The human impulse to freedom is often well protected in modern liberal culture(1); however, recent end-of-life cases reveal that freedom can be strained to the point where, increasingly, liberalism seems to require the death of some individuals for the sake of others. Sound policy on end-of-life ethical questions requires social resolve both to care well for the elderly and other vulnerable people and to reject false notions of freedom that present the choice for death as expressing the human desire for autonomy. In determining social policy that will balance the healthy concern for individual freedom with protection of the vulnerable, one cannot expect easy answers. There are, however, guidelines that can assist us in thinking through difficult questions.
These guidelines include:
• Basing all end-of-life reflections in a richer conception of human vulnerability than liberal culture currently fosters;
• Increasing legal and social respect and support for the family as the primary locus of support for the vulnerable;
• Rejecting the notion of a "right to die";
• Rejecting the transformation of the medical profession through the legalization of assisted suicide and euthanasia;
• Defining minimum standards of care to include artificial nutrition and hydration
Who Are the Vulnerable?
Liberal culture is well-disposed to recognize, respect, and grant the disabled their expressed wishes, even to the point of facilitating their desire for assistance in suicide claimed through an ostensible "right to die." Once, however, the capacity for self-expression is lost, vulnerability emerges; or so says our liberal culture. Vulnerability increasingly refers not to physical disability or incapacitation, but instead to dependence upon others to speak for us. Human dignity in our culture reduces to speak independently.(2) The adult sick and the elderly are not vulnerable, then, in the relevant sense, unless and until they lose the capacities to raise their own voices and express their own wishes. Liberal culture renders vulnerable entire classes of people, including the unborn, minors, the mentally disabled, and the legally incompetent.
One of the fundamental responsibilities of good government is protection of the vulnerable – to speak for those who cannot speak for themselves. Once we have identified the classes of people and individuals made vulnerable by our culture’s bias for self-expressed rights claims, we have identified the classes of people most requiring the protection of the law. The necessity of strong laws to protect the vulnerable increases as social pressures on the vulnerable increase,
Respecting the Role of the Family as Caregivers and Protectors of the Vulnerable
Medicine, our laws and the courts must err on the side of life in all cases. Recently we have discovered even this is not enough. The tragedy of Terry Schiavo’s death by court-imposed dehydration was the latest instance of the legal system regarding particular lives as not worth living. Instead of adjudicating among competing views of lives worth living, the role of the law and the courts should be to foster our sense of obligation towards each other as spouses, parents, and children. The courts fail in this fundamental responsibility when they opt for the death of the vulnerable despite pleas from family members willing to assume responsibility for their care. Today the laws must not simply err on the side of life, they must overcompensate on behalf of lives rendered vulnerable by a culture increasingly viewing disability and dependence as signs of lives no longer worth defending. They can do this by fostering stronger bonds among family members and privileging the claims of those family members willing to bear the burdens of caring for the vulnerable.
There is no "Right to Die"
The purported "right to die" is a fiction created by a culture that speaks only in rights claims. To some extent the claim for the right to die follows from our confused relationship with mortality. Sometimes death is welcome, and sometimes our extraordinary medical technologies intrude upon the release from suffering death provides.(3) Increasingly the elderly feel economic pressure to step aside from care and towards death. They do not want to burden their children by depleting financial resources. The choice for death becomes more intelligible in such cases. But we do not need recourse to a fictional right to die to avoid these quandaries. Indeed, public claims of a "right to die" only increase pressure on the vulnerable – again, especially the elderly – to see themselves as having an obligation to die and get out of the way. Laws that encourage people to view themselves as burdens to our autonomy must be resisted. Instead, the law must protect the vulnerable by reminding us of our obligations to them. We need now greater public reflection on the meaning of life and death and the means used to preserve life and ease the suffering associated with death.
Transforming the Medical Profession
The fictional "right to die" began as a claim against intrusive technology that sometimes sustains life by imposing burdens on the sick and the dying. It was, really, a legitimate claim to resist certain burdensome technologies. Today, however, the right to die expresses a welfare claim: it imposes an obligation on society generally and the medical profession more specifically. Since its origins in Greece and through its developments in Jewish and Christian cultures, western medicine has always chosen for life. Swelling demands for death as a "right" to be claimed against doctors must be resisted. Medicine must remain a healing art and the entitlement to use medicine to cause death must be rejected. The surest evidence of the perverting influence of rights to assisted suicide and euthanasia would be the transformation of medicine from a profession devoted to life into a profession devoted to dispensing with life.
Artificial Nutrition and Hydration is an Aspect of Minimum Care
The vulnerable person, even one in a persistent vegetative state (PVS), claims from us basic health care (including nutrition, hydration, and hygiene). Human life in all its stages requires care, including in principle food and drink. Providing food and drink is "a natural means of preserving life, not a medical act" meaning. We must not allow the means of delivering food and drink to confuse us. The use of complex and costly technology does not transform feeding and hydration into a medical act. The determinative moral question is whether feeding and hydration nourishes and preserves life. The obligation to provide assisted feeding lasts only as long as such feeding meets its goals of providing nourishment and alleviating suffering. Of course there are times when artificial nutrition and hydration cease to serve their ends and instead increase the suffering of the person and even threaten their lives. In such cases, nutrition and hydration are not nourishing; not a form of care and should be stopped.
A fundamental goal of good governance in a liberal society is the protection of the weak from the actions of the strong. Today, economic and social pressures are leading the strong in the United States to see the physically weak as obstacles to their good. We should note that claims of a right to die through assisted suicide are coming not from the disabled communities but instead from the able-bodied. Good law and good governance fulfills its obligations when it resists these claims to fictional rights and instead protects the inalienable right of all to life.
Dr. Joseph Capizzi is Associate Professor of Theology at Catholic University of America and a Fellow with the Culture of Life Foundation
1 The use of the term "liberal culture" throughout refers to a rights culture of political liberalism; "liberal" in this sense does not mean "Democrat" as opposed to "Republican." The most eloquent and significant description of a liberal culture in the sense this article intends is John Rawls, Political Liberalism.
2 See Eric Cohen, "How Liberalism Failed Terry Schiavo," The Weekly Standard, volume 10, no. 27, April 4, 2005.
3. Leon Kass states the emergence of the claimed right to die suggests "our growing disenchantment with the biomedical project." See his Life, Liberty and the Defense of Dignity (San Francisco: Encounter, 2002) 205.