Acts and Omissions

It is currently far more acceptable to allow instances of passive euthanasia (allowing someone to die by withholding treatment), as compared to active euthanasia (injecting them with a lethal drug that would prematurely end their lives). This is partly linked to our strong inclinations towards the sanctity of life. While many would be squeamish at actively taking a role in causing a death (even if acting on a person's wishes), they are less likely to feel the same way about causing a death in an indirect way (e.g. withholding potential treatment).

This can be clearly seen in the responses to the classic runaway cart scenario. In the scenario, there is a runaway cart hurtling down some tracks. It is currently headed for a group of four workers in the distance, who are too far away to warn and too preoccupied to notice in time to get out of the way. However, you can throw a switch diverting the cart onto a separate set of tracks which would spare the four workers, however, in doing so a single individual would be killed. Most people would find it acceptable to throw the switch.

However, in a separate scenario, the same cart is hurtling towards the same four people, but the only way to stop it is to push a bystander next to you onto the tracks. He happens to be quite a large individual with the bulk necessary to stop the cart. If you throw yourself on the tracks, it would be insufficient to stop the cart entirely and the four workers would still die. In this latter case, most people would not push the person onto the tracks to save the four people. The only fundamental difference is whether you would be directly on indirectly causing the death of one person in saving the four.

So this difference over the direct vs. indirect causation of death is deeply held and can seem to translate to a doctrine of acts and omissions. So I play an active role if I administer an injection or prescribe a cocktail of drugs which the patient then takes (note in this case I am merely giving the patient the means to end their life). A passive role would be to 'let nature take its course' for example by withholding drugs so a patient would die 'naturally' from an illness. Studies have shown that many doctors (and nurses) often carry out the latter for infants with severely deformities, for example, or in prescribing large doses of painkillers that will hasten death but provide some comfort in the case of terminal illnesses. Some nurses even allow very elderly patients in nursing homes to succumb to treatable illnesses such as pneumonia, rather that subject them to intrusive medical care, particularly if that patient has been ill a number of times.

Two classic contrasting examples illustrate our strange understanding of acts and omissions. The first is that of 'Baby Doe', a baby born with severe Down's syndrome, but also an oesophagus that was not fully formed. The baby was thus not able to digest food. An operation could be performed to fully connect the oesophagus which would allow for the normal intake of food but Baby Doe's parents requested that the operation not be performed. The baby died five days later after two courts upheld the parent's request. That the baby could have survived if the operation had been performed is not in doubt, though he would have faced severe mental deficiencies.

Compare this to the case of Samuel Linares, a young toddler that swallowed an object that became lodged in his throat. He was rushed to hospital but suffered severe brain damage due to the lack of oxygen intake to his brain. He was only kept alive by a respirator, and was comatose for over nine months, after which the hospital recommended that he be placed in a long term care unit, as it was unlikely that he would ever regain consciousness. His parents' request that he be taken off the respirator were ignored. Eventually, his father, armed with a pistol, forced his way into the ward and disconnected the respirator personally, cradling Samuel in his arms until the baby died. He then surrendered himself, weeping uncontrollably, to the police.

The two cases are especially illustrative because if both babies had lived, there is little doubt that Baby Doe would have a significantly better quality of life. Given Samuel Linares was in what was effectively a persistent vegetative state, and doctors were unsure if he would ever regain consciousness, it is doubtful if you can say he even had a quality of life at all. (A British High Court Judge made a similar remark when ruling about Anthony Bland, a football fan in a persistent comatose state as a result of the Hillsborough Stadium disaster).

Does it make sense that we allow Baby Doe's parents to effectively consign him to death (by not giving permission for the operation) while refusing to allow Samuel Linares' parents to make a decision allowing for their son to die peacefully by removing the respirator that was sustaining him? If one viewed the respirator as an artificial form of intervention that is sustaining Samuel's life, then one can argue that the parents should have a decision in stating that he should not be put on a respirator in the first place (a rejection of intervention to save life), just as Baby Doe's parents refused the operation (which was a rejection of a life saving intervention). If we agree that both should have the decision, why should we not allow Linares' parents to pull the plug on the respirator, assuming that doctors had done all they could, and it was unknowable and even doubtful if Samuel would ever wake up?