Brassington BMC Medical Ethics (2020) 21:41 https://doi.org/10.1186/s12910-020-00481-7 DEBATE Open Access What passive euthanasia is Iain Brassington Abstract Background: Euthanasia can be thought of as being either active or passive; but the precise definition of “passive euthanasia” is not always clear. Though all passive euthanasia involves the withholding of life-sustaining treatment, there would appear to be some disagreement about whether all suchwithholdingshouldbeseenaspassiveeuthanasia. Main text: At the core of the disagreement is the question of the importance of an intention to bring about death: must one intend to bring about the death of the patient in order for withholding treatment to count as passive euthanasia, as some sources would indicate, or does withholding in which death is merely foreseen belong to that category? We may expect that this unclarity would be important in medical practice, in law, and in policy. The idea that withholding life- sustaining treatment is passive euthanasia is traced to James Rachels’s arguments, which lend themselves to the claim that passive euthanasia does not require intention to end life. Yet the argument here is that Rachels’s arguments are flawed, and we have good reasons to think that intention is important in understanding the moral nature of actions. As such, we should reject any understanding of passive euthanasia that does not pay attention to intent. Short conclusion: James Rachels’s work on active and passive euthanasia has been immensely influential; but this is an influence that we ought to resist. Keywords: Euthanasia, Passive euthanasia, James Rachels, Intent, Withholding treatment, End-of-life care Background The intention of this essay is not to make any normative Euthanasia is a controversial and emotive topic, but nor- claim about assisted dying. Rather, it is built around the mative debate about it resembles trench warfare. People idea that a significant shift in the debate is likely to require who are in favour of liberal laws tend to stay in favour of conceptual clarity, and that a fruitful shift certainly will; liberal laws, but rarely persuade those who aren’tto and that there is significant unclarity surrounding a num- change their minds; and the same applies, mutatis mu- ber of aspects of euthanasia that impedes any such shift. tandis, in respect of people who are in favour of tight re- I shall focus in particular on an unclarity in the term striction or criminalisation. There is little argumentative “passive euthanasia”. The first part of my argument is innovation; what work there is tends to be – as Søren that there are at least two very different understandings Holm has indicated – a matter of fortifying established of the term in use. This means that participants in de- positions [1]. It is rather as if the soldiers in opposing bates are often talking past each other. This is bad trenches, accepting that there is no territorial break- enough; but the second part of the argument contends through to be made, have resigned themselves to half- that one of the candidate definitions of “passive euthan- heartedly throwing gravel at each other in the hope that asia” is deeply misleading. This generates (and prevents they might dent their way to victory. In this context, an- the simple solution, or dissolution, of) significant prob- other paper on euthanasia may be seen as attritional at lems for patients and medical staff who have to make best. It is not hard to see why. decisions in practice, and for the lawyers who may have to give an opinion on those decisions. The argument echoes many of the arguments mounted by Garrard and Correspondence: [email protected] Wilkinson in 2005 [2], in which they take aim at James CSEP/ Law, University of Manchester, Oxford Road, Manchester M13 9PL, UK © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. 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Brassington BMC Medical Ethics (2020) 21:41 Page 2 of 13 Rachels’s highly influential claims from 1975 [3] about might be the sort of thing lawmakers ought to consider; active and passive euthanasia.1 This is more than pleon- but it is not central to whether a putative mercy-killing asm, because – as we shall see – though the position ar- is euthanasia by definition. ticulated by Rachels is flawed, the influence of his paper I am now in a position to offer this as a simplified def- persists, and it is undesirable that mistaken claims inition of euthanasia: should be influential. Definition 1 Euthanasia is the intentional ending of one Main body person’s life by another, motivated solely by the best Defining euthanasia interest of the person who dies. I shall take as my point of departure Heather Draper’s Note the distinction between intent and motivation. definition of euthanasia, which is something of a touch- Motivation refers to a general desire to secure the best stone. For her, death by euthanasia interests of the patient, intent to the particular actions performed in the service of that motivation. This will must be defined as death that results from the prove important later. intention of one person to kill another person, using A potential difficulty concerning motivation and intent the most gentle and easy means possible, that is is that either may be unclear or impure. Agents can, and solely motivated by the best interests of the person frequently do, have mixed motivations for this or that 2 who dies [5]. action; further, agents may be psychologically opaque even to themselves, and unable as a result to say pre- It is reasonable to infer from this that any instance in cisely why they did something.3 It follows from this that which means other than the gentlest and easiest possible it may be difficult truly to assess motive and intent, and are selected to bring about death is not an instance of eu- correspondingly difficult to say with certainty whether a thanasia proper. This is because if death by euthanasia is given instance of ending a person’s life is, in the real motivated by the best interests of the person who dies – world, truly an instance of euthanasia. That said, the fact which may be taken to be a necessary though not suffi- that there may be obscurity on this matter does not cient part of euthanasia’sdefinition– it would always be mean that there always will be. Sometimes, and possibly in their better interests for the gentler available option to often, assessments of motive and intent will be straight- be used, the best being by definition that than which there forward; and for the sake of the conceptual clarification is no better. Therefore, intentional killing that does not that is the concern of this essay, possible psychological use the gentlest and easiest possible means cannot be eu- opacity matters little. We will only stand a chance of thanasia. At best, it is botched euthanasia; but it may not assessing whether an action fits the definition of euthan- even be that, since we would presumably want to distin- asia if we can get that definition straight in the first guish between instances in which the gentlest means are place; and getting a definition straight does not depend not selected, and those in which they are but in which on how likely it is that any putative instance of euthan- their administration (for some reason) goes wrong. asia really is properly so called. In what follows, we can Draper does not stipulate that death should be re- assume that the motives and intents attributed to actors quested; this means that, under her definition, non- are nothing more or less than they appear to be. voluntary euthanasia is possible. On the other hand, it We may append to Definition 1 a distinction between seems reasonable to assume that a positive desire to re- active and passive euthanasia. The former would de- main alive is trumps when making judgements about scribe an instance in which Alice brings about Bob’s best interests, and that the phrase “involuntary euthan- death, intentionally and motivated solely by Bob’s best asia” is consequently an oxymoron. Neither does Draper interest, by performing some procedure on Bob.4 The make any stipulation about the identity of the person latter would describe an instance in which Alice brings who does the killing, or about the relationship between about Bob’s death, intentionally and motivated solely by the killer and the killed. This seems correct. Who the Bob’s best interest, by withholding something necessary agents are might make a difference to the permissibility for his life to continue. A deliberate overdose of barbitu- of a given instance of euthanasia – that is a possibility rates might count as active euthanasia; removing a that merits investigation, but in another paper – and it 3I am grateful to Simona Giordano for bringing this point to my 1As well as calling his 1975 NEJM paper “Active and Passive attention.