?
3.  Suppose that we accept Rachels’s claim that killing someone is no morally worse than letting some-
one die. What would this imply for moral issues other than physician-assisted death? Do these
implications make Rachels’s claim more or less plausible?
4.  Has Rachels successfully argued that active euthanasia is morally permissible? Why or why not?
Was he trying to argue that it is morally permissible?
 G AY- W ILLIAMS   •   The Wrongfulness of Euthanasia      357

J. GAY-WILLIAMS

The Wrongfulness of Euthanasia

In this short paper, J. Gay-Williams argues that active euthanasia is morally wrong. After
specifying what counts as active euthanasia, the paper presents three independent arguments
for its main conclusion.

GUIDING QUESTIONS
1.  What is Gay-Williams’s main conclusion in this paper? How is that conclusion related to James
Rachels’s conclusion about active and passive euthanasia?
2.  What, exactly, does Gay-Williams mean by “euthanasia”?
3.  What are the three main arguments that Gay-Williams presents against euthanasia? Do you need to
find all of them convincing to accept the paper’s main conclusion?

My impression is that euthanasia—the idea, if not the from which recovery cannot reasonably be expected.
practice—is slowly gaining acceptance within our so- Finally, the action must be deliberate and intentional.
ciety. Cynics might attribute this to an increasing ten- Thus, euthanasia is intentionally taking the life of a pre-
dency to devalue human life, but I do not believe this is sumably hopeless person. Whether the life is one’s own
the major factor. The acceptance is much more likely or that of another, the taking of it is still euthanasia.
to be the result of unthinking sympathy and benevo- It is important to be clear about the deliberate and
lence. Well-publicized, tragic stories like that of Karen intentional aspect of the killing. If a hopeless person is
Quinlan elicit from us deep feelings of com­passion. given an injection of the wrong drug by mistake and
We think to ourselves, “She and her family would be this causes his death, this is wrongful killing but not
better off if she were dead.” It is an easy step from this euthanasia. The killing cannot be the result of accident.
very human response to the view that if someone (and Furthermore, if the person is given an injection of a
others) would be better off dead, then it must be all drug that is believed to be necessary to treat his dis-
right to kill that person. Although I respect the compas- ease or better his condition and the person dies as a
sion that leads to this conclusion, I believe the conclu- result, then this is neither wrongful killing nor euthana-
sion is wrong. I want to show that euthanasia is wrong. sia. The intention was to make the patient well, not kill
It is inherently wrong, but it is also wrong judged from him. Similarly, when a patient’s condition is such that
the standpoints of self-interest and of practical effects. it is not reasonable to hope that any medical procedures
Before presenting my arguments to support this or treatments will save his life, a failure to implement
claim, it would be well to define “euthanasia.” An es- the procedures or treatments is not euthanasia. If the
sential aspect of euthanasia is that it involves tak­ing a person dies, this will be as a result of his injuries or dis-
human life, either one’s own or that of another. Also, ease and not because of his failure to receive treatment.
the person whose life is taken must be someone who The failure to continue treatment after it has
is believed to be suffering from some disease or injury been realized that the patient has little chance of
J. Gay-Williams, “The Wrongfulness of Euthanasia,” from Intervention and Reflection, 10th edition (Wadsworth Publishing Com-
pany) by Ronald Munson, Copyright © 2016 by Ronald Munson.
358    PART V  •  READINGS

ben­efitting from it has been characterized by some as of his body acts against God, its rightful possessor,
“passive euthanasia.” This phrase is misleading and when he takes his own life. He also violates the
mistaken. In such cases, the person involved is not com­mandment to hold life sacred and never to take
killed (the first essential aspect of euthanasia), nor is it without just and compelling cause. But since this
the death of the person intended by the withhold­ing appeal will persuade only those who are prepared
of additional treatment (the third essential aspect of to accept that religion has access to revealed truths,
euthanasia). The aim may be to spare the person ad- I shall not employ this line of argument.
ditional and unjustifiable pain, to save him from the It is enough, I believe, to recognize that the
indignities of hopeless manipulations, and to avoid orga­nization of the human body and our pat-
increasing the financial and emotional burden on his terns of behavioral responses make the continua-
family. When I buy a pencil it is so that I can use it tion of life a natural goal. By reason alone, then,
to write, not to contribute to an increase in the gross we can recognize that euthanasia sets us against
national product. This may be the unintended con- our own nature. Fur­ thermore, in doing so, eu-
sequence of my action, but it is not the aim of my thanasia does violence to our dignity. Our dig-
action. So it is with failing to continue the treatment nity comes from seeking our ends. When one of
of a dying person. I intend his death no more than I our goals is survival, and actions are taken that
intend to reduce the GNP by not using medical sup­ eliminate that goal, then our natural dignity suf-
plies. His is an unintended dying, and so-called “pas­sive fers. Unlike animals, we are conscious through
euthanasia” is not euthanasia at all. reason of our nature and our ends. Euthana­ sia
involves acting as if this dual nature—inclina-
tion towards survival and awareness of this as an
end—did not exist. Thus, euthanasia denies our
basic human character and requires that we regard
ourselves or others as something less than fully
1.  THE ARGUMENT FROM NATURE human.

Every human being has a natural inclination to con­

tinue living. Our reflexes and responses fit us to fight
attackers, flee wild animals, and dodge out of the way 2.  THE ARGUMENT FROM
of trucks. In our daily lives we exercise the caution SELF-INTEREST
and care necessary to protect ourselves. Our bodies are
similarly structured for survival right down to the mo-
lecular level. When we are cut, our capillaries seal shut, The above arguments are, I believe, sufficient to
our blood clots, and fibrogen is produced to start the show that euthanasia is inherently wrong. But there
process of healing the wound. When we are invaded are reasons for considering it wrong when judged by
by bacteria, antibodies are produced to fight against standards other than reason. Because death is final
the alien organisms, and their remains are swept out of and irreversible, euthanasia contains within it the
the body by special cells designed for clean-up work. possibility that we will work against our own interest
Euthanasia does violence to this natural goal of if we practice it or allow it to be practiced on us.
survival. It is literally acting against nature because Contemporary medicine has high standards of ex-
all the processes of nature are bent towards the end cellence and a proven record of accomplishment, but
of bodily survival. Euthanasia defeats these sub­tle it does not possess perfect and complete knowl­edge.
mechanisms in a way that, in a particular case, dis- A mistaken diagnosis is possible, and so is a mistaken
ease and injury might not. prognosis. Consequently, we may believe that we are
It is possible, but not necessary, to make an appeal dying of a disease when, as a matter of fact, we may
to revealed religion in this connection. Man as trustee not be. We may think that we have no hope of recovery
 G AY- W ILLIAMS   •   The Wrongfulness of Euthanasia      359

when, as a matter of fact, our chances are quite good. This attitude could then carry over to their dealings
In such circumstances, if euthanasia were permitted, with patients less seriously ill. The result would be
we would die needlessly. Death is final and the chance an overall decline in the quality of medical care.
of error too great to approve the practice of euthanasia. Finally, euthanasia as a policy is a slippery slope.
Also, there is always the possibility that an experi­ A person apparently hopelessly ill may be allowed
mental procedure or a hitherto untried technique will to take his own life. Then he may be permitted to
pull us through. We should at least keep this option deputize others to do it for him should he no longer
open, but euthanasia closes it off. Furthermore, spon- be able to act. The judgment of others then becomes
taneous remission does occur in many cases. For no the ruling factor. Already at this point euthanasia is
apparent reason, a patient simply recovers when not personal and voluntary, for others are acting “on
those all around him, including his physicians, ex- behalf of” the patient as they see fit. This may well
pected him to die. Euthanasia would just guar­antee incline them to act on behalf of other patients who
their expectations and leave no room for the “miracu- have not authorized them to exercise their judgment.
lous” recoveries that frequently occur. It is only a short step, then, from voluntary euthanasia
Finally, knowing that we can take our life at any (self-inflicted or authorized), to directed euthanasia
time (or ask another to take it) might well incline us to administered to a patient who has given no authori­
give up too easily. The will to live is strong in all of us, zation, to involuntary euthanasia conducted as part of
but it can be weakened by pain and suffering and feel- a social policy. Recently many psychiatrists and soci-
ings of hopelessness. If during a bad time we allow ologists have argued that we define as “mental illness”
ourselves to be killed, we never have a chance to re- those forms of behavior that we disapprove of. This
consider. Recovery from a serious illness requires that gives us license then to lock up those who display the
we fight for it, and anything that weakens our deter- behavior. The category of the “hopelessly ill” provides
mination by suggesting that there is an easy way out is the possibility of even worse abuse. Embedded in a
ultimately against our own interest. Also, we may be social policy, it would give society or its representa-
inclined towards euthanasia because of our concern tives the authority to eliminate all those who might be
for others. If we see our sickness and suf­fering as an considered too “ill” to function nor­mally any longer.
emotional and financial burden on our family, we may The dangers of euthanasia are too great to all to run
feel that to leave our life is to make their lives easier. the risk of approving it in any form. The first slippery
The very presence of the possibility of euthanasia step may well lead to a serious and harmful fall.
may keep us from surviving when we might. I hope that I have succeeded in showing why
the benevolence that inclines us to give approval of
eutha­ nasia is misplaced. Euthanasia is inherently
wrong because it violates the nature and dignity of
3.  THE ARGUMENT FROM human beings. But even those who are not convinced
PRACTICAL EFFECTS by this must be persuaded that the potential personal
and social dangers inherent in euthanasia are suffi-
cient to forbid our approving it either as a personal
Doctors and nurses are, for the most part, totally com- practice or as a public policy.
mitted to saving lives. A life lost is, for them, almost Suffering is surely a terrible thing, and we have a
a personal failure, an insult to their skills and knowl- clear duty to comfort those in need and to ease their
edge. Euthanasia as a practice might well alter this. It suffering when we can. But suffering is also a natural
could have a corrupting influence so that in any case part of life with values for the individual and for oth­ers
that is severe doctors and nurses might not try hard that we should not overlook. We may legitimately seek
enough to save the patient. They might decide that for others and for ourselves an easeful death. Euthana-
the patient would simply be “bet­ter off dead” and sia, however, is not just an easeful death. It is a wrong-
take the steps necessary to make that come about. ful death. Euthanasia is not just dying. It is killing.
360    PART V  •  READINGS

DISCUSSION QUESTIONS
1.  Why, according to Gay-Williams, isn’t “passive euthanasia” really a form of euthanasia? Do you
find this argument convincing? Why or why not?
2.  Do you agree with Gay-Williams that euthanasia “sets us against our own nature”? Why or why not?
3.  How might someone object to Gay-Williams’s argument from self-interest? How do you think
Gay-Williams would respond to that objection?
4.  What would Susan Wolf (the author of an earlier paper in this section) say about Gay-Williams’s
argument from practical effects?
5.  Of Gay-Williams’s three main arguments against euthanasia, which do you find most convincing?
Why? Which do you find least convincing? Why?

Capital Punishment

ERNEST VAN DEN HAAG (1914–2002)

The Ultimate Punishment: A Defense

Ernest van den Haag was John M. Olin Professor of Jurisprudence and Public Policy at
Fordham University. In this paper, he argues in support of capital punishment (often called
the death penalty), both by explaining his reasons for supporting it and by trying to refute
arguments commonly given against it.

GUIDING QUESTIONS
1.  What does van den Haag mean by “maldistribution” of the death penalty? What arguments does he
give for thinking that maldistribution is not a good reason to oppose the death penalty?
2.  Does van den Haag think that the death penalty deters crime? Is this important for him? Why or
why not?
3.  What is van den Haag’s main reason for supporting the death penalty?
4.  Van den Haag considers “two moral objections” to the death penalty. What are they? How does he
respond to them?

In an average year about 20,000 homicides occur in year, most convicts sentenced to death are likely to
the United States. Fewer than 300 convicted murder- die of old age. Nonetheless, the death penalty looms
ers are sentenced to death. But because no more than large in discussions: it raises important moral ques-
thirty murderers have been executed in any recent tions independent of the number of executions.

Republished with permission of Harvard Law Review Association, from “The Ultimate Punishment: A Defense,” Ernest van den
Haag, 99(7), Winter 1978; permission conveyed through Copyright Clearance Center, Inc.