Part 2 of this paper has been presented at the Wittgenstein Symposium 1997 in Kirchberg, Austria, and part 3-4 XIth Annual Confecrence of the European Society for Philosophy of Medicine and Health Care (Nijmegen) in Padova, August 1997. Copyright R.H. Wettstein
The purpose of this paper is to give some insight into a much longer study and to suggest that philosophers specializing in ethics would do well sometimes to undertake their own field work related to their sophisticated reasoning and to get involved with social sciences or theology whenever these disciplines can illuminate philosophical abstractions. The issues I will address are: 1. passive euthanasia, 2. pain, 3. basic human values and 4. responsibility.
There is an open bioethic argument about the so-called problem of drawing a clear line between active and passive euthanasia (Wettstein 1995, 33-44). What active euthanasia is seems to be quite clear around the globe: Someone, normally a doctor or a nurse, injects a lethal dose to a terminally ill person with the intention of shortening his life. Active euthanasia can be voluntary or involuntary. The ethical issue revolves around whether active euthanasia should be allowed in dramatic circumstances, especially when it is asked for by the patient, thus when it is voluntary. In Holland this action has been depenalized under special circumstances, but in the same country we are told that hundreds of officially registered cases of involuntary euthanasia occur every year. This horrifies me.
There are also the non-registered cases. Once we are a bit familiar with the medical literature on that topic, we learn even from the Catholic side (Schattner 1993, 256, note 4) that both voluntary and involuntary active euthanasia are practiced in nearly all hospitals from time to time. The gray zone around active euthanasia raises the issue about passive euthanasia. In fact, doctors officially tell us that these cases of so-called active euthanasia are merely a special form of passive euthanasia or of indirect active euthanasia (1). However, when exactly does passive euthanasia stop and active begin? Doesn't passive sometimes slip into active euthanasia?
The problem of the 'slippery slope' is a case of a the slippery concept named 'passive euthanasia'. Conceptual subtleties about indirect and direct passive euthanasia or indirect active euthanasia do not help either. Roughly speaking, so we are told, passive euthanasia does not pursue the goal of killing but takes the risk of letting die. Thus, passive euthanasia is not a passive activity at all, it is not limited to switching off the respirator or stopping a treatment; it can also involve the active increase of pain killers and all sorts of measures that will mother the terminally ill patient. Passive euthanasia in most cases is a highly complex activity. It comprehends all the efforts of providing care and assistance to the dying patient and his family, including intangibles such as being there, giving time, listening and responding to spiritual desires. This complex relational effort has been coined by the World Health Organization as 'palliative care for dying persons'. Even in the German language, where the resistance against this uncommon Fremdwort 'palliativ' was first total, the expression is now being introduced into everyday language by the medical circles. Thus, 'palliativ' means 'softening pain and symptoms of illness, taking care of the whole person and his family or relatives, fostering his autonomy, giving him time and attention, responding to his spiritual desires'.
Nevertheless, philosophers and lawyers go on playing semantic games about passive euthanasia (2). This is amazing enough if you consider that 'passive aid in dying' is not even defined by our legal codes or laws. The point is that some brilliant people still stick hard and fast to the conceptual distinction of active and passive, because they simply have never worked as a volunteer in a hospice where palliative care is provided. So the ethical issue of passive euthanasia disappears once we are aware that palliative care exists. It is a Quineian showpiece of how certain terms can be explained when they are eliminated or replaced.
Of course, there still are ethical problems within the palliative care units. I do not mean the difficulties of not having enough time and education to provide it properly, which is main one. I think of ethic issues within palliative care such as when to apply sedation for a patient, e.g. what to do when chronic pain, which cannot be eliminated and thus becomes entirely dysfunctional, ends up paralyzing the personality of a patient. This point takes us to 2, the pain issue.
The answer to this question must at least be considered on two levels, the subcultural and the mainstream cultural one. In sports, for instance, when it stands for a subculture, there is usually a tolerance for pain as long as the competition is not over. (Astonishingly enough, in some overall cultural sports like football or tennis, pain simulation has become an art in itself!) In the heat of competition, the body not only tolerates more pain than under ordinary circumstances, but is also supposed to cope with it. The sentence As long as the body fights well, pains must be endured expresses a subcultural value of courage. The macrocultural aspects are more influenced by ideological and religious values. It has been demonstrated by an empirical investigation (Humbert 1989, 27 ff) that a Jewish sample group showed longer pain resistance, believing that pain killers are not good for health , whereas the sample population of Italians - mamma mia - had no remorse at all to ask for pain killers at a certain pain level. Another example is the feminist issue about whether or not pain should be borne during childbirth. Some women think it good to struggle against strong pains, others would ask for peridural injections. Pain sensations are individually and culturally valued as soon as they are expressed, and according to how the individual has integrated the social values, it can tolerate more or less pain. There is no pain language outside any value context. I shall come back to this assertion.
It is not sure at all whether hedonism represents an overall cultural value system such as pain should be avoided because it diminishes pleasure . This thesis is often put forward by philosophers, mainly from the utilitarian side. Of course, philosophers may very well study the hedonistic point of view as an abstraction which leads to the conclusion that pain is something completely negative; thus it should be avoided and softened whenever possible. Following this line of thought, people who see something positive in pain are masochists or sadists. I do not think that conclusion is very sound. Even pure hedonists must admit that pain most often has a very concrete function.
Biologically , pain usually functions as a warning system. It tells the body it is in danger; it has somehow fallen into the situation of a victim . Pain can also accelerate the curing process of the organism, i.e. by telling the hurt limb to move more carefully. There is undoubtedly an overall biological trend to avoid pain, which is part of the drive for survival. But avoiding pain does not necessarily mean seeking pleasure at any cost and at any time.
Culturally , medical pain management has been tremendously improved by the allopathic medicine during the last hundred, and especially the last twenty, years. This well known progress brings up the Prozac ideology: once you feel frustrated - and who doesn't from time to time? - , you have the right to be freed from any kind of suffering and pain. And not only that: you want to feel better than well (Kramer 1993, XV).
However, biologically as well as culturally, pain evaluation by the organism is not so straightforward. When we look at pain classification made by the medical sciences (Bonica 1990, 11 ff), we find at least five large categories: stabbing, chronic, phantom, psychosomatic and dysfunctional pain. Today's pain management can cope efficiently with stabbing and chronic pain but only insufficiently with phantom or psychosomatic, and not at all with dysfunctional pain. In regards to the latter category, pain has lost its biological sense and is simply destroying the personality (Wettstein 1995, 486-498).
Culturally, the better pain management systems work, the more the overall culture loses the psycho-social strategies against pain, the more and the faster people complain. This complex issue should not be eluded by the philosophers who try to know what pain is, for it makes up the phenomenon of pain as well as the value context mentioned before.
Coming back to the palliative issue: dying through sedation means that the pain has been completely killed, but at the expense of the patient's consciousness. During sedation, the patient remains in an artificial comatic state long before he dies. Not every sedation must intervene in the final stage. But in the very end, the patient does not feel himself any more when he leaves his earthly existence.
One could object here that the patient very often feels something during the comatic sedation. Should he recover consciousness, he might tell us all about the beautiful near-death experiences he had, the light at the end of the tunnel, his life film and so on. But if you read the serious near-death experience literature closely, you will realize that these experiences can also be like hell (Lorimer 1990, 86). You never know beforehand. There is no guaranteed life style that will shift your consciousness into visions of paradise when you are entering in the final coma. And near-death experiences always happen during a non-terminal coma.
In addition, we hardly know anything about the relationship between our life style and our supposed near-death experiences: We can suppose that spiritual achievement generally but not invariably improves our health and facilitates our final exit. There are health reprobates who can enjoy extremely good physical health until the dusk of their lives and on the other hand, there are saints and mystics with poor physical health and horrible deaths. Because there is no such guarantee of dying gently, the goal of psychically managing some pain in order to keep one's consciousness awake until the end seems to be reasonable. This is also true from the point of view of care providers. They can give better help to a person who can still communicate.
This argument could be consolidated by cultural factors. If you have grown up inside a culture which still has its rituals that actively help you endure pain, and which conveys a positive value to some types of pain, then you are more likely to accept it. The general point is, as long as the patient feels (chronic) pain which does not invalidate his personality, he is still consciously living. As a consequence, the wish for conscious living, involving the value of autonomy, has been traded off against the value of seeking pleasure or avoiding pain at any costs.
There are thus two basic options: I) overall hedonism: to avoid pain at any cost and to ask for sedation as long as pain remains, even if it is not dysfunctional; II) the position I just described, but for which I have no label. It is commonly accepted in palliative care units for the reasons I mentioned. Sedation is only proposed by the care unit (or asked for by the patient) when pain definitely threatens to invalidate the personality and the consciousness. On the grounds of what has been said before, II) represents a non-hedonistic position which values autonomy even more than the hedonistic. It is also more acceptable from an ethical point of view.
There is however in II) a general consensus that every kind of pain should be alleviated, especially for terminally ill persons, but it is accepted that not every pain can be completely killed. The idea that every pain must in future be suppressed is part of a medical ideology which undermines the patient's wish to give a sense to his suffering. There is not such an ideology in II). On the contrary, it holds that the pain experience is vital for the development of personality. II) is thus not the opposite of hedonism, the opposition could be called 'dolorism'. Unlike hedonism, II) tries to make sense out of pain as long as it does not invalidate the person. This is the argument I wanted to make clear.
But what is pain? I was shocked to discover that books dealing with pain in medical science hardly ever quote Wittgenstein's pain analysis (Bonica 1990). Is the reason for this blatant omission that the medical corporation shamefully ignores our dear schoolteacher from Kirchberg? Is it because philosophers never really try to discuss pain with doctors or is it just because what Wittgenstein said on pain is completely irrelevant to the pain we are afraid of before and while we die?
I will show that Wittgenstein's pain argument has some relevance in the ethical pain debate, but it is rather limited. I shall not dwell on Wittgenstein's argument against the possibility of having a private language to designate our own intimate emotions. This has become common knowledge (3). The conclusion which is drawn is also familiar: we do not have the slightest scientific knowledge about concrete pain sensations, even if medical science could discover all the mechanisms of pain transmission, generation and so on. Science can never verify whether the patient's pain is, let's say, really 'stabbing' and not 'biting'. Science can only explore symptoms of pain but cannot ultimately grasp its real causes. Even if medical science improves its pragmatic understanding of pain management, we cannot infer that medical science knows what pain really is. This is the practical consequence of Wittgenstein's insight that should be better known by physicians.
I will not give a new version of Wittgenstein's pain argument. The neglected aspect of those discussions I want to draw attention to is that the patient's pain language generally suggests the object of pain, it does as if this object he calls 'stabbing pain' existed. 'It is stabbing' suggests that there is something which is like a dagger and that this knife is striking the body. But instead of demonstrating as Wittgenstein did that there is no beetle in the box , no stab inside the stabbing pain, and that there is no way of grasping epistemologically the phenomenon of pain, I suggest the hypothesis that the pain language is basically a counterfactual language. You are immediately objecting that I am jumping out of the frying pan into the fire. The truth conditions of counterfactuals are still mysterious (Stegmüller 1969, 283ff).
But my point does not bring up truth issues about counterfactuals; it reflects the linguistic and social implications when human beings articulate counterfactuals. The language of counterfactuals covers basically two social scopes. First, it enables human beings to speak of material objects which are not present; thanks to the couterfactual structure language we can refer to an object which is not in our perceptual range of experience. If you went up on the top of Mount Tendre in the Jura on a clear day, you could see the Mont Blanc means that here and now in Kirchberg, we are not there to verify that sentence. But it also means that this kind of sentence could be verified, if an observer were on this place at this moment. Counterfactuals give instructions for verification of doubtful truth: Since we are not on the top of Mount Tendre, because we happen to be in the south of Austria, we can always have doubts on the truth of possible reference or coherence. But thanks to this what-if function, humans can at least lay down practical hypotheses of all sorts, orient themselves in time and space, build decision models and eventually wonder about the more sophisticated truth conditions and scientific hypotheses. This is precisely how pain language does not work.
This brings me to the second social task of counterfactuals. The pain description made by patients creates a fictional world beyond doubtful reality and not a hypothetical one about this reality. The fictional world cannot be doubted on the grounds of epistemic reference. It is free of any doubt and thus beyond the questions of truth and certainty. But it is not free of any kind of truthfulness and expressiveness , because it opens up an ethical and aesthetic dimension. Let us now see how.
Like any other language of fiction, the pain discourse depicts a theatrical situation. The patient complaining about pain is playing the role of a victim and not the one of a descriptive observer. In expressive role play language, the main goal is not to assert or to promise; it is to interpret (4) something well and with sincerity . But what is this something that has remained in our language? In drama, the actor performs his role; in the case of pain, the patient expresses his emotions and feelings. The fiction of the beetle in the box, i.e. the complaint about the gnawing cancer in the breast, thus has a similar reality to actors on stage. The pain-expressing patient is as real as the performing actor. While the actor represents a character by playing him, the pain discourse articulates the pain experience. Thus the pain does not exist as a factual reality 'behind' the discourse; neither does the character that is interpreted - when he is interpreted.
The obvious difference of these two realms is of course that the character of the play could be a real person, living or dead, but this is not necessary and it is actually totally irrelevant when the play goes on. The character is a character without designating a real person. The same holds for pain: the pain you have is the pain you express whether or not medical science can find good reasons for it. Immediate pain experience seeks its pain language before and without medical explanation.
My point is that pain language, understood as a fictional counterfactual language, solves Wittgenstein's epistemological problems by eliminating them. His intuition that pain language is ultimately descriptive is misleading, since in its essence it is not. Wittgenstein is right in saying that you cannot explain the reality of pain through hard sciences, because pain is not an object of them, but he did not realize that it is all the same an object of fictional language that in its expressive nature can be understood because of its social performance. The performing of pain is the 'object of pain', and doctors usually interpret such pain performances. Pain language is basically a matter of dialogue between two different role players: the mother or doctor in her or his role as helper or even savior and the victimized patient.
Pain however must not be verbally expressed. There is an other type of pain discourse. As soon as pain is controlled and tolerated silently by the patient, we can speak of a sacrificial attitude. This behavior must not, but it can be communicated by special behavior that may eventually receive respect and admiration. It is certainly not a help-seeking attitude of supplication, but one demonstrating responsibility. I will shortly point out in the last section (4) the theological problem of knowing which kinds of sacrifice truthfully express responsibility and which other kinds only pretend to, especially when they strive for prestige and social respect.
The main insight of that argument can be summed up in the following: Thanks to the skill of expressing themselves by a fictional counterfactual language, humans create sacrificial rituals. They sacrifice animals, food, men (in war) or employees (during recession), hoping that this ritual will reconcile their efforts and sufferings with a superior power. The sacrificial language is a dialogue with a fictional entity, God, the common wealth, the perennial existence of a corporation, of a group and so on. Thanks to social interaction, humans can work out not only the negative feelings such as pain, fear, shame and guilt, but can express positive emotions such as joy, awe, devotion and pleasure. The ritual creates an on-stage situation for feelings to be expressed. In many cultures, these rituals develop into theater plays at some historical stage.
Pain, victim and sacrifice are terms that belong to the same realm of discourse, a family resemblance which comprehends aesthetic and ethical components. In every culture, whether or not it has originated the theater, this linguistic possibility has created the culturally molded pain discourses. This discourse basically evaluates the threats to personal integrity. It is taught in the family, especially by the mothering attitude of the reference persons. As a victim, the pain expressor generally adopts the strategy of supplication. Pain is a social cry that is 'between' or beyond the body and the mind: Les 'maux' pour le dire (Humbert).
Pain language has at least three levels: (1) the descriptive, which is not essential: this is what Wittgenstein made clear. This result should inspire medical research, which basically studies the bodily aspect of pain; (2) the aesthetic, which is learnt by socialization and (3) the ethical, which brings into play sincerity. The last two levels are vital for understanding the word 'pain'. Whether it be victim or sacrifice, the pain expressiveness is always modulated by the sincerity and truthfulness that the patient will or can show. On the side of the care provider, empathy becomes the central skill of the saving role. The cheating possibilities in pain behavior point out the puzzling situations of doctor-patient dialogue, which are linked to the rationing issues of health expenses: Every actor in the health system is in a position where he is tempted to take advantage by cheating. The problem of knowing how serious a pain is, is therefore not a matter of verification or falsification, but of communication, value adjustments and of informed doctor-patient consent.
I come back now to the initial argument: the position which considers pain as what it is, namely interpretations of specific victim states, can therefore give sense to pain as long as the patient can express it in such a way that the care he is given helps him control his expression. Since hedonism denies or neglects the sense of pain, it is an obstacle to the interpretation effort.
But there are other, non-ideological hindrances against achieving that effort. Invalidating pains will also keep the person from expressing his pains in such a manner that the care giver cannot enter into a helpful palliative dialogue with the patient any more. Invalidating pain, which is very often a negative side effect of brilliant medical performances, pushes the patient into a kind of social exclusion. Although the patient might be surrounded by a lot of medical devices, he is isolated from the human community because of his invalidating pain. The effort for social integration through medical help can produce its opposite effect and cause psychic disintegration.
The second conclusion is that the pain language, when it is understood as an interpretation out of the sick role, opens up self-reference, as long as self-reference is understood as a psycho-social process and not a topic of descriptive philosophy. Our pain interpretation and behavior is part of self development and realization without which we cannot spiritually grow. Our spiritual commitment will help interpret pain as it helps interpret suffering (shock, trauma, mourning and so on).
The third and final conclusion is: When dysfunctional pain cannot be alleviated, when there is no chance on supplication and savior roles to lead to a satisfactory interpretation, the patient should feel free to ask for sedation, but also for help in suicide. Once palliative care and spiritual help is well established, which is not the case in many places and which is actually the main reason for the slippery slope threat, both types of demands should be on the chart of the patient's rights.
We have seen that the pain discourse depicted in (2) cannot be grasped without a frame of values, especially that of autonomy. But how can values be articulated on pure philosophical grounds? The answer is, they cannot. To be sure, we can establish that in a general sense usefulness is a common value in every society. This idea suggests some kind of utilitarianism that is roughly compatible with the biological concept of function. In the Kantian or also Christian tradition however, which holds that there are inalienable moral values outside the useful and the good, the concept of right incorporates another dominating value, which in a just society, as John Rawls puts it, is not subject to political bargaining or to the calculus of social interest (Rawls 1976, 4). From a Christian perspective, every person is loved by God beyond his social performance and independently of it.
I think that this non-utilitarian value frame copes better with end-of-life situations: When the terminally ill has definitely lost his social utility, he still remains an entire person to whom we owe full respect. What if his financial means are insufficient to pay for heavy medical treatments? The value issue brings up another tricky side: Who should show solidarity, who should pay? He himself, his family, his community as in some archaic situations or the State and its health system as in postmodern societies? And what about another central value, the value of life?
For sure, the intimate wishes about how to be treated strongly depend on the social integration of a person. His autonomy is never articulated outside a specific social context. If integration means that society affords any possible life prolonging treatment, then the patient's autonomy is theoretically endless, limited only by health care managed death. Since the patient may accept that his life has come to an end, the problem is that he does not necessarily want to exhaust the very often painful or suffering span of his end of life and ask for major life-sustaining treatments. In fact, he has often lost this accountability and thus his autonomy. It is on the whole accepted that the intrinsic value of life is decreasing once it has reached its biological conclusion at let's say eighty years or even before. The autonomy - if it is still there - can thus be used by the patient for liberating his terminally ill body by asking for help in suicide or for sedation. These are some preliminary remarks about the complexity of the three basic values in end-of-life situations: autonomy, integration and being alive.
In an archaic society with scarce resources, integration can mean that young people have to assist their elderly parents in committing their suicide or even to kill them once they have seriously articulated their wish for release. The group integration necessities, its need for survival, thus puts pressure on the individual's autonomy. His final demand is however still the expression of autonomy, because the candidate choses his point of time himself, but obviously, this autonomy can be understood solely on the grounds of the type of integration and sacrificial value standards that the community has established for its members. There is no autonomy without the constraints of some kind of integration and without a specific conception of sacrifice. These two elements are even necessary for the autonomy to find its expression. Autonomy without any active social involvment very often amounts to social exclusion.
You could object that these end-of-life questions are finally a matter that should be treated in utilitarian terms. Since life has its utility, the ending of life becomes a decreasing utility for the society, for the individual or for both of them. It can for instance keep its utility for the medical system, as long as this system has enough money. But when the resources decrease, the rationing problems pop up. In that situation, how can we be sure that we are not on a slippery slope of sacrificing the weak against their consent? I do not know of any convincing utilitarian answer to that question. The problem here brings another value into discussion, ordinarily called the 'dignity' of a person, which is somehow an intrinsic value, besides autonomy and integration. How strongly must the value of dignity be emphasized in such circumstances? What is dignity?
Dignity as I define it is revealed by the respect of the stronger for the weaker (Wettstein 1995, 73-76; 1996, 35-37). According to this definition, the loser, the sick or terminally ill have more dignity than the powerful and the healthy. Dignity thus becomes a safeguard against threatened autonomy. The question is now to know whether this dignity increases proportionally with the decrease of power. In general it does, but this proportionality will not continue endlessly, at least not for the patient. Dignity when it definitely loses the power to act and to decide, ends up destroying its original autonomy. Think of an Alzheimerian in his beginning stage: he can still decide on end of life treatments, he can formulate an appropriate Living will and he can even open a procedure for a demand of help in suicide once his illness has progressed up to a certain point. Dignity takes the end of life suffering seriously. Once the Alzheimerian has completely lost his mind, it's as if he were imprisoned on an island of dignity.
From a subjective point of view, such dignity may lose its value whenever the disease definitely compromises the faculties of the mind. For the subject, it is then the biologically weaker mind which may challenge the biologically stronger disease. On the social level however, care givers have to respect dignity unconditionally even if the patient can no longer enjoy its use. For them, the proportionality of the increase of dignity and the loss of power still holds. It is an ideal that a just society should strive for. As long as the social bond of dignity is maintained, there cannot be any slippery slope. But for the sake of personal autonomy, it is up to the patient to decide whether he wants to go into this stage of imprisoned dignity or not.
This is only half the story. To really avoid the threat against the weak, we must understand the trade-offs between autonomy and integration, dignity and life value, and this is made clear by an ethical conception which cannot be labeled as utilitarian or contractualist (Kantian). It is, frankly speaking, a new philosophical position. The problem is that these value twins cannot be justified in philosophical terms. Definitions and arguments on the complementarity and trade-offs of these concepts would soon come to an end. The sense of such an investigation can only be to create the value framework of a just society that should enable all members to position themselves according to their preferences for autonomy and integration (Wettstein 1995, 221-418). But how can theses preferences be expressed?
The philosopher must be aware that once the values of autonomy and integration are considered as elementary (apart from the values of life and dignity), they are nothing but conjectures about his intuitions. At least he should then ask himself about their empirical foundation. To do this so, he must not be afraid to take off his intellectual gloves and to soil his arguments with empirical mud. He must then shop around in the branches of the social sciences and find out which values people really stick to. I think that Milton Rokeach's approach is quite promising, the best I have discovered in my research. The value defined as a preference as well as a conception of the preferable (Rokeach 1973, 9), as something which is always cross-referencing inside a system of values to other values, can be analyzed by asking people to rank the relevant value set. Rokeach's empirical findings brought together 18 'terminal' and 18 'instrumental' values on two lists. The task for the test person is to accomplish his own personal rankings of the two lists. By doing this, he is transforming the random list into his own priority scale, and at the same time, he is fulfilling the behavioral definition of the value concept. When we analyze this test procedure, we are not concerned by what people think of when they understand the value list, whether everybody has for instance the same idea of peace. We are learning what they actually do when they express their preferences. Values can be thus studied statistically by the way samples of people rank them.
Just to give you an idea how the questionnaire works: Rokeach found out that the composite rank orders of terminal values for American men and women in the early seventies differ for position 4. The ranking from 1 to 3 is the same: Men and women put the value 'a world of peace' on the top, followed by 'family security' and 'freedom'. In position 4 men prefer 'a comfortable life' and women 'salvation'. The famous utilitarian value 'pleasure' ranks at position 17 for men and 16 for women, that means practically at the end! This should be a lesson for hard-core utilitarians.
Back to the argument: all we can do empirically, is to generalize from these and other empirical surveys. We can study social groups and classes and learn more about their specific behavior. This is of course not my present concern. I am more interested in the fact that the value of autonomy is reflected by freedom, perhaps also by salvation, and the value of integration covers certainly the Rokeach values 1-2 (a world of peace, family security). This would mean that there is a slight propensity for the integration value. But in other populations, freedom could very well be on top (Mayer-Fehr 1987, 189).
Don't I rely naively on the empirical approach which comes closest to my intuitions? Perhaps, but if so, the objector has to carry the burden of proof and show me better empirical value studies than the one of Rokeach. Since empirical improvements may very well challenge or modify the Rokeach surveys, I therefore have to confirm the same result by at least one other empirical device. In fact, the main findings of N. Bischof (Bischof 1986), psychologist and ethologist in Zürich, clearly reveal that autonomy and integration are active on practically every biological level, for individuals as well as for groups. For an ethicist, this second confirmation if considered as satisfactory is just the starting point for his work. Instead of describing these two general tendencies within the biosphere or within society, he will ask what society should look like to foster these two biological tendencies and what humans should do to develop these two values simultaneously and harmoniously in order to become fully what they are. As I mentioned before, they only can if society allows them to position themselves actively according to their individual preference either more on the integration side or on the autonomous side or somewhere in-between, and to modify their preference during their lifetime.
But still, on the prescriptive level, the two values are too vague; they must be coined into a specific content. To overcome that non-committal philosophical abstraction, we could figure out a hypothetical situation of a social contract like in Rawls' A Theory of Justice. But autonomy and integration do not fit into the classic separation of the good and the right. There is something basically good and right in both autonomy and integration. In addition, the individual must be educated accordingly so that he can take the real chance of positioning himself on the autonomy-integration scale.
Philosophically, we must admit that we can never deduce moral principles from the values of integration and autonomy, principles that will settle the frame of a just society enabling well educated individuals to cope with the conflicting demands for autonomy and integration. Such principles will always represent a hypothesis even if there is very strong evidence for them on the grounds of sophisticated arguments, deductions, 'veil of ignorance' and so on.
Since the moral principles we are looking for are not deductible, they are perhaps pre-existing in some past or present society. From a philosophical point of view, this is again very awkward. First, such principles could never pretend to have general validity. They could at best work in some cultures, but certainly not in all cultures worldwide. Second, we philosophers are not used to searching for deep truths in other sciences, we are convinced that only philosophical acumen can open up questions of ultimate truth. We would therefore never want to build a serious philosophical argument upon foreign hybrid truths.
But what if it is worthwhile undertaking that research? If there were two such general moral principles expressing the value of autonomy and integration? You never know beforehand! As for myself, I spent my life next to what I was searching for. Once I knew that I was looking for, I did not even have to make a painstaking empirical effort to discover it. You can find these principles yourself in the three Gospels Matthew 22,37, Mark 12,30-31 and Luke 10,27. Jesus when asked which would be the basic moral law, brought together two isolated passages of Deuteronomy 6,5 and Leviticus 19,18: Love the Lord, your God, with all your heart, with all your soul and with all your mind and love your neighbor as yourself.
You probably think that I am definitely mad. In fact this is what Greek philosophers said to Paul when he preached in Corinth (1 Cor 1,23). But another Paul, Paul Weingartner, showed that the second part of the biggest commandment is, from a purely semantic point of view, indeed the 'biggest' and the 'first': it has the most relevant Folgerungsmenge of basic ethical laws and the strongest normative force (Weingartner 1996, 182-202). Unfortunately, it would take too much time to develop Weingartner's subtle proof. I also have another excuse for not presenting his argument. In fact when I previously expounded some of my ideas about autonomy and integration, I did not intend to present them as being some sort of a logical axiom founding other ethical principles. As Weingartner himself pointed out, you can use the biggest commandment as a structural principle for a just human society. This is what I had in mind. It is obvious that the sentence love your neighbor as yourself gives very concrete hints on how humans can strive towards a better society. Individuals should be able to develop their sense of autonomy especially by being able to position themselves on the scale of autonomy and integration. The first part of the commandment love first your Lord with all your heart expresses, among other things, the human desire to be at home somewhere socially and spiritually, to belong to a loving group, the ultimate group being mankind in its whole, protected by a superior power, the house of the Lord . I cannot develop the social implications of this theological idea either. However, these - or eventually other - spiritual roots cannot be put away any longer by categorical imperatives or principles of justice.
There is a third relevant meaning of the double commandment pointed out by Weingartner: The commandment also refers to some virtues humans should and can develop. In fact, autonomy at the end of life and autonomy towards terminal pain also depend on the virtues and related skills that inhabit us and that we can make grow during lifetime, that we develop at the same time as we self-actualize. This brings me to my last topic.
Si vis vitam para mortem : if you want to live well, prepare for your death! But how can we prepare for our last hour in an unknown future while we are living and struggling for a better life now? What kind of ars moriendi will enhance our present life? These are the general questions. I can only expose one element of them.
From the time when Hans Jonas has published his Prinzip Verantwortung , the concept of responsibility has again become a central issue in moral and social thought. But as far as I know, no philosopher has ever tried to found that concept on today's liability issues. There are in every society specific laws governing the various cases of liability. The traditional continental view links liability to a fault committed by the harm-causing person. Liability and fault once had some 'analytical' relation. In postmodern risk societies, this kind of liability is not applicable any more in many circumstances, more precisely, in circumstances where the liable person is empowered by his social status. At a basic level, this is true whenever we drive a car. The pedestrian who wants to cross the road in front of me has nothing compared to the hundred horsepower of my car. The car driver is liable even if the pedestrian is negligent.
The same type of liability holds when the responsible person is at the top of a risky factory. He is then liable in a strict sense, even when he has not committed any fault or negligence. The more empowered he is, the more reliable he should be and, as a consequence, the greater should be the sanction for the harm which falls under his realm of responsibility.
On the 12th Wittgenstein Symposium some ten years ago, I already tried to convince hard-core philosophers that the philosophical responsibility must grow out of the recent legal issues about liability, especially strict liability (Wettstein 1988, 45-48). However, as psychologists are wont to say, philosophers, like any other kind of people, need to hear new things at least six times before they really register the message. I am trying it now for the second time in Wechsel and I do not make any illusions about my persuasiveness (see also Wettstein 1989, 55-77; 1997, 407-412).
The basic idea is that power can be measured by the investment a person undertakes, 'investment' being defined in a very broad sense, linked to the principle of deferred gratification: to invest means then to make a supplementary effort during a certain amount of time, to refrain from consuming in order to harvest the result of the supplementary effort later.
Power sometimes corrupts and absolute power sometimes corrupts absolutely. Power is not bad in itself, only too much or too less power that cannot be associated any more with responsibility is bad, because it will tempt us to shun responsibility. To prevent responsibility from being endemically dispersed, I had in mind to link it to the person's invested potential that could be settled by a social theory. When I was a 'pure' philosopher, I thought that a new elaborate liability system could definitely implement this idea in society. Of course, the philosophical reflection on strict liability should not be abandoned. But at some stage of the argument, we must be aware of a very common truth: Such a system, even the perfect one, in which the powerful should give up their position once they have to admit responsibility for the accidents that happen under their realm of power, will never work unless society refrains from stigmatizing such a sacrificial step back and unless it values that experience positively so that this person may again be socially integrated.
In addition to these social conditions, which are implicit in the command of love and explicit in Matthew 23,12, but which are far from being accepted or implemented in our societies, there must be a culture where the powerful 1) agree that every exercise of power, even the one of a self-made man, is given to them by the social potentialities - it is not something someone possesses like a property - and where they 2) consider their work, not only rhetorically as some politicians do, as a real service for their community.
To be a servant means to accept the possibility to be small and unimportant again. It means to let go. So stepping down the hierarchy ladder should be enforceable by some law of liability. But such a law would only work if responsibility is cultivated as a virtue of the love commandment (Bartmann 1998), if the responsible actor is inhabited by that virtue demonstrating openly a sort of self imposed expiation whenever a serious case of liability occurs. Nobody would however expiate his involvement of liability unless society will honor such acts and not marginalize or exclude him socially. The fear of exclusion occasions many acts of irresponsibility.
I do come definitely back to the end of life issue. We are all concerned about the constitution of our own bodies. It is neither a fault nor a sign of ethical or spiritual weakness to be handicapped or in poor health. But under all circumstances are we liable for our body. We should love what has been given to us. But we know that the bodily strengths will fade and weaken. If, thanks to a just society, we are able to find our way through the trade-offs and complementarities of autonomy and integration, we also should develop the virtues that instill real life to these values, and one of them is the virtue of behaving in a responsible manner that includes socially valued self-sacrifice.
Under legal conceptions, the patient is autonomous. But what is he willing to do for his bodily autonomy during his lifetime? Asking this question does not mean that I am suggesting a political program for aid in suicide. It means that people have to develop their virtue of responsibility inside their sphere of autonomy and integration. Someone who positions himself more on the integration side should not be pushed by the care giving context to accomplish the legal autonomy she or he has due to the patient rights. There is no general commandment of becoming more and more autonomous. This depends on how you love yourself best now, as an independent or as an employee, as a single or as a married person, and so on.
Palliative care discloses a realm where the person can accomplish his last positioning within the value spectrum of autonomy and integration. But palliative care which also fosters pain communication, does not provide an absolute guarantee for a gentle death. It does in general, but not invariably.
The main concern of this paper is this: If, thanks to the virtue of responsibility, you could develop the spiritual letting go during life time, then your objective of dying could be a very last letting go. However, this skill can be threatened by a terminal disease. Thus the power related to that skill will be jeopardized. In these situations, to act in a responsible way then means that you can, you are free to renounce the power of letting go. Asking for sedation or for help in suicide is then considered as a second best choice, but astonishingly enough, as a last example of a responsible stepping back.
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* The ideas expressed in this paper are developed extensively in a Thesis (Habilitationsschrift) called Leben- und Sterbenkönnen: Gedanken zur Sterbebegleitung und zur Selbstbestimmung der Person, Peter Lang, Bern, (1995) 1997. I am very much indebted to Steve Burns, Pully, for his remarks and for checking my English.
1. In the recently created 'Arbeitsgruppe über die Sterbehilfe' by the Swiss government, Eidgenössisches Justiz- und Polizeidepartement in Bern, 'indirect active euthanasia' means of course passive euthanasia which is not so passive at all...
2. I am thinking of an important congress at Paulusakademie in Zürich, 22-23 March 1997 Menschenwürdig sterben . In their speeches, the bioethicist A. Bondolfi and the lawyer G. Stratenwerth still pondered the expression 'passive euthanasia'.
3. But I think that the input of Wittgenstein's argument for philosophical self-reference theory has been largely overestimated by E. Tugendhat (1979).
4. This point is also put forward by physicians: «La douleur n'est pas une maladie, elle est modulée par notre étant mental et notre expérience. Le problème ne se situe pas au niveau de l'expérience comme telle, mais plutôt dans la façon d'interpréter cette expérience» ( Husebo 1993, 167). But I have not yet discovered in the medical discussion any conceptual analyses of counterfactuals.
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