|Bioethics and Medical
On Helping People to Die: A Pragmatic Account
Mary B. Mahowald
ABSTRACT: Helping people to die may involve killing and/or alleviation of pain in a dying person. A dual commitment to the avoidance of killing and the alleviation of pain raises the question of whether these two ways of helping people are always compatible. This paper addresses the question through use of sources in classical American pragmatism and contemporary bioethics. First, I apply Charles Peirces notion of pragmatism to the concept of killing through consideration of the empirical consequences of alternative interpretations. James Rachels account of the distinction between active and passive euthanasia is critiqued in this analysis. Second, I examine what it means to relieve pain by relating Jane Addams concept of maternal nurturance to an ethic of care and opposition to killing. Utilizing these concepts, I apply William James notion of pragmatism as a method of mediating or straddling different theoretical approaches to resolve the apparent incompatibility between pain relief and the avoidance of killing. To address social concerns raised by the practice of helping people to die, I propose a corrective insight of Addams, along with John Dewey, about the role of the philosopher as social critic. Thus understood, pragmatism is a means of avoiding abuses that may occur in the process. I conclude that so long as permissive practices are restrained sufficiently to avoid injustices, it is morally both possible and desirable to resist killing while relieving pain.
Here is the doubt that triggers my inquiry: I have two beliefs that are apparently at odds. The first is that we should never kill; the second, that we should always attempt to alleviate pain. The apparent conflict between these beliefs arises from the fact that death may constitute the ultimate pain relief.
Certain caveats attach to both beliefs. For example, killing in self-defense or to save others lives is acceptable, (1) and inflicting pain through medical interventions in order to cure or restore function is also acceptable. (2) In general, however, both beliefs dispose me, as Peirce would put it, (3) to distinct plans or habits of action: avoidance of killing and provision of pain relief. In health care, the commitment never to kill implies that euthanasia is wrong, and the commitment to alleviate pain demands actions that may hasten the dying process.
The question that arises from these two commitments is whether both can be sustained simultaneously. Can I always and in every case avoid killing and alleviate pain? Using the term "can" to formulate the question suggests that the issue is one of possibility rather than permissibility. (4) But the two are intertwined because the possibility is both logical and moral. Is it morally possible, then, to alleviate pain while avoiding killing in all circumstances?
My inquiry will proceed in Peircean fashion, i.e., by an effort to clarify the concept of killing through consideration of the empirical consequences of alternative interpretations. To clarify what it means to relieve pain I relate Jane Addams concept of maternal nurturance to an ethic of care and opposition to killing. To further examine whether my two beliefs are compatible I employ James notion of pragmatism as a method of mediation or of straddling different theoretical approaches to resolve disputes that might otherwise prove interminable. Finally I return to an essential insight of Addams, along with John Dewey, about the role of the philosopher as social critic. Pragmatism, I argue, provides a means of avoiding the injustices or abuses that may occur in the process of helping people to die.
First, then, what does it mean to kill someone? Among the possible meanings of killing, consider the following:
Helping someone to die can of course occur in contexts not associated with killing, as in hospice care, where the primary goal is to comfort the dying. If helping someone to die is equated with killing, however, it generally entails something more than comfort, viz., hastening death or facilitating suicide. The difference between this and the first definition is that in the latter case the action taken directly ends a life, whereas the action of helping someone to die only indirectly causes death. Both first and third definitions differ from the second in that the second involves omission rather than commission.
None of these definitions says anything about whether the one killed is human or wishes to die. No information is provided about the means through which the killer "ends," "lets," or "helps" the one killed. Nor do they mention the intention of the killer, the proximity to death of the one killed, or degree of pain or suffering endured by the one killed. Such variables are relevant to determination of whether any of these "endings," "lettings," or "helpings" are morally justifiable. In fact, the variables may be more significant than the definitions in determining whether a specific act or omission is morally justified. The variables necessarily influence the consequences to be considered in forming our plans of action (or inaction).
Consider, for example, James Rachels famous argument for the moral irrelevance of a distinction between active and passive euthanasia. (5) Rachels looked at the consequences of Jones and Smith drowning or letting their cousins drown, and imputed to each the same intention, viz., the cousins death. His description of the two cases excluded all variables except the fact that Smith directly ended his cousins life while Jones ended it indirectly. But Rachels did not consider all of the consequences that could be anticipated in making his argument, and this, to the pragmatist, is a serious flaw. Different beliefs are to be formulated on the basis of different variables.
What are some of the variables that Rachels might have considered? When Jones let his cousin drown in the tub after he apparently fell, he surely was as responsible for not saving him as Smith was for actually drowning him. But suppose the cousin had a terminal, intractably painful disease, Jones discovered him in the tub when he was nearly dead, and then refrained from giving him cardiopulmonary resuscitation (CPR) because if he survived he would be worse off than before. Or suppose the cousin was a competent adult who not only suffered from an intractably painful, incurable disease but had written a note to Jones asking him not to interfere with his suicide attempt and to actually "finish him off" by suffocation if he did not succeed in the attempt. On the first supposition, Joness letting his cousin die could be viewed as both legally and morally appropriate. On the second supposition, Joness non-intervention could be both legally and morally defended. If the cousin were unsuccessful in his suicide attempt and Jones completed the task in fulfillment of his explicit request, he would be legally liable for killing. However, it is unlikely in such circumstances that a judge or jury would convict Jones of murder, and his act could be morally defended on grounds that he thus respected his cousins autonomy and prevented a worse harm than death, i.e., survival in an even more compromised state.
The variables I have introduced in the Jones-and-his-cousin scenario illustrate the second and third definitions of killing: letting someone die by not preventing it, and helping someone to die by doing something to facilitate it. In health care practice and in legal decisions, the former is described as foregoing life-saving treatment, the latter as withdrawal of life-saving treatment. If Jones had suffocated his cousin, his act would be legally described and proscribed as euthanasia; if the traditional distinction between active and passive euthanasia were invoked, the suffocation might be labelled active euthanasia. By that same distinction, his refraining from prevention of his cousins suicide attempt could be termed passive euthanasia, even though legal rulings do not generally employ that terminology. Refraining from prevention of death could also be called assisted suicide, but legal rulings generally reserve that terminology for cases in which an individual helps another commit suicide by performing a specific act, such as prescription of a lethal dose of medication.
The distinction between doing and refraining is difficult to maintain because stopping treatment already started requires an action on the part of someone. (6) A clear case of doing occurs in the first definition of killing, and may be exemplified by the infamous report of Debbie, a young woman suffering from ovarian cancer, who was apparently deliberately and actively euthanized by a house officer. (7) Clear cases of refraining occur whenever life support is withheld rather than initiated; such cases occur with and without consent of the patient. Consider, for example, a 500 gram 24 week gestation newborn, whose parents and practitioners agree not to intubate at birth because of the high probability of severe morbidity and even higher probability of death within a short time. Or consider a severely symptomatic AIDS patient, who has explicitly indicated that she does not wish to be resuscitated if she arrests.
Instances in which the distinction between doing and refraining is unclear commonly occur when life-sustaining treatment has already been initiated, and, with or without the patients consent, the treatment is deliberately withdrawn. Despite legal and ethical arguments that there is no relevant difference between discontinuing and foregoing life-saving treatment, it cannot be denied that withdrawal does not occur passively, but rather by a specific action on the part of a clinician. The argument that discontinuation of life-saving treatment is thus permissible because one is merely refraining from an action is at odds with an accurate description of what happens. Nonetheless, legal rulings assume that the patient or surrogate alone decides to stop treatment.
The active/passive distinction doesnt work, then, because it doesnt adequately divide the possibilities. Adequate division requires the three definitions of killing Ive delineated. Although Rachels assumes only two definitions, his argument for the moral irrelevance of a distinction between active and passive euthanasia may apply to all three definitions. Depending on the variables, it may be as morally wrong or right to end a life, to let die, or to help someone die.
Peirce would undoubtedly look to the consequences of different definitions of killing to resolve the dilemma posed by the dual commitment to avoid killing and to relieve pain. In doing so, I suspect he would agree with Rachels overall argument but extend it to active discontinuation of life-sustaining treatment, and insist on consideration of the impact of all of the variables in different situations. Moreover, because Peirce would be concerned about long term consequences, he would consider slippery slope and rule utilitarian arguments. These arguments introduce further variables with which to reckon.
Caring clinicians are generally committed to reduce the pain and suffering of patients, while extending patients lives and their ability to function. The irony that arises in the relationship between alleviation of pain and prolongation of life is that death, by ending human experience, constitutes the ultimate pain relief. Rarely is this relationship tested because caregivers generally pursue both goals simultaneously and successfully. If and when severe pain and suffering are not relievable, they sometimes wish for that ultimate relief for their patients. At such times, we might see more numerous instances of active euthanasia if there were not such widespread, deeply-rooted taboos and laws against it.
Long before the recent articulation of a care ethic, Jane Addams argued for the extension of womens natural nurturant behavior to the larger social context. In doing so, she provided useful insights for the problematic relationship between pain relief and euthanasia. A committed pacifist, she totally opposed killing while arguing just as forcefully for addressing the problem of hunger in the world. The provision of nourishment, which occupies much of women's daily labor, is essential both to sustaining life and to relief of the pain and suffering of ill health. War is an obstacle to this task of nurturance.
The rationale by which Addams maintained both her pacifism and her commitment to the alleviation of hunger is captured in her notion of "bread labor" as "the very antithesis of war." (8) For Addams, the elimination of world hunger and the provision of conditions necessary for fostering human life and flourishing would render the competition of war unnecessary. Relieving the pain of hunger is thus not only compatible with but essential to the avoidance of killing.
Contemporarily, those who have argued most convincingly against physician-assisted suicide illustrate the same argument as Addams. Susan Tolle, for example, maintains that public support for legalization of euthanasia and physician-assisted suicide points to the frequent failure of clinicians to provide adequate pain relief to their patients. (9) If adequate pain relief were provided, there would be little need or desire for the practice. If it is not providable, however, would Tolle countenance euthanasia or assistance in suicide? If she concurred with Addams pacifism she would not do so, but neither would she be likely to oppose foregoing or discontinuing treatment. If severe pain were still not relievable, a pacifist might resort to the principle of double effect to justify hastening death as the unintended but foreseen consequence of adequate pain relief.
While Jamess account of pragmatism as a theory of truth is problematic for ethics, his account of pragmatism as a mediating method goes beyond Peirce in suggesting a means of resolving the apparent dilemma between pain relief and medical pacifism. Contemporary bioethicists have tended to utilize either principlist or casuistic approaches to cases. (10) In contrast, a Jamesean pragmatism utilizes both approaches, straddling back and forth as along Papinis corridor, using both or whichever is most conducive to resolution. (11) This approach in fact reflects the way most people think most of the time in resolving their doubts or dilemmas. It also makes explicit what any careful examination of principlism or casuistry reveals, namely, that the content of the principles articulated is drawn from our experience of particular cases, and that our understanding of cases is only possible through the generalizations that are identifiable as principles or maxims.
Jamesean pragmatism demands that we maximize our chances of resolving practical dilemmas by invoking both empirical and rational considerations. Short-hand ways of doing this, such as matching new cases with old paradigms and applying the governing maxims, are favored if we are faced with a genuine option, i.e., a choice between living, momentous, and unavoidable alternatives. (12) But principle-based decision-making may be used as a short-hand method too. Both are fallible, and neither is thinkable or applicable without the other.
One way in which the straddling method of James may be applied to the dilemmatic relationship between pain relief and medical pacifism is by examining the variables of cases in the context of the pertinent moral verities or principles. The verities are the principles of respect for autonomy, beneficence, and justice. The variables go beyond those mentioned in our revised version of Rachels case of Jones and his cousin. These include the patients wishes, the immanence of death, the extent of the patients pain or suffering, the cost and availability of pain relief, and the means by which death may be hastened.
In a Jamesean application of pragmatism as a mediating method, the verities would have to be interpreted in the context of the variables, all of which need to be examined. (13) None of the principles would be construed as absolute, not even respect for patient autonomy; rather, the principles are tools or instruments to be used in a way that maximizes their observance in light of the variables of each case. Mere definitional distinctions are thus not adequate in resolving concrete dilemmas. James would hardly, therefore, be opposed to physician-assisted suicide or even active euthanasia solely on grounds that they are not classifiable as passive euthanasia or letting someone die.
Some critics fear that liberal policies with regard to euthanasia and physician-assisted suicide would naturally or inevitably move from willingness to implement the desires of competent, dying, suffering persons to willingness to do this for those who are not dying, whose pain is relievable, and those who are incompetent. Mere willingness in such circumstances could lead to something yet more onerous, positive eugenics, i.e., a readiness or desire to end the lives of those whose health status is severely compromised or costly to support. Persons with disabilities are strongly opposed to legalization of physician-assisted suicide on this basis. (14) They are often opposed as well to the apparent ease with which the law allows termination or non-initiation of life-support.
If Addams had addressed the concerns of persons with disabilities about the eugenic potential of policies about euthanasia and physician-assisted suicide, she would probably have had two main worries: the possibility of pressuring the disabled to die and the possibility of exacerbating prejudices or negative attitudes and practices towards the disabled. At the same time, Addams would not want to deprive the disabled of the same right to die and to be relieved of pain and suffering that the non-disabled experience. Her ideal of social equality would thus demand measures designed to place wedges along the slippery slope of social permissiveness to insure that eugenics is not practiced through measures that help people to die. Rules formulated to restrict such measures would be supported by Addams to the extent that they insured maximally just consequences for all of those affected.
One concrete means Addams would surely have advocated to maximize justice in policies about helping people to die is the involvement of persons most affected by the enactment of those policies. Like Peirce, she viewed genuine collaboration as a way of overcoming the nearsightedness that compromises the reliability of beliefs emerging from our inquiries. She would therefore regard bioethicists and clinicians who attempt to resolve the dilemma of pain relief vs. medical pacifism as not only undemocratic but illogical if they fail to involve those most affected in the process.
To return to the question that provoked my inquiry, my doubt about the compatibility between amelioration of pain and avoidance of killing has been assuaged through an examination of the consequences that arise in different circumstances for different definitions of killing. My attempt to follow a pragmatic method has utilized not only principlist and casuistic but care-based approaches, which led to realization that pain relief is in fact a means of avoiding killing. It also involved examination of short-term as well as long-term consequences of helping people to die, especially the consequences to those most affected by such "helping" measures. I conclude that so long as permissive practices are restrained sufficiently to avoid eugenics or other injustices, it is morally both possible and desirable to resist killing while relieving pain. To protect for all of us the right to die and to adequate pain relief, while insuring that our right to life and dignity be respected no matter what our circumstances, critical pragmatism demands the placement of wedges at appropriate points along lifes inevitably slippery slope.
Peirce acknowledged that the belief in which inquiry culminates is not unmixed with doubt that may prod subsequent inquiry. Self-conscious of my own fallibilism, while disposed to act on the beliefs I have developed here, future experiences and input from those directly affected may compel revision. Like James, I remain dogmatic about not being dogmatic.
NOTES(1) Because I am not a complete pacifist. (2) Because I am not a Christian Scientist. (3) 1972. (4) It may be that pain is always relievable, if, after other means or doses fail to provide relief, sedation renders the patient unconscious. Prior to that point, however, death may be hastened through the administration of pain medication that reduces respiratory effort.
(6) For example, turning off the switch on a ventilator.(7) Name withheld, 1988.
(8) 1945, p. 96. The term "bread labor" was taken from historical accounts of Russian peasant leaders following the abdication of the Czar. The future of each peasant depended "not upon garrisons and tax gatherers but upon his willingness to perform bread labor on his recovered soil, and upon his ability to extend good will and just dealing to all men" (1945, p. 92).(9) Tolle, 1994; Lee and Tolle, 1996.
(10) Beauchamp and Childress, 1994; Jonsen and Toulmin, 1988.(11) James, 1955. (12) James, 1962. (13) I have developed the distinction and relationship between verities and variables in Mahowald, 1996. (14) Gill, 1991, 1992. References
Addams, Jane, Peace and Bread in Time of War (New York: Kings Crown Press).
Beauchamp, Tom and Childress, James, Principles of Biomedical Ethic, 4th edition (New York, Oxford University Press, 1994).
Gill, Carol, "Life, Death and Disability: How Eugenics and Abortion Put Activists in a Quandry," Mainstream December 1991, January 1992.
James, William, " The Will to Believe," in Essays on Faith and Morals (Cleveland, Meridian Books, The World Publishing Company, 1962).
James, William, "What Pragmatism Means," in Pragmatism (Cleveland: Meridian Books, 1955).
Jonsen, Albert R. and Toulmin, Stephen, The Abuse of Casuistry (Berkeley, CA: University of California Press, 1988).
Lee, Melinda A. and Tolle, Susan W., "Oregons Assisted Suicide Vote: The Silver Lining," Annals of Internal medicine 124, 2 (Jan. 15, 1996), 267-269.
Mahowald, Mary B., "Medically Assisted Reproductive Technology: Variables, Verities, and Rules of Thumb," Assisted Reproduction Reviews 6 (1996), 175-180.
Name withheld, "Its Over Debbie," Journal of the American Medical Association 259 (1988), 272.
Peirce, Charles Sanders, The Essential Writings, ed. Edward C. Moore (New York: Harper and Row Publishers, 1971), 125-26.
Rachels, James, "Active and Passive Euthanasia," New England Journal of Medicine 292 (1975), 78-80.