'Pulling the plug' isn't euthanasia

Margaret Somerville*

Recently, I saw an illustration that accompanied an article about euthanasia. It showed the silhouette of a patient lying on a bed. There was an electrical outlet on the wall behind the bed and an unplugged connecting cord hanging down over the side of the bed.

Except in very rare circumstances - for instance, if the treatment were withdrawn without the necessary consent or against the patient's wishes - withdrawal of life-support treatment is not euthanasia. Yet many people, including the artist who penned this illustration and many health-care professionals, mistakenly believe that it is.

In my experience, they are confused with respect to the ethical and legal differences between withdrawal of treatment that results in death and euthanasia, and why the former can be ethically and legally acceptable, provided certain conditions are fulfilled, and the latter cannot be. This is a central and important distinction in the euthanasia debate, which needs to be understood.

Failure to understand it leads, among other problems, to physicians responding affirmatively to surveys that ask them whether they or their colleagues have carried out euthanasia, when in fact they have not, and members of the public saying they agree with euthanasia, because they agree with people's rights to refuse medical treatment.

First, the primary intention is different in the two cases: In withdrawing life-support treatment the primary intention is to respect the patient's right to refuse treatment; in euthanasia it is to kill the patient. The former intention is ethically and legally acceptable; the latter is not.

Patients have a right to refuse treatment, even if that means they will die. They have a right not to be touched, including through medical treatment, without their consent - a right to inviolability. This right protects a person's physical integrity and can also function to protect physical and mental privacy. The right to inviolability is one aspect of every competent adult's right to autonomy and self-determination.

Pro-euthanasia advocates use recognition of this right to refuse treatment even when it results in death to argue that, likewise, patients should be allowed to exercise their right to autonomy and self-determination to choose death through lethal injection. They say that there is no morally or ethically significant difference between these situations, and there ought to be no legal difference.

They found their argument by wrongly characterizing the right to refuse treatment as a "right to die," and then generalize that right to include dying through euthanasia and physician-assisted suicide. But the right to refuse treatment is not a "right to die" and does not establish any such right, although death results from respecting the patient's right to inviolability. The right to refuse treatment can be validly characterized as a "right to be allowed to die," but this is quite different from a right to be killed that euthanasia would establish.

Moreover, a "right to be allowed to die by refusing treatment," is a "negative content" right - a right against one's integrity being breached without one's consent. In contrast, a "right to die" through access to euthanasia would be a "positive content" right - that is, a right to something. In general, the law is very much more reluctant to recognize positive content rights, than negative content ones.

This pro-euthanasia line of argument is yet one more example of promoting euthanasia through deliberate confusion between interventions, such as valid refusals of treatment, that are not euthanasia and those that are.

This brings us to the issue of legal causation, which also differentiates refusals-of-treatment-that-result-in-death from euthanasia. In the former, the person dies from their underlying disease - a natural death. The withdrawal of treatment is the occasion on which death occurs, but not its cause. If the person had no fatal illness, they would not die. We can see that when patients who refuse treatment and are expected to die, do not die. In contrast, in euthanasia death is certain and the cause of death is the lethal injection. Without that, the person would not die at that time from that cause.

The fact that the patient dies both in refusing treatment and in euthanasia is one of the sources of the confusion between the two. If we focus just on the fact that in both cases the outcome is death, we miss the real point of distinction between death resulting from refusing treatment and from euthanasia.

The issue in the euthanasia debate is not if we die - we all eventually die. The issue is how we die and whether some means of dying, such as euthanasia and physician-assisted suicide, should remain legally prohibited. In order to maintain that they should, we need to be able to show how currently accepted practices, such as respect for patients' refusals of treatment, are not euthanasia and differ from it and assisted suicide.