A good bit of public attention in recent years has been focused on developments at the beginning of life: new reproductive technologies, for instance, and research on embryos. But questions about what we ought to do for those near the end of life may be more enduring and are, at least by my lights, more puzzling.
My aim here is to think through a few of those puzzles--not so much to solve them as simply to seek increased clarity about where and why we are puzzled. To the degree that I have a thesis to assert, it is captured in the words of Edgar in King Lear: "Men must endure / Their going hence, even as their coming hither; / Ripeness is all."
Let us suppose that we can agree on the following points. (Not everyone will agree, of course, but the most fruitful clarifications and discussions often arise among those who already agree on a good bit. Moreover, these points of agreement have been--and, I think, in considerable measure still are--widely shared in our society.)
* We are not "vitalists," as that term is sometimes used. A vitalist thinks that preserving life (even, as it is sometimes put, "mere biological life") is always the most important human good--and, hence, that life must always be preserved if it can be, at whatever cost to other goods. If we thought this, we could not have a category of permissible "allowing to die."
* We come to our deliberations about end-of-life care with some principles in hand, but we also form judgments about particular cases. There are bound to be instances in which our principles suggest one course of action, while our sense of the particulars of the case inclines us in a different direction. In such instances neither the principles nor our response to the particulars always holds trump in moral reasoning. To be sure, some principles we would be reluctant to change: they are so fundamental to everything we believe that changing them would be akin to a conversion. Likewise, there are some cases about which we can hardly imagine changing our mind. But our deliberations always move back and forth between principle and particular response, and adjustment can take place on either pole.
* Among the principles we want to uphold but must explore in relation to cases is that we should never aim at or intend the death of any of our fellow human beings (recognizing possible exceptions in cases where they are themselves threatening the lives of others). A slightly different but related formulation would be that we want to affirm the equal dignity of every human being. Hence, we should not think of ourselves as possessors of another's life or judge that another's life is not worthy of our care. (We might add that there is nothing wrong with wishing, hoping, or desiring that a suffering person die; the wrong would lie in acting in a way aimed to bring about that person's death.)
* Committed to such a principle of equal respect, we are led quite naturally to a certain way of caring for others who are ill, suffering, or dying. On the one hand, we should not aim at their death (whether by action or omission). We shouldn't do whatever we do so that they will die. On the other hand, because we do not think that continued life is the only good, or necessarily the greatest good, in every circumstance, we are not obligated to do everything that might be done to keep someone alive. If a possible treatment seems useless or (even if useful) quite burdensome for the patient, we are under no obligation to try it or continue it. And in withholding or withdrawing such a treatment, we do not aim at death. We simply aim at another good: the good of life (even if a shorter life) free of the burdens of the proposed treatment. There is nothing terribly unusual about this. All of us, all the time, choose among various life courses open to us. When we are young, we may have many life choices available. The older we get, the more that range narrows. If we become severely ill, the range may be quite narrow. And if we are irretrievably dying, the narrowing process may have left almost no choices at all. Yet, all along the way, we choose a life from among this range of life choices. We may choose a life that is more daring and heroic (though shorter) than some other possibilities. That is not the same as choosing death. Likewise, one might imagine a severely ill patient deciding to forego a painful round of possibly useful treatment--choosing thereby a predictably shorter life, but a life free of the burdens of that treatment.
It is quite possible that we can agree on these points, yet not agree entirely on what is right to do in certain cases. Two sorts of cases, in particular, are baffling. There are patients who seem to be increasingly, or even entirely, beyond the reach of our care. The patient in a persistent vegetative state would be at the furthest boundary--still clearly a living human being, though seemingly unaware of any care we provide, but able to live indefinitely if given tube feedings. There are also patients...