euthanasia and particularly the question of passive as opposed active forms of euthanasia have been intensely debated in the media and in medical circles during the last few decades. The very issue of euthanasia is one that is, from one perspective, opposed to the medical ethos and the emphasis on saving rather than terminating life. This is the main reason why there is such a prolific and voluble debate on this issue in contemporary society,
Another reason or the focus on the issue of active and passive euthanasia is that, "Since the turn of the century, there has been a dramatic shift in the places where people die" (Decisions Near the End of Life: CEJA Report, 1992, p. 2229). The consequence of more people dying in hospitals has shifted the focus of terminal patient care from the home to the arena of the physician and the hospital. Consequently, this also refers to decisions about life and death that have to be made and hence the attention given to medical views and protocols on the issue of euthanasia.
In other words, "This move of the locale of death from the privacy of the home to medical institutions has increased public awareness about medical decisions that lead to patient's deaths" (Decisions Near the End of Life: CEJA Report, 1992, p. 2229). This is also linked to the advancements and progress in medical technology and the increasing sophistication and effectiveness of life-support systems and apparatus -- which in turn has led to the question of whether to terminate life by stopping life-support in certain hopeless cases. This leads to as host of problematic ethical and philosophical issues; such as the difference, if any, between active and passive euthanasia and how passive euthanasia in particular can be morally justified. As one pundit notes "There is no such thing as a "natural" death. Somewhere along the way for ju (Decisions Near the End of Life: CEJA Report, 1992, p. 2229). st about every patient, death is forestalled by human choice and human action…" ( CEJA).
Taking into account the often complex agreements that surround this issue, the central thesis will be discussed in this paper is that the AMA document and position towards euthanasia is largely justified and any critique of the AMA stance must take into account the important issue if intention. It will be suggested that a purely analytic interpretation of the AMA document often becomes an exercise in semantics and tends to ignore the underling intentionality and the ethos of care that is implied and inferred by the statement made by the AMA on this sensitive issue.
The AMA and passive and active euthanasia
James Rachels in his article entitled Active and Passive Euthanasia (1975) argues that, contrary to the AMA policy statement (1973), there is no moral distinction between active and passive euthanasia. He is opposed to the apparently ambiguous nature of the AMA statement. The AMA policy stated the following:
The intentional termination of the life of one human being by another -- mercy killing -- is contrary to that for which the medical profession stands and is contrary to the policy of the American Medical Association. The cessation of the employment of extraordinary means to prolong the life of the body when there is irrefutable evidence that biological death is imminent is the decision of the patient and/or his immediate family. The advice and judgment of the physician should be freely available to the patient and/or his immediate family. ( Sullivan, 1977, p. 54)
The AMA therefore makes the distinction between active and passive termination of life and between intentional acts that lead to death and the cessation of treatment. The issue of active euthanasia is therefore seen to be different to passive euthanasia. The latter is not seen to be ethically or morally reprehensible, while the former is considered to be ethically and medically wrong. It is this distinction, or rather the interpretation of this differed has given rise to an often convoluted philosophical and ethical area of discourse.
In the first instance Rachels objects to this distinction on ethical, moral as well as rational grounds. He states that "…a strong case can be made against this doctrine" (Rachels, 1975, p.29). Central to this case is that there is an inconsistency in the acceptance of active euthanasia as opposed to the condemnation of active euthanasia. Rachel proposes that both forms of euthanasia are morally flawed.
He states that in many cases the active form of euthanasia is more ethically acceptable, as passive euthanasia such as the withholding treatment can lead to intense suffering for the patient. Rachels even suggests that from an ethical and rational point-of-view that if a decision is taken that there is no hope for the patient then active termination is more morally correct than passive euthanasia on grounds of a prolongation of suffering. Rachel state that being "allowed to die' can be slow and painful, compared to lethal injection.
He applies this rationale to the example of babies born with Down's syndrome. If we apply the AMA policy statement, "…a baby may be allowed to dehydrate and wither, but not be given an injection that would end its life without suffering…" (Rachels, 1975, p. 31) This is obviously intensely cruel. On this basis Rachel questions the AMA document and the acceptance of passive euthanasia as being ethical. He also argues that this document promotes life and death decisions that are based on irrelevant grounds (Rachels, 1975, p. 31).
In many ways Rachels view could in a philosophical sense linked to the views of Emmanuel Kant who refers to moral absolutes as guidelines for rational thought and action. These are also referred to as categorical imperatives. In terms of this theory one could argue that euthanasia goes against the moral absolutes of the universe. In contrast to the utilitarian approach, Kant is concerned with the moral and ethical values of the action itself and not the consequences or the ends. This view is therefore non-consequentialist in nature. (Rachels, 1975, p. 31).
Therefore, Rachel's article inserts an important question mark behind the apparent difference between passive d active euthanasia. He suggests that both forms are equally morally and ethically unacceptable and asks the crucial question that complicates this issue: "Is killing in itself worse than letting die?" (Rachels, 1975, p. 31).
There are many convincing aspects to the argument that Rachels suggests. Ethically speaking there does at first glance seem to be a contradiction in the AMA document and it could be argued that passive euthanasia is just as ethically suspect as active forms of euthanasia. However on another more rigorous interpretive level it becomes clear that Rachels' argument is somewhat disingenuous and evades or fails to note certain aspects and issues that are referred to and implied by the AMA document. This is the view put forward Sullivan and others.
Sullivan suggests that Rachel is misconstruing and confusing the issues at stake by focusing on the issue of active killing as opposed to "letting die." In other words, Sullivan suggests that Rachel's interpretation of the AMA policy document is too simplistic and avoids some of the deeper and rather obvious implications of this document. As he states, "… nobody who gives the matter much thought puts it that way" (Sullivan, 1977, p. 56).
He comments that the AMA document does in fact not mention active and passive euthanasia and that it does not state or imply the sharp distinction between the two that Rachel makes in his article (Sullivan, 1977, p. 56). This refers to a "…distinction that puts the moral premium on overt behavior & #8230; while totally ignoring the intentions of the agent" (Sullivan, 1977, p. 56).
The above point that Sullivan makes about intention and intentionally is crucial to this argument and I feel that it goes to the heart of the debate. In essence, while Rachels' argument does have some cogent aspects, it deals with the issue on only one level and does not take into account the importance of intention in the interpretation of the AMA document. It is clear from this document that the intention is not to kill to cause death unnecessarily or to cause any suffering. On the contrary the intention is that, within the ambit of modern science and medicine, the best life choice should be made by the medical practitioner, taking into account the fundamental trajectory of medical ethics, which is to save life where possible and to reduce suffering. This is a view that I feel is more in line and is more of an adequate reflection of the AMA document.
This view is supported by the difference between ordinary and extraordinary measures. This important distinction in the AMA document should, as Sullivan suggest, be taken into account in an analysis of the alleged disparities and contradictions in there document.
As Sullivan and others state, the AMA document clearly says that ordinary measures should be extensively applied, but not "…extraordinary means to…