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Thesis Doing harm and allowing harm differ morally, even when the outcome is the same

Omar Ragab Fellow
· 5 replies
Applied ethicsAnalyticIslamicUtilitarianismPeter Singer#acts-and-omissions#doing-and-allowing#end-of-life#killing-and-letting-die
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Where it stands

At the hospital where I work, the distinction between doing and allowing comes up every week. Withdrawing a ventilator from a patient with no prospect of recovery is treated very differently from giving a lethal injection, by law, by most religious authorities, and by most of the doctors I know. The patient dies in both cases.

The thesis I want to defend: the difference is real and morally significant. It is not just a legal convenience.

The argument in brief. When I do harm, I introduce a threat into someone's life that wasn't there; I make myself the cause of their loss. When I allow harm, the threat comes from elsewhere (the disease, the water, the other person), and my failure is a failure to help. Both can be serious. Walking past a drowning child you could easily save is monstrous, as Singer's famous example shows. But it's monstrous in a different way from holding the child under.

I know the strongest objection: James Rachels's bathtub case: Smith and Jones each stand to inherit if a young cousin dies. Smith drowns his cousin in the bath; Jones finds his cousin already slipping under and simply watches him drown. Most people judge them equally bad, which suggests the difference does no work when motives and outcomes are held fixed.

I think Rachels shows something important but not what he claims. Over to you.

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5 replies

For the thesis 2

  1. Bilal Rashid

    For Fellow

    For. In Islamic bioethics there's broad agreement among many scholars that futile treatment can be withdrawn and life is then in God's hands, while actively ending a life is forbidden. Families I have known accept the first far more readily, and I don't think that's confusion. Withdrawing treatment stops resisting a death the illness is causing. The injection causes it. People's sense of who the agent is tracks something real.

    Helpful · 3
  2. Elin Hedqvist

    For Fellow

    For. I've sat with more people at the very end than I can count, some of them after treatment had been stopped. What happens is not what people imagine. When treatment is withdrawn, sometimes the person breathes on for hours or days, which tells you the illness is the cause. That isn't sentimental; it's evidence about what is doing the killing.

Against the thesis 2

  1. Pieter van Dijkhuizen

    Against Fellow

    Against. Rachels's case is designed exactly right: same motive, same outcome, same knowledge. If doing versus allowing mattered in itself, we'd judge the drowner worse. We don't. So whatever is going on in your hospital, it's not that the distinction has intrinsic weight. It's that it usually comes packaged with differences in intention, risk and certainty, and those are what matter.

    Helpful · 2
  2. Priya Raghavan

    Against Fellow

    Against, with a psychologist's caution. There's a well-documented "omission bias": people judge harmful omissions less harshly than harmful acts even when everything else is equal, and the bias shows up in cases where it's hard to defend, such as reluctance to vaccinate a child because a rare side effect would be "our fault". So the strength of our intuition here might be partly a bias, not a perception of a moral fact. Elin's evidence about causation is better than the intuition.

    Helpful · 1

Other replies

  1. Omar Ragab

    Fellow

    Revised version: Pieter and Priya are right that when intention, outcome and knowledge are fixed, the distinction does little or no work. Rachels wins his case. But in real medicine they're almost never fixed, and Elin's point holds: whether the disease or the clinician is the cause is a real difference, not a feeling. So I'd now say the distinction is morally significant as a marker of causation and agency, not as a freestanding rule.

    Helpful · 2