The ultimate decision, interpreting the living will

Eric Cohen, editor of the New Atlantis and resident scholar at the Ethics and Public Policy Center writes about the issues involved in end of life care. What Living Wills Won’t Do From the April 18, 2005 issue: The limits of autonomy. (Weekly Standard 04/18/2005, Volume 010, Issue 29)

In the end, the retreat to moral libertarianism and liberal proceduralism is inadequate. We need, instead, a moral philosophy, a political philosophy, and a medical philosophy that clarify our roles as caregivers, citizens, and doctors attending to those who cannot speak for themselves.

As America ages and dementia becomes a common phenomenon, the dilemmas that the Schiavo case thrust onto the nightly news will only become more urgent and more profound. As a society, we will need to navigate between two dangers: The first is the euthanasia solution, and the prospect of treating the old and vulnerable as burdens to be ignored, abandoned, or put to sleep at our convenience. The second is that the costs of long-term care will suffocate every other civic and cultural good–like educating the young, promoting the arts and sciences, and preserving a strong defense.

The axes of the issue:

  • Moral – about whether or not to kill people.
  • Political – about the extent to which the law should stay out of personal affairs.
  • Medical – about the extent to which the purpose is to save lives and prevent suffering.
  • No matter how you want it to be, the question comes down to money. It is the cost of care and who pays that cost that is always the first consideration. Human dignity, suffering, convenience, and morality are always subject to what can be done at an affordable cost. This is why the dilemma is a severe political issue. You are always faced with the choice between doing something to save or prolong a life, which costs, and not doing that thing which means that you allow death. Only when you can afford it do considerations of whether the person wants it or whether it will be effective come into play.

    Even Cohen is incoherent when it comes to the Schiavo case. He confuses the simple act of feeding with the slicing open of an abdoment to be able to force nutrients directly into the stomach. This confusion illustrates one issue which the political (legal) process has clarified in the words prescribed for a living will. A person can declare that he does not with his or her body to be violated by surgury to implant a feeding tube and this is accepted in many states as a binding directive on care givers.

    Since cost is the fundamental issue, and we are faced with the growing importance of this issue by the Medicaid shortfalls in many states, the decision will very likely rest with who is paying for the care. In this scenario, a difficult political process, one that has already evolved for near three decades, will need to move much closer towards effective decisions. The state will have to accept that when it assumes the cost of care that it also assumes the decision making authority. It will be forced to codify and execute that authority. The decision will have to be made about what care will be provided in what circumstances.

    Euthanasia and suicide are easy ways out that have, for the most part, been dismissed. They are on one end of the continuum. Intensive care life support is on the other. It is accepted for those who are envisioned as having any possible hope of recovery. The nursing home provides the kinds of care needed for the vast middle of this continuum of maintenance care. Each of us individually and as a society need to determine the level of care we consider to be appropriate and at what point the decision should be made that enough is enough.

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