The common good, terminal illness, and euthanasia.

• Author: Dougherty, Charles J.

In one sense, dying is the most personal and private of all events. Each of us comes to the end of a unique life and dies his or her own death. Along with birth, death sets the natural boundaries of a particular life's trajectory. But unlike birth, the consciousness of death can define a person's plan of life. In existential terms, the consciousness of an inevitable person death provokes an anxiety that is radically individuating. The fact of my death makes this my life.(1)

Yet no aspect of human experiences is wholly personal and private. Like birth, our knowledge of death comes from others. The way we die--when, under what circumstance, and from what cause or reason--is shaped in profound ways by relationships with others and by large social and institutional forces. The symbolic significance attached to death is derived from religious and cultural realities that precede and survive individuals. And it is precisely because death is such as intensely personal and private event, so defining of the individual, that the social arrangements that attend death are so important. What could be more important for society than events that shape individuals?

The character of dying and how th dying are cared for has changed in profound ways in the last several decades.(2) In all of our prior history, death for those who reached adulthood came generally in what is now mildlife. It came swiftly, "a thief in the night." It came without significant resistance from medicine; little could be done to ward off impending death. Now death is generally an event of old age. It typically follows a long pattern of chronic illness and decline. It comes only after exhaustive medical interventions, some of which plainly increase the length and intensity of suffering and all of which increase costs to the health care system.

This change in dying, and especially its impact on the deaths of individuals, has produced a social consensus over the last two generations on a patient's or proxy's right to refuse life-sustaining medical measures, a hospice movement designed to improve the quality of life in dying, and a growing debate over legalization of doctor-assisted suicide and active euthanasia. What are the social dimensions of these developments, especially the third, since it stands before us as a social choice? Aside from real and projected impacts on individuals, how does our treatment of the terminally ill effect society as a whole? How might changes in social arrangements surrounding dying affect the common good?

These issues are taken up here under three headings. First, some general observations are offered about the notion of the common good. Second, some changes are proposed designed to better serve the common good in the way dying patients are cared for. Finally, some reasons are developed to show why legalization of doctor-assisted suicide and active euthanasia cannot serve the common good.

The Common Good

Traditionally, the common good has been the key term of articulating and assessing the implications for society as a whole of changes in social practice or public policies.(3) But the notion of the common good is problematic in our society. The idea comes to us from ancient Greco-Roman civilizations and from medieval Europe. Thus, the birth and development of the notion of the common good is derived from civilizations far more homogeneous than contemporary American. The diversity in our society--of races, ethnic groups, religions, languages, culture, and lifestyle--makes it more difficult for us to understand and assent to the idea that there is some good or goods that are of value to us as members of society irrespective of our many differences.

American politics, especially in the twentieth century, work against generation of a practical consensus on the common good. The checks and balances built into our Constitution hobble attempts to develop unitary policy visions. Moreover, interest group politics encourage the perception that the public interest is merely the balance struck among competing, highly organized, and well-financed private interests. In other words, Americans tend to think of the common good in descriptive terms instead of normative terms: how the political agenda is set and carried out by the influential few rather than what is best for the nation taken as a whole.(4)

Also, our excessive American individualism has enshrined such a thoroughgoing relativism in our cultural affairs and our intellectual life that we have become deeply skeptical about assertions of ethical goodness or badness that move beyond what any person takes to be good or bad in his or her own experience.(5) Even the most homogenous societies--say the Athens of pericles or the Florence of Machiavelli--can have deep disagreements about which choices serve the common good. American is not distinctive in his sense. Our distinctiveness lies in a dogmatic normative relativism pervading our public life: Nop one has the right to tell anyone else what is good, not only for him or her, but for us. This disposition regards claims about the common good, no matter how modest in substance and style, as arrogant and oppressive.

As a result, surprisingly little has been published on the common good in contemporary scholarly literature.(6) In John Rawls's influential Theory of Justice, for example, there are only two brief references to the notion of the common good, in spite of considerable attention to the theories of the good.(7) Thus, there is no contemporary consensus on the meaning of the notion and little explicit discussion of it.

In spite of these daunting challenges, discussion of the common good is imperative if public policy is to reflect anything more than money, opinion pools, and assertions of individuals' rights. There must be some moment in public life where this question is engaged in its simplest ethical terms: What course of action is best for us? This is especially true when the arena in question--dying and care for dying--is so important to individuals and therefore to society, the context in which individuals are made. The following brief reflections on the common good are offered in hopes of advancing such a discussion.

The common good is a good for all, not a good for each. The common good is something collective, not simply the sum of what is good for each member of the society in a distributive sense. It is a good that pertains to the general social realationships in which individuals seek specific goods. Because the common good is a general good, it may frustrate acquisition of specific goods for individuals.

Traffic lights, for example, plainly serve the common good because they allow for orderly movement through dangerous intersections. They structure social relationships in a way that serves everyone's interests generally. Yet any number of inidividuals can be frustrated by the order traffic lights impos. It plainly serves the common good to prevent environmntal destruction of rivers. The beneficiaries of this application of the common good include generations into the future. But the measures necessary to protect rivers from environmental destruction may thwart goods for others, including the creation of jobs and other economic opportunities. It serves the common good to ban romantic relationships between psychiatrists and their patients because of the emotional vulnerability of psychiatric patients. Yet this ban may frustrate many mature and conflict-free romances between some psychiatrists and patients.

In each of these cases an important public good is at stake--safety in transportation, the integrity of our natural environment, protection of the vulnerability of patients--even though other goods legitimately sought by individuals may be frustrated b y each of these. Thus, discussion of the common good cannot begin and end with what serves the good of each and every person in society. Nor can it be left an open question morally whether it is better or not to save lives at intersections, better or not ot preserve the environment, better or not to protect the valnerable from exploitation.

On the other hand, measures that serve the common good must serve the interests of individual persons in general and in the long run. It must, as the words themselves suggest, provide a mutual benefit that all can share. So the common good must include goods that serve the interest of individual persons. It cannot be use to violate an individual's basic human rights. This is an especially demanding standard in a society with strong traditions of respect for persons ans autonomy. So although the common good is not equivalent to the good of each, no good can be part of the commonm good if it does not serve the good of most individuals over time.

The tension between serving all, but not each, and yet respecting individuals can be located more precisely in the social relationships that fulfill or frustrate individual persons. The idea of the common good assumes a social realims: Society is real. It...