Is letting a 17-year-old die morally equivalent to killing her?

A spate of news articles appeared yesterday, reporting that Dutch 17-year-old mental patient Noa Pothoven was euthanized. This formulation—she was euthanized—caused outrage in certain circles. This is factually incorrect, they say. She was not euthanized. She took her own life.

What are the facts of the case? She was sexually attacked and assaulted three times, beginning at age 11, which led to severe depression and anorexia. She wrote an autobiographical account of her troubles. At age 17, she decided she had had enough. With her parents’ acquiescence, she refused food and drink, and last Sunday, she died.

So why do people like Politico correspondent Naomi O’Leary and Reason writer Elizabeth Nolan Brown insist that she was not euthanized? Because Noa’s problems, as the latter writer puts it, “did not come to an end with the state permitting a doctor to kill her.” She chose to commit suicide, while her parents and doctors stood by and did nothing, respecting her wish to die. That’s not euthanasia, O’Leary and Brown say. O’Leary found this to be infuriating “misinformation.”

To this, many others respond: of course it’s euthanasia. What else do you call it when a doctor stands by and allows a patient to starve herself to death—all the more tragic in this case because the patient is just 17 years old?

The question looks like an unresolvable semantic one. But logic-chopping ethicists come to the rescue with a distinction: Noa was subjected to passive, not active euthanasia. The difference, as the BBC explains, lies in the difference between killing and letting die. Nobody killed Noa (in fact, she asked for help, and was rightly refused); but they did let her die.

If you leave it at that, no one is the wiser, because the real questions, clearly, are: (1) Is there a moral difference between active and passive euthanasia in this case? And: (2) Did Noa’s parents and doctors do right or wrong?

Given a case that sounds so outrageous to some, it is easy to glibly declare that there is no difference. But there are plenty of cases in which there certainly seems to be a difference between killing and letting die. Changing the case makes this rather clearer. Suppose a 50-year-old man like me is severely depressed and wants to die. Is there a difference between you shooting him through the head, and his doing the same thing while you stand by idly? (Let’s assume it’s you could easily and safely take the gun away; perhaps the gun is on the table, closer to you, I say I will kill myself in ten minutes, and I have already made clear that I will not fight you for the gun.) Clearly there is a difference between killing and permitting suicide, in this case. But wherein lies the difference?

There are a couple differences, actually. First, in the case of active euthanasia, you are taking action. We can ask the question, “Why did you pull the trigger?” We can ask a similar question in the second case, “Why didn’t you stop him?” but the questions are actually quite different.

Second, more to the point and more importantly, to permit active euthanasia requires that we adopt policies, moral and legal, that distinguish between murder and euthanasia. But there is no such requirement if we permit only passive euthanasia: here we need only adopt policies to distinguish between suicide and passive euthanasia. (For one thing, it’s not passive euthanasia if nobody knows you’re committing suicide.)

Active euthanasia is more morally fraught because it resembles murder, and murder is rightly regarded as one of the very worst crimes it is possible to commit. But allowing someone to commit suicide looks very different indeed from murder, because the motives are deeply different. If you stand by while your 50-year-old friend commits suicide, you might very well feel guilty later, and people might well blame you for doing something wrong (or rather, for not doing what you should have done); but nobody can sensibly accuse you of murder.

Ultimately—as is the case with most ethical questions—it is ultimately about the policies, the rules, the principles. Do we want to be a society that approves of people committing suicide? Should that be regarded as a real possibility for people? Should it figure into their calculations as an option, sometimes? And then, if so—do we want to take the morally fraught step of helping people to carry out this dreadful choice?

Let’s briefly consider both sides here.

The more conservative approach points to the impact that the choice has on others, that the policy has on society at large, and whether we even have the right to throw away a gift given to us by the divine. No man is an island, and the official approval of suicide causes trauma far beyond that experienced by a person suffering in bodily pain or depression. The trauma is compounded when others participate in carrying out the decision. In the case of Noa, consider the lifelong trauma her dramatic act will have on her parents, family, friends—and now also the broader society in which other 17-year-olds might be tempted to solve their problems this way.

The reason that liberals and libertarians are typically in favor of euthanasia (passive at least, and often active as well) is that this respects the choice of the individual. Whether to go on living is a deeply personal decision, they say. Hence society’s rules should permit a negative outcome if that is our choice. If this encourages others (or rather, alerts them to the possibility) to do the same, perhaps that’s for the best. Why should people be forced to live if they don’t want to? Even if there are some awful consequences, this is the price we pay for freedom.

This is not an easy question, and you’re frankly an idiot if you pretend that it is. But there’s a complicating factor in Noa’s case. She was young, just a few years older than my son. I can’t imagine “permitting” him to commit suicide as I stood by. The idea fills me with horror.

The admitted fact is that she lacked a mature mental capacity. Moreover, while I don’t really approve of the clinical language, one might say she was ill in addition to being young. Now, typically, as in the case of the 50-year-old, we might credit the person’s choice as being mature and considered, and therefore free and worthy of the respect of a person with dignity. Do we owe a mentally ill young person the duty to dignify her choice as also one that is free? I’m not so sure. She was unformed, and she was not thinking straight. Had she been my daughter, I would have had her committed to an asylum that would help her get better. I would not have respected her choice, being one made by an immature and ill person.

I pity Noa’s parents and doctors. But I also accuse them of doing something very wrong indeed—by not taking action when they clearly should have.

By the way, it’s not lost on me that one might argue that anybody, regardless of age, with severe depression might be thought to be sufficiently impaired that we should not credit his decision to end his life as being free, and hence we should always work against it and instead institutionalize the person. But I’m not making that argument, as it raises further, hard questions. Noa’s case strikes me as being rather clearer. The combination of her youth and her mental incapacity mean that her caregivers had absolutely no obligation to credit her choice.