The doctrine of acts and omissions, tested by parents and philosophers

Charlie Gard, Isaiah Haastrup and Alfie Evans have all been at the centre of high profile court battles between their parents and their NHS Trust to decide upon their future care.  The death of a child is known to cause moral distress for everyone involved and in recent months when parents and their child’s carers cannot agree on a treatment plan a media frenzy.  Why is it that coming to a consensus decision with parents in some cases is so challenging that we ask a court to decide?

For many, it is accepted that withholding treatment allowing a patient to die enables healthcare professionals to provide the patient with a death they themselves would prefer.   The doctrine of acts and omissions proposes that there is a moral difference between carrying out an action and merely omitting to carry out an action, a moral distinction is made.  However, it is also valid to argue that this distinction is a nonsense, since stopping treatment is a deliberate act.  You cannot withdraw treatment from Charlie, Isaiah or Alfie without actively removing their ventilator.  When we witness the suffering and distress children experience in these complex cases health professionals are drawn to this distinction to do what we identify as being in the best interests of the child.

The philosopher James Rachels has an argument that shows that the distinction between acts and omissions is not as helpful as it looks and could be just one of the reasons why parents are unable to accept the withdrawal of treatment for their children and take these decisions to court.  In order to test a moral code, philosophers will test and retest their reasoning within different contexts.  Rachels asks us to consider the following case:

Smith sneaks into the bathroom of his 6-year-old cousin and drowns him, arranging things so that it will look like an accident.  Smith does this as the death of his cousin will result in a large inheritance.

Jones stands to gain a similar large inheritance.  Like Smith, Jones sneaks into the bathroom with the intension of drowning his cousin, but the cousin accidentally slips and knocks his head and drowns in the bath.  Jones could have easily saved his cousin but instead watches ready to push the child’s head back under.  This however does not prove necessary.

In this context many would regard Smith and Jones as equally guilty as they both intended to murder their cousin.  According to the doctrine of acts and omissions Smith is morally guiltier than Jones, since he actively killed the child, while Jones just allowed the boy to die. In law, Smith is guilty of murder and Jones isn’t guilty of anything.  For those who don’t find the difference between killing and letting die persuasive in the Smith/Jones case, will not comprehend a distinction in the doctrine of acts and omissions.

Lorraine Highe

Senior Lecturer, London South Bank University



Rachels, J. (1975) Active and passive euthanasia, The New England Journal of Medicine, vol 292, pp.78-80.

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