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:
1. Killing means ending the life of someone.
2. Killing means letting someone die when one could have prevented it.
3. Killing means helping someone to die.
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 cousin’s death. His
description of the two cases excluded all variables except the fact that Smith directly
ended his cousin’s 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, Jones’s letting his cousin die could be viewed as both legally and
morally appropriate. On the second supposition, Jones’s 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 cousin’s 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 cousin’s
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
patient’s 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 doesn’t work, then, because it doesn’t
adequately divide the possibilities. Adequate division requires the three definitions of
killing I’ve 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 women’s 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 James’s 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 Papini’s 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 patient’s wishes, the immanence of death, the extent of the
patient’s 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 life’s 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.
|
