Medicine, Healthcare and Philosophy 1: 245–253, 1998. © 1998 Kluwer Academic Publishers. Printed in the Netherlands. Scientific Contribution The notion of “killing”. Causality, intention, and motivation in active and passive euthanasia Thomas Fuchs Psychiatrische Klinik, Ruprecht-Karls-Universität, Voßstr.4, D-69115 Heidelberg, Germany Abstract. As a new approach to the still unsettled problem of a morally significant difference between active and passive euthanasia, the meanings of the notion of killing are distinguished on the levels of causality, intention, and motivation. This distinction allows a thorough analysis and refutation of arguments for the equality of killing and letting die which are often put forward in the euthanasia debate. Moreover, an investigation into the structure of the physician’s action on those three levels yields substantial differences between the two ways of acting. As can be demonstrated, only a teleological notion of the organism is able to grasp the characteristic feature of active euthanasia. On this basis it is argued that an action against the organism as a whole must, on the interpersonal level, be at once directed against the patient as a person himself. Key words: acting and refraining, euthanasia, killing and letting die, medical ethics, mind-body dualism Introduction European debate on euthanasia has flared up again under the influence of developments in the Nether- lands. The Deutsche Ärztetag (Annual Meeting of the German Medical Association) rejected any attempts to follow the example of the neighbor country; however, due to the growing criticism of unnecessary prolong- ation of life, it has also edited new guidelines concerning the withdrawal of treatment in the termin- ally ill. 1 Similarly, based on the Dutch experience, the Swiss Academy of Medical Arts has confirmed the verdict against active euthanasia in its guidelines on physicians’ aid-in-dying, but left more room for passive euthanasia. 2 In the discussion, however, a core question remains as yet unsettled: What exactly may be regarded as the threshold between forgoing or withdrawing life-sustaining treatment on the one hand, and killing the patient on the other? And is this threshold ceteris paribus morally significant? If such a relevant difference cannot be demonstrated, the barrier against active euthanasia would be kept up only for pragmatic reasons, and the defence of the status quo would have to rely on auxiliary arguments such as, danger of abuse, slippery slope, weakening of the general protection of life, etc. Arguments based on possible secondary costs may weigh heavily at first sight, yet could well prove to stand on weak ground if they cannot be related to a moral difference in the matter itself. In general, to be sure, physicians are well aware of such a difference, insofar as they feel a special reluctance to the idea of a lethal injection. However, as the example of the Netherlands shows, primary moral intuitions do not always remain stable if they are not supported by insight and arguments; this is especially true for the difficult borderlands of bioethics. 3 Proponents of active euthanasia have therefore repeatedly tried to demonstrate that primary moral feelings are not matched by a justifiable ethical differ- ence between active and passive euthanasia. Medical decisions or actions with lethal outcome, so it is argued, would be morally equivalent to killing the patient; but if forgoing or stopping treatment and lethal injection all mean “killing”, then why exclude one of these options? By using its different connotations and equivocations, the notion of “killing” is thus inter- preted in a way that discards traditional distinctions in this area. In contrast to that I will try to elucidate substantial ethical differences between stopping treat- ment and killing. I will do so from a phenomenological perspective, that is, by analyzing the inherent struc- ture of the physician’s action on behalf of the dying patient. Killing and its levels of meaning In order not to overlook important argumentative distinctions, we have to clarify above all the notion of killing with its various levels of meaning. Their