Bioethics 34(5)
DOI:10.1111/bioe.12707
Abstract
Bioethicists involved in end-of-life debates routinely distinguish between ‘killing’ and ‘letting die’. Meanwhile, previous work in cognitive science has revealed that when people characterize behaviour as either actively ‘doing’ or passively ‘allowing’, they do so not purely on descriptive grounds, but also as a function of the behaviour’s perceived morality. In the present report, we extend this line of research by examining how medical students and professionals (N = 184) and laypeople (N = 122) describe physicians’ behaviour in end-of-life scenarios. We show that the distinction between ‘ending’ a patient’s life and ‘allowing’ it to end arises from morally motivated causal selection. That is, when a patient wishes to die, her illness is treated as the cause of death and the doctor is seen as merely allowing her life to end. In contrast, when a patient does not wish to die, the doctor’s behaviour is treated as the cause of death and, consequently, the doctor is described as ending the patient’s life. This effect emerged regardless of whether the doctor’s behaviour was omissive (as in withholding treatment) or commissive (as in applying a lethal injection). In other words, patient consent shapes causal selection in end-of-life situations, and in turn determines whether physicians are seen as ‘killing’ patients, or merely as ‘enabling’ their death.
From the Discussion
Across three cases of end-of-life intervention, we find convergent evidence that moral appraisals shape behavior description (Cushman et al., 2008) and causal selection (Alicke, 1992; Kominsky et al., 2015). Consistent with the deontic hypothesis, physicians who behaved according to patients’ wishes were described as allowing the patient’s life to end. In contrast, physicians who disregarded the patient’s wishes were described as ending the patient’s life. Additionally, patient consent appeared to inform causal selection: The doctor was seen as the cause of death when disregarding the patient’s will; but the illness was seen as the cause of death when the doctor had obeyed the patient’s will.
Whether the physician’s behavior was omissive or commissive did not play a comparable role in behavior description or causal selection. First, these effects were weaker than those of patient consent. Second, while the effects of consent generalized to medical students and professionals, the effects of commission arose only among lay respondents. In other words, medical students and professionals treated patient consent as the sole basis for the doing/allowing distinction.
Taken together, these results confirm that doing and allowing serve a fundamentally evaluative purpose (in line with the deontic hypothesis, and Cushman et al., 2008), and only secondarily serve a descriptive purpose, if at all.
