By Dr. Roni Rosenberg, Senior Lecturer at Ono Academic College and Reichman University 
Active vs. Passive Euthanasia: Key Distinctions
Euthanasia raises complex philosophical, ethical, legal, and religious questions and is typically divided into active and passive categories. Active euthanasia involves deliberate actions, such as administering a lethal injection, to end the life of a terminally ill patient to alleviate his suffering for his own benefit, while passive euthanasia entails withholding life-prolonging treatments, leading to the death of a terminally ill patient to alleviate his suffering for his own benefit. [1]
Between these two categories, there is also physician-assisted suicide (or assisted dying), which typically involves prescribing a lethal medication to a terminally ill patient, who then administers it to himself. The key distinction between active euthanasia and physician-assisted suicide lies in who carries out the act: in active euthanasia, the physician causes the patient’s death, whereas in physician-assisted suicide, the patient ends his own life. [2]
Additionally, there is the scenario where a physician disconnects a patient from a life-support machine. Some classify this as passive euthanasia, arguing that the patient dies from the underlying illness rather than as a result of the physician’s actions. [3] In contrast, others consider disconnecting a patient from life support as active euthanasia, as it involves a deliberate action by the physician that leads to the patient’s death. [4]
Most countries distinguish between active euthanasia and assisted dying, which are categorically prohibited, and passive euthanasia, as well as the withdrawal of life-saving support such as ventilators, feeding tubes, and other medical interventions, which are permitted in certain circumstances. For example, in the UK, active euthanasia and assisted dying are prohibited, but passive euthanasia as well as the withdrawal of life-saving treatment is permitted in certain circumstances. [5] Recently, however, a bill was proposed aiming to allow assisted dying under specific restrictions. [6]
The Act-Omission Distinction in Criminal Law and Its Relation to Euthanasia
Criminal law similarly differentiates between act and omission when it comes to causing harm. This distinction corresponds to the concepts of “killing” and “letting die.” If harm is caused through an act, a person can be convicted if a causal link is established between his conduct and the resulting harm. In cases of omission, however, an individual is only convicted if he was under a duty to act and his failure to fulfill that duty caused harm. For instance, if A witnesses a child drowning and fails to save him, A would be convicted only if he had a legal duty to act, such as being a lifeguard or the child’s parent.
One of the main rationales for distinguishing between active and passive euthanasia is based on the act-omission distinction. For example, a well-known case, Barber v. Superior Court 147 Cal. App. 3d 1006 (1983), involved a terminally ill patient who was placed on a ventilator after surgery. At the family’s request, the physician disconnected the ventilator and also removed feeding tubes, which led to the patient’s death. The court found that the physician’s conduct was categorized as an omission, not as an act, and acquitted the physician of murder charges. The court ruled that the physician had no duty to act in this situation.
Similarly, in Sampson v. State 31 P.3d 88 (2001), two terminally ill patients sought court approval to have a physician assist them in committing suicide. The plaintiffs argued that there should be no legal distinction between withholding life-support or medication, which was allowed, and assisting in suicide, which was prohibited. The court ruled that the two scenarios were legally distinct, with one involving an act and the other an omission. The court noted that liability only arises from omissions if there is a duty to act.
Reevaluating the Act-Omission Distinction in Euthanasia
Despite this, in my recently published book, I argue that the act/omission distinction in criminal law is not relevant to the differentiation between passive and active euthanasia. First, criminal law typically deals with cases where the victim’s death is undesirable, and the victim does not wish for it. In contrast, when discussing euthanasia for a terminally ill patient who suffers, death is not necessarily a bad thing but may be seen as a positive outcome. Second, the rationales given for the distinction between act and omission in criminal law are not necessarily applicable to the distinction between forms of euthanasia. Hence, if passive euthanasia is permitted on grounds of alleviating suffering, autonomy, and human dignity, then it seems consistent to allow active euthanasia for similar reasons.
While practical arguments may exist for distinguishing between active and passive euthanasia, or between physician-assisted suicide and passive euthanasia, I will not delve into those here.
To further elaborate on my second argument, I will explore the distinction between acts and omissions in criminal law and the reasoning behind it. The key question is why we make this distinction, especially when all factors—such as intent, outcome, and efforts to prevent harm—are the same. This question is far from simple, and many philosophers contend that there is no moral difference between causing harm through an act and causing harm through an omission.[7]
One of the primary rationales for this distinction is the liberty rationale. According to this rationale, the requirement for a duty to act in cases of omission arises from the concern that, without such a duty, an individual’s liberty would be significantly impaired. Without clear limitations, people would constantly be required to help others or incur expenses to save them. In such a scenario, individuals would not be able to play with their children, talk to their spouse, or simply watch television, as they would always be expected to engage in rescue efforts. The duty to act in cases of omission is thus designed to restrict interference with personal liberty so that individuals are only obligated to intervene in specific, legally defined circumstances. [8]
However, it is difficult to argue that this rationale is relevant to the distinction between active and passive euthanasia, even if we argue that the death of the patient is not intrinsically good. A doctor does not claim that connecting a patient to a ventilator, for example, infringes on his liberty, as the very essence of his profession is to help patients—this is the foundation of the doctor-patient relationship. It would be absurd to suggest that legislators or courts determine that a doctor has no duty to act in cases involving terminally ill patients to protect the doctor’s personal freedom. Additionally, cases related to passive euthanasia are relatively rare and do not require significant action from the doctor, meaning the infringement on liberty in these cases is minimal.
In light of this, the rationale for distinguishing between acts and omissions in criminal law does not seem relevant to the distinction between active and passive euthanasia. Why, then, is passive euthanasia permitted? Because it helps the patient end his suffering, fulfills his autonomy, and preserves his dignity. However, these arguments—of relieving suffering, autonomy, and human dignity—are just as relevant to active euthanasia as they are to passive euthanasia. Therefore, one could argue that if passive euthanasia is permitted under certain conditions, then active euthanasia must be permitted as well.
Another rationale is based on the idea that a prohibition against an act does not reduce an individual to a mere means to an end, while a prohibition against an omission does.[9] According to this view, prohibiting an act of killing does not force a person to use his body to save a life, whereas prohibiting an omission (failure to help) compels someone to intervene, thereby using his body to save another. This rationale implies that the duty requirement in omissions defines the circumstances in which the legislator deems it appropriate to use a citizen as a means to an end, and these instances would naturally be rare.
However, this rationale does not adequately explain the distinction between active and passive euthanasia. It is difficult to argue that the legislator does not require the physician to save the patient, since this would reduce the physician to a mere means to an end. The doctor is unlikely to raise this concern because saving the patient is inherently part of his role and due to the close relationship between the doctor and the patient.
In contrast, a causality-based rationale may offer a more plausible explanation. According to this view, an act directly causes an outcome, while an omission does not, or at least its causation is more indirect. [10] According to this rationale, if we assume that death is intrinsically bad even in euthanasia cases, we can explain the distinction between active and passive euthanasia. In active euthanasia, the physician’s act (e.g., administering a lethal injection) directly causes the patient’s death. On the other hand, in passive euthanasia, the physician’s omission (e.g., withholding life support) leads to death, but the causal link is less direct. Given considerations of the patient’s suffering, autonomy, and dignity, it would not be appropriate to impose a duty on the doctor to intervene and prolong the patient’s life.
However, this view assumes that death in these cases is inherently bad, which is open to debate. If one argues that the death of a terminally ill patient is beneficial because it ends his suffering at his request, then even according to the causation rationale, not only is there no reason to distinguish between active and passive euthanasia, but active euthanasia could be seen as more moral, as it ends the patient’s suffering more quickly and without pain.
In conclusion, if we accept that death, in the case of a terminally ill patient, can be viewed as intrinsically good, then active euthanasia may, in fact, be considered more morally acceptable than passive euthanasia. Even if we do not see death as inherently good, most arguments supporting the distinction between acts and omissions fail to provide a compelling rationale for differentiating between active and passive euthanasia. At its core, if passive euthanasia is permitted on grounds of alleviating suffering, respecting autonomy, and preserving human dignity, then active euthanasia should be allowed for similar reasons. It is also worth noting that, if there is no meaningful connection between the act-omission distinction in criminal law and the differentiation between active and passive euthanasia, the same logic applies to the distinction between physician-assisted suicide (as it is currently proposed in the UK bill)[11] and passive euthanasia.
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