Killing? Or Letting Die?

Rosemary Flanigan

March 5, 2010

Our Ethics and Human Values Committee is discussing whether or not there is a distinction between killing and letting die. To that end, we’re reading a chapter from Dan Callahan’s Troubled Dream of Life and James Rachels’ 1975 NEJM (292:2) article, “Active and Passive Euthanasia,” in which he tries to call the distinction irrelevant.

And reviewing the articles made me think of our futility discussions.

Two issues to distinguish: 1) What justifies, medically and morally, saying that it no longer makes sense to continue life-extending treatment? And 2) What is the meaning of that judgment when it is used to stop life-extending treatment?

As we have argued over the past weeks, once a judgment has been reached about futility, it is considered acceptable by long-standing medical tradition to stop treatment. But what of the judgment by which we reached that notion? Is it, as Rachels alleges, “intending” death?

Callahan makes a forceful attack against Rachels’ attempt to negate any difference (since the end is the same: the patient is dead) by making us recall what nature is: at some point treatment will not keep us alive; we shall die, despite what others may do to us.

To think otherwise is to see the physician, not just responsible for the omitted treatment, but—“as if they were gods—to intend what nature once wrought.”

Also, Rachels’ facile eliding over the distinction collapses causality and culpability—it is not the underlying pathology that is the cause of death, he says, but the actions (or their omission) of providers. And Rachels has his followers because the tehnological imperative has so taken hold on our minds that we transfer the causality of death to the actions of physicians: Did he/she do too much?

Too little? How strange.