Obviously decisions about what ought to be done in any given
circumstance presuppose the acceptance of beliefs regarding what can in fact be done. In
short moral judgments presuppose metaphysical commitments, beliefs about the way the world
is. Unfortunately, social pressures in most modern societies militate against the open
admission of any metaphysical commitments on the part of persons involved in making moral
judgments in the field of applied ethics known as biomedical ethics. Ethical decisions in
the area of medicine need to be seen as acceptable to as large a segment of the community
as possible. However, since the community in most modern societies is remarkably
heterogeneous with respect to assumptions concerning the way the world is, any explicit
reference to metaphysical assumptions on the part of one discussing biomedical ethics is
apt to be challenged by at least some members of the community. Hence those involved in
discussions of biomedical ethics tend to do so without any explicit admission of the
metaphysical presuppositions underlying their treatment of various issues. However, the
refusal to state metaphysical presuppositions cannot justify the conclusion that no such
presuppositions are involved in a discussion. Indeed the situation of the ethicist with
regard to metaphysical presuppositions seems roughly analogous to the situation of the
biologist as regards the concept of teleology. Von Brueck is alleged to have remarked,
"Teleology is a lady without whom no biologist can live, yet he is ashamed to show
himself in public with her." (1) Analogously one might
maintain" Metaphysics is a person without whom no ethicist can reach conclusions, yet
he or she is ashamed to be seen in public with that person." Regretably the
ethicist’s reluctance to admit her relationship to metaphysical presuppositions
precludes the consideration of the plausibility of the ethicists conclusions. Since these
conclusions may have considerable social impact this tendency to operate from hidden
assumptions is unfortunate to say the least. In what follows I propose to examine the
metaphysical presuppositions to be found in some common arguments in the field of
biomedical ethics and to raise the question of just how plausible these assertions may be.
Should it appear that their plausibility is open to serious questioning this might suggest
that we may be a bit too hasty in our ready acceptance of some of the more popular
conclusions in the field. The presuppositions involved are two in number, the first
involving the relationship of the individual to her world, the second involving the degree
of freedom the individual possesses.
The first of the highly questionable assumptions might be described by
the phrase "social atomism." (2) John Hardwig
describes this attitude as "...one of our deeply embedded American dreams: the
individualistic fantasy." (3) He contends that
"...this fantasy leads us to imagine that lives are separate and unconnected, or that
they could be if we chose." (4) As Hardwig notes the
most common expression of social atomism is the rhetorical question "Whose life is it
anyway?"
Now as Hardwig points out the answer to that question is not as obvious
as contemporary residents of the United States liable to suppose. He writes "We are
not a race of hermits..." (5) and then on the basis of
the effects that our lives, or our deaths may have on others he proceeds to argue for the
existence of a duty to die. Interestingly enough Kam C. Wong is equally opposed to
the belief that we are social atoms although Wong uses that observation to reject the right
to die. Wong writes "The case for the right to die is summed up in one neat and
deceptively compelling argument, 'Whose life is it anyway?' (In traditional China the
answer is: 'My parents.' This gratuitous statement is necessary to inform readers of the
ever lurking cultural conflict underscoring the debate.)" (6)
Having said this Wong goes on to observe that "The taking of life (abortion or
suicide) affects others near and far, close and distant, past and future". (7)
The point of course is well taken and extends beyond issues of suicide or abortion. It is
in fact the case that even the decision to reproduce or to refrain from reproduction has a
profound impact on the future of the species. It is one of the irony’s of our
obsession with the individualistic fantasy that it allows us to regard decisions of the
utmost social significance as "private" or "personal" issues. As both
Hardwig and Wong point out, what is true at the beginning of life is also true at the end
of life. Just as the perpetuation of a genotype though the decision to reproduce affects
vast numbers of persons besides the one making that decision, so too the decision to
continue or end a given life can have far-reaching social ramifications. Hardwig, in
arguing in favor of a duty to die stresses the negative impact one’s continued life
may have on one’s family and on the community as a whole. Among these he notes the
significant burdens of "...emotional burdens, extensive caregiving, destruction of
life-plans, and ...financial hardships on...loved ones." (8)
Raanan Gillon takes this argument one step further noting that "...one of the
criteria that, as health care workers we shall have to get used to, is the notion that all
our interventions need to be assessed for their efficacy, efficiency, and effectiveness,
and also, for their costs and opportunity costs in producing benefit for patients and
potential patients." (9) Gillon is calling attention to
the fact that supplies and/or services provided to sustain the life of one person are by
the same token withheld from some other person. The antibiotic used to fight pneumonia in
a severely debilitated 84 year old patient is not available for use in the case of an 8
year old with a strep throat infection. In the United States the decision as to whether
patient receives treatment is seen as an individual decision at present. Yet clearly it
has social ramifications. Hardwig’s reference to the effect on those closest to the
patient represents the tip of the iceberg so to speak, and he is willing to admit that
"If our society were providing for the debilitated the chronically ill and the
elderly as it should be, there would only be very rare cases of duty to die". (10)
Yet as Gillon’s remarks remind us even if the burden of prolonging every
person’s life were to be borne by the whole of society it would still be a burden.
There would still be costs even if it were society as a whole which bore those costs. This
being the case the decision for or against life prolonging treatment still affects more
than the individual.
Wong would agree that the decision for life prolonging treatment, or
either passive or active euthanasia, affects many more persons than the patient herself.
As Wong points our "...taking one’s life is not just simply terminating
one’s isolated, if autonomous, existence... It takes away part of society, community,
family and humanity". (11) In short just as Hardwig can
appeal to the social nature of human life to establish a duty to die Wong can provide an
analogous argument for a duty to live.
It is not impossible that both duties may co-exist. Furthermore, it
seems not only possible but likely that debates over the right to live or the right to die
involve serious over-simplification of the issue. There is more at stake in questions of
life and death than simply the fate of an isolated individual. Our heedless assumption of
the truth of social atomism clouds our vision of this fact.
Beyond the dubious nature of our popular assumption of social atomism
however, there is yet another highly questionable presupposition in the background of most
contemporary discussions of biomedical ethics. That is our presuppositions concerning the
nature of human freedom; presuppositions which lead to the adoption of autonomy as the
ultimate test of morality. Thus Beauchamp and Childress list autonomy, non-malificence,
beneficence, and justice as primary moral principles, (12)
while Engelhardt recognizes only autonomy and beneficence. (13)
Furthermore as Childress remarks"...nonconsequentualists contend that the principle
of autonomy always trumps the principle of beneficence when only the patients welfare is
involved (i.e., when there is no harm to other parties)." (14)
Ignoring the previously discussed question of the possibility of a situation where only
the patients welfare is involved there is still the issue of just what is meant by
"autonomy". Beauchamp defines it as "...personal self-governance; personal
rule of the self by adequate understanding while remaining free from controlling
interference’s by others and from personal limitations that prevent choice." (15)
Unfortunately, phrases such as "...adequate understanding...",interference from
others..." and "...personal limitations which prevent choice..." are
remarkably vague. Surely lack of information might count as such a limitation, but just
how much information must one have at one’s disposal to be free of this particular
limitation? Or again, limited ability to understand relevant information might be
construed as interfering with self-governance but the question immediately arises as to
just how great a limitation must be present to render one incapable of autonymous
decision-making.
None of these questions are new to the field of bioethics. Hospital
ethics committees routinely agonize over the question of whether a given patient’s
decision to accept or reject a given treatment was informed and autonomous. Did the
patient really understand the consequences of the decision? Was the patient really
capable of rational thinking at the time the decision was made. Beyond this there are more
complex questions regarding subtle social coercion. Recent arguments concerning
physician-assisted suicide have called attention to the danger of such coercion. For
example, Herbert Hendin observes that, "...a doctor who suggests euthanasia as an
option to a patient...or relatives who respond too readily to a patient’s mention of
euthanasia send a powerful message that they believe that the patient should not continue
to live." (16) Hendin quite correctly questions whether
the decision to die in such circumstances can be viewed as truly autonomous. Even in the
absence of the overt suggestion of the desirability of death, many terminally ill persons
are subjected to social pressures favoring that decision. As Edmund Pellegrino points
out"...the patients’ own mention or decision to die may be less motivated by
intolerable suffering than by a conscious or unconscious attempt to act beneficiently
towards family, doctor, or society." (17) As he
correctly observes "The benefit sought may be relief of guilt for being the 'cause'
of distress and trouble to others or the wish to die 'nobly'". (18)
But of course the wish to die "nobly" or "with dignity" is all too
often "...fear of how one looks in the eyes of the "other world" — of
the healthy, the occupied, the busy, the physically unencumbered." (19)
This being the case one can again question whether it is truly an expression of autonomy
should one decide to die as a means of protecting one’s "dignity".
Finally this emphasis on the priority of autonomy ignores completely
the deeper metaphysical issue of the degree to which any human act can be construed as
freely chosen. From the scientific perspective human behavior is the result of genetic and
environmental factors. Surely the environment in which a person has been nurtured is a
major contributing factor in whether the person opts for or against death in any given set
of circumstances. As evidence of this consider the wide spread acceptance of the duty to
die in less technologically sophisticated cultures. In such cultures as Hardwig notes
"...everyone knows that if you manage to live long enough, you will eventually...need
to take steps to end your life." (20) While it might be
comforting to advocates of the primacy of autonomy to assume that in those cultures
everyone autonomously chooses to die under those circumstances, whereas in modern
technologically sophisticated cultures only some persons make that choice, that would seem
to be far too simple an explanation. Persons from the first sort of culture have been
taught or conditioned if you will to accept the necessity of their own death. Persons from
the second sort of culture have not been so conditioned. But if this is true, autonomy
does not enter the picture. The moral issue ceases to be the question of practicing
autonomy and becomes the question of whether or not persons should be taught to accept
their own death under certain circumstances. In short the question shifts from one of
personal ethics to one of social ethics.
If the preceding observations are sound, bioethics presents an
interesting situation by adopting fundamental values which involve very dubious
assumptions on the metaphysical level. Why should persons as deeply imbedded with the
scientific spirit as members of the medical community be so content to adopt such
assumptions? There seem to be three possible answers with each possessing at least limited
validity. The first and least significant answer to the question is simply the human
tendency to accept assertions in the field of ethics without inquiring into the background
assumptions which allow us to regard these assertions as meaningful. Thus in a world where
no actions are without some affects on society we can accept assertions based on an
assumed social atomism. In a world where no decision is free of external influences we can
extol autonomy as the sine qua non of morality. At least to some degree our ability to do
these things reflects our tendency to refrain from inquiring into our own assumptions.
Beyond this however there would appear to be two other influences at work.
One of these influences involves the sociology of health care. Recent
decades have witnessed a change in the distribution of power within the health care
community. To many philosophers this has appeared as primarily a change in the
conceptualization of the physician-patient relationship. (21)
The sociologist Daniel Chambliss, on the other hand, has called attention to the degree to
which power relationships within the hospital community are involved in the shift from
technological considerations as to what can be done, to humanistic considerations of what
should be done. The shift from the former to the latter involves a shift of power from the
scientifically oriented physician to the care oriented members of the hospital community
(e.g., nurses, social workers, chaplains, etc.) As Chambliss points out there are group
interests involved in questions of biomedical ethics. The crusade to protect the patients
non-existing autonomy can effectively mask these internal organizational issues.
Finally there is the ever present desire to evade responsibility
operating in the glorification of patient autonomy. In his discussion of DNR orders
Chambliss quotes a nurse as saying "...nobody will take responsibility for saying
‘I’m the one who said this patient is DNR’...". (22)
By insisting that the patient make the decision the problem is eliminated. However, if
what has been said here is true, it does so at the expense of committing us to a highly
dubious view of the world. However, if we are to address the issues of bioethics in a
constructive way we must be willing to face the issues rather than evade them throughout a
flight from reality. The question is not "Should we be free to do whatever we want
when it doesn’t affect others ?" Instead it is "What should people be
encouraged to want in view of the fact that even their life and death decisions do affect
others?" When society is willing to give up its illusions and face that question
there will be more significant progress in the field of biomedical ethics.
|
