Life and death : philosophical essays in biomedical ethics

449 Pages·1993·16.194 MB·English

by  Dan W Brock

How should modern medicine's dramatic new powers to sustain life be
employed? How should limited resources be used to extend and improve
the quality of life? In this collection, Dan Brock, a distinguished philoso-
pher and bioethicist and coauthor of Deciding for Others (Cambridge, 1989),
explores the moral issues raised by new ideals of shared decision making
between physicians and patients.
The book develops an ethical framework for decisions about life-
sustaining treatment and euthanasia, and examines how these life-and-
death decisions are transformed in health policy when the focus shifts
from what is best for a patient to what is just for all patients.
Professor Brock combines acute philosophical analysis with a deep un-
derstanding of the realities of clinical health policy. This is a volume for
philosophers concerned with medical ethics, health policy professionals,
physicians interested in bioethics, and undergraduates taking courses in
biomedical ethics.

Life and Death
Cambridge Studies in Philosophy and Public Policy
GENERAL EDITOR: Douglas MacLean
The purpose of this series is to publish the most innovative
and up-to-date research into the values and concepts that
underlie major aspects of public policy. Hitherto most re-
search in this field has been empirical. This series is primarily
conceptual and normative; that is, it investigates the structure
of arguments and the nature of values relevant to the for-
mation, justification, and criticism of public policy. At the
same time it is informed by empirical considerations, ad-
dressing specific issues, general policy concerns, and the
methods of policy analysis and their applications.
The books in the series are inherently interdisciplinary and
include anthologies as well as monographs. They are of par-
ticular interest to philosophers, political scientists, sociolo-
gists, economists, policy analysts, and those involved in
public administration and environmental policy.
Other books in the series
Mark Sagoff The Economy of the Earth
Henry Shue (ed.) Nuclear Deterrence and Moral Restraint
Judith Lichtenberg (ed.) Democracy and the Mass Media
William A. Galston Liberal Purposes
Elaine Draper Risky Business
R. G. Frey and Christopher W. Morris (eds.) Violence,
Terrorism, and Justice
Ferdinand Schoeman Privacy and Social Freedom
Paul B. Thompson The Ethics of Trade and Aid
Life and Death
Philosophical essays in biomedical ethics
DAN W. BROCK
BROWN UNIVERSITY
M CAMBRIDGE
W UNIVERSITY PRESS
CAMBRIDGE UNIVERSITY PRESS
Cambridge, New York, Melbourne, Madrid, Cape Town, Singapore, São Paulo,
Delhi, Dubai, Tokyo, Mexico City
Cambridge University Press
The Edinburgh Building, Cambridge CB2 8RU, UK
Published in the United States of America by
Cambridge University Press, New York
www.cambridge.org
Information on this title: www.cambridge.org/9780521428330
© Cambridge University Press 1993
This publication is in copyright. Subject to statutory exception and to the provisions of
relevant collective licensing agreements, no reproduction of any part may take place
without the written permission of Cambridge University Press.
First published 1993
A catalogue record for this publication is available from the British Library
Library of Congress Cataloguing in Public Data
ISBN 978-0-521-41785-3 Hardback
ISBN 978-0-521-42833-0 Paperback
Cambridge University Press has no responsibility for the persistence or accuracy of URLs for external or
third-party internet websites referred to in this publication, and does not guarantee that any content on
such websites is, or will remain, accurate or appropriate. Information regarding prices, travel timetables
and other factual information given in this work are correct at the time of first printing but Cambridge
University Press does not guarantee the accuracy of such information thereafter.
Contents
Sources and acknowledgments page vii
Introduction 1
PART i: PHYSICIANS AND PATIENTS
MAKING TREATMENT DECISIONS
1 Informed consent 21
2 The ideal of shared decision making between
physicians and patients 55
3 When competent patients make irrational
choices
(Coauthored by Steven A. Wartman) 80
PART II: LIFE-AND-DEATH DECISIONS
IN THE CLINIC
4 Moral rights and permissible killing 95
5 Taking human life 123
6 Death and dying 144
7 Forgoing life-sustaining food and water:
Is it killing? 184
8 Voluntary active euthanasia 202
Contents
PART III: LIFE-AND-DEATH DECISIONS
IN HEALTH POLICY
9 The value of prolonging human life 235
10 Quality of life measures in health care and
medical ethics 268
11 The problem of low benefit/high cost
health care 325
12 Justice and the severely demented elderly 356
13 Justice, health care, and the elderly 388
14 Truth or consequences: The role of
philosophers in policy-making 408
Index 417
VI
Sources and acknowledgments
These essays were written, each as an independent, self-
contained work, over a period of nearly fifteen years, though
most are from the latter half of that period. They have been
selected from a substantially larger group of essays in
biomedical ethics that I have written during this period. In
the introduction which follows I will show briefly how the
essays are related and state the themes of the larger coherent
whole of which they form a part, but I want here to make
clear the principles by which they were selected.
While a few of these essays address general issues in moral
philosophy concerning taking and saving lives, the large ma-
jority are from my work in biomedical ethics; other work in
moral philosophy, such as a number of papers on utilitar-
ianism, has been omitted. Even within my work in biomed-
ical ethics, however, I have included my more philosophical
essays within the broad theme of life and death, and omitted
essays addressed more to practical cases or policy issues.
Biomedical ethics is a paradigm of an interdisciplinary field,
and my intent here is to provide one example of what the
discipline of philosophy has to contribute to its work. The
point is not, of course, that there is a clear and clean dis-
tinction between the strictly philosophical contributions or
contributors to the field and the contributions or contributors
from other disciplines. Rather, these essays were written in
the belief that many of the underlying philosophical issues,
sometimes staples of moral philosophy, have not received
enough attention in the biomedical ethics literature in the
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Sources and acknowledgments
face of the dramatic pull of individual cases where life and
death are at stake. It is my disciplinary belief, and no doubt
bias, that our thinking on the dramatic cases and policy issues
of life and death that command professional and public at-
tention can be deepened by careful attention to these more
philosophical issues. In this respect, by selecting the more
philosophical papers, I have at the same time selected what
for nonphilosopher readers may be some of my more difficult
and less easily accessible work in biomedical ethics. It is left
to the reader to judge, of course, whether the more difficult
point of entry is warranted by the subsequent philosophical
analyses to be encountered. A number of other essays have
been omitted because they largely cover ground already rel-
atively easily accessible in book form in my book, coauthored
with Allen Buchanan, Deciding for Others: The Ethics of Sur-
rogate Decision Making, published in 1989 by Cambridge Uni-
versity Press.
Some readers will recognize a close affinity between some
of the views developed in these essays and two of the reports
of the President's Commission for the Study of Ethical Prob-
lems in Medicine and Biomedical and Behavioral Research,
Making Health Care Decisions and Deciding to Forego Life-
Sustaining Treatment. This is not because I have shamelessly
borrowed from those reports, but because I served as staff
philosopher on the Commission in 1981-82 with special re-
sponsibility for some of the more philosophical sections of
these two reports. These reports, like the rest of the Com-
mission's work, were truly team efforts and I do acknowledge
with gratitude that I did shamelessly accept the good influ-
ences of the other very talented members of that staff. Many
of the essays in this volume represent my attempts to explore
some of the philosophical issues underlying the Commis-
sion's work in more detail than was possible in the Com-
mission's reports, though other staff members are not
responsible for what I have done with those issues here.
The essays appear here largely as originally published. I
have edited a few papers to remove some repetition, but only
when doing so did not prevent each essay from standing
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