The active/passive distinction amounts to this: Passive euthanasia (also called negative euthanasia) refers to the withholding or withdrawing of a life-sustaining treatment when certain justifiable conditions exist… and allowing the patient to die. Active euthanasia (also called mercy killing or positive euthanasia) refers to the intentional and/or direct killing of an innocent human life either by that person (suicide) or by another (assisted suicide)….

Voluntary euthanasia occurs whenever a competent, informed patient autonomously requests it. Nonvoluntary euthanasia occurs whenever a person is incapable of forming a judgment or expressing a wish in the matter (e.g., a defective newborn or a comatose adult). Involuntary euthanasia occurs when the person expresses a wish to live but is nevertheless killed or allowed to die.

This distinction combines with the active/passive distinction to form six different types of euthanasia: voluntary active, voluntary passive, nonvoluntary active, nonvoluntary passive, involuntary active, and involuntary passive.²

Two additional concepts are relevant to the discussion of euthanasia. First, voluntary euthanasia refers to mercy killing that takes place with the explicit and voluntary consent of the patient, either verbally or in a written document such as a living will. Second, nonvoluntary euthanasia refers to the mercy killing of a patient who is unconscious, comatose, or otherwise unable to explicitly make his intentions known. In these cases it is often family members who make the request. It is important not to confuse nonvoluntary mercy killing with involuntary mercy killing. The latter would be done against the wishes of the patient and would clearly count as murder.³

The mere fact that something has biological life, says Rachels, whether human or nonhuman, is relatively unimportant from an ethical point of view. What is important is that someone has biographical life. One’s biographical life is "the sum of one’s aspirations, decision, activities, projects, and human relationships."⁵

Two implications follow from Rachels’s view: (1) Certain infants without a prospect for biographical life, and certain patients (e.g., comatose patients or those in a persistent vegetative state) are of little intrinsic concern, morally speaking. Though they may be alive in the biological sense, they are not alive in the biographical sense. And the latter is what is relevant to morality. (2) Higher forms of animals do have lives in the biographical sense because they have thoughts, emotions, goals, cares, and so forth. They should be given moral respect because of this. In fact, a chimpanzee with a biographical life has more value than a human who only has biological life.⁶

Genesis 1:26—Then God said, "Let us make man in our image, in our likeness,…"

Genesis 2:7—the LORD God formed the man from the dust of the ground and breathed into his nostrils the breath of life, and the man became a living being.

Deuteronomy 30:20—For the LORD is your life,…

Deuteronomy 32:39—I put to death and I bring to life, I have wounded and I will heal, and no one can deliver out of my hand.

1 Samuel 2:6—The LORD brings death and makes alive; he brings down to the grave and raises up.

Acts 17:25, 28—…he himself gives all men life and breath and everything else…. For in him we live and move and have our being.

Some believe that food and water should be viewed as any other treatment, and cases where passive euthanasia would be justified in general — cases, for example, in which it would be appropriate to stop renal dialysis — are cases where foregoing artificial nutrition and hydration would be justified. On the other hand, there are those who argue that artificial food and water should not be foregone.... Three reasons are offered for this.

First, ethically speaking, artificial food and water are in a category different from life-sustaining medical treatments. The latter clearly function to treat some specific disease or to assist some diseased bodily function. But food and water do not have as their direct or immediate intention the cure of any pathological condition whatsoever….

Second, when an extraordinary treatment is foregone, then death may result. But such a death need not be directly intended as a final end for the person or as an immediately caused means to some end (e.g., a painless state that death brings). It is the disease itself that actually causes death directly. However, if food and water are withdrawn or withheld, then death is intentionally brought about directly and immediately by that act itself….

When food and water are withdrawn, however, this act itself brings about a new and lethal situation for the person, namely, a starvation or dehydration situation. The removal of food and water is morally identical to denying a patient air by placing a plastic bag over his or her head because they both directly and intentionally bring about death in a very short time and they deny the patient ordinary, natural resources needed to sustain life….

There is another reason that food and water are morally different from an extraordinary life-sustaining treatment. If we forego an extraordinary life-sustaining treatment, we are focusing on the quality of the treatment itself, and our intention is to spare a person an unduly burdensome means of medical intervention. On the other hand, if we forego food and water, we are focusing on the quality of the patient’s life itself, not the treatment. We are not considering ordinary/extraordinary treatments, but valuable/unvaluable lives. In the latter case, we make a judgment that the life of a person who is in a certain situation is no longer morally valuable and we violate our duty to respect human life.⁹

We recognize that nutritional support is both a universal human biologic requirement and a fundamental demonstration of human caring. Because we believe there should be a basic covenant between all of us to care for those who are incapacitated, we are committed to the provision of food and water to those who cannot feed themselves….

…we believe that physicians, other health professionals, and health care facilities should initiate and continue nutritional support and hydration when their patients cannot feed themselves. We are concerned that demented, severely retarded, and comatose individuals are increasingly viewed as "useless mouths." We reject this dehumanizing phrase. Rather than encouraging physicians to withhold or withdraw such patients’ food and water, we encourage physicians to respond to God’s call for improved physical, social, financial, and spiritual support of all vulnerable human beings.¹⁰

Just as pro-life groups predicted, the adoption of living will legislation helped achieve a sea change in the practices of the medical profession. We now see open advocacy—and implementation—of both direct killing and involuntary denial of lifesaving treatment against the express desires of the patient. Especially among health care providers, but also among many in the general public, the "quality of life" ethic has largely replaced the "equality of life" one.

The result is that we can no longer safely count on a general respect for life to protect patients, or leave matters to be worked out informally among doctors, patients, and their families. The hard reality is that the presumption has now shifted to favor death, not life, for people with significant disabilities. Because these disabilities can happen to any one of us, our relatives, or our friends, it is now essential to set down affirmatively in writing that should we become disabled, we do want the presumption to be for life. Failure to sign a Will to Live is now likely to leave you or your loved ones unprotected, at the mercy of health care providers and courts dominated by those with very different values from a universal respect for human life.¹¹