Traditionally, the concept of euthanasia is a controversial one; the question of whether taking a life of another human being is acceptable in any situation or not, is in itself a universal moral issue. How, then, can allowing a person to die, even a terminally ill individual, be considered any more humane, let alone moral, than actively killing him or her? “Passive” euthanasia, or allowing a terminally ill patient to die, has come to be seen as a more permissible alternative to the prohibited “active” euthanasia. However, it is the purpose of this paper to show that passive euthanasia is actually less humane and perhaps more immoral than active euthanasia-if active euthanasia is immoral at all. Thus, if active euthanasia is considered immoral, so should passive euthanasia.
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I will begin by defining passive euthanasia and the conditions under which an occurrence must proceed in order to be considered as such, so as to better understand the motives and goals of this brand of “mercy killing.” Once this foundation is clearly laid, I will discuss, using specific and theoretical cases, why there is no difference between “letting” someone die and “making” someone die, as argues by James Rachels. I will suggest that there is no difference between acts and omissions, therefore making it not a question of morality in the intentions, but in the means. I will also show the immorality of letting someone die, considering its contradiction to the original purpose of euthanasia. This will be supported by traditional ethical thought, specifically Kantian, and Utilitarian thought, and will show that a doctor performing passive euthanasia has the same intention and goal as one performing active euthanasia. Finally, I will address critical arguments raised in support of passive euthanasia and possible counterpoints to my own suggestions. All this aims at demonstrating that passive euthanasia is no more permissible than active euthanasia; and if active is forbidden, so then, must be passive. Though euthanasia has been sanctioned as necessary given the right conditions, passive euthanasia is the wrong means through which to carry it out.
Defining Passive Euthanasia
According to Garrard and Wilkinson, passive euthanasia is a means of hastening the death of a terminally ill individual “by not providing something which would, if provided, delay death.” This, presumably, is in the patient’s best interest, alleviating further pain or fulfilling the dying patient’s request. For clarity’s sake, we can delineate three conditions that an occurrence must meet in order to be considered passive euthanasia: it must involve bringing about death through withdrawing or withholding treatment keeping the person alive; the main purpose of this is to hasten the death of a terminally-ill individual; finally, the purpose of this quickening is in the patient’s interest (by lessening suffering or pain, etc). 
Typical cases of passive euthanasia involve the withdrawing of life-support mechanisms (such as ventilators, dialysis, and nasal gastric tubes) that aid a dying patient. One may ask that this be done, in which case it would be categorized as voluntary passive euthanasia, while if one falls into a coma, for example, without expressing the request and it let die, it would be considered non-voluntary passive euthanasia. A third, more puzzling category exists known as involuntary passive euthanasia, where the patient expresses not to be allowed to die under any circumstances, but is overridden seemingly by the better judgment of others. Currently, the American Medical Association policy states that active euthanasia is prohibited; but on withholding or withdrawing life-prolonging medical treatment, the following position is taken:
The social commitment of the physician is to sustain life and relieve sufferingâ€¦for humane reasons, with informed consent, a physician may do what is medically necessary to alleviate severe pain or cease or omit treatment to permit a terminally ill patient whose death is imminent to die. However, he may not intentionally cause death. 
Thus, the AMA endorses passive euthanasia, but not active euthanasia on the grounds of the physician’s intentions and responsibility in the ends of his action. I will show that the belief in this distinction is unfounded and irrelevant to the concept of morality.
Nevertheless, passive euthanasia is allowed in all fifty states. It is legal to withdraw life-supporting treatments, including nutrition and hydration, with the consent of the patient or the patient’s proxy. Only one state, the state of Oregon, has passed a Physician Assisted Suicide law, allowing active euthanasia only in this form.  Oregon’s “Death with Dignity Act” allows terminally ill residents of Oregon “to obtain and use prescriptions from their physicians for self-administered, lethal medications” and that “ending one’s life in accordance with the law does not constitute suicide.”  The law insists that a person must have six months or less to live and be competent, that is capable of making rational and reasonable decisions. However, the drugs must be self-administered, and only after a long process that includes a waiting period after the request is made, a witness, a written directive, family notification, a psychological evaluation, and even a second opinion on the terminal diagnosis of the patient.
It is clear that the Oregon legislature has gone to great lengths to ensure the validity of this form of euthanasia by covering all grounds of moral ambiguity, including the issue with the physician actually doing the administering of the lethal dose. Why then, have the other forty-nine states not jumped on the wagon? What is the real problem that society has against active euthanasia that makes passive euthanasia a more promising alternative? Is it even the better alternative? The aim of this paper is to prove that it is not.
“Making Die” vs. “Letting Die”
In his famous 1975 article “Active and Passive Euthanasia”, James Rachels makes the case that there is not such a drastic moral difference between active and passive euthanasia, especially not enough to allow the latter to be sometimes permissible, while the former is always forbidden: “One reason why so many people think that there is an important moral difference between active euthanasia is that they think killing someone is morally worse than letting someone die.”  Rachels suggests that there is not a moral distinction based on the following two hypothetical cases:
Case 1. Mr. Smith stands to gain a large inheritance if his young cousin was to die. Motivated by greed, Smith sneaks into the bathroom while the cousin is taking a bath and drowns her.
Case 2. Mr. Jones also stands to gain a large inheritance if his young cousin was to die, and he too sneaks into the bathroom, planning to drown her. Just as Jones enters the bathroom, the girl slops, hits her head, and falls face down, unconscious, in the water. Jones is poised to force her head back down should it be necessary, but it is not. The girl drowns while Jones does nothing. 
In the first case, we see that Rachels is attempting to illustrate active euthanasia in a different context. Here, Mr. Smith is actively killing his cousin. In the second case, Mr. Jones “merely” stands by and watches his cousin die. Rachels argues that morally, both men had the same motivation and end in sight. Do we dare say that one man’s action was more reprehensible than the other’s? If we do venture to admit that Mr. Jones did not actively bring about the death of the child, we contradict the universal moral principle of the Good Samaritan. Some states in the U.S. like Vermont and Minnesota require by-standers at the scene of a crime to call 911. Why would these laws be of concern if watching someone die were not reprehensible? Mr. Jones, in fact, went a step further and prepared to finish the job should misfortune not carry it out to the full. One cannot say, then, that “letting die” is less immoral than killing. Admittedly, these are extreme cases that Rachels used, and do not account for the circumstances under which physicians must make decisions and the weight of the responsibility. But they do show that “the bare difference between killing and letting die does not, in itself, make a moral difference.”  The motive of a doctor is to save the patient from further suffering and pain, and the consequence is the hastened death of a terminally ill patient, in spite of the method used. There is no moral difference, then, between active and passive euthanasia.
Another way of looking at this is through the failure of the “Doctrine of Acts and Omissions”. Simon Blackburn of the Oxford Dictionary of Philosophy defines it as the moral difference between carrying out an action and merely omitting to carry out an action. He suggests “if I happily discover you in danger of death, and fail to act to save you, I am not acting, and therefore, according to the doctrine, not a murderer.” But as we have seen through Rachels’ cases, the doctrine does not hold up. The intention of a person is too important to society to excuse the innocence of someone who merely stands by and lets someone die. If a doctor, for example, wishes to get home early for dinner and decides to allow a patient stabbed in the heart with a dagger die in order to achieve this goal, we would not consider him innocent. Yes, the dagger in the heart was the initial primary cause of death, but circumstances changed once he was brought to the hospital and put under the responsibility of that doctor. He becomes the reason for the patient’s death because he had the chance to at least attempt to save him and did not. His intention was to let the patient die, and the patient died. He might as well have dug the knife in deeper. Thus, a doctor who lets a patient die is just as responsible as one who actively kills the patient, due to the importance of intention and consequence.
The causation argument is made that because passive euthanasia is an omission, it cannot be the cause of death and therefore is not permissible. However, this argument is seriously flawed due to the fact that we constantly attribute causal power to omissions. For example, what would we say caused an intelligent student to fail the exam? She did not study; she omitted to revise. What caused the car crash? One of the drivers failed to signal to the other car, and thus omitted to signal his intentions.  Thus, we cannot say that passive euthanasia does not cause death, for without the doctor’s action-however indirect-still brings about the death of the patient.
The Immorality of Letting Someone Die
Euthanasia, by definition, means, “help with a good death” derived from the Greek ÎµÏ… meaning “good” and Î¸Î±Î½Ï„Î¿Ï‚ meaning “death”.  Thus, we arrive at the true question. If there is no moral difference between letting someone die and actively killing someone, should passive euthanasia be considered more permissible, more moral than active euthanasia? Does passive euthanasia really fulfill the definition and original purpose of euthanasia? The question will be considered first in regards to the physician and the responsibility placed in him or her. Second, we will consider it in regards to the patient-is it truly in his or her best interest?
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It is commonly held that passive euthanasia is more permissible than active euthanasia because it does not make the physician’s action the cause of the patient’s death directly. However, as we explained earlier with Rachels’ cases this apparent moral difference is made irrelevant by the intention and result of the action. The question is not if aiding a terminally ill patient hasten his or her death is moral, because it has already been socially accepted for the most part that certain circumstances warrant it. It is considered immoral to allow a competent terminally ill person to continue suffering in pain when the patient has expressed the wish to die. The true purpose, then, of morally valuing passive euthanasia as more permissible than active euthanasia and therefore “moral” is to alleviate guilt and responsibility from the physician. This in itself might be considered immoral considering a physician’s main concern in his actions is supposed to be the patient’s well being. Thus, a physician’s intention is clouded. Can he or she really determine what is best for a patient when his or her career is at risk? Is it worth to opt for the more painless route of active euthanasia and face criminal prosecution and perhaps a higher sense of guilt? No, clearly, would be the answer for most for the law makes people inherently selfish by avoiding punishable actions. Passive euthanasia would be the optimal choice as it keeps the guilt away and it fulfills the patient’s wishes. But does it? We will explore this question later.
It becomes more difficult, however, when dealing with non-voluntary and involuntary passive euthanasia. The Medical Association deems it permissible to aid in death a terminally ill patient with consent of the patient or the patient’s proxy. This would be endorsing voluntary and non-voluntary passive euthanasia respectively. The physician is still protected because of the consent of the patient or the patient’s family/proxy. It is deemed permissible that someone else determine whether or not another person would want to continue living or not under a terminal but unconscious condition. Similarly, if a patient originally expresses the wish never to be allowed to die, under any circumstances, the physician, family, or proxy may deem the person originally incompetent of making such a decision, or of envisioning such drastic future conditions.
However, one could say that euthanasia in general, indeed, is moral in all these circumstances, but is passive euthanasia moral? To answer this question fully, we must look at it from the patient’s perspective, for we know that the physician’s well being is looked after by passive euthanasia. A patient who is terminally ill and expresses the wish to die-either personally or though a proxy-does so in order to alleviate whatever makes his or her life unbearable to continue living. This might be physical pain of the disease, physical dependence on machines, or even the mental anguish of knowing their family is suffering as well. The point is that a terminally ill patient who is competent makes the decision to hasten his or her death because living whatever is left of his or her life would be unbearable and unjust to endure. In requesting help in hastening his or her death from a physician, the patient is asking the physician to alleviate that pain and suffering that would otherwise continue.
With that in mind, we can turn to two theoretical cases:
Case 1. Mrs. A has esophageal cancer and after six operations and being treated for extreme infections, she is on life support. She tells her family that she wishes to die to end her suffering and her family consents. According to standard practice, the physician turns off life support and extubates her, and administers painkillers to alleviate pain. Nevertheless two hours later, Mrs. A is still in extreme distress and continues to live for several days in severe pain unless her heart gives out.
Case 2. Mr. K is in a vegetative state and has been for a long time. His family requests that he be euthanized, as they can no longer afford to keep him alive and suffering. The physician extubates Mr. K in order to allow him to die. After being deprived of the medicine keeping him alive, as well as food and water, Mr. K dies.
In these cases, we look at two varying circumstances under which a physician would administer passive euthanasia. In both the wish of the patient and the family is to end pain and suffering by hastening death. However, this is achieved effectively in neither case. In the first, the patient still suffers extreme pain before she dies, and for no reason at all but the stigma placed on a doctor actively bringing about the death of a patient. In the second case, the patient is left to die of deprivation of basic needs, something society would deem inhumane in everyday circumstances. Just because the patient is in a vegetative state does not mean he does not feel hunger or thirst or pain.
Is it really moral, then, to draw out a person’s death once it has been decided upon and consented to? What is the purpose of doing so beyond lessening the guilt of the physician and those who might have had a part in the decision? Society has placed a stigma on doctor’s ability to actively bring about the death of a patient not because it is any more immoral than passively doing so, but because it gives doctors too much power over a person, too much responsibility. Don’t doctors face this power of life and death every day? And if that is the case, Oregon’s law has found a way to still keep the physician at one degree of separation from the act of killing by merely producing the lethal doses. Again, the morality of actively killing is not the issue, but the personal stigma against it and the fear of guilt is.
Would Mill Approve?
Regardless of the fact that the morality of euthanasia is a recent concern due to the advancement of technology, the issue of life and death is not. John Stuart Mill’s philosophy of utilitarianism, composed of the Greatest Happiness Principle, supports the need for a clear first or defining principle for mortality. Utilitarianism is a consequential philosophy, valuing actions by the morality of their consequences.  The Greatest Happiness Principle, then, deems that “actions are right in proportion as they tend to promote happiness; wrong as they tend to produce the reverse of happiness.”  Thus, the more happiness an action promotes for the greatest number, the more “right” it is.
As pertaining to euthanasia, Mill’s philosophy provides a somewhat ambiguous answer. How can we deem whether someone’s hastened death will promote the great happiness or not, let along if a passive death or an active death by euthanasia is more “right”? However, as part of his philosophy, Mill believes that the pursuit of happiness and the absence of pain is the most moral end for an action. He suggests that there can be higher pleasures of the mind and intellect, and lower pleasures of the body, and thus this is why we are separate from animals in our pursuit of pleasure.  He adds that dignity is one of these higher pleasures intrinsic to the human being. Can we not say, then, that if the pursuit of pleasure and absence of pain is crucial to one’s morality and being, should it not be an individual’s personal right to decide when that pain outweighs the pleasure of life? Should not an individual be able to decide when he or she no longer wishes to experience this overwhelming pain in favor of the pleasure and relief that death would bring-and further should he or she not have the right to immediately access this pleasure and not at the expense of potentially more pain? Torr supports this by suggesting that according to Mill, “it is the subsequent quality of life, not the intrinsic sanctity of life, that provides the basis for moral judgment.”  The final consequence of passive euthanasia would indeed only bring further pain with eventual death and would fulfill the patient’s pursuit for happiness. Active euthanasia, on the other, hand would indeed bring happiness and peace to the competent patient, as well as to the family members and friends who wish the physical pain of their loved one to cease as soon as possible. Why would passive euthanasia be the proper method, the moral method to employ when this end is pursued? It so obviously depletes a patient of the one higher pleasure they might have left: dignity.
The complexities regarding the lines drawn between life and death are everlasting. Determining what will produce the most benefit, the most happiness is not easy-let alone choosing how a person should die. But a quote from Mill perhaps sums it up: “No person is an entirely isolated beingâ€¦a person may cause evil to others not only by his actions but by his inaction.”  We are all interconnected, as are our actions. It is nearly impossible then, to claim that one’s action’s however indirect cannot possibly have been the cause of pain or suffering or death in another person. It is not possible to distinguish morally a difference between actively killing someone and passively killing someone in the context of euthanasia.
Passive euthanasia cannot be considered more permissible because of the simple fact that it does not have the patient’s well being in mind, but that of the physician. While a physician’s well being is still important, his happiness, according to Mill, is expendable is it causes greater happiness to others. Passive euthanasia is not more humane, for often it causes more unnecessary pain. It is reasonable to worry that admitting active euthanasia as permissible could be the first push down a slippery slope but this is true of any law granting positive rights. The answer is not to be afraid to do what is more efficient and beneficial to everyone but to ensure that it is done correctly and in a controlled manner. One may ask, nevertheless, how does a doctor rise above the stigma of “actively” killing someone, however justified? As we have proved, doctors performing passive euthanasia are just as responsible for the death of their patients, and this has not presented such a problem. It should be a patient’s choice to end his or her life passively or actively-indeed different circumstances may warrant different actions. Some people may opt for one over the other for personal reasons. Ultimately, the point is one should not be more permissible than the other, especially not based on the grounds of morality, for when it comes to the well-being and happiness of the patient and those involved, passive euthanasia is not the most effective and moral mean to these ends.
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