Passive versus Active
Legal and medical sources distinguish between passive euthanasia and active euthanasia. Active euthanasia involves commission: doing something to end a person’s life. If a physician gives a patient a type or amount of medication designed to cause death, this action is termed active euthanasia. Passive euthanasia involves omission: refraining from care needed to maintain a person’s life. If a health care provider denies nutrition and hydration to a patient, the patient certainly will die. This decision to withhold fluids results in death, so it is passive euthanasia.
An unusual type of euthanasia has become increasingly common: Continuous Deep Sedition (CDS) without Hydration. The patient is put into a continuous deep sleep with strong medication. The patient is therefore unable take food or drink by mouth. If the patient is also denied hydration by an IV or other means, he or she will certainly die of dehydration. This type of euthanasia involves an act of commission, the medication to put the patient in deep sleep, and an act of omission, denial of nutrition and hydration. There is both an active and a passive element to this type of euthanasia.
Under Catholic teaching, euthanasia is intrinsically evil and always gravely immoral, regardless of whether death results from commission or omission.
Pope Saint John Paul II: “For a correct moral judgment on euthanasia, in the first place a clear definition is required. Euthanasia in the strict sense is understood to be an action or omission which of itself and by intention causes death, with the purpose of eliminating all suffering.” [Evangelium Vitae 65]
There are three fonts of morality: (1) the intended end or purpose of the act, (2) the moral object, (3) and the circumstances. If any font is evil (morally bad), the act is a sin. If the second font (moral object) is evil, then the act is intrinsically evil and always immoral to knowingly choose. Intrinsically evil acts are immoral by their very nature; the act is evil, in and of itself, regardless of the intended end or circumstances. The moral object is the end, in terms of morality, toward which the intentionally chosen act is inherently ordered. The intentional (deliberate, voluntary) choice of an act with an evil moral object is always objectively sinful.
Under the doctrine of the three fonts of morality, euthanasia is intrinsically evil because it is the direct and voluntary killing of an innocent human person. Euthanasia is therefore a type of murder. Evangelium Vitae describes euthanasia as an act or omission which “of itself” causes death because every intrinsically evil act is immoral in and of itself, by the very nature of the act. The phrasing “by intention causes death” does not refer to the font of the intended end or purpose of the act, but to the intentional (deliberate, voluntary) choice of the inherently disordered act itself. What makes an act intrinsically evil and therefore always immoral? It is the intentional knowing choice of an act that is inherently ordered toward an evil moral object.
The moral definition of euthanasia includes the intended end or purpose (first font) “of eliminating all suffering”, as well as the deliberate choice to directly kill an innocent human person (second font). The circumstances (third font) may include that the person is suffering greatly and/or is terminally ill. But no circumstances, however dire, can ever justify any intrinsically evil act. Notice that the intention to eliminate all suffering is a good intended end. Yet euthanasia is always gravely immoral. Neither a good intention, nor a dire circumstance, can ever justify any intrinsically evil act.
Society today has become so sinful that patients are put to death for a range of intended ends other than eliminating suffering, including saving the government or the family money, and eliminating the burden of caring for an elderly, ill, or handicapped person. In such cases, when the intention to eliminate suffering is absent, the act has the same evil moral object, and so it remains intrinsically evil. But then it is not strictly a type of euthanasia, yet it remains a type of murder.
Euthanasia is murder with the intention of eliminating all suffering, often in the circumstance that the person is terminally ill. But today the term euthanasia is used, in medical and legal sources, regardless of the intended end and in a much wider range of circumstances. Even so, the act remains intrinsically evil and always gravely immoral.
For the remainder of this article, I will use the term euthanasia in the looser sense, even when the intended end is perhaps something other than relieving suffering.
Euthanasia of the Elderly
A healthy adult can live without intake of fluids for up to 14 days . However, if the person is in a weakened state, because they are very old or very young, or gravely ill, the number of days they can survive without fluids can be as few as 4 days . Patients in a hospital, especially the elderly, are certainly in the latter category. When all hydration is withheld, they usually die within days.
See my previous post on Euthanasia in the British National Health Service: 130,000 Patients Euthanized a Year. Under NHS guidelines in the UK, physicians were labeling elderly patients as near the end of their life, despite having no recognized terminal illness. Then the patients were put on the so-called Liverpool Care Pathway (LCP), which included continuous deep sedation (CDS) and withdrawal of artificial nutrition and hydration (ANH). Under deep sedation, a patient cannot take food or drink on their own. Withdrawal of hydration in that circumstance always results in death. The patient is dehydrated to death.
The NHS has supposedly discontinued using the LCP. But the practice reportedly continues in many places; it is simply no longer called LCP.
Pope Saint John Paul II taught on the subject of withholding nutrition (food) and hydration (water) from patients:
“I should like particularly to underline how the administration of water and food, even when provided by artificial means, always represents a natural means of preserving life, not a medical act. Its use, furthermore, should be considered, in principle, ordinary and proportionate, and as such morally obligatory….”
“The obligation to provide the ‘normal care due to the sick in such cases’ (Congregation for the Doctrine of the Faith, Iura et Bona, p. IV) includes, in fact, the use of nutrition and hydration (cf. Pontifical Council ‘Cor Unum’, Dans le Cadre, 2, 4, 4; Pontifical Council for Pastoral Assistance to Health Care Workers, Charter of Health Care Workers, n. 120). The evaluation of probabilities, founded on waning hopes for recovery when the vegetative state is prolonged beyond a year, cannot ethically justify the cessation or interruption of minimal care for the patient, including nutrition and hydration. Death by starvation or dehydration is, in fact, the only possible outcome as a result of their withdrawal. In this sense it ends up becoming, if done knowingly and willingly, true and proper euthanasia by omission.” [Address, 20 March 2004]
Under Catholic teaching, continuous deep sedation with denial of nutrition and hydration is a type of euthanasia. It is murder under the guise of “end-of-life care”.
Sometimes, to try to justify this type of medical decision, it is claimed that the person is terminally ill, and will die from their illness prior to the time when they could be expected to die from dehydration (14 days). But in fact an elderly or ill person is unlikely to survive to the maximum 14 days without fluids, and will usually die from dehydration in a much shorter time, as few as 4 days . In addition, even when the person has a terminal illness, CDS without hydration is routinely used despite the expectation that the person would like well beyond 14 days with adequate nutrition and hydration. Euthanasia is never justified, even if the patient is terminally ill and would eventually die at a later time.
Moreover, many news reports indicate that some elderly persons are given CDS and are denied hydration, despite not having any terminal illness at all. Here is a report from the BBC in 2013: Liverpool Care Pathway: ‘They told my family I was dying’. An elderly woman was in the hospital for a dislocated shoulder, and she developed pneumonia. The hospital denied her food and water, even though she was conscious and begging for food and water.
“All I remember is they weren’t feeding me. Up above my bed they put ‘nil by mouth’ and I was begging for food,” she recalled.
She said that when she asked doctors and nurses for food, she was ignored.
“I was being left to die. If it hadn’t have been for my family I would be dead now. I would just have been another statistic on the books.”
Her family were told she had 48 hours to live but when her granddaughters visited her in hospital they said she did not look like someone who was dying.
“Nanny was sitting up in bed and she was saying, “I’m really hungry, I’m really thirsty,” said Helen.
“We were ushered into an office with five medical staff and told about the LCP and that Nan was very elderly and her system was shutting down and there was not a lot they could do. So they would withdraw the food and meds and let her go peacefully.
“We said, ‘but she’s got a dislocated shoulder, how can this happen?’ And they were saying, ‘she is very old’ and we had five people staring at us and it was very intimidating,” Helen said.
If her family had not intervened, she would have been dehydrated or starved to death. The woman was not terminally ill. She in fact left the hospital and survived her illness and injury.
The claim is that this decision to withhold food and water is a way to allow the person to die “peacefully” or with dignity. But euthanasia is always gravely immoral. And in many cases, there is not even an intention to eliminate suffering; the person is murdered because they are elderly, or because they would be a burden (financial or emotional) to others.
Euthanasia of Children
In researching euthanasia of the elderly by means of continuous deep sedation (CDS) and withholding of artificial nutrition and hydration (ANH), I came across a disturbing article which attempts to justify euthanizing handicapped children by withholding food and water: Parental Perceptions of Forgoing Artificial Nutrition and Hydration During End-of-Life Care. The article was published in 2013 in “Pediatrics”, the official journal of the American Academy of Pediatrics. However, the authors are all Canadian, so the patients and events described in the article likely occurred in Canada, where passive euthanasia has long been legal, and where active euthanasia become legal later this year (2016).
The article claims: “Forgoing artificial nutrition and hydration (FANH) in children at the end of life (EOL) is a medically, legally, and ethically acceptable practice under specific circumstances.” However, the cases described in the article include children who were merely handicapped, not terminally ill. The end of their life was caused by the withdrawal of food and water (or artificial nutrition and hydration). They were not even put into continuous deep sedation. They were conscious and were willfully dehydrated to death.
The article describes 7 cases: four infants (1 to 6 months of age) and three teenagers (14 to 15 years of age). Five of the children died in 2 weeks or less; two survived over two weeks before dying. Four of the children had what the article calls “static” conditions; their illnesses were not progressive (were not getting worse).
Quotes from the parents in the article clearly indicate that the decisions to withhold food and water were largely based on the perception that the child would not have a high quality of life.
“by feeding him, we were, from what we could see, decreasing his quality of life” (Elizabeth).
“I kind of even started to not feed him . . . I was sick with watching him. He was just so clearly uncomfortable” (Marilyn).
And in other cases, the parents were concerned about their own quality of life. The parents did not want to suffer the burden of caring for a handicapped child:
“I feel bad because, I think it’s a weakness maybe in myself, but I just I don’t think I could raise a child that is handicapped to that degree. I have so much admiration for people who, who do that, which really I didn’t have before. So thinking of the quality of life for my family, yeah, that was a big consideration . . . .” (Richard)
And some of the patients considered whether withholding food and water was a type of murder:
“I thought that a lot of people would think it was disgusting and horrible and murderous if we ever said that we were going to take away the food. So I never discussed it with anyone outside of [husband] and our doctors and [friend] who’s a doctor, because I just felt that people would think that it was, you know, paramount to murder.” (Jessica)
Yes, some people, including Pope Saint John Paul II, believe that withholding food and water from a child until that child dies as a result is tantamount to murder. In fact, it is Catholic teaching that people have a right to nutrition and hydration, even if it must be provided artificially. Food and water (nutrition and hydration) are never considered extraordinary measures that can be withheld from a terminally ill person. However, none of these children were terminally ill.
These children did not die from any illness or injury. A deliberate decision was made to end the child’s life by withholding food and water until death. The quotes in the article show that the parents decided to end the lives of their children in part due to assertions by the physicians and health care staff that this type of intervention is supposedly moral and medically indicated:
“Parents were reassured to learn that death after FANH is indeed comfortable and that their child would not ‘starve to death.’ Once the decision was made, parents continued to need reassurance and guidance from health care professionals as death approached.”
Well, it is true that these children did not starve to death. They instead were dehydrated to death. FANH is a euphemistic term meaning “forgoing artificial nutrition and hydration”. In some cases, nutrition and hydration by a nasogastric tube was necessary and withheld. But in other cases, the child was capable of taking food and drink by mouth, if fed by parents or health care providers.
Euthanasia is often justified by the supposedly typical case of a terminally ill person, close to death, who is suffering a great deal. But as soon as it become legal, it is expanded to kill many persons who are not terminally ill at all. The same socio-political process happened with abortion. The legalization of abortion was argued based on extreme cases: rape, incest, and severe birth defects. Then once it is legal, abortion becomes widespread and is available on demand. What the culture really wants is arbitrary decision making completely free from moral or legal restrictions.
Please take a look at this list of my books and booklets, and see if any topic interests you.
 Govert den Hartogh, Continuous deep sedation and homicide: an unsolved problem in law and professional morality; Medicine, Health Care and Philosophy. 29 December 2015. pp. 1-13.
 Rapoport, et al., Parental Perceptions of Forgoing Artificial Nutrition and Hydration During End-of-Life Care; Pediatrics. Volume 131, Number 5, May 2013.