Opponents of euthanasia often pose the argument that it is better to allow a patient to die than it is to actively kill them. It is morally permissible for a physician to allow a patient to voluntarily stop eating and drinking or to sedate the patient and let nature take its course, but it is not morally permissible to facilitate the means for a patient to commit suicide or to administer death hastening measures. This is difficult territory to navigate. I do not intend to address the issue of whether or not euthanasia is morally permissible in this post. Rather, I want to take a look at four different end of life options and argue that they are morally equivalent. VSED (voluntarily stopping eating and drinking), TS (terminal sedation, essentially pulling the plug and managing pain), PAE (physician assisted suicide), and VAE (voluntary active euthanasia) are all the same in terms of their moral permissibility. As such, if you allow someone to refuse treatment, or a doctor to “pull the plug,” then you must also admit that active euthanasia (the doctor administering a lethal dose) is also permissible.
So how do we determine the moral permissibility of an action? What are the factors of actions which make them morally distinct? Well, all actions are comprised of consequences and intent, and it is these components which determine the morality of the action. Now, there are a variety of philosophical traditions which give preference to one or another, either the consequences or the intent, and yet others which argue for completely separate factors. However, I do not wish to go through the laborious task of examining this issue from every philosophical angle; I imagine such a feat would be nigh impossible. As such, I will concern myself with consequences and intent, the major factors that most people think about.
As far as consequences are concerned, this criteria is not useful in helping to evaluate these actions, as the presumed outcome is the death of the patient. It is the same in every situation, and therefore, doesn’t really give us much in the way of distinguishing the actions from one another. So then we are left with the intent.
Let’s start with the intent of a physician who passively allows his patient to die, considering first the option of allowing a patient to voluntarily stop eating and drinking. This option is generally considered in terms of the patient. It is a legally and ethically established principle that a competent and well informed patient has the right to refuse life-prolonging treatment, under which nutritional sustenance can also be categorized.1 Centering the argument around the patient, however, completely ignores the actions of the physician. It is important to note that that a legal consensus, or even a moral one for that matter, does not preclude a physician from having reservations about allowing a patient to completely stop eating and drinking.2 The question that needs to be asked, therefore, is what is the physician’s intent?
Even prior to this question, however, proponents of VSED will claim that the physician is not actually doing anything; VSED is advantageous because it relies on the patient and does not call for direct physician involvement.3 The physician’s intent does not actually exist, or if it does, is completely irrelevant. Let us consider then, for example, a man standing at a street corner, waiting to cross. He observes another man about to be hit by a car. The man on the corner does nothing to warn or perhaps even save the man in the street. The man on the corner, however, could have been thinking that the man in the street deserves to die; perhaps the two had a falling out in the past, and the man on the corner was finally getting his revenge. Is that man not morally culpable for his thought? His intent is clearly relevant to the morality of his inaction. Although it was inevitable that the man in the street would be hit by the car, the observer’s intent still existed.
With that in mind, the answer to the earlier question of the physician’s intent is that the physician intends for the patient to die. Granted, he does not actively take part in killing the patient, but not intervening conveys the same intent of the patient’s eventual death. The alternative is interfering with the patient’s decision, an action that would prolong the patient’s life, demonstrating intent to keep the patient alive. The physician’s choice of allowing the patient to voluntarily stop eating and drinking demonstrates that the physician accepts and intends for the eventual death of the patient.
The same can then be said for terminal sedation. The argument again exists here that it is not the physician’s intent to hasten the patient’s death using terminal sedation, but rather to just allow the patient to die. The patient’s death is foreseen by the physician, but it is not intended.4–5The response is still the same. Although the physician may only be sedating the patient, he still has the option of intervening to prolong the patient’s life, and refusing that option again conveys intent towards the patient’s death. Further, terminal sedation calls for halting all life-prolonging treatment, including nutritional sustenance. In this way, it is not morally differentiable from VSED.
Before continuing with the options of PAS and VAE, I would like to note that the issue of intent contains a high degree of relativity that cannot possibly be adequately discussed in this short length. There are several considerations a doctor may make: the legal ramifications for himself, his occupational ramifications, his own personal moral or religious views, his perceptions of the patient’s personality, the patient’s degree of suffering, etc… Each of these factors definitely impacts the morality of the action. The problem is that none of these considerations is universal; it may be applicable to some doctors while not to others. Consequently, I pose the intent for the patient’s death as universal. Any physician who allows a patient to engage in VSED or TS is demonstrating that intent. Otherwise, he would intervene, terminate the doctor patient relationship, or advise the patient otherwise.
The intent for both patient assisted suicide as well as active voluntary euthanasia is the same as the aforementioned options; it is intent towards the patient’s death. PAS, by its very definition, puts the physician in the role of facilitating the patient’s desire to die. By adopting this role, the physician is effectively conveying intent for the patient’s death.
Coming to VAE, it is clear that the physician desires the termination of the patient’s life, whatever the reason behind that desire may be. The intent to end somebody’s life is implicit in the deliberate action taken toward that end.
Conclusively, because they both signify the same intent, there is no significant intrinsic moral difference between allowing a patient to die and actually killing the patient.6
2 Schwarz, Judith. “Exploring the Option of Voluntarily Stopping Eating and Drinking within the Context of a Suffering Patient’s Request for a Hastened Death.” Journal of Palliative Medicine 10, no. 6 (2007): 2.