Semi-statistical views of health

On a purely statistical views of health, the health of a bodily system is its functioning near the average or median. This leads to the absurd conclusions in Kurt Vonnegut’s “Harrison Bergeron”: we should push those who are above average closer to the average.

A better view is Bourse’s semi-statistical view on which non-statistical facts determine the direction in which functioning counts as better and the direction in which it counts as worse, and then one says that the health of the system is its functioning either better than average/median or sufficiently close to the average/median.

The semi-statistical view has the following curious consequence. A government program to promote exercise if successful in significantly improving cardiac function in a sufficiently large number of participants and thereby raising the average/median is apt to make some non-participants who would otherwise have been marginal with respect to cardiac function fall below the norm. Thus, some non-participants are literally sickened by the program, and non-consensually so.

Humanity and humans

From childhood, I remember the Polish Christmas carol “Amidst the Silence of Night” from around the beginning of the 19th century, and I remember being particularly impressed by the lines:

Ahh, welcome, Savior, longed for of old,
four thousand years awaited.
For you, kings, prophets waited,
and you this night to us appeared.

I have lately found troubling the question: Why did God wait over a hundred thousand years from the beginning of the human race to send us his Son and give us the Gospel?

The standard answer is that God needed to prepare humankind. The carol’s version of this answer suggests that this preparation intensified our longings for salvation through millenia of waiting. A variant is that we need a lot of time to fully realize our moral depravity in the absence of God. Or one might emphasize that moral teaching is a slow and gradual process, and millenia are needed to make us ready to receive the Gospel.

I think there is something to all the answers, but they do not fully satisfy as they stand. After all, a human child from 100,000 years ago is presumably roughly as capable of moral development as a modern child. If we had time travel, it seems plausible that missionaries would be just as effective 100,000 years ago as they were 1000 years ago. The intensification of longings and the realization of social moral depravity are, indeed, important considerations, but human memory, even aided by writing, only goes back a few thousand years. Thus, two thousand years of waiting and learning about moral depravity would likely have had basically the same result for the individuals in the time of the Incarnation as a hundred thousand years did.

I am starting to think that this problem cannot be fully resolved simply by considering individual goods. It is important, I think, to consider humankind as a whole, with goods attached to the human community as a whole. The good of moral development can be considered on an individual level, and that good needs a few decade rather than millenia. But the good of moral development can also be considered on the level of humankind as well, and there millenia are fitting for the development not to ride roughshod over nature. Similarly, the good of longing for and anticipation of a great good only needs at most a few decades in an individual, but there is a value in humankind as a whole longing for and anticipating on a species timescale rather an individual timescale.

In other words, reflection on the waiting for Christ pushes us away from an overly individualistic view. As do, of course, other aspects of Christian theology, such as reflection on the Fall, the Church, the atonement, etc.

Am I fully satisfied? Not quite. Is the value of humankind’s more organic development worth sacrificing the goods of thousands of generations of ordinary humans who did not hear the Gospel? God seems to think so, and I am willing to trust him. There is doubtless a lot more to be said. But it helps me to think that this is yet another one of those many things where one needs to view a community (broadly understood) as having a moral significance going beyond the provision of more individualistic goods.

Two more remarks. First, a graduate student pointed out to me (if I understood them right) that perhaps we should measure individual moral achievement relative to the state of social development. If so, then perhaps there was not so great a loss to individuals, since what might matter for their moral wellbeing is this relative moral achievement.

Second, the specifically Christian theological problem that this post addresses has an analogue to a subspecies of the problem of evil that somehow has particularly bothered me for a long time: the evils caused by lack of knowledge, and especially lack of medical knowledge. Think of the millenia of people suffering and dying of in ways that could have been averted had people only known more, say, about boiling water, washing hands or making vaccines. I think there is a value in humankind’s organic epistemic development. But to employ that as an answer one has to be willing to say that such global goods of humankind as a whole can trump individual goods.

(Note that all that I say is meant to be compatible with a metaphysics of value on which the loci of value are always individuals. For an individual’s well-being can include external facts about humankind. Thus the good of humankind as a whole might be metaphysically housed in the members. The important thing, however, is that these goods are goods the human has qua part of humanity.)

More on doing and allowing

Let’s suppose disease X if medically unchecked will kill 4.00% of the population, and there is one and only one intervention available: a costless vaccine that is 100% effective at preventing X but that kills 3.99% of those who take it. (This is, of course, a very different situation than the one we are in regarding COVID-19, where we have extremely safe vaccines.) Moreover, there is no correlation between those who would be killed by X and those who would be killed by the vaccine.

Assuming there are no other relevant consequences (e.g., people’s loss of faith in vaccines leading to lower vaccine uptake in other cases), a utilitarian calculation says that the vaccine should be used: instead of 316.0 million people dying, 315.2 million people would die, so 800,000 fewer people would die. That’s an enormous benefit.

But it’s not completely clear that this costless vaccine should be promoted. For the 315.2 million who would die from the vaccine would be killed by us (i.e., us humans). There is at least a case to be made that allowing 316.0 million deaths is preferable to causing 315.2 million. The Principle of Double Effect may justify the vaccination because the deaths are not intentional—they are neither ends nor means—but still one might think that there is a doing/allowing distinction that favors allowing the deaths.

I am not confident what to say in the above case. But suppose the numbers are even closer. Suppose that we have extremely precise predictions and they show that the hypothetical costless vaccine would kill exactly one less person than would be killed by X. In that case, I do feel a strong pull to thinking this vaccine should not be marketed. On the other hand, if the numbers are further apart, it becomes clearer to me that the vaccine is worth it. If the vaccine kills 2% of the population while X kills 4%, the vaccine seems worthwhile (assuming no other relevant consequences). In that case, wanting to keep our hands clean by refusing to vaccinate would result in 158 million more people dying. (That said, I doubt our medical establishment would allow a vaccine that kills 2% of the population even if the vaccine would result in 158 million fewer people dying. I think our medical establishment is excessively risk averse and disvalues medically-caused deaths above deaths from disease to a degree that is morally unjustified.)

From a first-person view, though, I lose my intuition that if the vaccine only kills one fewer person than the disease, then the vaccine should not be administered. Suppose I am biking and my bike is coasting down a smooth hill. I can let the bike continue to coast to the bottom of the hill, or I can turn off into a side path that has just appeared. Suddenly I acquire the following information: by the main path there will be a tiger that has a 4% chance of eating any cyclist passing by, while by the side path there will be a different tiger that has “only” a 3.99999999% chance of eating a cyclist. Clearly, I should turn to the side path, notwithstanding the fact that if the tiger on the side path eats me, it will have eaten me because of my free choice to turn, while if the tiger on the main path eats me, that’s just due to my bike’s inertia. Similarly, then, if the vaccine is truly costless (i.e., no inconvenience, no pain, etc.), and it decreases my chance of death from 4% to 3.99999999% (that’s roughly what a one-person difference worldwide translates to), I should go for it.

So, in the case where the vaccine kills only one fewer person than the disease would have killed, from a first-person view, I get the intuition that I should get the vaccine. From a third-person view, I get the intuition that the vaccine shouldn’t be promoted. Perhaps the two intuitions can be made to fit together: perhaps the costless vaccine that kills only one fewer person should not be promoted, but the facts should be made public and the vaccine should be made freely available (since it is costless) to anyone who asks for it.

This suggests an interesting distinction between first-person and third-person decision-making. The doing/allowing distinction, which favors evils not of our causing over evils of our causing even when the latter are non-intentional, seems more compelling in third-person cases. And one can transform third-person cases to be more like first-person through unencouraged informed consent perhaps.

(Of course, in practice, nothing is costless. And in a case where there is such a slight difference in danger as 4% vs. 3.99999999%, the costs are going to be the decisive factor. Even in my tiger case, if we construe it realistically, the effort and risk of making a turn on a hill will override the probabilistic benefits of facing the slightly less hungry tiger.)

Medical conscience exemptions

After listening to a talk by Christopher Kaczor, and the ensuing discussion, I want to offer a defense of a moderate position on the state not compelling healthcare professionals to violate their conscience, even when their conscience is unreasonably mistaken. I think a stronger position than the moderate position may be true, but I won’t be defending that.

This is the central insight:

1. It is a significant harm to an individual to violate their conscience, even when the conscience is irrationally mistaken.

One reason that (1) is true is the Socratic insight is that it is much better to suffer wrong than to do wrong, together with the Conscience Principle that to act against conscience is always wrong.

My argument will need something a bit more precise than (1). For convenience, I will stipulate that I use “grave” for normative considerations, goods, bads and harms whose importance is at least of the order of magnitude of the value of a human life. The coincidence that “grave” not only means very serious but also place of burial in English—even though the etymologies are quite different—should remind us of this. When you read the following, whenever you read “grave” and cognates, don’t just read “serious”, but also imagine a grave.

Then what I need is this:

2. It is a grave harm to a conscientious individual to gravely violate their conscience, even when that conscience is unreasonably mistaken.

(I suspect this is true even if one drops the “conscientious” and “gravely”, but I am only defending a moderate position.) The reasons for (2) are moral and psychological. The moral reasons are based on the aforementioned Socratic insight about the importance of avoiding wrongdoing. But there are also psychological reasons. A conscientious person identifies with their conscience in such a way that gravely violating this conscience is shattering to the individual’s identity. It is a kind of death. It is no coincidence that the Catholic tradition talks of some sins as “mortal”.

Next, here is another reasonable principle:

3. Normally, the state should not require a healthcare professional to provide care when the care is likely to come at a grave cost to the professional.

For instance, the state should not require a healthcare professional to donate her own kidney to save a patient. For a less extreme case that I will consider some variations of, neither should the state require a professional who has a severe bee allergy to pass through a cloud of bees to help a patient when allergy reaction drugs are unavailable and when other professionals lacking such an allergy are available.

In order for (3) to be useful in pracice, we need some way of getting rid of the “Normally” in it.

Notice that (3) is true even when the grave cost to the professional results from the professional’s irrationality. For instance, normally a healthcare professional who has a grave phobia of bees should not be required to pass through the cloud of bees, even if it is known that the professional would not be seriously physically harmed. In other words, that the cost results from irrationality does count as an abnormality in (3).

Under what abnormal conditions, then, may the state require the professional to offer care that comes at grave cost to the professional? This is clearly a necessary condition:

4. The need is grave.

But even if the need is grave, if someone else can offer the care for whom offering the care does not come at a grave cost, they should offer it instead. If the way to save a patient’s life is for one doctor to pass through a cloud of bees, and there is a doctor available who is not allergic to bee stings, then a doctor who is allergic should not be made to do it. Thus, we have this condition:

5. There is no way of meeting the need without someone being required to take on a likely grave cost.

We can combine these two conditions into a neater condition (which may also be a bit weaker than the conjunction of (4) and (5)):

6. If the care is not provided by this professional, a grave harm will likely result to someone.

This suggests some principle like this:

7. Unless failure of this professional to provide this instance of care will likely result in a grave harm, the state should not require a healthcare professional to provide care when the care is likely to come at a grave cost to the professional.

Now we go back to (2), the claim about the grave cost of violating conscience. Let us charitably assume that most medical professionals are conscientious, so that any given medical professional is likely to be conscientious. Then we get something like this:

8. Unless failure of this professional to provide this instance of care will likely result in a grave harm, the state should not require a healthcare professional to provide care that gravely violates their conscience, even when that conscience is unreasonably mistaken.

But this cannot be the whole story. For there are also conditions that render one incapable of doing central parts of one’s job. For instance, someone with a grave phobia of fires should not be allowed to be a fire fighter. And while a fire fighter with that grave phobia should not be made to fight a fire when someone else is available, if they had the phobia at the time of hiring, they should not have been hired in the first place. And if they hid this phobia at the time of hiring, they should be fired.

We have, however, a well-developed societal model for dealing with such conditions: the reasonable accommodations model of disability legislation like the Americans with Disabilities Act. It is reasonable to require an office building to put in a ramp for an employee in a wheelchair who is unable to walk; it would be unreasonable for a bank to have to hire a guard specially to watch a kleptomaniac teller. What is and is not a reasonable accommodation depends on the centrality of an aspect of a job, the costs to the employer, and so on.

So my moderate proposal says that we handle the worry that a particular conscientious objection renders a professional incapable of doing their job by analogy to the reasonable and unreasonable accommodations model, and qualify (8) by allowing in hiring or licensure the requirement that the accommodations for a conscientious restriction on practice would have be reasonable in ways analogous to reasonable disability accommodations. A healthcare professional who has only one hand could, I assume, be reasonably accommodated in a number of specialities, but likely not as a surgeon.

The disability case also should push us towards a less judgmental attitude towards a healthcare professional whose conscientious objections are unreasonably mistaken. That an employee became a paraplegic from unreasonable daredevil recreational activity does not render the employee uneligible for otherwise reasonable accommodations.

What about the worry about the rare cases where a healthcare professional has morally repugnant conscientious views that would require discriminatory care, such as refusing to care for patients of a particular race? Could one argue that if patients of that race are rare in a given area, then allowing a restriction of practice on the basis of race could be a reasonable accommodation? We might imagine an employee who has panic attacks triggered by a particular rare configuration of a client’s personal appearance, and that does seem like a case for reasonable accommodations, after all.

Here I think there is a different thing to be said. We want our healthcare professionals to have certain relevant moral virtues to a reasonable degree. Moral virtues go beyond obedience to conscience. Someone with a mistaken conscience may not be to blame, for the wrongs they do, but they may nonetheless lack certain virtues. The case of the conscientious racist is one of those. So it is not so much because the conscientious racist would refuse to care for patients of a particular race that they should not be a healthcare professional but it is because they fail to have the right kind of respect for the dignity of all human beings.

One may think that this consideration makes the account not very useful. After all, a pro-life individual is apt to be accused of not caring enough for women. Here I just think we need to be honest and reasonably charitable. Caring about the embryo and fetus has human dignity does not render it less likely that one cares about women. Compare this case: A vegan physician believes that all higher animal life is sacred, and hence refuses to prescribe medication whose production essentially involves serious suffering of higher animals. Even if such a physician’s actions might cause harm to patients who need such (hypothetical?) medication, the belief that all higher animal life is sacred is not evidence that the physician does not care about such patients–indeed, it seems to render it more likely that the physician thinks the patients’ lives to be sacred as well, and hence to be cared for. There may be specialties where accommodation is unreasonable, but the mere fact of the belief is not evidence of lack of relevant virtues.

Consent and sex

Here are some facts about sex and consent.

1. Without valid consent, sex is always seriously wrong.
2. Merely proxy consent for sex (say, by parents on behalf of a child) is never valid.
3. Child consent for sex is never valid.
4. Consent may be withdrawn at any time when discontinuation is still possible.

And yet:

5. Sometimes sex is permissible (with consent, of course).

There aren't many cases other than sex where the analogues of 1-5 apply. Here's one potential such case. The Nuremberg code forbids medical experiments that involve a significant risk of serious injury or death to a healthy subject, except in the case of self-experimentation, assuming the other conditions of the code are met. But if such self-experimentation is permissible, it seems likely that it would be morally permissible (though we may have good reasons to rule it out in professional medical ethics codes) to hire someone to perform such experiments on one. To do such experiments without valid consent from the employer/subject would be seriously wrong, neither proxy nor child consent would be sufficient for validity, and one would have to stop whenever consent was withdrawn.

But notice an important feature of the medical experiment case: the reason these strong consent restrictions are in play is because of the significant risk of serious injury or death. If one modifies the experiment to make the risk insignificant, weaker consent standards come into play. In particular, parents will then be validly able to consent.

But in the case of sex, the reason for the strong consent standards does not come from risks of injury or death, whether physical or psychological. For we can suppose a case where the person is unconscious, where 100% effective prophylactics are used and where the person will never be informed of the event, and hence there is no danger of physical or psychological injury. Even so, the strong consent standards for sex apply. For instance, merely proxy consent is still not sufficient.

Notice, too, another interesting feature of the medical experiment case. Even when the experiments are done in a moral good way, it is regrettable that there was no other way of getting the benefits. But sex isn't like that: when it is engaged in in a morally good way, typically there is nothing regrettable about it--quite the opposite.

So there seems to be something exceptional about sex and consent. The other cases where such strong requirements of consent need to be in place are look to be cases where one needs permission to impose something very bad on someone. That's not what's going on in sex. What is going on? My view is that sex is tied very closely to love, and love requires freedom... But filling out detail isn't easy.

Treatment and enhancement

Let's grant that my ability to use my hands is normal. Suppose a world-class violin maker loses the little finger on her non-dominant hand. This slightly impedes her ability to use her hands. But the incredible amount of gross and fine motor skills that a top violin maker needs to have exceed my own merely normal skills to such a degree that she is going to do better in any non-gerrymandered manual activity (wiggling ten fingers is gerrymandered!) than I.

But my own abilities are normal. So if her abilities exceed mine, how can hers fail to be normal? Yet it seems clear that to the extent that reattachment of the finger would be treatment rather than enhancement, even though it takes someone whose abilities are above normal, and raises her even higher above what is normal.

So we should not define the kind of abnormalcy or disability that calls for medical treatment in terms of a below-normal degree of overall function. For overall function is affected by compensation—the violin-maker's manual skills compensate for her genuine loss. Rather, we must look at something like local function, the function of a particular bodily subsystem. And here it is clear that when she lost her finger, she lost the full use of a subsystem. Disability is the loss of the full functioning of a subsystem, not necessarily of the whole.

But now here we have an interesting thing. An operation that destroys the functioning of a bodily subsystem that otherwise would have functioned properly, even if it does not adversely affect—or maybe even enhances—overall functioning of the person, nonetheless is producing a disability. Now a physician should be a healer. Sometimes to heal one must destroy a subsystem—amputating a gangrenous limb is an example. Even in those cases, the destruction is a moral reason for the physician not to do the operation, though a reason that may well be outweighed (as it is in the gangrenous limb case) by the need for healing.

But this is far more problematic when the destruction of a subsystem is not done in order to heal the system as a whole, even if in some way the person as a whole benefits. Suppose Sam has a job that consumes all his waking hours and involves no contact with people, and his normal interest in social relationships makes him less good at his job. Moreover, suppose the sad economic realities are such that he has no hope of another job. He is going to live a life of loneliness and unfulfilled sociality. Should we give him drugs that would destroy his sociality? Such drugs would improve his life, after all. Yes: but they would do so by destroying a subsystem. And their positive effect would not be a form of healing—at most a form of enhancement at adaptation to unfortunate circumstances. So there is strong—I think conclusive—moral reason why a physician should not give Sam the drugs.

And the same line of thought applies in a much more controversial, because more realistic, case: sterilization.

Treatment versus enhancement

I don't think you have much hope of having a distinction between treatment and enhancement unless you have the notion of the normal state or proper function of the human body. I previously thought we want a distinction between treatment and enhancement for such purposes as figuring out what the task of the physician as such is and what requests from the patient the physician has a right to turn down flat. For instance, a physician who receives a request to remove a cancer, and who judges that removal of the cancer is feasible, safe and ethically permissible, has a medical duty to either remove the cancer or refer to someone else. On the other hand, a physician who receives a request to pierce a patient's ears for earrings, even though she no doubt judges this to be feasible and ethically permissible, has no medical duty to perform the procedure or refer to someone else, since it is not a medical treatment.

But a new kind of case seems to me to make the distinction even more pressing, and this is cases where it is not possible to ask the patient's consent. Suppose that in the middle of heart surgery, the surgeon notices an old bullet lodged near the heart. The bullet does not impair the heart's functioning, so the patient's consent to the heart operation does not extend to the bullet. But it is intrinsically morally permissible for the surgeon to remove the bullet if she reasonably judges that doing so is good for the patient (of course, there may be laws and regulations that prohibit this, in which case it will be extrinsically impermissible). On the other hand, if a brain surgeon removing a cancer from someone's brain reasonably judges, on the basis of the latest research, that moving a few neurons around will make the subject super-fast at arithmetic with large numbers, that is unacceptable. Likewise, if in the course of a Caesarian the physician notes that the tubes could be tied and judges that the patient would be better off not getting pregnant, that too is unacceptable, whether or not consensual sterilization is permissible (this is, alas, not a hypothetical case).

One can try to handle this with "presumed consent", but that's kludgy, and probably doesn't work. Presumed consent from an unconscious suicidal patient for emergency treatment following the attempted suicide is going to involve dubious counterfactuals, like asking what the patient would want if the patient were fully sane (there might be no fact of the matter about this), and, besides, you probably can't make sense of "sane" without the concept of normalcy. Moreover, we can imagine cases where one can presume that the patient would consent if asked, but the action is still wrong. For instance, one may well know of many patients that they would agree to have a gift of diamonds worth millions sewed into them as a part of surgery, if they were going to be later notified and could have the diamonds safely removed through another surgery and if there was no other way for them to be given the diamonds. But to sew in the diamonds as part of heart surgery, without having sought the patient's consent, is morally impermissible--or at least it's bad medicine.

Healing and harming

Plato was impressed with the idea that he who can best heal is he who can best kill. I doubt it. The big brawny person with the nail-studded club can kill as well as a physician. But a weaker claim seems plausible: those who are competent to make one well are competent to make one unwell. The reverse is false. Competence with clubs and poisons does not imply competence in surgery and healing drugs. Similarly, it is easy to completely destroy a car and hard to be a mechanic. The asymmetry is interesting. It suggests an important asymmetry between good and evil.

Two kinds of professions

Compare the metalworker and the swordsmith. The metalworker's profession is defined by a particular technique for achieving human ends: the production and modification of items made of metal. The swordsmith's profession, on the other hand, is not defined by any particular technique. It is, instead, defined by an end: the existence of a sword. The two sets of skills may overlap: both a swordsmith and an metalworker can make a sword of metal, and in so doing remain within their professional competency. But a swordsmith can remain within her professional discipline in producing a sword of horn, wood and flint (say, in an emergency when metals are unavailable), while the metalworker who made such a sword would not be working within her profession. On the other hand, the metalworker remains within her professional competency when she makes a metal spoon, while the swordsmith is not working as a swordsmith when she makes a spoon—even though she may be as qualified to produce a spoon as any metalworker, and more so than some.

We can in general distinguish means-defined professions and end-defined ones. Examples of means-defined ones: software engineer, electrical engineer, chemical engineer, metalworker, woodworker, machinist, applied mathematician, lawyer. Examples of end-defined ones: civil engineer, aviation engineer, swordsmith, bowyer, cabinet maker, physicist, pure mathematician, biologist, legislator. There will also be cases of professions defined both by and end means. Some of these result from specializations within a means-defined or an end-defined profession—and sometimes it will be unclear which way is the better way to look at it. Is a biomathematician an applied mathematician (means-defined) who uses mathematical methods for the sake of gaining biological knowledge, or is a biomathematician a biologist (end-defined) who uses mathematical methods to pursue the end distinctive of her biological profession (namely, biological knowledge)?

It may be that in all cases of end-defined professions there are some constraints on which means count as part of the distinctive activity of the profession. Thus, it may be argued not be a part of the civil engineer's profession to pray that the bridge not collapse, even though doing so promotes the end that defines her profession. However, it is not clear that this is so. It may be a prejudice to say that the civil engineer does not pray qua engineer.

Nonetheless, despite borderline cases, a basic division into professions primarily defined by a means or set of means, and those defined by an end or set of ends, seems helpful.

Does any of this matter? I think it can. For instance, consider this question: Is it the job of the physician, qua physician, to execute criminals? Assume that the case is one of the rare cases where capital punishment is morally permissible. As has been noted at least since the time of Plato, the physician's professional knowledge makes her the most effective person at both preserving life and taking away life. Moreover, her skills may particularly enable the taking away of life to be reliably painless. If the physicians's profession is primarily defined by means or techniques, then to execute painlessly falls under her profession just as much as to heal. If, on the other hand, her profession is defined in terms of ends, presumably the relevant end is something like the good functioning of the body, and this goal is not promoted by killing. And euthanasia is also not something that falls to the role of a physician.

I think our concept of a physician is a mix. When we talk of the crime of practicing medicine without a license, we are thinking of medicine as in part defined by a particular set of techniques. One does not count as practicing medicine without a license if one suggests to someone that she refrain from eating too many cheeseburgers or if one prays for her health. But only in part. If someone who is not a medical professional intentionally stabs someone else to death with a surgical knife, she would not, I suspect, be charged with practicing medicine without a license in addition to murder, no matter if she had pored anatomy books to figure out how to do the deed.

Still, I think, the primary focus in the medical profession is on the end. Consider that the physician remains within her medical role if the means she recommends to promote end of health involve pharmaceuticals, surgery, physical exercises, psychological exercises, the taking of a placebo, etc. Almost anything that in a morally acceptable way promotes health—with the possible exception of the supernatural—can legitimately fall within the scope of her medical recommendations. She might even diagnose that the patient's headaches are due to financial worries and recommend that the patient come up with a good budget. She would be going beyond her medical competence, I suppose, if she recommended a particular set of safe investments, but that may only be because recommending investments is not a skill that physicians typically have. (A particular practitioner of profession will not have all the skills that can fall under the professional role—the bowyer who cannot work in fiberglass can still be a competent bowyer.)

Moreover, most of the subdivisions within medicine, with the most obvious exception being surgeon, are end-based: the neurologist, the psychiatrist, the gastroenterologist and the pediatrician are each defined by which instances of the goal of health it is their special task to promote.

The pharmacist, on the other hand, is equally defined by means and by end. She does not act within her role if she prepares medication for an execution. It is, after all, her job to take solicitude for the health of the patient, ensure that she is not allergic to the drugs, etc. But she also does not act within her role if she performs surgery.

Euthanasia and the role of the physician

Consider this argument:

1. (Premise) It is not professional for a physician to perform a procedure when there is not sufficient scientific evidence or professional experience about the sequelae of the procedure for the patient.[note 1]
2. (Premise) There is not sufficient scientific evidence or professional experience about the sequelae of euthanasia for the patient.
3. Therefore, it is not professional for a physician to euthanize a patient.

In support of premise (2), note that a crucial thing to have scientific or professional evidence about in the case of a medical procedure is what kinds of things, if any, the patient will be conscious of after the procedure. Now, there is good reason—and perhaps we can consider it "scientific reason"—to think that after the patient is killed, it will no longer be the case that the patient will be conscious of the particular pain, discomfort or indignity that prompted the request for euthanasia. However, there is no scientific evidence or professional experience about whether the patient would or would not have other pains, discomforts or indignities. In fact, there is no scientific evidence or professional experience about whether the patient would or would not have any conscious experiences whatsoever after the procedure.

For an analogy, consider a neurosurgical procedure that could be performed on a suffering patient, which procedure would place the patient in a coma-like state. Suppose further that there was no scientific evidenece or professional experience as to which of the following hypotheses was true:

4. There are no conscious patient experiences following the procedure.
5. The patient is conscious after the procedure, and her conscious states are extremely unpleasant.
6. The patient is conscious after the procedure, and her conscious states are extremely pleasant.
7. The patient is conscious after the procedure, and her conscious states are neither extremely pleasant nor extremely unpleasant.

Surely, the physician who performs the neurosurgical procedure in a responsible way has to have grounds for thinking that (5) isn't the likely outcome for this particular patient. Moreover, for the procedure to be done professionally, those grounds have to be of the sort recognized by the profession—namely, they have to be scientific or based in professional experience.

Observe that the patient's belief as to what the outcome of the procedure would be will not suffice to render a procedure professional. Suppose there is no scientific evidence or medical experience as to whether morphine fights colon cancer. If I request morphine from the physician because I believe, on non-scientific and non-medical grounds, that it fights colon cancer, the physician would not be acting professionally in granting my request. This is true even if my non-scientific and non-medical belief is justified, or even if it is knowledge, say because I know that an angel told me that morphine alleviates colon cancer. It is the physician's professional expectations as to the major sequelae of the procedure that are relevant to whether the physician should perform a procedure or prescribe medication, not the patient's beliefs. Professional medical practice, as it is generally understood in our society, requires both the actual or presumed or proxy informed consent of the patient and the physician's professional judgment.

Could one argue that a physician could kill a patient because she justifiably believes on non-professional grounds that this would be good for the patient? Perhaps the physician justifiably thinks she has an excellent philosophical argument against an after-life or a conclusive theological-cum-empirical argument for the claim that this patient, if killed, would go to heaven. Here, one needs to distinguish three questions:

8. Whether a procedure is or is not professional.
9. Whether a procedure is or is not unprofessional.
10. Whether a procedure is or is not morally permissible.

My argument, I think, does show that killing the patient is not a professional medical procedure. It does not immediately follow from this that it is unprofessional. For instance, reading a fun novel is not (typically) a professional medical procedure, but the physician who reads a fun novel is not behaving unprofessionally (typically). Possibly, however, when we add to (1) that the procedure is "by the physician in her medical role", then we can strengthen the conclusion of (1) to say that the procedure is unprofessional. Nonetheless, there is a further question whether the procedure is morally permissible or not. There might be times when it is morally permissible or even obligatory to violate professional standards (and then perhaps obligatory for any licensing body to take one's license away). Whether euthanasia constitutes such a case is a question I haven't addressed in this post. (Of course, I think euthanasia is always morally wrong, but I think this on grounds other than 1-3: it's wrong because it's an intentional killing of a juridically innocent non-aggressor.)

New blog on abortion

Here is a new blog on abortion, by a physician and a friend of mine.

Euthanasia, patient autonomy and the physician's task

In this post, I am not going to distinguish between a doctor's "helping" a patient kill herself and the doctor's killing the patient herself, since in both cases the doctor kills, in the former case in concert with the patient and the latter alone. To help an assassin pull the trigger or aim the gun is to be a co-assassin. There are two different kinds of reasons given for allowing doctors to kill suffering terminally ill patients: care and autonomy. Those who focus on care base their argument on the patient's suffering and the physician's task in relieving that suffering. One difficulty with justing the euthanasia on such grounds is that once one sees euthanasia as a part of the physician's task of relieving the suffering, then it would become the physician's job to euthanize an incompetent patient (an eight-year-old?) who is suffering, terminally ill and yet begs to live, but where either no proxy is available or the proxy consents, just as it would be the physician's job to do life-saving surgery on an incompetent patient who resists the surgery. But even a lot of supporters of physician-assisted suicide will say that this is going too far.

Suppose instead that we base the killing of the patient on autonomy considerations: the patient chooses to be killed. Here, it is not clear what role in the justification is played by the fact that the patient is terminally ill and suffering, except maybe an epistemic role in providing evidence that the patient is not insane to request killing. After all, if the point is that people have the right to make deep decisions about life and death matters, then it seems that it would be equally the right of a patient who is quite well physically and mentally but who wishes to avoid creditors to request being killed by a physician, whereas surely this is not a request a doctor should accede to.

Now, a defender of euthanasia might object that a limiting condition on a physician's following of patient instructions is the good of the patient, and the person seeking to escape creditors would do better to declare bankrupcy than to be killed. Thus, just as on the first view, euthanasia was justified by care with consent being a limiting condition, on this view euthanasia is justified by consent with care being a limiting condition. However, this is problematic in a different way: It misunderstands the doctor's role. While those who took the first view were wrong in thinking that care calls for killing, they were right that care is the doctor's task.

Consider a surgeon who removes a malignant tumor. It would surely be very strange to say: "In order to honor the patient's choice to determine what is and what is not a part of his body, Dr. Magrodska removed Mr. Jones' tumor." Surely the right thing to say is that Dr. Magrodska removed the tumor because it was malignant, with Mr. Jones' consent being a mere necessary condition (and one that could be satisfied in other ways were Mr. Jones to be incompetent). Professionals are not servants of their clients' wishes, and physicians are professionals par excellance.

Now, there may be things that only a physician is qualified to do and which are done primarily as a response to the patient's wishes. Certain kinds of elective cosmetic surgery are such. But I think it is correct to say that in such a case the physician is not acting as a physician. Rather, she is acting as a medically-trained beautician. And even there she risks losing her status as a professional altogether if she does not act from a belief that the surgery makes the patient more beautiful. That a task requires medical training does not make the task a medical one (not that killing people painlessly requires medical training—see my previous post). Someone with medical training may be needed as consultant for a film set in a hospital—but such consulting is not a medical task.

There is thus a tension between the aspects of care and autonomy in the justification of killing terminal patients. If one focuses on care, then consent becomes a mere limiting condition and one arrives at abhorrent conclusions about killing vociferously protesting children. But if one focuses on autonomy, then physician-assisted suicide ceases to be a medical task.

Physician-Assisted Suicide

Derek Humphry wrote, as part of a defense of Physician-Assisted Suicide (PAS):

The help of a physician [in PAS] is imperative, because loved ones and family members untrained in the medical profession are rarely able to help a loved one to die [...].

This idea seems a standard part of the arguments for PAS.[note 1]

But there are four ways of reading "able" in "able to help": morally, legally, technically or psychologically, as well as combinations of these. Hymphry is presumably not claiming that family members are morally unable to help, that it is wrong for them to "help", since it would be really weird to suppose that medical training somehow gives one permission to kill when before the killing would be immoral. Nor is he claiming that unlike physicians they are legally unable to kill, for instance because they would be charged with murder, since the legality of PAS is precisely what is at issue, and if PAS is illegal, then physicians are also legally unable to "help".

Probably the best reading is "technically able to help", given the mention of training. But on that reading, the claim is false. There are many highly reliable methods of basically instaneously killing a person, at least if the killer has a normal amount of dexterity and physical strength. At the expense of some gruesomeness, let's briefly mention shotguns and large axes. One might object that in those cases, it is not a matter of helping but a matter of doing the whole job oneself. But it is easy to give the victim a role, say having the victim pull the trigger with a string.

Perhaps, then, we should read "able to help" as "psychologically able to help". On this reading, medical training makes it psychologically possible to kill. This is scary in that it makes medical training be akin to military training, a regime that makes one into someone who is not merely technically but psychologically capable of killing, overcoming our innate resistance to killing (on the latter topic, see this fascinating book by Rachel MacNair). Besides, if psychological resistance is the issue, one doesn't need a physician, just an able-bodied psychopath.

Maybe the best reading of the quote from Humphry is to combine the technical and psychological. The technical skills of the ordinary person, just much as those of the physician, make possible multiple relatively painless methods of killing, but these methods are messy, and are likely to be traumatic for the perpetrator. The methods available to the physician are neater. I think, though, there is a more perspicuous way of putting the difference: The methods available to the ordinary person make it look like the family member has killed a person, while the methods available to the physician make it look like a medical procedure has been performed. But once we formulate it in this way, it seems that the main "advantage" of the methods available to the physician is that they hide what has happened—the destruction of a human body. And that, in turn, is no advantage at all, since it hides from the moral imagination the truth of the situation, thereby skewing the decision.

Objection 1: Humphry could simply be worried about cleaning up after a killing committed with an axe or a gun.

Response: That seems unlikely. Besides, if mess is the issue, someone formerly in the special forces could surely be hired to do a neat and instantaneous job. Physicians are not the only people with technical skills for killing.

Objection 2: Being killed medically is more dignified than being killed with a gun.

Response: I simply do not see this. Why should being poisoned by an injection administered by someone in a white coat be more dignified than being shot dead? After all, we think of soldiers in wartime as dying with honor and dignity when they are shot by the enemy. I think the issue is not that being killed medically is more dignified, but that being killed medically hides the truth about what is happening. And dying in such a sneaky way is, if anything, less dignified.

Final comment: If I am right, then a major reason for PAS is a desire to make killing look less like a killing. And that desire is illegitimate if PAS is morally permissible. At the same time, I think the presence of that desire reflects something good: it reflects a revulsion at killing. But to kill the patient in a way that hides the destruction of the body is not the right way to respond to that revulsion. The right way to respond to that revulsion is to recognize the dignity of human life, and to care for rather than kill the patient.