Baroness Warnock, a leading British medical ethicist, has publicly asked a question that many people, philosophers and lay people, have been pondering privately: “Is there a duty to die?”
Solidifying her reputation as a “philosopher provocateur”, Lady Warnock, a long time advocate of euthanasia, whose previous work has included investigations of fertility treatments, and special education for disabled students, dares to say what has previously been unspeakable. According to an interview earlier this month in the Times Online:
“If you’re demented, you’re wasting people’s lives – your family’s lives – and you’re wasting the resources of the National Health Service,” she said.
“I’m fully in agreement with the argument that if pain is insufferable, then someone should be given help to die, but I feel there’s a wider argument that if somebody desperately wants to die because they’re a burden to their family, or the State, then I think they, too, should be allowed to die.”
No one could accuse her of being reticent. The Baroness elaborates:
“With 700,000 people suffering, it really is a problem that has got to be faced. The fact is we have to take a fairly unsentimental view. Care may get better, but if so, at huge cost. There’s no point saying we ought to spend more, because we can’t.
“People talk about it as if the only respectable motive for wanting to die is for your own sake. But it seems to me just as respectable to want to die partly for the sake of others, and for the sake of society.”
The Baroness gets to the heart of the matter and does not flinch:
“If society has an obligation to look after them, I really want to know what for? For whose benefit? It’s not for the benefit of society, as the person is not in a position to contribute, and it’s not for the benefit of the person, so it must be something abstract about our being unable to bear saying ‘We can’t do this any longer’.
“If I were in a state of acute misery or pain, or an insufferable degree of dependency, I don’t see why I should feel an obligation to others to let them keep on changing my nappies.
“It sounds very callous, but most people I know dread being kept alive in a state of mental incapacity, more than cancer or anything else. If so, then I don’t see why society should force them to go through with something they fear the most.”
Not surprisingly, Lady Warnock’s comments have ignited controversy. Her comments have been vehemently criticized by Alzheimer’s associations, Right-to-Life groups, and politicians.
I do not agree with the Baroness’ claim that there may be a moral duty to die, but I think she is asking the right questions about the way that the senile elderly are being kept alive at tremendous cost, both financially, and also psychologically, to family members and care givers. She puts is quite succinctly: “If society has an obligation to look after them, I really want to know what for?”
We need to ask ourselves the same question in the US. Does anyone benefit from our perverse insistence on indefinitely extending the lives of the senile elderly? Are we fulfilling the wishes of the elderly people involved? Would they want to be kept alive, incapacitated, incontinent, and incapable of participating in the most basic tasks or social interactions? It’s difficult to imagine that anyone would want that.
And if we are not keeping these people alive for their own benefit, are we doing it to satisfy ourselves of our own moral values as a society? If so, do we have any right to use other people in an effort to make ourselves feel better?
Does it make any sense to spend a major proportion of the healthcare budget on people who are virtually insensate and will never recover? Does it make any sense, financially or morally, to divert resources from young people, who may not even have access to the healthcare system, to elderly people who have already received a lifetime’s worth of benefits from that same system?
There are no easy answers to these questions, but Baroness Warnock has done a service in raising them. It is long past the time where we should examine the rarely examined principle that the lives of the senile elderly should be extended indefinitely by the continuous use of vast amounts of human and financial resources. The Baroness has gotten to the heart of the matter: “For whose benefit?”
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I am for the right to die, but I have also run across heirs who do not have the best interests of their elderly family members at heart.
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I'm unsure how much conversation your post will elicit and will be checking back with interest. Discussing death forces each of us to face mortality and that is always tough. Just as a for example due to my dad's health scare this past month, I wrote him a will, a health care directive and a general power of attorney for heath care which we executed at the hospital mere hours before his surgery. He had not written a will since I was two years old. I can write those documents in my sleep and work free for my parents, but yet it took major surgery to force him to contemplate dying and what level of care he would want if he was not able to make decisions for himself.
Life is uncertain. A bus could run me or you over today on our way to martini lunch and there you or I would be, possibly unable to communicate our desires. Which is why it is so important to make our wishes known before fate strikes us down. I do not want to be Terry Shiavo.
I am conflicted on this one--having first voted against then for our Oregon Right to Death with Dignity act. I feel my second vote was correct as I believe in choice. This has been borne out by Oregonians signing up for this, in order to have control over their dying, yet not using it in the end. This bill has also improved end-of-life care to manage depression and pain.
I am reminded of humankind's ultimate "Other"--the Neanderthals. They have often been portrayed as the "losers" and judged more primitive than us superior homosapiens. Archeologists uncovered Neanderthal remains of an old (30 or 40-year-old) man who had been severely crippled. The fact that he survived his early accident but was kept alive as he could not fend for himself speaks to the humanity of the Neanderthal. How can we be any less humane?
I all for the right to die, but Warnock's comments are very disturbing, troubling and frankly they remind me of one of the Nazi propaganda films I saw in high school.
Slippery slope indeed.
1. As a Catholic, I am opposed to euthanasia of human beings. However, for the senile elderly, I do see it as humane and decent to allow them the option to discontinue treatment or life support when there is no chance of a meaningful recovery - provided the patient does not suffer as a result of stopping treatment.
2. Having worked in health care and dealt with the decline of several elderly relatives - I know that it is often the family that insists upon heroic life-saving measures, even when there is no hope of recovery for the patient. Even when there is an advance directive, the spouse still has the right to keep the patient "alive" and they often do, despite what they "thought they'd do" when thinking about the future while sitting healthily in an attorney's office drawing up the will.
3. Even patients who at one time said they'd "rather just die" than go through, say, chemo or major heart surgery in their late 80s, often choose differently when faced with the reality of impending death.
It's a complicated issue.
"To elaborate just a little more -- I am for "the right" to die, but not "a duty." The decision would have to be the individual's own and not one pressed on them by their family."
I do think that terminally ill people have a right to die, but certainly not a duty.
If I understood correctly, Lady Warnock was talking about the senile elderly. Even then, I doubt that she is correct that there is "duty" to die. I'd frame the issue somewhat differently:
Do we have a duty to keep the senile elderly alive after they no longer know longer know who they are? The reality is that we do not allow them to die, which is what would happen without a massive amount of effort and expenditure on our part. Who benefits from our refusal to let them die?
"The fact that he survived his early accident but was kept alive as he could not fend for himself speaks to the humanity of the Neanderthal. How can we be any less humane?"
But is it humane to keep a senile elderly person alive once she no longer knows who she is? Is it humane to preserve her life through forced feeding, incontinence and continued application of medical technology?
"Slippery slope indeed."
It is a slippery slope and fears that a law that no longer impels us to keep the senile elderly alive does raise the possibility that this would be extended to people who are impaired for other reasons. Yet is this a justification for keeping the truly senile elderly alive? To protect other people? What about their own suffering?
"As a Catholic, I am opposed to euthanasia of human beings. However, for the senile elderly, I do see it as humane and decent to allow them the option to discontinue treatment or life support when there is no chance of a meaningful recovery - provided the patient does not suffer as a result of stopping treatment."
I suspect that religious doctrine does contribute to our unwillingess to let people die after they no longer no who they are. Some people (not you, obviously) feel that religious doctrine always conflicts an humane efforts to let people die, but I'm not sure that is really the case.
Needless to say, I am pro-right to die, and I hope we can have this debate and draw some lines. As much as I loved my grandma, it was a waste of resources to keep her alive those last few years, and I doubt she would have wanted that anyway. I wish she had had the chance to weigh in before she was too far gone. Like Ida, the 100 year old that had her leg amputated in one of Amy’s other posts, life is not always the compassionate choice.
"for the last couple of years, she was just a shell. She would sit in her chair, eyes closed, head titled to the side, mouth open, completely unresponsive to her environment. Even in that sorry state, the doctors continued to resuscitate her when her heart stopped, despite grandpa’s pleas that she be allowed to go quietly."
How very sad for her, for you and for your family. This is precisely the kind of situation that Baroness Warnock was trying to address. Who do we think benefits from keeping people like your grandmother alive.
"for the last couple of years, she was just a shell. She would sit in her chair, eyes closed, head titled to the side, mouth open, completely unresponsive to her environment. Even in that sorry state, the doctors continued to resuscitate her when her heart stopped, despite grandpa’s pleas that she be allowed to go quietly."
This mirror what my father in law is going through right now. My husbands mother had a SEVERE stroke two years ago, and my FIL struggled to keep her at home, but she need full term care and now she is in a nursing home. My FIL is at her side 24/7 but sadly my husband has sensed that his father is starting to slip, so its no a good situation at all.
"Needless to say, I am pro-right to die, and I hope we can have this debate and draw some lines."
This is a denate we NEED to have, Yes!
Amy:
"Yet is this a justification for keeping the truly senile elderly alive? To protect other people? What about their own suffering?
Yes, these are extremely difficult questions and there are no easy answers.
On a lighter note, I like to call it "Weekend at Bernie's" syndrome.
The best argument is/should be... what is best for the patient? Not some measurement on a scale that weighs costs/benefits to society of a human being's existence. That's just wrong.
I admit I have a visceral reaction to the idea of a "duty to die." But I find that the further and further away I get from my Catholic upbringing, I become comfortable with a wider variety of circumstances that euthanasia is acceptable.
I suspect another reason people in general are so hesitant, besides religious orthodoxy, is the finality of death. To understate, it's hard to undo death. My five year old is paralyzed by any decision, no matter how small, that can't be undone. She frequently asks, but what if she wants to change her mind? Humans in general like to keep our options open, especially when it comes to life and death.
For those to compare these questions to Nazis or other reprehensible views aren't engaging in the actual quandary. If we accept that extreme pain unlikely to subside is grounds for euthanasia (acknowledging that some disagree), it stands to reason that there may be other situations where euthanasia is called for. Like senility.
The "pro-life" group in my state spends a lot of resources opposing health care reform. They assert that government run health plans will inherently lend themselves to rationing. (Surprise, they don't like the taxes necessary for a health plan to work.) Rationing becomes default euthanasia to them. I don't agree with their conclusions, but I also don't see an inherent immorality in, to use their lingo, "rationing." Isn't the reverse even worse? The reverse being many more people (often younger) being denied relatively cheap care that saves more lives?
Sometimes it takes a shocking statement like this one to move the discussion further. In my mind we need to allow people the right to die with a level of dignity. I can not say this time or that time for someone else, but as long as I have the ability to think for myself and express those thoughts, I think I should have a say.
There was a time, not too long ago, when the cutting edge of human progress could be found here. I hope we can get there again.
"Certain segments of those in power have already begun referring to the disabled and senile elderly, in fact anyone who does not work and contribute to the tax base, as "useless eaters". You'll hear that term commonly used soon enough. Lady Warnock's comments are simply the equivalent of the sound of a door opening."
I don't think so. There is a very great difference between someone who does not contribute to the tax base and someone who is forcibly being kept alive after they no longer have awareness of who they are and, as is always the case in senile dementia, have NO chance of recovery.
"Man is the only creature that prolongs the life of a fellow who can no longer contribute to the society."
That's true. However, being unable to contribute to society should not be the standard ending efforts to keep someone alive. The only reason to end those efforts is if the person no longer had any awareness of who he or she is, and no hope of recovering that awareness.
"The best argument is/should be... what is best for the patient? Not some measurement on a scale that weighs costs/benefits to society of a human being's existence. That's just wrong."
You raise two critical points.
The first is what is best for the patient, taking particular account of the patient's wishes. Virtually no one wants to be kept alive after he no longer knows who he is and is reduced to an existence of forced feedings, incontinence, and hours and hours of motionlessness in beds and chairs. The heart of the Baroness' critique is her question of who benefits from keeping people alive in this way.
Second, although the utilitarian argument is distasteful, and it not the only standard for determining what we should do, we still must consider the implications of what we are already doing. Whether we wish to recognize it or not, we already rational healthcare according to what the government will pay for. To the extent that the government is providing hundreds of millions of dollars of nursing home care to the senile elderly, it cannot use that money to fund prenatal care, care for children, and research into curing cancer and other diseases. A strong moral argument can be made that we are funding the wrong types of care.
"Is euthanasia part of the solution?"
Baroness Warnock is clearly talking about taking active steps to die, euthanasia. That seems to me to be getting a little ahead of ourselves. The first question that we should address is whether we are required to use measures to keep senile elderly people alive after they no longer know who they are. Although it is a difficult question, it is a much easier one than the issue of actively assisting death.
"I suspect another reason people in general are so hesitant, besides religious orthodoxy, is the finality of death. "
I agree. I think there is also a related issue that pushes us to forcibly keep people alive. No one wants to think that they would be allowed to die if they had a chance of recovery. They are most worried about the slippery slope argument articulated by Umbrellakinesis and ktm. If we mandate keeping everyone alive, regardless of prognosis, we will never start down that slope.
While that is certainly true, Lady Warnock challenges us to think about the impact of our philosophy on those at the top of the slippery slope. They can no longer speak for themselves, and we need to ask our selves if we are really serving their best interests by keeping them alive to prevent sliding down the slippery slope.
"I can not say this time or that time for someone else, but as long as I have the ability to think for myself and express those thoughts, I think I should have a say."
I strongly agree.
"As children we learn the phrase 'it's a free country' but if you don't have the right to die then you don't have this most fundamental of freedoms."
Yes!
1) medical care, which is designed to restore or maintain health and life
2) palliative care, which is designed to keep a patient comfortable
3) routine care, such as food, water, clean sheets, regular bathing, a heated or air-conditioned room, and so on, that simply maintain minimal conditions of human existence.
Medical care can be discontinued if it is believed that such care is "futile" -- in other words, not really doing anything but extending the process of dying, or not significantly contributing to an improved quality of life. Of course, the problem is who defines what is "futile."
I can see why discontinuing medical care in the case of a senile patient makes sense. You don't want to do a cardiac bypass on a 90 year old senile patient. One the other hand, it's difficult to say that, for example, a urinary tract infection in a senile patient shouldn't be treated.
Withholding routine care from a senile patient would be very ethically problematic. It's one thing to discontinue a senile patient's feeding tube, quite another thing to stop feeding a senile patient by mouth. I'm not sure what the moral justification for that would be.
"One the other hand, it's difficult to say that, for example, a urinary tract infection in a senile patient shouldn't be treated."
I don't find it difficult and I will say it: I makes absolutely no sense, indeed it is cruel, to treat a urinary tract infection in a senile elderly person.
Here's why. Everyone is going to die. People with senile dementia are trying to die, usually at the end of a long life, and with absolutely no hope of recovery. All we do by treating a urinary tract infection is ensure that they won't die of a relatively painless cause, but they have to wait for something more painful and more serious. Do we really have the right to do that? Does anyone want us to do that to them? If no one wants that, why are we doing it? Who is benefiting from our decision to keep these people alive.
However, if we are not our bodies, or if we are more than our bodies, then the question of whether or not we have a duty to die becomes more difficult.
It seems to me that concepts such as "duty" and "burden" only really make sense if people are more than just physical husks, if in fact we are spiritual as well as physical. These are spiritual concepts.
So I guess it depends on whether or not you believe you are a spiritual being having a human experience, or whether you are a flesh-and-blood machine with a rudimentary form of consciousness.
If the former, and if those caring for you are also the former, then there may be great spiritual value in your suffering. If the latter, then there may be no value in it.
I will not be giving Lady Warnock my medical power of attorney.
Well, what you would have to do is to have senility legally defined as a terminal condition, in the same way that PVS was defined in Florida as a terminal condition (a definition that was pivotal in the Schiavo case.) The problem is that there are varying degrees of senility, and I think it might be difficult to define at what point senility would be seen as terminal.
And then I think you run into a "slippery slope" in the case of mental illness. If you refuse medical care to an elderly senile patient, do you also refuse medical care to a severely mentally ill elderly patient? If so, what is "elderly?"
Also, another problem is that antibiotics are so inexpensive and so easy to administer that, in the minds of many people, they would be considered more like routine care than medical care. A lot of people would not like the idea that we would let some old guy die from a UTI because we didn't give him ten bucks worth of Cipro.
I'm not really arguing with you here. It's just that there are a lot of issues that would have to be worked out, and expanding the list of terminal conditions to include senility and perhaps mental illness would be resisted by many people.
My mother has recently been diagnosed with dementia but she prefers not to give either of her children medical power of attorney or to otherwise specify her wishes. I can't seem to convince her that it would be to her benefit. So she will probably be subjected to uncomfortable, undignified, expensive, and possibly unwanted procedures.
I wish this subject were an academic one, but it's a little too close to home.
But isn't there a point at which a person becomes so disabled that we would say that the person isn't having a "human" experience in any significant sense?
I mean, if you are immobile, can't communicate, can't comprehend, perhaps even can't see or hear, can't care for yourself, the normal enjoyments of life are gone, and there is no chance of those functions being restored, what is the goal of medical care? What are we trying to accomplish? I would argue that at the point at which the only goal of medical care is the mere extension of life, at that point medical care is futile.
And at that point, if the patient or the patient's family has the financial resources and willingness to use those resources to continue life in such a condition, that's great. But I would argue that at that point the public has no obligation to pay for continued care.
...BUT, it certainly is something that intelligent, reasonable people can discuss. I doubt the climate is right for even a modicum of discussion on this topic in our country. Unfortunately, the religious (read that, superstitious) among us have veto power over this kind of thing.
Good for the lady to raise the issue. Hooray that she is willing to take the barbs sent her way in response.
I think the concept of “duty” presented by Warnock is not exactly the same as is being discussed. In my reading of her own words, it seems she is comparing this “duty” to the same sort of self-imposed duty one might feel in giving his/her life for the benefit of others in a variety of situations, all of which society views, for the most part, as honorable acts; military service, police service, firemen, etc --- actions considered noble in large part because the person chooses to do so rather than being coerced into doing so.
It does not appear to me that she is saying each of us has a duty to die unwillingly if we become ill. But there may be those among who do, in fact, feel a sense of “duty”, a sense of obligation, to do what will benefit others, and that may include our own dying. Then she is saying, in those instances, why should we refuse to allow them this choice when we allow others that choice in other settings.
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I don't know.
"Here's why. Everyone is going to die. People with senile dementia are trying to die, usually at the end of a long life, and with absolutely no hope of recovery. All we do by treating a urinary tract infection is ensure that they won't die of a relatively painless cause, but they have to wait for something more painful and more serious. Do we really have the right to do that? Does anyone want us to do that to them? If no one wants that, why are we doing it? Who is benefiting from our decision to keep these people alive."
All the forms of assisted or permitted death - abortion, suicide, euthanasia - really should be debated. I would prefer debate and decisions at state level where communities are closer to the decision-makers leaving an allowance for people to move elsewhere when they disagree.
Every living thing dies. Having the right to choose our death is a fundamental liberty. If society wishes to interfere with that right they force families and individuals to seek relief outside of the law and perhaps in more painful and dangerous ways.
I have a very dear friend whose uncle shot himself in the head a year ago because he did not wish to continue cancer treatments or face the pain anymore. He tried very hard to arrange it so his wife would not be the one to find him but his plans didn't work and you can guess the pain of it.
Give us liberty for heavens sake. This enforced mothering of society over every little thing, whether smoking or eating or dying, give it up.
Live and let live. Live and let die.
I reread Baroness Warnock's words several times, and nowhere in them do I see the word "duty", nor any equivalent statement. She, like many who have commented here, seems to me to be talking strictly about the right to choose.
That said, I offer my opinion that while you do not have a civic duty to die, you most assuredly do have an evolutionary or natural duty to do so. In fact, there is no escaping it. You WILL fulfill that imperative, whether you want to or not.
I made the comparison to Nazi propaganda, because comments like Warnock's was how alot of "Selective "mercy" killing" started.
The infirm, mentally ill and disabled were the first to experience the "final solution" (Gods rest their souls)
Yes, this debate needs to happen, but stripping the value of human life to nothing more than what each person's contribution/burden to society is disturbing.
I support a persons right to die, it should be THEIR choice, not the govt's.
My great, great fear is not death, but significantly outliving my sane, rational mind. That, to me, is true Hell.
*****On dying dutifully: “During life, a person will have been admired if he really wanted to do his duty, or to do what he regarded as in the best interests of his family, his community or his country. He will have been thought well of for not always preferring his own interests to those of others. Why, then, when he has reached the end of what he may regard as his useful life, may he not be allowed to do what he thinks is in the best interests of those he loves, or impersonally, in the best interests of the State, which is expensively caring for him? Why may not someone who has always really wanted to behave well be recognised and admired in continuing that desire, in asking for death?”
An analogy that I think is appropriate to this discussion is comparing schizophrenia and dementia. Individuals with schizophrenia often go off their meds because they miss feeling “alive” even though they are delusional without those meds. This seems to say that even though they are not coherent on our terms, they are still sentient even when delusional. Might this be true for senility, also? Might these individuals still be gaining some degree of human experience of a sort to which we cannot relate?
And if they decided before-hand that they did not want to live that way based on a errant perception or belief about how it would be, maybe they would like to continue, but can no longer communicate that to us. The problem is that we don’t know what they are experiencing. I am for honoring their requests made before-hand, but I have to wonder if once they become delusional, they would still make the same decision if they could.
The idea of a duty to die is sickening to me. It is a concept that is destructive to a balanced socialism. Indeed, it is the soul of fascism, which can be found at the intersection of the extreme left and right.
Yes, "straw man" seems in order here...
She has an advanced directive, but she's told us, her daughters, in no uncertain terms, and in words that I will someday also say, "Please prolong my life, not my death."
“If I were in a state of acute misery or pain, or an insufferable degree of dependency, I don’t see why I should feel an obligation to others to let them keep on changing my nappies.” This is a personal choice, based on how she feels. She talks about people being forced to stay alive, but at the same time she also says dementia patients should be euthanized for the good of society. Should?
I find a lot wrong with the industry of the old and dying, not with those needing care. Don't get me wrong - if someone wants to actively die, I respect that choice, but I would never persuade or dissuade it. I feel it is a personal choice and I resent the Baroness for trying to push this as a societal problem. She is forcing a different issue, the value of the elderly in society, instead of a person's right to choose.
There is no "duty" or "right" to death. These both imply a correct way to die, or a correct way to deal with dying members of society. Personally, I feel there is as much to learn from dying as there is from living and birth. Having said that, I have determined under what conditions I believe a DNR is appropriate.
"If the former, and if those caring for you are also the former, then there may be great spiritual value in your suffering. If the latter, then there may be no value in it."
I agree, and for people with certain religious beliefs, there is a "duty" to live. Moreover, I don't agree with Lady Warnock that there is a "duty" to die. However, I don't think the rest of us have a duty to forcibly keep people alive indefinitely when they have lost all awareness of themselves.
"And then I think you run into a "slippery slope" in the case of mental illness. If you refuse medical care to an elderly senile patient, do you also refuse medical care to a severely mentally ill elderly patient? If so, what is "elderly?"
No, the only situations I am talking about are those where recovery is impossible. Although Lady Warnock goes much farther than I would, I suspect that she would specifically exclude mental illness.
"Also, another problem is that antibiotics are so inexpensive and so easy to administer that, in the minds of many people, they would be considered more like routine care than medical care. A lot of people would not like the idea that we would let some old guy die from a UTI because we didn't give him ten bucks worth of Cipro."
It's not a matter of money, in this case; it's about preventing human suffering. Who benefits when we indefinitely prolong the life of the senile elderly? It's not them, so who is it? (rhetorical questions; I'm not asking them specifically to you)
"I would prefer debate and decisions at state level where communities are closer to the decision-makers leaving an allowance for people to move elsewhere when they disagree."
If it is truly a right as you suggest, and I agree that it is, we should not leave it in the hands of state law makers. It should be decided at the Federal level, in my judgment.
"When my aunt was diagnosed with dementia she immediately got her affairs in order, gave me her medical power of attorney, in which she specified she wanted no extraordinary means to keep her alive. Without that document, over the next several years she would have been hooked up to feeding tubes whe she refused to eat and been rushed to the hospital emergency room every time she fell down. Since she specified she didn't want such care, she has been cared for but not subjected to extraordinary and uncomfortable and possibly upsetting procedures."
She was very wise to do so. Unfortunately, many people are like your mother and leave the decision making until it is too late to decide.
"...BUT, it certainly is something that intelligent, reasonable people can discuss. I doubt the climate is right for even a modicum of discussion on this topic in our country. Unfortunately, the religious (read that, superstitious) among us have veto power over this kind of thing."
I wonder if it was easier for Baroness Warnock to raise the issue in her country than it would be here. The US is probably the most religious of all first world countries and definitely stifles debate.
"In my reading of her own words, it seems she is comparing this “duty” to the same sort of self-imposed duty one might feel in giving his/her life for the benefit of others in a variety of situations, all of which society views, for the most part, as honorable acts; military service, police service, firemen, etc --- actions considered noble in large part because the person chooses to do so rather than being coerced into doing so."
That's a very good point. I hadn't considered that until I read your comment.
"The idea of a duty to die is sickening to me. It is a concept that is destructive to a balanced socialism. Indeed, it is the soul of fascism, which can be found at the intersection of the extreme left and right."
For myself, I don't find it sickening, but I don't think that such a duty actually exists.
"... while you do not have a civic duty to die, you most assuredly do have an evolutionary or natural duty to do so. In fact, there is no escaping it. You WILL fulfill that imperative, whether you want to or not."
Of course, and the only thing keeping the senile elderly from doing so is that we forcibly keep them alive.
"My great, great fear is not death, but significantly outliving my sane, rational mind. That, to me, is true Hell."
About 20 years ago, the father of a friend was diagnosed with early Alzheimer's disease. Having witnessed his mother's prolonged decline and death, he was terrified that the same thing would happen to him. No one could give him assurances that it would not. He committed suicide instead.
He could have had a few more years of meaningful life, but he chose to give those up in exchange for making sure that he would not end up the same way that his mother did.
People should be left in a position where they feel that those are their only choices.
"And if they decided before-hand that they did not want to live that way based on a errant perception or belief about how it would be, maybe they would like to continue, but can no longer communicate that to us. The problem is that we don’t know what they are experiencing. I am for honoring their requests made before-hand, but I have to wonder if once they become delusional, they would still make the same decision if they could."
I'm not sure what Baroness Warnock would say, but I'm not talking about people who are delusional. I'm talking about people that have lost all capacities except involuntary ones like breathing and digesting food ... and suffering. The ability to suffer is one of the last things to go. These people can feel pain and much of what we do to keep them alive can be painful. Why are we extending their pain? Who benefits?
"She has an advanced directive, but she's told us, her daughters, in no uncertain terms, and in words that I will someday also say, "Please prolong my life, not my death."
Your mother is extremely articulate and has captured the choices succinctly. Most people agree with her.
"If she's a Baroness she's the product of centuries of inbreeding and would be well advised to keep her mutant thoughts to herself."
Why?
"I feel it is a personal choice and I resent the Baroness for trying to push this as a societal problem. She is forcing a different issue, the value of the elderly in society, instead of a person's right to choose."
But whether you agree or disagree (and I disagree with her about a "duty" to die), this is a societal problem of massive dimensions. As I said above, although we don't acknowledge it, we are already rationing healthcare. The current system presupposes that the senile elderly have MORE value than children and the mentally ill (among others) whose care is not guaranteed no matter how badly they need it.
It seems to me that we are ethically obligated to take a hard look at the choices we have made as a society and ask ourselves if this is the best possible outcome.
"I wish that people who were facing mental decline and/or terminal conditions had more of a choice regarding the end of their lives. I wonder if such a concept could ever be possible."
Theoretically, a living will provides a choice. Unfortunately, living wills are often ignored by hospital personnel.
One question is the extent to which a senile person suffers. Rick Lucke put it this way:
"Might this be true for senility, also? Might these individuals still be gaining some degree of human experience of a sort to which we cannot relate? . . . The problem is that we don’t know what they are experiencing."
I think he has a point. I have not had enough contact with profoundly senile people to know how much they may or may not be suffering -- whether or not there may be some residual quality of life they experience that is not apparent to us.
To the extent that a senile person suffers, is that a result of the senility, or because their suffering has not been properly assessed and treated? If is it a problem of insufficient assessment and treatment, then suffering is really more a matter of palliative care, of making sure that the patient is as comfortable as possible.
Evaluating pain and discomfort in senile patients is not easy, but protocols have been developed that help in that assessment. One protocol notes that
"Common signs displayed by people with late-stage dementia who experience physical or emotional discomfort include: increased agitation, fidgeting, or repetitive movements; tense muscles, body bracing; increased calling out or repetitive verbalizations; decreased cognition, decreased functional ability or withdrawal; changes in sleep pattern; falling; increase in pulse, blood pressure, and sweating."
So I think the first question to ask would be the extent to which the suffering of senile patients can be reduced by proper comfort care.
The problem with withholding basic medical treatments from senile patients is that, in the absence of an advanced directive or other evidence, we end up deciding whether *someone else's* life is worth living. And therein is the slippery slope.
Again, I'm not disagreeing with you, but there are many factors that have to be considered and any public policy has to take all of those factors into account.
"My great, great fear is not death, but significantly outliving my sane, rational mind. That, to me, is true Hell."
Me, too. In fact, I hate when that happens.
My great irrational fear is of being buried alive. Premature interment, as in an Edgar Allen Poe story, or a Vincent Price horror movie. This is a childhood fear that has survived into adulthood, and while reason tells me that the likelihood of it happening is low, it still could happen.
Or, I could be buried alive in my own flesh, like a Terry Schiavo. The irony is that if I were actually buried alive (you can see I've given this some thought), I would suffer some minutes or hours of the purest, most agonizing panic imaginable, before asphyxiating or suffering cardiac arrest. I would then be able to die.
But for those like Terry Schiavo, imprisoned in their own broken bodies, the imprisonment is prolonged by well-intentioned relatives and their insistence on continued "life" support.
What seems to bother most people on this site when imagining themselves ancient, insentient, incontinent, and all-but-dead, is this "buried alive" predicament. And some have alluded to suicide as a preferable solution.
I must say, a quick, bloody, bullet to the brain seems preferable to a prolonged, painful and expensive decline. But that thought led me to this one:
Does my life even belong to me, that I can throw it away? Or does it belong to the one who gave it to me, and is my duty to live it out to whatever end he/she/it has in store for me, having faith that the one who called me into being will not send me out in a way I cannot bear?
Thanks again, Amy, for a thought-provoking post!
You said, “I'm talking about people that have lost all capacities except involuntary ones like breathing and digesting food ... and suffering. The ability to suffer is one of the last things to go. These people can feel pain and much of what we do to keep them alive can be painful. Why are we extending their pain? Who benefits?”
I understand your point, and I agree, although once again I have to say that we don't actually know what they are experiencing. And I think the point Warnock is making is that this applies to a broader array of suffering than just that to which you refer. I think her point is that perhaps we could, and should, consider a person's will to die to lessen their family's suffering --- even before they reach that stage --- as a selfless, heroic, honorable, courageous, “dutiful” act, rather than interfering to prevent them from such an act.
And for those religious folks who think such an act is not courageous, I might wonder why they consider Jesus courageous. Is this not the supposed idea behind his suicidal behavior? Was his committing himself to premature death not done supposedly to alleviate the suffering of others? I wonder if such an act would not be one of the most Christ-like things one could do.
"... once again I have to say that we don't actually know what they are experiencing. "
But we have chosen to ASSUME that what ever it is, it is worth extending. That is the assumption that we need to question, particularly because there is no objective evidence that this assumption is correct.
I found caring for the senile elderly the worst experience of my internship, because it seemed obvious to me and to everyone else that what we were doing by treating these patients in the hospital was extending their suffering. Yet over and over and over again, every single day, we rationalized our behavior by saying "we don't have the right to decide." But we WERE deciding, and they were paying the price.
A decade later, as a result of that experience, I spent time doing graduate work in medical ethics to try to understand what is going on. There are no ethical principles within non-religious medical ethics that compel us to treat the senile elderly the way that we do.
Honestly, I don't think that keeping them alive is for their benefit. It is solely for our benefit. Our deepest fear is that someone will end our life when we are still sentient, simply because we are old and infirm. Therefore, we insist that everyone who is old and infirm must be kept alive indefinitely, even those who are not sentient, to protect ourselves from our own fears.
Our efforts to consider our own psychological needs first are aided by the fact that the senile elderly are deliberately hidden away from view, warehoused in nursing homes, with occasional trips to the hospital for added suffering.
Simply put: we can no longer justify indefinitely prolonging the life of the senile elderly based on an unexamined assumption that they might be enjoying a quality of life at some level we cannot perceive. If we are indeed prolonging the suffering of hundreds of thousands of people, we cannot let ourselves off the hook by claiming that we were trying to err on the side of caution.
"Does my life even belong to me, that I can throw it away? Or does it belong to the one who gave it to me, and is my duty to live it out to whatever end he/she/it has in store for me, having faith that the one who called me into being will not send me out in a way I cannot bear?"
Those are religious questions and for many people, religion will provide the answer to them.
I would ask the opposite question. Should forcibly be extending the lives of those who are naturally trying to die?
"My geriatrics clinical instructor said that we were not to judge our elderly patients by our own standards of living. He said that what may look like an awful life to us, could be very rewarding for someone at a different stage. I wonder if that couldn't even be said for those that don't know who (or what) they are."
My personal opinion is that such statements are an ethical cop-out. There is no evidence that those individuals are leading a rewarding existence, and copious evidence that they are suffering within the limits of their capacity to suffer. Therefore, there is no justification for holding tight to an assumption that is directly contradicted by what we see.
Amy, you and I worked in an older medical community so know that having a family doc, who knew the patient and the family, made it possible to intervene and graciously end life. Families suffer when the government or the medical ethics committee members become involved. Our Oregon statue of Death with Dignity act comes close to government supporting personal choices.
Thanks again for opening these doors.
Imagine if you will for a moment a senior person who is suffering from senile dementia seemingly unaware of who they are and their surroundings and completely unable to interact with others on any social level without any hope of recovery. Someone completely unable to excersise any control over their body or it's basic human functions. Then imagine that their soul is actually alert, vibrant, and fully functioning but torturously trapped within a physical form that will not allow them to convey in any way the fact that they are "still there". Year after year we keep their physical forms functioning and alive while thier mind endures what would surely be an excrutiating existance. Then one day their heart fails and they are awash with joy and euphoria that this horrific emotional ordeal will soon be over. But oops, no, I'm sorry-here comes the doctor saving your "life" and the nightmare begins anew.
If the above described scenario were remotely possible would anyone wish to inflict such a fate on a loved one?
"... having a family doc, who knew the patient and the family, made it possible to intervene and graciously end life. Families suffer when the government or the medical ethics committee members become involved."
It's true. Unfortunately, the days of the family doctor are in the past and not likely to return any time soon. Instead we have to fall back on medical ethics committees and the government.
"I still believe it should be decided at the state level, that is, unless you have given up completely on the concept of states as independent bodies of government."
My personal feeling is that basic rights, like those in the Bill of Rights, should be guaranteed by the Federal government, so no one can take them away.
Your comment is very powerful.
"Then imagine that their soul is actually alert, vibrant, and fully functioning but torturously trapped within a physical form that will not allow them to convey in any way the fact that they are "still there"."
Their soul or their mind? If it's soul, what does it mean to have a soul that is alert and vibrant, as opposed to a mind that is alert and vibrant?
There is a fundamental sociological underpinning which I think wealthy and poor, conservative and liberal, aristocratic and the sine-nobilitate (not in behavior but in legal documentation), can agree on: we are all better off if the person next to us (on a train, in a government hearing, in our employer's budget meeeting) values the principle that no one has the right to tell me when my right to continue breathing comes to an end.
Society could discard any individual for any reason, if given the chance to make such decisions. The idea that someone is OBLIGED to die to clear the way for those who might take over their estate or whose inheritance is being "squandered" in the care of that person, is offensive to humanity and to the virtues of a democratic society in essential ways.
And by the way, there is a clear moral discomfort and logical incoherence in the Baroness' argument, in that instead of simply positing and demonstrating that the irreparably frail have a "duty to die", she makes competing claims to prop up her untenable argument: she says for instance that "most people I know dread being kept alive in a state of mental incapacity, more than cancer or anything else. If so, then I don’t see why society should force them to go through with something they fear the most", which sounds a lot more like a moral argument for euthanasia than it does for sacrificing oneself for the benefit of society's purse.
She clearly wants to make it sound like she's thinking about the quality of life of the poor person suffering a terminal illness or reduced to a vegetative state, but that is not her argument; her argument is that one should give up their life when it gets expensive and time-consuming for younger, healthier people to maintain. She seeks recourse to the "I wouldn't want to live like that" argument to make herself sound less inhumane.
Essentially, she does not believe in the moral viability of her own argument, which is tantamount to admitting it is not an ethical argument, but an argument about how and when we decide that a human life is no longer worth the paper our money is printed on.
"It is an inescapable truth, and very sad, that the person making this argument is a baroness. In fact, it is shockingly offensive."
The Baroness is a "life peer". She did not inherit her title and it does not pass to her descendants. It is an honor awarded solely to her in recognition of her contributions to British medical ethics. Helen Mary Warnock was created Baroness Warnock by Margaret Thatcher in 1985.
"we are all better off if the person next to us (on a train, in a government hearing, in our employer's budget meeeting) values the principle that no one has the right to tell me when my right to continue breathing comes to an end."
No, I don't think we are all better off. That's why I wrote the post. The idea that we are all better off this way is an assumption that does not comport with the reality of senile dementia.
Moreover, it is merely an illusion that "no one" determines when your life comes to an end. Other people very well might determine to continue your life forcibly, long after you would have died naturally and painlessly.
"The world over people share the belief in the existance of the soul. Moreover, that the soul is infinite and continues when the body expires whether through ascention into heaven , realization of nirvana, or reincarnation to another form. In light of that universally held belief, is it unreasonable to posit that the soul would be acutely aware of its diminished ability to thrive?"
Either way, that information is never going to be accessible to us, so we can't use it to make decisions about whether or not we should forcibly extend life or aid people in taking their own lives.
There is a vast distinction, however, between that issue of sympathetic euthanasia and the concept, however well-intentioned, of a "duty to die". That one's death is an ethical act because it spares expense or trouble to other human beings is an enormous stretch by any contortion of any ethical principle from any age of philosophy. There have been civilizations that have enshrined such ideas in their written or unwritten laws, but such a concept is totally alien to the type of law we have in modern democratic societies.
Thank you for the information regarding the Baroness' peerage, and how she came by it. It's a worthwhile piece of information; it still sets her apart from the immense majority of people who live in her own country. It still gives her access to a rarefied stratum of high society, and I think there are a lot of people in this world who would object to anyone of privilege arguing that the state or the family should be spared the trouble of helping to ease the agony of the infirm.
I agree with the value of your posting this here, and I agree with your conclusion, as stated:
Does it make any sense to spend a major proportion of the healthcare budget on people who are virtually insensate and will never recover? Does it make any sense, financially or morally, to divert resources from young people, who may not even have access to the healthcare system, to elderly people who have already received a lifetime’s worth of benefits from that same system?
There are no easy answers to these questions, but Baroness Warnock has done a service in raising them. It is long past the time where we should examine the rarely examined principle that the lives of the senile elderly should be extended indefinitely by the continuous use of vast amounts of human and financial resources. The Baroness has gotten to the heart of the matter: “For whose benefit?”
But I think it would be a troubling development if any government were to pass blanket legislation that imposed a ban on providing service in such cases.
"But I think it would be a troubling development if any government were to pass blanket legislation that imposed a ban on providing service in such cases."
What if, instead, the government simply refused to pay for such services? Almost all of these services are provided at government expense.
I think that you and I are basically in agreement. I agree with what you say, and only point out that there are, even as you have said, certain aspects of this issue that we just cannot know with full certainty. That lack of knowledge cuts toward both sides of any argument that might be articulated because of the uncertainty it creates.
I think it is important to point out that much of this discussion has been confused and muddied by the misrepresentation of Warnock’s statements. People are condemning her for something she did not say, AND arguing against that same non-statement.
Warnock’s point was merely that we should view it as an honorable and respectable act when someone is willing to forfeit their life for the benefit of their loved ones, or even for the benefit of their society, which is something that has been historically honored in virtually every culture known.
J.E. Robertson,
I’m not entirely clear on what you mean by this statement:
“That one's death is an ethical act because it spares expense or trouble to other human beings is an enormous stretch by any contortion of any ethical principle from any age of philosophy.”
Taken on its face based solely on what is written, your assessment would seem to ill-informed. History is full of examples in which such a death is considered honorable, and therefore ethical. I think there might be a problem with your understanding of what Baroness Warnock actually advocates. Her primary concern is that people have a choice of when and how to end their own life. Follow AmyMD’s link in the second paragraph and read Warnock’s own words.
I don't know if I'm convinced that this is true. I have found that quality of care is about money. The elderly tend to have more money than the young. Very few young families have good coverage or money. If you live in poverty - you're screwed.
My step-grandmother's stroke was treated in the old-fashioned manner - as if it was a stroke from God. She was taken to the hospital within 15 minutes of having her stroke, yet she received no modern treatments. This was in 2004. Her family were too accepting of the situation and trusted the doctors. From that point on, her family treated her as if she senile. She died in 2006. She had insurance, but the hospital didn't have the money to be modern. I still get creeped out when I think about the condition of that hospital she was in.
My autistic cousin's family became extremely involved in his treatment when he was diagnosed at the age of 5. He's off at college this year. His dad works for Microsoft. In the case of autism, money talks, insurance didn't exist for them.
My 53 year old aunt with Downs has always been treated really well, as a child and now. She was considered to too smart to qualify for any govt. aid but my grandparents had good insurance.
Good medical care is a societal issue, I agree. I do think we need to look at how the money is spent and the equality with which care is dispensed. I'm not convinced that medical care is ageist.
I blame insurance companies.
"I don't know if I'm convinced that this is true. I have found that quality of care is about money. The elderly tend to have more money than the young."
I was alluding to the fact that the cost of care for the elderly is borne by the Federal government via Medicare and Medicaid. Virtually no one pays for years of nursing home care and medical treatments out of their own pocket. Care of the elderly is guaranteed; care of everyone else is not.
Perhaps he wouldn't have chosen that way out had he some assurance that both law and medical ethics would support a choice to have his life terminated when it reached a point, of his own definition, which made it unbearable.
That is the crux of the matter, as I see it. I can put down my dog, cat, or horse (all of which I love dearly), but not my mother, brother, or son. Is there any logic to that?
"I can put down my dog, cat, or horse (all of which I love dearly), but not my mother, brother, or son. Is there any logic to that?"
It seems to me that sometimes we treat dogs and horses better than we treat human beings.
This is certainly NOT a universally held belief. I, and a great many others, entirely reject this belief, which I posit is the product of the terror in which many people regard the possibility that they will return to the nothingness from whence they came. It is nothing more than an expression of ego.
I am reminded of a scene from the wonderful BBC production of Robert Graves' "I, Claudius", in which his mother Antonia whimpers, "I want to be a god... I want to live forever."
When Baroness asks these questions, she is asking them from a perspective of a wealthy, educated person, who is also in a country that has NSA care.
When you ask these questions, you are not only questioning whether it is valid for "elderly [are] being kept alive at tremendous cost," but whether your country (yes, that crazy place you call home) has the potential for answering them.
I am going to go with a NO on that one. Not because I am against euthanasia, or dying with dignity -- in fact, quite the opposite. I just believe that US public has far more important questions and issues to resolve prior to solving this one, such as those that pertain to human rights, human care, education and poverty.
Warnock indeed asks a great question. You just happened to be asking it from a wrong nation.
"to be considering these questions in US, where people are literally barred from having their very valuable life extended, because they are just not rich enough to receive treatment for an illness that otherwise may not be terminal, is outrageous."
The reason we ought to be considering them is because they affect the lives of hundreds of thousands, if not millions, of people each year. Those people cannot and should not be forced to prolong their private agonies until the US adopts universal healthcare coverage.
Moreover, one of the reasons so many people in the US are uninsured is that premiums are so high. Premiums are so high because we are providing massive amounts of health care to people who may not even want it.
While economics issues must be considered, they do not invalidate a principled moral argument in favor of euthanasia.
I don't believe there is a "proper policy" toward this subject... or a single right answer. I have deep doubts that there is ANY right answer. To my mind, the best we can do is leave the decision to the parties involved, be sure they fully understand each choice and it's repercussions, and pray they make it with as much empathy and compassion as they're capable of.
It's a decision I have made - and live with every day of my life.
However, beyond public dialog on the subject, I generally don't believe the matter to be "the state's" business.
Thank you for your kind response to my comment. I would have to say that I am surprised at your statement that "Premiums are so high because we are providing massive amounts of health care to people who may not even want it."
I would have to strongly disagree with this statement. And really, in order for it to ring true I would have to await for your clarification. Current research indicates that U.S. is spending more on health care than any other country in the world. These expenditures however, have nothing to do with quality or amount of care one receives, whether they are in possession of a premium health care insurance or not.
Reasoning for high costs of health care in U.S. have been identified as following:
"rising costs of medical technology and prescription drugs to the high administrative costs resulting from the complex multiple payer sstem in the U.S> For example, it has been estimated that betwenn 19.3 and 24.1 percent of the total dollars spent on health care in the U.S> is spent simply on administrative costs. The growing shift from non-profit to for-profit health care providers, such as the growth of for-profit hospital chains, has also contributed to the increased costs of health care. By 1994, research showed that administrative costs among for-profit hospitals had increased to 34.0 percent...” (p2 of 8, http://dll.umaine.edu/ble/U.S.%20HCweb.pdf)
Hence, it seems that at heart of your health care problem in U.S. is not excess care, but corporate greed. That, and utter disregard for human lives.
"It is likely the most difficult decision any of us will face. I think society should - to a large degree - stay out of it."
But we're already deeply in the middle of it. We essentially mandate that people must be forcibly kept alive. So we have made a decision. We need to ask ourselves if our decision is correct.
"Current research indicates that U.S. is spending more on health care than any other country in the world. These expenditures however, have nothing to do with quality or amount of care one receives, whether they are in possession of a premium health care insurance or not."
That is consistent with what I am saying. If massive amounts of money are being spent on warehousing elderly people in nursing home and forcibly extending the lives of the senile elderly, we aren't likely to have much to show for those expenditures.
You and your colleagues, no matter how nice, or talented, or hardworking you may be, participate fully in an already destructive, cruel business that literally kills people. Such unthinkable acts take place every day across U.S., and they are justified and backed by those of medical profession. The U.S. health care system is rotten to the core, and when examined, leaves much to be desired.
Your question of whether those who can afford it may even be able to buy a dignified end, or those who cannot afford it may have the right to proclaim themselves worthless, is not a worthwhile question. It is an unrealistic, philosophic discussion that you may present to a classroom setting in order to instigate debate, but this system you represent needs far more practical solutions, ones that hopefull entail healing people first, and save murder and suicide for later, more enlightened times.
"that portion of expenditures seems to pale in comparison to the kind of financial abuses that U.S. health care BUSINESS environment created."
If that's the case, you should be able to provide some dollar figures to substantiate that charge. I think if you look for those figures, and find the actual figures, you will realize that your claim has no basis.
The key problem with healthcare expenditures is that providing actual healthcare costs an massive amount of money. It is tempting to suggest that reforming healthcare business practices will save money, but it won't save anywhere near enough. Only rationing healthcare will control healthcare costs.
I have shown the requested figures in my previous post. I really do not have any intention to spend further time in any kind of argument on this subject. But speaking of figures, why don't you show us some? I am certain that we will all be able to gain a better perspective on point you are trying to make.
And I would also like to reiterate following -- the fact that the health care in U.S. is a BUSINESS should be disturbing enough to a professional such as yourself. Now, I am certain that you will respond to this, having the last word on the subject, as it is your post after all. So, let me just say that this was enjoyable and I look forward to more of your postings.