Getting Real About the Difference Between Killing and Allowing to Die
​Andrew Stumpf, PhD, Assistant Professor, Dept. of Philosophy, St. Jerome's University

The moral significance of the distinction between killing and allowing to die has been “[o]ne of the most important questions in the debate over the morality of euthanasia and assisted suicide” (Sulmasy, 1998, p. 55), having played a key role in both public deliberation and bioethical debate in both the U.S. and Canada throughout the last few decades. Those who dispute the significance of the distinction argue as follows: There is broad consensus that consented withdrawing of life-sustaining treatment is morally permissible; there is no morally significant difference between killing a patient and allowing a patient to die; so administering a lethal injection to end a patient’s life is morally permissible. Promoters of the moral significance of the distinction dispute the second premise and so reject the conclusion. The debate over the moral difference between killing and allowing to die in the bioethics literature has carried on for decades and the pro and contra sides remain entrenched, without apparent hope of consensus. In the first part of this paper, we survey thirty-two key sources for and against the claim that the distinction is morally significant. We argue that many of the approaches and positions within this debate suffer from a fatal flaw: they deal in abstractions that are out of touch with the relational situation and concrete decision-making context of physicians who must respond to patient requests for withdrawal of life-sustaining treatment and for assistance in ending their lives (via physician-assisted suicide or active euthanasia). We demonstrate that the abstractness of much thinking and writing in debates over the killing / allowing-to-die distinction makes it irrelevant to the specific ethical questions heath-care practitioners have to answer by acting. In the second part, we propose to move the debate forward by attending carefully to the lived moral experience of such practitioners, and to the concrete relational and situational factors that surround their decisions. Our approach does not claim to resolve the debate one way or the other, but it provides us with a test by which we can weed out unhelpful contributions to the debate. Furthermore, our approach promises to steer ongoing debate in a more helpful direction. In 2020, we will carry out this approach through a research project funded by the Canadian federal government’s Social Sciences and Humanities Research Council. We will conduct open-ended interviews with twenty Canadian physicians involved in end-of-life care, who, as part of their practice, must respond to patient requests for withdrawal of life-sustaining treatment and requests for active assistance to die. Attending to the awareness these physicians have of their own moral agency and responsibility in these situations will help to reveal what is really at issue in the debate over the significance of the distinction between killing and allowing to die. By presenting the paper at the CMR we invite input into the design of our upcoming project.