Thursday, February 23, 2012

End of Life Autonomy


In this post, I will discuss Policy 6 of Sean Faircloth’s new atheist strategy. This policy calls for autonomy in end-of-life decisions.

Specifically, this relates to questions of euthanasia - whether a person facing a life of extreme and prolonged suffering or a state in which the person effectively ceases to exist and only the body remains, should be permitted to choose death.

At this point, I want to warn against taking a list of ten policy objectives to be the equivalent of ten commandments - proposals that every true non-believer or believing secularist must accept as true or be branded a heretic. We must not follow the course if the political right and hold these up as a litmus test where acceptance, regardless of reasons, is a requirement for membership - and where debate and disagreement is deemed intolerable.

Nor should we adopt the attitude of the contrarian - that, if religious people are against it, we must be for it, and visa versa.

Rather, we need to constantly return to these policies with a critical eye in the light of new knowledge and fresh realizations and be willing to alter or to abandon them as the evidence suggests.

I bring this up here because I have two concerns about this policy.

I do not deny that as an abstract policy divorced from real-world considerations, it sounds wonderful. Nor do i deny that there are some real-world considerations that speak in its favor. The only value that exists is that which exists between states if affairs and desires, and there are clearly situations in which continued life will thwart more and stronger desires than death. These include situations where an agent is in excruciating pain or unable to act or think so as to realize these desires.

I abhor the thought that some day my money will go to somebody changing the diapers on this body that I now occupy, rather than having that money go to something I truly value - promoting understanding and appreciation of the real world. I would rather have my savings go to a museum than to a nursing home.

Finally, I want to stress that when it comes to forcing somebody to endure 6 months of agony they could otherwise avoid, the argument, "My god would be unhappy if you did not endure 6 months of agony" is not a good argument for forcing somebody to endure 6 months of agony.

However, I have two wholly secular objections against such a policy.

One of them is that insurance companies and family members will come to pressure people to end their lives for wholly selfish reasons.

Insurance companies will be able to significantly improve their bottom line by finding ways of encouraging patients to choose the less costly (to them) option of death over more costly forms of treatment. Using the power of their marketing departments, they will likely find ways to get their customers to choose what is, for the company, the least expensive form of care. Every company does this – from the hotel chain trying to get customers to purchase amenities to the restaurant trying to sell coffee and dessert the chocolate factory trying to find more ways to get more people to buy more chocolate at a higher price. This is an inherent and important part of doing business.

Where death is an option, the instant an insurance company realizes that – given the limited prospect for the patient paying future premiums and the cost of various treatment options - death is the least expensive option for the company, then this is the option they will market to the customer. The company that finds the most efficient way of identifying when death is the more profitable option and successfully gets patients to choose that option is the company that will have the best balance sheet and will draw the most investment. This, in turn, will force other companies to follow suit.

They will do this in the same way a restaurant tries to find ways to get customers to order the most profitable items on the menu.

A part of this marketing strategy will almost certainly involve getting the family involved in supporting the option. Their encouragement would likely be very helpful in successfully selling this option to the patient.

Now, I am not necessarily talking about people maliciously conspiring against the patient. As humans, we are subject to motivations we do not consciously acknowledge. It will just feel like the right thing to do, and people will find it easy to convince even themselves that it is in the best interest if the patient. Assert that they were motivated by money and convenience, and they will be genuinely upset - because they do not want to admit the truth even to themselves.

The second problem with end-of-life autonomy is that, in practice, it will require that we lower our aversion to killing. Where we lower the aversion to killing, other forms of killing may become psychologically easier for more people - and those consequences may be worth avoiding.

This is the same type of argument that I used against incest in my previous blog post. People act to fulfill the most and strongest of their desires, given their beliefs. One of those desires that most people have is an aversion to killing. There are almost certainly cases in which this aversion to killing is what tips the balance – preventing a person who otherwise has a reason or a desire to kill from doing so. If we lower the aversion to killing to allow for end-of-life autonomy, we may find that we have more killing than is good for us.

This "aversion to killing" argument might sound to some a lot like the "sanctity of life" argument we get from certain right-wing, mostly religious sources.

Well, it is a lot like that argument. Yet, where is it written that somebody on the political or religious right must be 100 percent wrong about all things at all times?

There are a couple of differences between my use of the "aversion to killing" argument and the claims we get from the political right. I apply this argument consistently to the issue of capital punishment. I argue against capital punishment that society may be better off with a general aversion to killing so strong that is averse even to killing its worse criminals. Furthermore, I argue that killing in this sense applies to beings with interests, that a fetus without brain development has no desires, and thus no interests to consider in this respect. Nor do I argue for a moral absolute allowing for no exceptions. We have reason to promote an aversion to killing - but we have reason to promote a lot of other desires and aversions as well that may, in certain circumstances, outweigh the aversion to killing.

There is nothing in this argument that requires a god or intrinsic values or categorical imperatives or any of the various mythologies that plague moral philosophy. This argument only looks at the desire-fulfilling qualities of using social forces such as moral praise and condemnation to promote an overall aversion to killing.

Psychological and sociological research may well find ways around these objections. Perhaps we can avoid some of these problems by requiring an independent review board to determine that end-of-life choices are truly the unmanipulated will of the patient. Perhaps we can effectively promote an aversion to killing except as an act of mercy. In this latter case, please note that the question is not whether philosophers can make an intellectual distinction in some abstract sense, but whether we can effectively engineer our social institutions to bring about this effect in the real world of everyday action.

With these considerations added on, I tend to argue for a system of state’s rights on the question of end-of-life autonomy. Let different states establish their own practices and let us see what the results are. Let some practice an absolute prohibition, while others attempt to show mercy to those patients who are suffering by providing end of life options, and let us look at the effects of these different practices in different states.

With this evidence, we can then make an informed decision as to whether to require end-of-life autonomy. At this point, I do not think we have sufficient evidence to demand end-of-life autonomy. There are too many valid reasons to worry. Instead, we should call for giving states the liberty to choose for themselves, while insisting that, "My god demands that you spend the next six months in anguish" is NOT a good reason to require that a person spend the next six months in anguish.

Speaking more generally, we should not commit ourselves to any particular set of conclusions independent of an examination of these types of concerns. Nor should we commit ourselves to finding something wrong with every argument and piece of evidence or consideration merely because the political right thinks that it has merit. Sometimes, they actually do have merit.

We should be willing to take an honest look at legitimate concerns (where "my god wants you to suffer" is not a legitimate concern) and be ready to change or drop any policy objective based on the available evidence. Otherwise, we risk becoming the secular equivalent of the deaf and blind religious or political dogmatist.


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