FROM Rethinking Life and Death
After ruling our thoughts and our decisions about life and death for nearly two thousand years, the traditional western ethic has collapsed. To mark the precise moment when the old ethic gave way, a future historian might choose 4 February 1993, when Britain’s highest court ruled that the doctors attending a young man named Anthony Bland could lawfully act to end the life of their patient. A Dutch historian, however, might choose instead 30 November 1993, the date on which the Netherlands parliament finally put into law the guidelines under which Dutch doctors had for some years already been openly giving lethal injections to patients who were suffering unbearably without hope of improvement, and who asked to be helped to die. Americans have not witnessed such momentous judicial decisions or votes in Congress, but twelve Michigan jurors may have spoken for the nation when, on 2 May 1994, they acquitted Dr. Jack Kevorkian of a charge of assisting a man named Thomas Hyde to commit suicide. Their refusal to convict Kevorkian was a major victory for the cause of physician-assisted suicide, for it is hard to imagine a clearer case than this one. Kevorkian freely admitted supplying the carbon monoxide gas, tubing, and a mask to Hyde, who had then used them to end a life made unbearable by a rapidly progressing nerve disorder known as Lou Gehrig’s disease, or ALS.
These are the surface tremors resulting from major shifts deep in the bedrock of western ethics. We are going through a period of transition in our attitude toward the sanctity of human life. Such transitions cause confusion and division. That is why, for example, although the majority of people in most countries support laws allowing abortion, others sincerely believe that abortion is so great a wrong that they are prepared to block access to clinics that carry out abortions, to damage the clinics themselves, and even to go to the paradoxical extreme of murdering doctors because they performed abortions. Other symptoms of our bewilderment can be found everywhere. Here are three examples:
• The American Medical Association has a policy that says a doctor can ethically withdraw all means of life-prolonging medical treatment, including food and water, from a patient in an irreversible coma. Yet the same policy insists that “the physician should not intentionally cause death.”1
• Twenty years after the introduction of “brain death” as a criterion of the death of a human being, one-third of doctors and nurses who work with brain-dead patients at hospitals in Cleveland, Ohio, thought that people whose brains had died could be classified as dead because they were “irreversibly dying” or because they had an “unacceptable quality of life.”2 Organ transplantation is based on the idea that we die when our brain is dead—yet even the doctors and nurses most closely involved do not really accept this.
• A recent survey asked pediatricians in senior positions in the United Kingdom to say whether they agreed or disagreed with a number of different statements, among which were these:
1. Abortion is morally permissible after twenty-four weeks if the fetus is abnormal.
2. There is no moral difference between the abortion of a fetus and the active termination of the life of a newborn infant when both have the same gestational age [that is, the same age dating from conception] and suffer from the same defects.
3. There are no circumstances in which it is morally permissible to take active steps to terminate the life of an infant with severe defects.
Nearly 40 percent of the senior pediatricians responding indicated that they agreed with all three of these statements, even though you can’t agree without contradicting yourself.
Each of these three examples is a snapshot that catches people halfway through a shift in their views. The American Medical Association has come to see the pointlessness of keeping people alive for ten, twenty, or thirty years if there is no hope that they will ever recover consciousness—but it has not yet summoned the nerve to abandon the traditional doctrine that it is always wrong to end the life of an innocent human being intentionally. Health-care professionals who work with organ transplantation have been taught that patients whose hearts still beat are dead because their brains are dead, but they have had difficulty reconciling this with their own feelings and way of thinking. Senior pediatricians have come to accept prenatal diagnosis and late termination of pregnancy if a serious abnormality is found. They also can see that there is no real difference between a late fetus and a newborn infant at the same gestational age. But active euthanasia for severely disabled infants remains illegal and is not sanctioned by medical codes of ethics, no matter how premature the infants may be, or how serious their defects.3
These are not academic problems found in the abstract theories of philosophers who remain remote from the real world, publishing papers in learned journals. These contradictions have direct consequences for human beings at the most deeply significant moments of their lives. The farce that the traditional ethic has become is also a tragedy that is endlessly repeated with minor variations in intensive care units all over the world. Since 1989, for me at least, the icon of this tragic farce has been the image of Rudy Linares, a twenty-three-year-old Chicago housepainter, standing in a hospital ward, keeping nurses at bay with a gun while he disconnects the respirator that for eight months has kept his comatose infant son Samuel alive. When Samuel is free of the respirator at last, Linares cradles him in his arms until, half an hour later, the child dies. Then Linares puts down the gun and, weeping, gives himself up. He acted against both the law and the traditional ethic that upholds the sanctity of human life; but his impulses were in accordance with an emerging ethical attitude that is more defensible than the old one, and will replace it.4
The traditional ethic is still defended by bishops and conservative bioethicists who speak in reverent tones about the intrinsic value of all human life, irrespective of its nature or quality. But, like the new clothes worn by the emperor, these solemn phrases seem true and substantial only while we are intimidated into uncritically accepting that all human life has some special dignity or worth. Once challenged, the traditional ethic crumples. Weakened by the decline in religious authority and the rise of a better understanding of the origins and nature of our species, that ethic is now being undone by changes in medical technology with which its inflexible strictures simply cannot cope.
This is not a cause for dismay or despair. A period of transition on so fundamental an issue is bound to be filled with uncertainty and confusion, especially among those who have been brought up to accept the traditional ethic as beyond question. But it is also a period of opportunity, in which we have a historic chance to shape something better, an ethic that does not need to be propped up by transparent fictions no one can really believe, an ethic that is more compassionate and more responsive to what people decide for themselves, an ethic that avoids prolonging life when to do so is obviously pointless, and an ethic that is less arbitrary in its inclusions and exclusions than our traditional one. To achieve a better approach to life-and-death decision-making, however, we need to be open about the ways in which the traditional ethic has failed.
Readers will already know that I do not speak in hushed tones when I refer to the traditional ethic of the sanctity of human life. Nor do I try to disguise its failings by invoking sophisticated, distinctions and complex doctrines. I am not interested in continuing to patch and adjust the traditional approach so that we can pretend that it works when it plainly does not. The failures of the traditional ethic have become so glaring that these strategies can offer only short-term solutions to its problems, solutions that, like the policy of the American Medical Association on patients in irreversible coma, need to be reformulated almost as soon as they are pronounced. To break with the traditional way of approaching these issues is inevitably to clash with our usual moral beliefs. Some find this shocking. In part, this has more to do with the directness with which I describe what we already do than with any radically new suggestions I make about what we should do. When sensitive practices have long been veiled, ripping the veils aside can be shocking enough. But I readily admit that that is not the only reason why this book will shock readers. Some of the conclusions that I draw are very different from the ethical views most people hold today. That, however, is not a ground for dismissing them. If every proposal for reform in ethics that differed from accepted moral views had been rejected for that reason alone, we would still be torturing heretics, enslaving members of conquered races, and treating women as the property of their husbands. The views I put forward should be judged, not by the extent to which they clash with accepted moral views but on the basis of the arguments by which they are defended.
Supporters of the traditional sanctity of life ethic who know my previous writings will not be surprised to find themselves under siege in this book. But the book may also make uneasy some who have more affinity with the position I defend. This will include some who believe that they can coherently defend liberal abortion laws by saying that they are “pro-choice,” without having to say when human life begins, or to show why the fetus should not count as a human being. Other natural allies of my position who may not like what I say here are those who have proposed changing the definition of brain death so that the death of the parts of the brain responsible for consciousness is sufficient for a patient to be declared dead. Even supporters of the present definition of brain death may be uncomfortable with the argument I put forward. These people may be disturbed because they have sought to present what they advocate in a form that leaves intact as much as possible of our traditional ethic. For those concerned with only one particular reform, that is a sensible political tactic—why take on the whole world when you can get by with only the antiabortion movement against you?
We can try to deal one at a time with the problems of the sanctity of life ethic. But the overall result will be a jigsaw puzzle, the pieces of which have to be forced into place, until the whole picture is under so much pressure that it buckles and breaks apart. I think there is a better way. There is a larger picture, in which all the pieces fit together. Whatever issue of the moment may concern us, in the long run we all need to see this larger picture. It will offer practical solutions to problems we now find insoluble, and allow us to act compassionately and humanely, where our ethic now leads us to outcomes that nobody wants.