Friday, October 09, 2009

Making Suicide an Option

David Velleman offers a fascinating argument in 'Against the right to die'. Sometimes options can reduce our autonomy, e.g. by reshaping the 'meaning' or social significance of our choice. You might most prefer the option of staying home by default, but once someone invites you to dinner, this option is replaced by the very different (and less desirable) option of staying home by refusing their invitation.

Similarly, Velleman argues, establishing a 'right to die' (as per physician-assisted suicide or voluntary euthanasia) replaces the option of staying alive by default with the significantly different option of explicitly choosing to stay alive. Velleman continues:
[I]f others regard you as choosing a state of affairs, they will hold you responsible for it; and if they hold you responsible for a state of affairs, they can ask you to justify it. Hence if people ever come to regard you as existing by choice, they may expect you to justify you continued existence. If your daily arrival in the office is interpreted as meaning that you have once again declined to kill yourself, you may feel obliged to arrive with an answer to the question, "Why not?"

There's something intuitively distressing about this, though it's surprisingly difficult to pin down. After all, isn't it a good thing to conform one's actions to what's justified? I see two potential worries here. Firstly, demands for justification can be experienced as burdensome in a way that threatens to suck the joy and value out of life if they become too ubiquitous. But perhaps situations of terminal illness and the like are sufficiently rare and high-stakes that moral mindfulness here would be justified on rule utilitarian grounds.

The second concern, and Velleman's main worry, is that others might respond unreasonably in ways that change what the terminally ill patient has most reason to do. Suppose that the patient could still find value in his continued existence, so long as he could continue to interact with his friends and family in a happy and dignified manner. "Unfortunately," Velleman says, "our culture is extremely hostile to any attempt at justifying an existence of passivity and dependence."
[The patient] can therefore assume that his refusal to take the option of euthanasia will threaten his standing as a rational person in the eyes of friends and family, thereby threatening the very things that make his life worthwhile. This patient may rationally judge that he's better off taking the option of euthanasia, even though he would have been best off not having the option at all.

A curious thing about this argument is that it seemingly depends upon most people rejecting it. If everyone shared Velleman's positive attitude towards care-dependent life, then there would be no such problem of misguided social pressure to worry about. On the other hand, those who consider the terminal patient unjustified in extending his life might not be so bothered by the outcome of his feeling pressured towards doing what is (by their lights) the right thing.

Or would they? Matters are complicated by the fact that the (dis)value of the outcome is massively dependent upon the patient's attitudes. So, even if it would be best if the patient were happy to die now -- leaving more resources for his grandkids' college funds, or for other citizens with curable health problems -- our preference ordering might change upon learning that the patient isn't yet ready to die. For we may plausibly think that it's so egregiously bad for a person to feel pressured into a premature death (whether from social pressure or an alienating sense of 'duty') that this disvalue outweighs the costs of continued terminal care.

This seems pretty plausible to me. No loving family could possibly want Grandma to die before she was ready, just to save a few lousy bucks. On the other hand, if she has gotten all that she can out of life, and cares deeply about providing her descendants with the opportunity for a better life, then she might quite reasonably prefer to die now rather than deplete her grandchildren's college funds -- even if her experience is still intrinsically pleasant enough (such that she would have happily continued it a bit longer if there had been no such cost to doing so).

Such an attitude seems entirely admirable, and even perhaps 'ideal'. But if we acknowledge this, it leaves us in the awkward position of seeming critical of the terminal patient who clings to life, and hence of potentially depriving them of the respect that makes their life still worth living at all. Tricky. (Though this problem doesn't seem altogether inevitable, given that an ideal may be supererogatory, not 'required' or expected.)

Then again, the assumption that continued existence is a "given" seems so deeply ingrained in our ordinary thoughts that Velleman's worries may well be moot. Even if our political institutions introduced a 'right to die', would that really make it such a live question that we would come to reconceptualize of living as an explicit 'choice' that needed to be justified? The default expectation may persist even as alternative options are provided for those who want them.

P.S. It is said that old Eskimos, when they felt their time had come, would go for a "long walk" out into the snow. Does this alternative cultural expectation seem worse? Would it likely be experienced by many as a burdensome, alien 'duty' as they approached old age? Or, if internalized to seem an entirely appropriate and even welcome way to conclude one's life, might it even be more dignified than the drawn-out hospitalized endings more common in our culture?

When considering this topic, it does seem essential to ask both:
(1) What is the best option now, holding fixed local attitudes towards death?
and
(2) What would be the best attitudes towards death for a society to inculcate?

Answers welcome...

9 comments:

  1. His hidden assumption about most people not agreeing seems pretty reasonable.

    I would expect desire or need for money to pressure people into pressuring grandma, and everyone gets to lose, at least sometimes.

    "No loving family?" I'm quite capable of harbouring the desire to save money AND grandma simultaneously. Indeed, a decent working definition of 'saint' would be someone who isn't so capable. I would not act on the money part, but that doesn't make the temptation go away, nor does it obliterate the possibility that grandma will think of it all by herself and try to do 'the right thing.'

    On the other hand you can take the argument further. Knowing ahead of time that if you want to live on life support, you're gonna have to pay for it, allows both the social and personal financial-moral issues to be brought up and resolved in advance.

    Long term care insurance already exists, which means that part at least is a simple matter of going down to the broker and thinking, "Hmm, is my possible future life worth that much money?" I find that most people can make this decision decisively, even if not always accurately.

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  2. Oh, I didn't mean that they wouldn't have any (pro tanto) desire for grandma to commit premature suicide -- only that they couldn't really want this outcome all things considered. To care deeply about someone entails caring deeply that they don't unnecessarily die before they're ready (and especially not for some relatively 'cheap' seeming benefit to oneself).

    So, if this attitude accurately reflects the relative weightings of the values involved, then even consequentialists (who think it would have been best if the patient were to happily consent to euthanasia) would not want the patient to feel morally pressured into consent. It would no longer be right (value-maximizing) thing to do, if done from the wrong motives.

    The upshot of all this is that -- contrary to initial appearances -- Velleman's argument doesn't really depend on the assumption that the care-dependent life is perfectly justifiable, after all. For consequentialists may reject that assumption, and think that the patient ought not to want to cling to life. And yet, they may agree with Velleman that it'd be unfortunate if this patient who (unreasonably) wants to live were to feel pressured into death.

    P.S. I agree that it's much preferable to avoid these worries by buying appropriate insurance in advance. But people aren't always so responsible, so it's still worth asking about the non-ideal case.

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  3. Related to your Eskimo example, an outstanding film by the great Imamura.

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  4. Ah, I see what you're saying now.

    Still, given the group normally referred to by 'we' assigns infinite negative value to a life lost prematurely, (in this case, without consent) then the fact that less loving and less responsible families exist is enough by itself to prove that euthanasia should be illegal.

    It's easier for me as I don't think life is priceless...but it certainly sounds utterly callous to say that out loud, don't you think?

    I've always admired that story about Inuit culture. Buffered as it likely would be by genuine respect for the elderly and deep, deep community ties, it almost certainly would allow those who wanted to live to continue.

    I understand many elderly people come to harmoniously accept their impending death. The Inuit tradition would allow them to not only accept it, but to take control of it.

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  5. Hmm, I doubt that anyone really assigns 'infinite' value to anything. We always have to make tradeoffs, and it's not as though anyone's willing to sacrifice everything else for the slightest chance at decreasing the risk of premature death.

    In case of euthanasia, we need to weigh these costs against the benefits of increased autonomy and dignity for those who do welcome greater control over their end-of-life. Not to mention the public health savings that may enable us to invest in saving more lives of those with curable illnesses (who might themselves die prematurely otherwise). It may "sound" callous to say such things. But it would be callous to implicitly deny treatment to more people who stand to gain decades more healthy life from successful treatment. Or so I'm inclined to think: universal sympathy entails utilitarianism.

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  6. No loving family could possibly want Grandma to die before she was ready, just to save a few lousy bucks.

    Well, not all families are loving. Family members often desire that an sick elderly person to perish, to relieve medical costs, or to get at her inheritance, etc. Unscrupulous or "golddigging" relatives might assist in their granny's death, unless there was written consent or laws to the contrary, or when they could get away with it. Again, hypotheticals without much context, uh, sir. "Pulling the plug" does happen, even in the USA, more frequently than many realize--usually with po' folks, or some elderly person with no relatives around. The problem is creating policies and laws which prevent unscrupulous doctors and nurses from eliminating a sick or old person's autonomy, and playing God, more or less.

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  7. I referenced the desires of "loving families" as providing a clue about how to evaluate outcomes. Obviously the preferences of the unscrupulous offer no such moral guidance, so aren't relevant in that context.

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  8. Coming as someone who doesn't know that much about the Inuit culture, I might ask the question as to what the common attitudes are towards discussing death? Is this tradition of the elderly choosing to die spoken of openly, is it part of the mythology or does it happen often enough it's just an open fact of the culture? I guess the reason I'm asking is because this draws parallels with admittedly anecdotal accounts of difference in attitudes to death between atheists and the religious.

    It might just be part of the happy folklore that atheists tend to be less afraid of death, but it seems plausible that not having the chance to wish for a life after death forces you to think about it and once you've had a chance to think about it in that way, it tends not to be as scary.

    A similar process may form part of the Inuit experience and get us out of the problems Velleman proposes; a healthy attitude is to confront this particular problem more broadly in the culture and preferably before a person becomes terminal.

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  9. Have you ever seen someone reject a definitely, 100% life-saving measure as too expensive? Specifically, for someone else's life?

    "But it would be callous to implicitly deny treatment to more people who stand to gain decades more healthy life from successful treatment."

    Yes, that is what I was trying to bring to mind. (It worked. Yay!)

    "universal sympathy entails utilitarianism."

    I'm inclined to turn it around. Utilitarianism is universal sympathy, as opposed to a moral framework, and instead is something to pursue within a moral framework.


    That Guy Montag,

    Rob's link above to Imamura's film addresses at least one permutation. Specifically the line, "At the top of the mountain, hundreds of skeletons and hungry black crows wait for the next arrivals as the resigned grandmother and one grieving son make the final ascent together, the woman strapped to her son's back."

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