---Important distinctions---

I. Voluntary, non-voluntary, involuntary

 A. Problem with informed consent.

 B. Living will? (Catch 22)

II. Active v. passive (traditional treatment)

 A. Killing v. letting die (The latter has always been accepted.)

 Question---Is letting die always a form of euthanasia?  Discontinue treatment for other  reasons.

 B. Who or what is responsible?  What did the patient die from?

 C. Ordinary v. extraordinary care

  1. ordinary: what any human being needs to stay, water, air...

  2. extraordinary

   a. not ordinary

   b. unusual, painful, invasive

   c. it just won't help.

  3. grey areas eg....

   a. insulin for the diabetic (not ordinary).

   b. "artificial" delivery of food and water (unusual, painful, invasive).

  4. moral/legal ramifications

   a. traditionally the cessation of ordinary treatment was considered active    euthanasia, because you die of starvation, dehydration etc., not of the    disease or whatever.

   b. now (at least in some states) law permits cessation of ordinary treatment.

 D. Moral issue: Would the moral justification for allowing someone to die suffice to justify    suicide or active euthanasia?

Rachels: If the only difference between two actions is that one is killing and one is letting die, there is no moral difference between the actions.  (The unstated but obvious conclusion is that active euthanasia is morally acceptable.)

I.  The AMA statement 1973

 A. "mercy killing" is just wrong

 B. ceasing treatment is acceptable when,...

  1. it means cessation of extraordinary treatment

  2. there is irrefutable evidence that death is imminent

  3. decision is made by patient and/or family

II. Making the active/passive distinction leads to absurd consequences.

 A. Causes more suffering.

 B. Leads to life and death decisions made on irrelevant grounds.

  1. eg. Down's Syndrome infants (the one with the blockage can be allowed to die   while the one without must be kept alive, yet in the relevant respects the infant's   conditions are the same.)

  2.  (Rogers) This particular example doesn't prove the point since the infant with   the blockage does not fit the AMA criteria.

III. Smith and Jones (Ceteris paribus, eg. same motive, same result, killing and letting die are morally the same.)

IV. Why do we often feel there's a difference?

 A. In practice most cases of killing are worse than cases of letting die (the former are  usually murder, while the latter are usually euthanasia).  But this is irrelevant.

 B. We might say that with passive the doctor doesn't do anything...but of course he does.

Callahan: There is a difference between killing and letting die which has moral implications.  The important distinction is between deaths caused by human action and death caused by nonhuman events.  He doesn't present an argument against active euthanasia, but by insisting that the distinction is justified he allows for the possibility of such an argument.

I. It is quite true that...

A. Death can result from our omissions as well as from our commissions. We can bring about a death by failing to act as well as by acting.

B. The crucial moral point is our intentions.  We can intentionally bring about someone's death by omission, and if we do we are responsible.

--nonetheless there are differences--

II. Metaphysical (the ultimate nature of things): there is a sharp difference between the self and the external world.  We do not have total control.

A. If there were really no difference, since ultimately everyone is "allowed to die", we've killed everyone.

B. There's a difference between killing and "giving up" in the face of nature.

III. Moral

A. Certainly there are cases where we are as responsible for letting die as we would be had we killed.  In such cases there's no moral difference.  But the fact that there's no moral difference in some cases does not mean there's no moral difference in all cases.

B. Shutting off life sustaining equipment: respirator, feeding tube

1. Person dies of the disease/accident etc.

2. But whether or not it was right to shut off the equipment depends on the situation.  If someone could be cured, or does not want to die yet, it is wrong to let them die of the disease.

3. Implication is that there might be cases where giving up in the face of nature and letting someone die of a disease is justified, but killing them would not be.

IV. Medical Implications: Treating active killing as if it were the same as ceasing treatment would involve doctors in a significant change in job description which might prove very harmful.

A. Doctors might not feel so inclined to work so hard to save lives.

B. Might abuse power to kill.  (Slippery slope..psychologically, if we allow the killing of some now, we'll get comfortable with the idea and allow more and more.)

Singer:  The reasons which would ordinarily make killing another human being wrong actually work to justify (active) voluntary euthanasia.

I. You'd kill your dog if it were sick, suffering, and incurable.

II. Usually it's much worse to kill a human being than to kill an animal because...

 A. We can fear death (Murder frightens us)

 B. We want to go on living (Our preferences are thwarted)

 C. We have a right to life since we are capable of desiring our own continued existence.

 D. Our autonomy ought to be respected.

III. These points justify active voluntary euthanasia

 A. What we fear is continued life

 B. Our preference is to die

 C. We can waive the right

 D. Our autonomy ought to be respected

IV. Practical problems, can we be sure that patient...

 A. wasn't pressured by family etc.?

 B. wasn't murdered? (Why easier w/active?)

 C. made a truly rational decision?

V. Solutions

 A. Note first that these are not problems for the morality of voluntary euthanasia per se.

 B. Safeguards, e.g. (p.222)

VI. Isn't there always the possibility of misdiagnosis?  Yes, but the suffering prevented by allowing active voluntary euthanasia will outweigh the harm of a very small number of  unnecessary deaths.

VII. Can't we take care of the dying patient well enough (pain killers etc.) that death will not be preferred?  Maybe in  the future this will be the case, and when it is, the issue of voluntary euthanasia won't arise, but for the time being we need to permit it.

Harris: Consequences if we argue that there is no difference between killing and letting die: the survival lottery.

I. What if you could save the lives of two sick patients by killing one healthy person?  Basically question is should you kill two people or only one.

II. Harmful side-effects of doctors just hauling people off the streets...excessive power to doctors, fear in the population at large.

III. So institute the lottery.  If overall more lives are saved then overall there's less to fear in that world than in the actual world where premature death is more likely.

IV. Practical issues

A. Too many old people...write a computer program to ensure maintenance of optimum age distribution throughout society.

B. Self-inflicted conditions...exempt them from the lottery.

C. Practical problems probably make it unworkable, but perhaps that is a terrible shame which will result in the unjustified killing of many .

Hard to tell if he's serious.  In any case, if it seems absurd that you should kill an innocent person to save the lives of two sick people, the question is why?  One answer would be to say that Callahan is right, there is difference between killing and letting die.  The former is death caused by a human agent, the latter is death caused by a force of nature.  This is a difference which can have  moral significance in some situations, and this is one.  If you have to cause the death of a person in order to prevent natural causes killing two others, better to let the two die.

Rogers in conclusion: There's a bit more to be said about the active/passive distinction

I. Remember, not all cases of "letting die" are really euthanasia.  We may not be aiming at the quick death of the person, but rather at improving their quality of life for the time being.  In a situation like that the reason justifying the cessation of treatment would not justify killing.

II. Slippery Slope.  Allowing active killing in some very limited cases (e.g. the sort of cases which fit Singer's proposed criteria) would lead to allowing more and more killing until we allow the killing of those whom right now we would never think of killing.
E.g. Voluntary > non-voluntary > involuntary.

A. Response: (Singer would probably say this) No, we can draw a clear line between the legitimate cases and the illegitimate.

B. Counter response: Maybe we can logically, but psychologically?  Doctors, nurses get used to stepping in and killing...have to overcome some initial gets easier over time.  Only test is history.

III. God? Classic argument against suicide--you don't belong to yourself.  You are like the soldier put at your post.  It's not up to you to decide when it's time to quit.  It's one thing to give up in the face of irresistible odds, it's another to leave your post when you could remain.  The iceberg problem!