Academic journal article The Hastings Center Report

Profoundly Diminished Life: The Casualties of Coercion

Academic journal article The Hastings Center Report

Profoundly Diminished Life: The Casualties of Coercion

Article excerpt

A war of words is being waged about whether physicians can refuse, unilaterally, to provide life support for patients who are hopelessly or terminally ill. For many years one scenario predominated: the patient or his family said, "Stop this treatment and let me die," while the physician said, "I cannot stop lest I be sued, or indicted for murder." Physicians coped by inventing "slow codes" and "show codes" until time and the courts freed them to write "no codes." And families, once excluded along with patients from making decisions, gradually won the right to speak for a loved one who no longer could.

Suddenly we see a reversal. A patient or family says, "Do everything," while the physician says, "Stop." In Minnesota, Helga Wanglie's physicians and hospital objected to sustaining indefinitely a woman in a persistent vegetative state while her family admonished that only God can take a life.[1] In Washington, D.C., the physicians caring for Baby Rena, an eighteen-month-old in constant pain with AIDS, hydrocephalus, respiratory distress, heart failure, and kidney dysfunction, believed that medicine must not be used to torture the dying and made plans to go to court Her foster parents insisted that all treatment be continued, because God would surely work a miracle.[2]

In these new scenarios, physicians typically argue that it is not only permissible, but morally mandatory to cease aggressive treatment. The treatment is futile, they argue, or pointlessly cruel. The families of these patients, however, do not agree that their loved one would be better off dead. They may hold a vitalism that all life is of value, regardless of its quality. Or they may believe that personhood is not lost just because one can no longer think.

I will argue that this dispute about whether physicians ethically can, or ought, unilaterally to refuse to provide life support revolves around fundamentally irresolvable moral conflicts concerning our most deeply held beliefs about the value of life, especially profoundly diminished life. Thus the "futility debate" is itself largely futile.

The fundamentally intractable nature of this dispute, in turn, prompts coercion and the threat of coercion: where a dispute cannot be resolved by rational argument or persuasion, then believers of one side can only prevail on dissenting others by force. This, not the dispute about the value of diminished life, provokes the practical moral dilemmas. Physicians do not wish to be coerced into providing care that they believe is medically or morally wrong. Families do not want to be precluded from supporting the lives of their loved ones by the veto of physicians who have monopoly control over the means to those patients' survival. And the people who pay the taxes and insurance premiums that fund such care may object where they see "social hijacking" committed by patients and families pursuing private goals at common expense.

If the central moral challenge concerns coercion in the face of an irresolvable value conflict, then a proper solution must inquire how best to preserve freedom for each party to honor its own values without coopting unwilling others. Despite the acrimony and divisiveness often surrounding these cases, I will suggest that considerable freedom can be preserved for all.

The Standard Arguments

"Profoundly diminished life" refers to patients whose condition is irreversibly very poor. Two scenarios predominate. First, like Nancy Cruzan, Karen Quinlan, or Helga Wanglie, the patient maybe permanently unconscious, or perhaps deeply demented. Many of these patients are not terminally ill, in that they can survive many years with proper nutrition and nursing care.

Second are the terminally ill who will die soon no matter what medical interventions are provided. They may be awake and aware, but they have no realistic prospects for enjoyment or personal fulfillment in what remains of their lives. …

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