Abstract
In this chapter, I outline the act-omission distinction, which holds that certain actions are impermissible (such as those that cause death), but that failures to act may be permissible, even if the outcomes are the same. Focusing on end-of-life decisions, I then survey the main arguments that have been levelled against the distinction and responses to these. First, there is the difficulty of drawing lines between actions and omissions. Second, there are questions about the causal role played by an agent in bringing about an outcome, whether by action or omission. Third, if we accept that agents can be considered causally responsible for omissions, there is the argument that consequences, rather than how we characterise what we are (not) doing, are what counts, morally-speaking. Despite such challenges, many clinicians feel the distinction captures something morally significant. I therefore close with a modest proposal for future research, which would seek to combine insights from both the philosopher’s desk and the patient’s bedside.
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Notes
- 1.
However, the nature and import of appeals to “nature” are contested (e.g. Baggini 2004, 181–182).
- 2.
On the doctrine of double effect see Woods and Graven, Chap. 12, this volume.
- 3.
It is nevertheless notable that such a formulation tethers the notion of “activity” to physical behaviour, rather than, say, social action, such as a decision-making process (which might involve thought and speech, but not necessarily any physical behaviour). In theory, although I will not pursue the idea here, such social action, absent any physical behaviour, might play a relevant causal role.
- 4.
A solution to this problem has been adopted in Israel, where life support machines require users to take regular action if treatment is to be continued. Omitting to do so results in the machine ceasing to support life and, therefore, the cessation of treatment through passive means or inaction. This sort of solution, which was analysed decades ago by Williams (1973, 21), Skegg (1978, 435) and Lowe (1997), rests on the idea that withdrawing and withholding are equivalent because failure to restart the machine is clearly an omission (i.e. withholding) and clearly also analogous to stopping the machine (i.e. withdrawing). In response, Dunstan has asked: “[i]n whose interest is it to encourage doctors to employ mechanical devices to excuse themselves from that moral agency which their profession both entitles and obliges them to bear…?” (Dunstan 1997, 160).
- 5.
And, indeed, of the proportionate/disproportionate distinction (e.g. Singer 1994).
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Huxtable, R. (2020). On Killing and Letting Die, Acts and Omissions: For and Against the Distinctions. In: Emmerich, N., Mallia, P., Gordijn, B., Pistoia, F. (eds) Contemporary European Perspectives on the Ethics of End of Life Care. Philosophy and Medicine, vol 136. Springer, Cham. https://doi.org/10.1007/978-3-030-40033-0_16
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