|Bioethics and Medical
Medicine, Metaphysics and Morals
ABSTRACT: Moral decisions concerning what ought to be done always assume metaphysical presuppositions concerning the way the world is. In the field of biomedical ethics, some of the metaphysical presuppositions underlying many current discussions of issues of life and death seem particularly implausible. These include our assumption of the reality of social atomism and our beliefs relating to the possibility of autonomy. Given the implausibility of these two assumptions, many discussions have focused our attention on the wrong issues by reducing questions of alternative social practices to questions of individual preferences. Far from facilitating intelligent solutions to our problems, this merely clouds the issues involved.
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 ethicists 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 ironys 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 ones continued life may have on ones 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. Hardwigs 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 Gillons remarks remind us even if the burden of prolonging every persons 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 ones life is not just simply terminating ones 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 interferences 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 ones 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 patients 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 patients 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 ones "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 Im 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 doesnt 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.
(1) Quoted in Beverage, W.I.B. - The Art of Scientific Investigation, 3rd ed., New York, Random House 1957. p.83.
(2) Cf. Mann, D. - "Porn Revisited" Journal of Social Philosophy Vol. XXVII, No. 1 Spring 1997. p. 83.
(3) Hardwig, John. "Is There a Duty to Die?". Hastiness Center Report 27. No. 2 p. 35.
(6) Wong, Kam C. "A Matter of Life and Death: A Personal Reflection on the Right to Die." Vales Newsletter, Spring 1997, Vol. No. 2, p.4.
(8) Hardwig - op. cit p. 38
(9) Gillon, Raanan - "Intendig or Permitting Death...To Conserve Resources" - in Intending Death: The Ethics of Assisted Suicide and Euthanasia. Beauchamp-New Jersey 1996. Prentice Hall.
(10) Hardwig - op cit p. 40
(11) Wong - op cit p. 4
(12) Beauchamp, T. and Childress J., Principles of Biomedical Ethics, 4th ed. New York: Oxford University Press. 1994.
(13) Englehardt, H.T. - The Fountain of Bioethics New York: Oxford University Press 1996.
(14) Childress, J. "The Normative Principles of Medical Ethics" in Medical Ethics, 2nd ed. Veatch London: Jones and Bartlett 1997, p.33.
(15) Beauchamp, T. - "Informed Consent" in Medical Ethics ed. Veatch London: Jones and Bartlett. 1997. p 195.
(16) Hendin, H. - Seduced by Death: Doctors, Patients, and the Dutch Care. New York: W.W. Norton 1997 p. 157.
(17) Pellegrino, E.D. - "The Place of Intention in the Moral Assessment of Assisted Suicide and Active Euthanasia" in Intending Death: The Ethics of Assisted Suicide and Euthanasia ed. Beauchamp, New Jersey: Prentice-Hall 1996.
(20) Hardwig - op cit. p 34-35
(21) For Example see: Brody, H. - "The Physician-Patient Relationship" in Medical Ethics. Second Ed. Veatch London: Jones and Bartlett 1997 pp. 75-79.
(22) Chamblis, D.F.- Beyond Caring: Hospitals, Nurses, and the Social Organization of Ethics, Chicago 1996, University of Chicago Press p. 165.