In dealing with this exceedingly difficult area of medical ethics, it is illustrative to compare the difference in philosophical approach between Dutch doctors and their colleagues in other countries.
As a matter of moral principle, the British Medical Association makes a distinction between, on the one hand, breaking off or withholding treatment which is artificially prolonging the dying process or which is counter-productive, and, on the other, measures taken with the intention of ending a person’s life. In other words, it draws a distinction between allowing death to occur and causing it. Its guidelines say that doctors should never withhold treatment with the intention of hastening death. The former is regarded as acceptable and natural; the latter as illegal and wrong. The BMA writes, "There is a difference between respecting the competent patients’ autonomous refusal of treatment and intervention, even if it results in the patient's death, and acts or omissions with the intention of causing death." Conversations on this subject with British geriatricians reveal the difference in philosophical approach: while they stress that death should be allowed to come "naturally" or "when the time comes", the Dutch seem obsessed with the notion of controlling the moment of death.
The notion of "nature" is key. Obviously it is not possible to say with certainty when death will occur. But there is a difference between withdrawing treatment which is artificially prolonging life, or embarking on palliative treatment which may have the result of accelerating death, and withdrawing treatment with the explicit intention of shortening life unnaturally. If Dutch doctors, like their British counterparts, took non-treatment decisions only because they were artificially prolonging life, they would not refer to these as having been taken "with the explicit intention of shortening life." When a doctor decides that a patient is dying, the explicit intention in Britain will generally be to make the patient as comfortable as possible and to allow death to come when the time is right. Even if palliative medicine is administered in the knowledge that it will accelerate death, this is not the explicit intention. (The Dutch survey has a separate category for this anyway, although more detailed breakdown of the figures shows that, even in some of these cases, the decisions are taken "with the explicit purpose of shortening life".)
In other words, the concept of "nature" allows us to distinguish, in general terms at least, between different courses of medical action. It seems indubitable that the Dutch, having admitted in their law and medical practice the principle that death is sometimes the right medical solution for terminal illness, now act very regularly on the basis that medical decisions should be taken with the explicit aim of causing death. It is an indication of the extent to which lifting the absolute ban on mercy killing has corrupted the analytical faculties of pro-euthanasia commentators and practitioners that they cannot see the difference between these two approaches.
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