The Limits of Moral Objectivity
It is commonly agreed that life-sustaining treatment decisions should be oriented by the voice of the patient. But when that voice falls silent and is nowhere recorded, from what direction and source should medical care take its moral bearings? In the years ahead, when the decision of a surrogate for an incompetent patient is challenged, it may increasingly fall to ethics committees to answer this question, the hardest one of all.
Across the country, ethics committees are poised to embark on a search for clear standards of institutional review and assessment of surrogate decisions. Behind the search for standards lies a deeper quest for moral objectivity upon which to ground the surrogate's authority within the framework of a liberal ethic of individual autonomy and self-determination.
I suggest that this quest is philosophically misguided. The attempt to base the legitimacy of surrogate decisionmaking on the objectivity of the surrogate's judgment cannot succeed. It grows out of, but at the same time is precluded by, the philosophical foundations upon which our conventional wisdom in bioethics rests--in particular, by underlying notions of moral pluralism, subjectivism, and skepticism. These notions are characteristics of the liberal roots of our current mainstream bioethic of autonomy.
These are big terms to throw around in a small essay. What I have in mind can be made clear by focusing on three aspects of liberalism that are especially significant. The first is the notion that the good for persons consists in a certain sense of autonomy or freedom: namely, the freedom to define and to pursue one's own good in one's own way, subject to constraints imposed by others' equal freedom to do the same.
The second tenet of liberalism is a corollary of the first: no one should be allowed to impose her sense of the good on anyone else. The state should protect individuals from this kind of imposition, by others and by society at large (or the state itself).
Finally, there is a sense of moral skepticism or, at any rate, moral subjectivism underlying the entire liberal outlook. If there were a universal pattern of life that constituted the good for persons, and if that pattern could be known rationally and objectively, then the moral tilt toward autonomy and neutrality would certainly be less appealing and harder to defend. It is precisely because no one can definitively say which pattern of life constitutes the good that everyone should be free to define and pursue a good subjectively. This will not be the good, but it will at least be their good, and not that of someone else who happens to have more power or more wealth, but not (we assume) greater moral wisdom.
Now these ideas are certainly not the whole of liberalism, but they are characteristically liberal concepts. And they have a particularly compelling resonance in the care of the dying. As a society, we no longer believe that we can define a "good death" for particular individuals. That ultimate determination is up to each one of us, a last meaningful act in a life of making meaning.
When it comes to the moral freedom and authority of competent patients in terminal care situations, unless harm to others is involved, the ethical message of liberal pluralism and subjectivism holds sway. Very often, I suspect, the main function of ethics committees is to give clear voice to this message when it is not being heard, and to defend it when necessary.
When the patient is no longer able to function as a subject defining his or her own good, however, this liberal framework does not provide an ethics committee with a clear mission, and it may arguably saddle the surrogate with an impossible task. …