Drawing philosophical distinctions between specific actions in end-of-life care is essential to understanding the ethical differences (and, therefore, the ethical appropriateness) of those actions. At our May Unpacking Bedside Bioethics session on withdrawing and withholding life-sustaining treatments, we received a few questions asking if turning off a pacemaker was equivalent to passive euthanasia. I want to dive deeper into this question—exploring how the concept of “passive” euthanasia came to be, questioning whether it’s a helpful concept, and ultimately arguing why we should abandon it.
First, let’s start with the case that raised the question.
John, an 85-year-old patient, has been in hospice care for several months during which his health has deteriorated. He has a cardiac implantable device (e.g., a pacemaker) that was implanted several years ago to regulate his heart rhythm. He now finds himself experiencing frequent episodes of shortness of breath, fatigue, and discomfort. John expresses his wish to discontinue/ turn off his pacemaker. He explains that he no longer wishes to undergo procedures or interventions that only “drag out his death.” John is clear that he does not want to hasten his death but simply wants to allow nature to take its course. John’s physician calls ethics and is concerned that “turning off a pacemaker is euthanasia and would be killing the patient.”
In this case I would advise this physician that turning off a pacemaker is not morally equivalent to killing the patient (and therefore not euthanasia). It would be morally equivalent to allowing a patient to refuse medical treatment, something which all patients with decision-making capacity have a right to do. The difference lies in the direct cause of the patient’s death. When turning off a pacemaker, the direct cause of death is the underlying heart condition. Euthanasia, on the other hand, is when a new agent (like a lethal dose of a drug) is administered by the physician to the patient. While the physician is the final actor in turning off a pacemaker, they are not the direct cause of death (the heart disease) and therefore are not morally responsible for causing the patient’s death.
Enter passive euthanasia.
One of the earliest explicit examples of “passive euthanasia” is from Samuel Kron’s 1968 article “Euthanasia: A Physician's View” published in The Journal of Religion and Health where Kron writes that “Passive euthanasia refers to the withholding of a treatment that would otherwise prolong life.” In this article, Kron argues that in end-of-life scenarios, if a physician is not actively ending a patient’s life through a new agent or prolonging their life with medical technology, they are practicing passive euthanasia.
For Kron, there seem to be three choices when caring for terminally ill and dying patients, either end the patient’s suffering by practicing active euthanasia, prolong their life as long as possible through heroic means, or practice passive euthanasia by forgoing medical technology.
Kron writes,
Consider the case of a child with leukemia for whom everything possible has been done, and yet the child is hemorrhaging and approaching a terminal state. Picture further the agonizing suffering of the parents as they watch their child die. Should the physician use heroic measures, such as transfusions, tracheostomy, respirator, etc., to prolong death for a few more hours? By not doing so, he is in effect practicing passive euthanasia.
Kron seems to invoke laws that prevent physicians from forgoing medical interventions, “Under present laws, it is illegal for physicians thus to discontinue treatment, because by doing so they are shortening lives for medical reasons.” (Kron, 336) He recommends that medical students be taught to prolong life in every case as the opportunity to practice the techniques of life-sustaining treatments even in hopeless situations would at least give the physician helpful experience. Kron does advocate that the American Medical Association and American Bar Association join forces to explore changing the law which prohibits physicians from “shortening a life for medical reasoning” - hoping for an exception for patient’s who have lost brain function who can be kept alive with newly developed mechanical devices.
Not every mid-century physician shared Kron’s stark views that forgoing life-sustaining treatment was equivalent to passive euthanasia. For example, it was largely agreed upon (and Kron even notes this in his article) that the ordinary/extraordinary distinction held in Catholic moral theology allows for physicians to forgo extraordinary interventions (life-sustaining technologies) and only requires physicians to provide ordinary treatment (largely understood as hand-feeding as the patient can tolerate). At this time Catholics did not consider forgoing extraordinary treatment equivalent to passive euthanasia.
Passive Euthanasia loses any real meaning after the 1983 President’s Commission on Bioethics “Deciding to Forgo Life-Sustaining Treatment.” In this document, the framework is laid for the ethical appropriateness of forgoing, withholding, and withdrawing medical treatment based on the values of the patient. Now, if the patient does not want medical interventions to sustain life, there is no ethical obligation to use medical interventions to sustain life. In fact, providing treatment over and against patient values and wishes is considered unethical - a problematic manifestation of paternalism. This leaves the concept of passive euthanasia floundering, without any real meaning. No longer is the action itself the central marker in the ethics of end-of-life care, but we have shifted to centering the wishes of the patient.
In today’s world, many (if not most) end-of-life situations involve deciding when to forgo or stop life-sustaining treatments. If we take this definition of passive euthanasia to be ethically relevant today, it means that every decision made to forgo or withdraw life-sustaining interventions counts as passive euthanasia - as the intent behind the action is that death occurs. To avoid passive euthanasia we would be unable to make any decisions about forgoing or withdrawing life-sustaining care, meaning we would be entirely at the mercy of medical technology. Medical technology, then, becomes the ethical bar - not individual, religious, or community values. What we can do becomes the moral guide for what we should do.
Now that we have the unique ethical analyses of withholding and withdrawing treatment, passive euthanasia has no distinct meaning. It muddles rather than clarifies. It confuses rather than illuminates. Withdrawing and withholding are unique categories with ethical analyses distinct from euthanasia. Withholding medical care without patient consent that could be beneficial is just harm. Withholding interventions that have no benefit to the patient is just providing appropriate medical care. It’s time to abandon the antiquated term “passive euthanasia” and stick to language that clarifies rather than confuses.
Citations
Brassington, Iain. “What Passive Euthanasia Is.” BMC Medical Ethics 21, no. 1 (2020): 41–41. https://doi.org/10.1186/s12910-020-00481-7.
Kelly, Gerald. “The Duty to Preserve Life.” Theological Studies (Baltimore) 12, no. 4 (1951): 550–56. https://doi.org/10.1177/004056395101200405.
Kron, Samuel D. “Euthanasia: A Physician’s View.” Journal of Religion and Health 7, no. 4 (1968): 333–41. https://doi.org/10.1007/BF01532348.
