Active & Passive: a bogus distinction?

The word "euthanasia" sparks emotions at its very pronouncement. For those in favor, "the good death" is at once a wish, a hope, and a right. For those opposed the word means the intentional termination of a life -- a suicide or a murder -- regardless of method or motive. For the sake of clarification, if not argumentation, let's recognize at the outset that any decision regarding treatment of the terminally ill is a death decision. Whether the decision is to effect a full-frontal assault on the forces that conspire to shorten ones life or to hasten the inevitable, either option is a choice among options available at the end of life. Once again, what is new here is the impact of technology: not long ago there were limited options as death approached, and it approached at an earlier age. Inevitably, Nature would 'take its course'. Now medical advances and overall improvement in basic health have increased our longevity -- and now we stay alive long enough to get cancers that only show up as opportunity and age allow. Medical advances can now keep any particular body alive; so it is an old ethical question in a new guise we face: "Should we?"

The assumption was that if life has an intrinsic value it must always be preserved. Even for Natural Law this is not necessarily the case. While life has an inherent value, death is part of the telos of any living thing. As Callahan pointed out, the denial of the reality of our finitude is at the root of our core values in American medicine and, as he predicted, we cannot deny it for long. And so, in the legal history from Quinlan to Crusan in less than twenty years we moved from a presumption of an impossible duty to sustain all life to a precedent to permit the physician to assist in the consultation of ending one's life. In this process a line has been both drawn and crossed. James Rachels' holds that the line -- a line between active and passive euthanasia -- ought not to have been drawn in the first place.

The distinction between two types of euthanasia was proffered as an articulation of what is acceptable and unacceptable practice. The root is clearly in Natural Law wherein the obligation to avoid doing an intentional evil is much stronger than the intention to do good (non-maleficence vs. beneficence). Accordingly, active interference in the life processes is deemed impermissible, unless according to principles of double-effect or totality of the body. Yet not interfering with the death process (letting nature take its course) is a passive acceptance of our mortal condition that is permissible (IF there is no proportional benefit to be gained by a particular course of action). Thus distinctions between two categories of actions include the following:

Passive	Active
Deciding NOT to undergo treatment DNR orders ("do not resuscitate") Proportional increase in meds as needed (ex.: in the case of Ca., morphine)	Suicide (active termination by patient) Kevorkian's actions (facilitating pt.) Oregon's "Death w/Dignity" Act (P.A.S.) The case of Elizabeth Bouvier

To this array further distinctions can be made as to who makes the decision for treatment: if it was autonomous it is considered voluntary, and involuntary if not. The latter are clearly the more problematic:

	Passive	Active
Voluntary:	(everything as per above)	(everything as per above)
Involuntary:	Decisions involving children, Incompetent adults, Any patient in a coma, or "persistent vegetative state"	Quinlan: N.J. court precedent Crusan: Supreme Court decision re- garding nutrition & hydration

Especially since the Crusan decision, documentation regarding the patients' expressed intentions about life sustaining treatment has become crucial in facilitating treatment decisions. Thus to the array we can add a mediating buffer about "Living Wills" or "Advanced Directives". These documents effectively move some decisions from the "involuntary" portion of the grid to the "voluntary" one, since we act on the patients clear, rational expressed last intentions.

	Passive	Active
Voluntary:	(everything as per above)	(everything as per above)
	Living Will	a.k.a. Advanced Directives
Involuntary:	Decisions involving children, Incompetent adults, Any patient in a coma, or "persistent vegetative state"	Quinlan: N.J. court precedent Crusan: Supreme Court decision re- garding nutrition & hydration

This appeared to be a neat categorization for ethical and legal discrimination: if an action was autonomous and passive, no moral, ethical or legal foul was proffered in a decision that "allowed the patient to die". Even in the non-voluntary category, if the decision is unchallenged by the medical staff and the patient's family, if it is clear that no "proportional benefit" to the patient can be gained by initiating a given course of treatment, then not treating in those cases is also an acceptable course. The "Active" category then was tainted as active termination of life, and thus included actions of unjust killing. At the time prior to Quinlan, it seemed to be a clear separation between acceptable "passive" euthanasia decisions and "active" euthanasia decisions that were "god-like" judgements of life and death. (Passive decisions were NOT referred as euthanasia decisions by the families and medical staff that supported them, leaving the negative connotation of the word for non-passive choices)

Prior to Quinlan:

	Passive	Active
Voluntary:	-- acceptable --	-- Not acceptable --
	Living Will	a.k.a. Advanced Directives
Involuntary:	-- conditionally acceptable --	-- Not acceptable --

Clearly, after the Quinlan case, this distinction was no longer legally viable. Both moral and legal judgements in this area were considered suspect. Enter James Rachels with what appears to be yet another stretched philosophic argument that tries to muddy-up the waters by erasing the active-passive distinction. Ironically, the analogy seems to offer an objection to all euthanasia decisions -- but actually it opened the door wide to consider all such decisions as potentially, or conditionally, acceptable.

Rachels presents a clear, unambiguous scenario. Is it permissible to stand by idly while someone drowns though you have the capacity to save him or her? While legally permissible (or minimally, "non-prosecutable") such non-action can be heinously immoral. In fact, in the scenario he presents, such standing-by is akin to actively killing the innocent person. On the surface this seems to argue that any process, active or passive, that leads to the death of another is wrong, but this is not Rachels' position. By calling into question the validity of the active/passive distinction Rachels is actually challenging the morality of some passive decisions and re-orienting the inquiry to consider the beneficence of some active decisions. If one has decided not to have a potentially life-prolonging operation, and thus has made a decision not to forestall death, that same decision may be condemning a patient to a slow and painful demise. In true Utilitarian fashion, if one has decided to end one's life and ending it sooner is less painful than postponing the inevitable, Rachels would say the balance falls in favor of the active choice. The bottom line is that either decision is one that accepts death -- the only question is how. If active euthanasia is an option considered humane when provided to animals in pain, then it may indeed be immoral to not permit that same option for humans. Effectively the distinction between "good passive" and "bad active" is erased. Decisions per individual cases are to be weighed out according to the merits of the case (presumably in a Utilitarian fashion). Whether a patient opts for assistance in dying in Oregon, or opts for "doing everything," the choice is theirs. This affords the greatest latitude for patient autonomy, avoid paternalism, and can indeed provide the greatest balance of pleasure over pain.

	Euthanasia Decisions
Voluntary:
	Living Wills
Involuntary:

Actually, it is only fair to point out that "removal of life support" as in the Quinlan case is no longer viewed as problematic, even by many Natural Law advocates (including the Catholic Church). When there is little or no benefit to the patient, when there is no potential to return the patient to an autonomous state of functioning, life-sustaining measures are not mandated. This removes the difficulty of trying to decide in advance whether to beginning a course of treatment (such as intubation) is warranted; procedures in the ER are aggressively advanced, and withdrawn when no longer warranted. Again, as in the case of Quinlan, when such measures are withdrawn and the patient continues to live, Natural Law demands due care and respect to continue that basic care for as long as needed 9and for Karen Ann, that was nearly a decade).

There are still problems, obviously. Allowing the option of medical assistance in suicide reverses the presumption of the practice of medicine to assist in life processes. In an era where treatment always has a dollar-and-cents aspect to it, this tends to make the poor implicitly more expendable and less worthy of extensive life care. Because of our fear of death we may be ineffective in "objectively, rationally and impartially" weighing out our alternatives. The cost of allowing wholesale active euthanasia may be to high for our society to bear, not in an economic sense, but in a societal sense; it may be societies obligation to protect the sick when they are at their most diminished capacity. That is why in reaction to the increasing call for euthanasia options the hospice movement has garnered so much attention. Effectively hospice has shown that pain management is the real concern with most patients and that when humane care is provided -- as opposed to framing medical treatment as providing cures -- patients very often cope well with the dying process.

The emphasis on Care is perfectly in line with the Feminist critique of ethics in general. ALL of the systems reviewed up until now have reflected the thinking of the men of the times that articulated and produced those ethical principles. By nature, men are said to think in terms of systems, and those systems in ethics tend to emphasis procedures to determine what is, and what is not, just. Overemphasis on ethics of Justice has come at the expense of a key moral component, Care. Bypassing the active vs. passive debate altogether, the ethics of Care contends that the systematic weighing-out of euthanasia options or the relating of action to principle can be bypassed by providing basic, and genuine, palliative care. A "return to Care" is a return to universally recognized virtues and a social commitment to provide for others as we would want to be provided for.