THE PATIENT'S LIFE
8.1. The physician
The questions we have so far treated apply to all health-care providers: doctors, nurses, psychologists, dentists, researchers, and so on. We will now be getting more specific, and will begin with ethical issues mainly faced by those people called "doctors": physicians. Of course, what is said will apply to all providers who deal with the aspects of the patients we mention.
DEFINITION: A physician is a person who serves other human beings by seeing to their physical health.
Obviously, veterinarians are "physicians" of animals, where as physicians as such treat human beings. Physicians differ from psychologists in that they deal with physical health, while psychologists and psychiatrists deal with mental health. This is not to say that the physician doesn't care about his patients' mental health; it is just that he is not specifically trained to treat it.
The first question that arises about the physical status of a patient is his life.
8.2. What human life is
[For an in-context discussion of this topic, see Modes of the Finite, Part 3, Section 1, Chapter 7, and especially Part 3, Section 3.]
The primary question here is one whose answer can be scientifically arrived at, but by the science of philosophy, not that of medicine or even, strictly speaking, biology. Philosophy uses biological evidence, but the biological evidence turns out to be such that it can't, by itself, say what life is, or what constitutes human life as opposed to the life, say, of a human cell in a tissue culture. But this does not mean that the philosophical answer is a matter of opinion or is not scientific, or is "up for grabs."
Now, to be sure, physicians are more interested in when a body is living a human life than in what human life in fact is; but they are increasingly facing issues in which apparently human things are being "defined by society" as not human (as no longer human, or as not yet human, or as something other than human); and unless they have a clear notion of what makes a body a human body, they will be parties to the kind of horrors we found in Hitler's Germany--which, after all, was the result of the society's "definition" that Jews weren't really human.
So the issue is crucial, and it is essential to have objective evidence about it.
DEFINITION: A body is alive when its parts are interacting in such a way that the body functions as a dynamic whole.
That is, the objective difference between a living body (any living body) and a corpse is that the living body is a dynamic unit. It does things as a unit, and is not simply a set of parts that happen to be connected together. When the body ceases to function as a unit, even if some parts are still active, it is dead and a corpse. No biologist would dispute this. Thus,
DEFINITION: the life of the body is the interaction of the parts: its unifying energy.
This is what philosophical and religious writings are actually referring to when they talk of the "soul." The human soul, as was implied by the arguments in Chapter 3, can act without organizing a body (and so is immortal); but what it is as a soul, is precisely the energy uniting the body (the interaction of the parts), without which the body is an inert lump of decaying flesh.
Biologists generally recognize (because it is obvious) that when the body is alive, its parts are interacting, and when it's dead, they're not; and so they should have no problem with the "soul" in the sense we mean it. But I'm not going to use the term, because they get understandably nervous in talking about a spiritual soul in the human body, which can exist and act without the body at all, because the evidence that this happens is not biological. And they think it makes the soul a kind of "something" that is driving the body, rather than simply the way the parts of the body are behaving together or "cooperating," if you will, so that the whole body acts as a unit. But the latter is what we mean, even though it turns out that in the case of the human being, this interaction goes beyond being a mere interaction.
One thing we can observe about the unifying energy of any body is this:
The unifying energy keeps the body at an energy level higher than can be accounted for by the physics and chemistry of the parts themselves.
Obviously, if this is the case, it follows that when the parts are not interacting in a living way, then the parts themselves, which were maintained in an unstable, high-energy state by the unifying energy, will move down to their natural physico-chemical equilibrium. Thus,
Decay of the parts (i.e. going back to their lowest, "ground-state" equilibrium) is a sign that the body is not alive.
We are getting into medically useful territory already. But we have not settled the question of when the body is living a human life, since obviously there are many kinds of living bodies, all of which are alive. The next step is this:
The kind of living body is determined by the kind of unifying energy it has.
This has to be the case, because bodies in fact change their parts all the time (by eating and getting rid of waste) and are recognizably the same living body, even though their parts are different. Bodies can live even with inorganic parts, such as plastic hearts, as long as they perform the same function as the original part of the body does.
The problem here, however, is that the unifying energy (the interaction of the parts) is not observable from outside the organism, for the simple reason that it unifies the parts into a whole and excludes from the unity any "foreign object." Hence, any measuring or observing instrument introduced into the body to get a look at it would automatically not be acted on by it, because it would be recognized as something not to be unified into the body.
We must use indirect evidence to find out what kind of energy is unifying the body.
To do this, we know that the unifying energy makes the body function as a distinctive unit. Therefore, the behavior of the body argues to the kind of unification it has.
But we know that sleeping people are still human beings, fundamentally capable of doing human things; and so they must be still organized in a human way.
Thus, distinctively human behavior is a sufficient condition for knowing whether something is a human being; but it is not a necessary one.
That is, if something that looks human is talking or playing the piano, then it must be a human being, because only human beings can do that. But if it's not doing this, or even any other distinctively human act, it doesn't follow that it's not human (because the person could be asleep).
We also know that no organism that does not have in its cells the human genetic structure is a human being; because only bodies with this type of genetic structure ever exhibit human activity. Hence, here we have a necessary condition for being human: without it you aren't one.
But human corpses have the human genetic structure in their cells, and human cells (e.g. skin cells) grown in a tissue culture also have the full human genetic structure and are alive. But they are not human, because they can never do anything but what skin cells can do, and so are not fundamentally capable of human behavior. So not everything, and not even every living thing, with the human genetic structure is a human being.
Thus, though having the human genetic structure in the cells is a necessary condition for being human, it is not a sufficient one. Hence, it is not what human life is either.
Then where does that leave us? Presumably, with the fact that the genetic structure of an organism limits the unifying energy to being nothing more than (a given example of) a given type of unifying energy. So we were right in saying that it has to be the kind of unifying energy in the organism as a whole that is the "kind of life" the body is living.
And this discussion allows us to conclude the following:
If a body is a living body (i.e. functioning dynamically as a unit), and if it is a whole organism, and not a part that is artificially nourished and kept alive, and if its cells have the human genetic structure, then the presumption is very strong that it is a human being.
This does not absolutely settle the issue, however, since there are organisms like caterpillars which obviously are living bodies; but they turn into butterflies, which, with the same genes, are obviously dynamically organized in a totally different way, arguing to two different forms of unifying energy at different times in the same organism. This shows that a given genetic structure can be compatible with more than one unifying energy.
How would we be able, then, to settle the issue? By seeing why we argue that there are two different unifying energies in this case. And we argue this way because (a) the unifying energy builds a unit with different sets of organs (as the caterpillar has no real legs and many pseudo-legs, no wings, and so on, while the butterfly has six legs and wings), and (2) these organs adapt it to different living activities such as crawling and flying, eating leaves or eating nectar, etc.
If a body went through "phases" but still was fundamentally capable of doing the same things, especially if it had organs that seemed to adapt it to doing the things it was only later actually going to be able to do, then this would argue to a single unifying energy on both sides of the change of phase.
Thus, a boy before puberty and a youth after puberty are very different in many respects; but the prepubescent boy already has testes, even though these do not produce sperm, and so make no sense for his life before puberty. The organ is activated after puberty, but it is there before puberty, arguing to the fact that even before puberty, the body is already organized as a sexual kind of thing. That is, no one calls a ten-year old not human because he can't do all the things (specifically sexual ones) that an adult human can do--because he can do so many distinctively human acts that there is no real doubt that the body is organized in a human way.
Hence, the only reason for saying a body has different unifying energies at different times is if it has different sets of organs at different times, adapting it to entirely different sets of living activities.
Before going on, let me make this very clear:
While it is not absolutely straightforward to say whether X is a given kind of being or not, it is not a matter of "choice," any more than it is a matter of choice that the earth is round, or that bodies are composed of atoms. It is something that is objectively and empirically discoverable, not something for you or for "society" to "create" by its perception of things.
So Hitler was absolutely wrong when he proceeded to read Jews out of the human race; and even though the German people went along with him, they were objectively wrong too. Jews, just like any other human being, have the human genetic structure in their cells--which is observable under a microscope--have basically the same organs as any other human being, and behave because of those organs in basically the same way. The shape of their noses is irrelevant, just as is the color of skin of a Black person or the shape of a Japanese person's eyes.
We all believe this. Now you have seen the objective evidence that what you believe is factually true.
Now let us apply what has been said to the beginning of life. We can immediately say this:
Human sperm and human eggs are not human beings.
Why? Because (a) they don't have the full human genetic structure (each has only half the human chromosomes), (b) they have none of the human organs, and (c) their life activities are completely different from human ones. Actually, no one since ancient times doubts any of this.
In ancient times, it was thought in some circles that the sperm was a kind of "seed" (that's what the word means, actually) of a human being, with a "homunculus" ("little human being") wrapped up in it, the way a chicken can sometimes be seen inside an egg shell just before it emerges. But the biological evidence against this now is overwhelming.
Then does human life begin with the zygote: the fertilized egg, or is this and the embryo like a caterpillar, which only later will be reorganized into a butterfly.
The problem with a theory that asserts this is that the very earliest organs seen to develop are organs that make no sense for the life inside the uterus. Granted, the very first visible organ is the heart, but the second one you can see is the eye. Why have an eye, if there's nothing to see? And very rapidly, the embryo develops all the other organs like ears, mouth, lungs, stomach, hands, legs, etc., etc., none of which are of any use to an organism that is being fed "intravenously," so to speak, by the umbilical cord, and has nowhere to walk and nothing to grab. The only organ which is specifically adapted to life inside the uterus, in fact, is the umbilical cord itself, which is obviously an IV tube, necessary because the organism is not adapted for life in a watery environment.
Since this building of organs only adapted to extra-uterine life happens from the very outset, there is no reason for saying that the human body is ever organized in any pre-human way.
Thus, if the fertilized egg/embryo/fetus is a living unit, then it is a human being, and therefore a person. But perhaps it is a part of the mother, and is living with the mother's unifying energy, the way the other parts of her body are.
The problem with this is that a living body is primarily a unit, which means that the parts function for the sake of the whole organism. So if the embryo/fetus is a part of the mother, it would have to be functional for the good of the mother's body.
But the biological evidence dealing with this is the following: (a) The mother's body tries to reject the implantation of the embryo, which (like a tapeworm or other parasite) produces chemicals blocking the rejection. Thus, the mother's body is treating the embryo as a foreign, invading body. (b) The early development of the body tends to cause "morning sickness" in the mother, which mothers can tell you is hardly something that is beneficial to the mother as a whole. (c) The embryo in developing will take chemicals (such as calcium) from the mother's body if the mother doesn't take enough in as food, and the embryo will develop normally at the expense of the mother. (d) Occasionally, the blood of the mother and the embryo are incompatible (different rhesus factors), such that if they mix, the mother's blood will kill that of the embryo.
Hence, there is no evidence that the egg, embryo, or fetus ever functions as a part of the mother's organism, and abundant evidence that it is a foreign body which happens to be inside the mother.
But is the embryo, at least, actually a living unit, or is it like the cells in a tissue culture, which have no dynamic unification among themselves. Some biologists have argued from "twinning" in early fetal development that at this stage, the embryo is actually a mass of cells, not a unified organism.
What twinning means is this: At the earliest stages of development, if you separate the cell mass into two parts, each part will grow into a whole organism, the identical twin of the other (obviously, since they have absolutely the same genetic structure). This is, in fact, how identical twins occur. But if they grow into separate, distinct units, then they couldn't have been a single unit beforehand, could they?
Oh, yes, they could. If you take a mature geranium plant and cut off a branch (which clearly was unified into the whole organism as a part of it) and put it in water, it will put out roots; and then you can plant it, and Voilà! An identical twin of the plant. You can cut the arms off a starfish, and each arm will grow into a whole starfish, and the starfish will grow back the missing arm. But that doesn't mean that a starfish is "an unorganized mass of cells." It clearly has unified, integrated behavior; it's just that its unifying energy (which obviously, as the interaction of the parts, permeates the organism) is not destroyed in the part when it is taken off, and so can regenerate replacements for what is missing.
This is potentially the case with any organism, since it built all its parts in the first place; it is just that when organisms get very complex, there isn't enough energy available to regenerate parts and cause all the behavior that the organism is capable of; and so it sacrifices the one for the other.
And there is the fact that, from the very beginning, embryonic development occurs in a definite, regular, systematic way, in an unbroken sequence right up to adulthood. So, once we see that "twinning" can occur in organisms which clearly are units, we can say:
There is ample evidence that the fertilized egg/embryo/fetus is a dynamically organized unit, and so is a living body, distinct from the mother.
And since, as we saw, the unifying energy of this body can't be other than the human unifying energy,
The human being begins to exist as such at the moment when, at fertilization, the human egg's organization is disrupted and the body begins developing toward human adulthood.
So a human embryo is not a "potential" human being; he is already an actual, living human being, and, as we saw, since anything organized as a human being is a person,
The human egg/embryo/fetus is a person, with all his human rights, including the right to life.
Now then, let me take up the arguments on the other side.
First, "a woman can do what she wants with her own body." But, even if this were true, a pregnant woman is two people. What she does to her fetus is done to a different body, not her own.
"Abortion is a private matter, between a woman, her God, and her doctor." But since abortion involves a third person, it is no more a "private" matter than a mother's killing her six-year-old in the "privacy" of her home is a private matter.
"No one should impose his moral values on anyone else." Then the woman should not impose her values on the fetus by taking his life. Abortion opponents are not trying to make women live up to moral standards; they are trying to protect people (fetuses) from being destroyed because the mother is subjecting them to her mistaken moral standards.
"A fetus is no more a human being than an acorn is an oak tree." An acorn is organized in a different way from the way the young, developing oak is organized, and it will stay an acorn forever unless it is planted. The fetus must develop into an adult or die.
"Don't be silly. Embryos look more like fish than human beings. No one can call that a human being." It isn't the way something looks that makes it human. That same "argument" was given for "proving" that Black people "couldn't" be human beings.
"The rights of the mother are more important than the rights of the fetus." No one's right ever extends to the violation of anyone else's right.
"Well, maybe the fetus is biologically 'human,' but it's clearly not a person, because it can't exercise its freedom the way people can. Then sleeping people lose their personhood, and with it their rights; so you can kill them too.
"But personhood isn't an all-or-nothing, black-or-white thing; people develop; and at the early stages, there's no real, practical difference between an embryo and a tadpole." Or between a three-week baby and a frog. If personhood depended on whether a person could exercise his freedom, then all you'd have to do to take personhood away would be to tie somebody up. Granted, the personality of a person (the way he interacts with others) develops; but personhood (the fact that something is a free being) and personality are very different things; and it is personhood, not personality, that is the basis of rights.
"Who is going to take care of all these unwanted babies?" Ask that same question of the unwanted six-year-olds, and see if the answer is, "Then kill them."
"But even if fetuses are people, there are some times when you are forced into a tragic choice, and a person has to be sacrificed for the greater good." Beware. Hitler is just three steps ahead of you down that road. The end never justifies the means. Once you deny this principle, any morally wrong act, however heinous, can be justified.
"This is just another instance of men oppressing women." Half of the people killed in abortions are women. Killing is pretty oppressive.
"I'm not pro-abortion, I'm pro-choice. I don't favor having abortions, I think they're abominable, but I think women have to have the option, if contraception fails." It's only that choice that matters. What about the choice to do drugs? To have five husbands? To become a prostitute? To smoke? To carry a gun? To kill her six-year-old? You really think women should have the option to kill people?
"Well, it's only your opinion that fetuses are people." Then why are there laws protecting your life? it's only your opinion that you are a person (prove it); and if someone doesn't think you are and wants you out of the way, then they should have the option of killing you.
"But it's not just my opinion; the majority of people agree with me." We're back to Hitler's Germany again.
"But the point is that this is a moral matter, and you shouldn't have a law against it." Killing you is not a moral matter? If it is, there shouldn't be a law against it?
These are the actual "reasons" given for allowing abortions. As you can see, many of them refute themselves and those that don't ignore what is being done in an abortion. There are in fact no serious arguments that the fetus is not a person, which is, of course, what would have to be established beyond a reasonable doubt in order to make killing fetuses allowable.
Then why are people arguing this so fervently? The basic reason is that a woman cannot be equal in sexual irresponsibility to a man unless she can kill her children and get away with it. It is a question of what the feminists insist on calling "reproductive freedom," and you have to understand where they are coming from if you want to grasp their mindset.
A man can impregnate a woman and not even be aware that he has done it. There are no biological consequences for him. But a woman who gets impregnated obviously has consequences. So she can't be as "free" as the man is unless she can get rid of the consequences (supposing the contraceptive not to have worked) before they become burdensome.
But if she can't be as "free" as the man is, she is unequal to the man in this respect. Hence, the option to have an abortion must be available, or women are unequal to men.
That's the logic--such as it is--of their position. The obvious answer is that irresponsibility is not a measure of superiority, and instead of perpetrating horrors to make women as evil as men are, they should be working to force men to take the consequences of their sexual activity: to take care of any children that result from their acts.
Note that it's not only the slaughtered children who suffer from the blindness of women who are trying to be "equal" in this way. As I write this, the National Review reports that the evidence about the safety of RU-486, the so-called "abortion pill" is being falsified. When it was reported, for instance, that there were "no complications" from a clinical test, and one doctor declared that this could not be true, because he himself had treated at least one woman who had lost a lot of blood from the pill, the answer was, "We didn't mean that there were no complications to the subjects; we meant that there were none to the test.
So the pill will probably be approved as safe when it isn't. Once you buy a big lie that actually kills people, what's the problem with little lies that only cause things like bleeding?
But enough of this. The point is that
It is always immoral to choose to kill a fertilized human egg, embryo, or fetus, for any reason whatever. The only time he may be killed is when the Double Effect allows the death to be kept out of the choice.
But it never does, does it? After all, you can never say that the fetus is an "unjust aggressor," and so killing in self-defense wouldn't arise. This is not so. Though the fetus is clearly formally innocent (because he can't make a malicious attack against the mother), the fetus's development inside the mother conceivably could in fact bring about her death. For instance an ectopic pregnancy (one where the fetus implants itself in the fallopian tube instead of the uterus) will result in the mother's death if the fetus is not removed before viability.
Now traditional ethicians get around the difficulty of "killing the fetus" by removing the whole fallopian tube (with the fetus inside) on the grounds that "there's something wrong with the organ," and so you're removing a diseased organ, which happens to result in the death of the fetus. They call this "indirect killing." But in fact, there's no "diseased organ" there; what's wrong with the organ is that the fetus is growing in it, and the fetal growth (here) is killing the mother. So the cure is really not to take the tube out, but the fetus.
But the point is that you don't have to pretend that the organ is the problem to make this (like all cases of self-defense) "indirect killing" (i.e. killing in which the death is not chosen). First, in self-defense, whether the attacker is innocent or guilty is irrelevant. Innocent or guilty, he has a right to life, because the right follows from his humanity, not from his virtue or vice. Hence, he can't lose the right. But, as we saw in discussing the Double Effect and rights, you can perform an act which results in the death of an attacker without choosing the death.
So in all cases where a fetus's development (for whatever reason) will with moral certainty result in the death of the mother (i.e. barring a miracle) before the fetus can survive a normal or Caesarean birth, then the fetus may morally be removed from the mother even if this results in his death. It is the removal of the fetus which saves the mother, not the death (babies have survived abortions, after all), and so the death is not the means for saving the mother's life. And in the case we are discussing, where the mother will die before viability, it is either remove the fetus and choose the mother's life, or do nothing and have both die.
But in cases of removing the fetus, the means of doing this that involves the least damage to both parties (mother and child) must be chosen.
Current abortion practices of killing the baby with saline solution (i.e. acid, in effect), or pulling him apart limb from limb may be safe for the mother, but are incredibly barbaric. We don't kill rats that way. It may be that the only decent way to save a mother's life and not butcher her child would be for her to have a hysterectomy, which would, of course, render her unable to have any more children. But a child is not to be sacrificed so that Mommy can have a different one that she'd like better.
8.2.2. Fetal tissue experimentation
Well, supposing abortions or miscarriages (which medical people call "spontaneous abortions) have occurred. Use of this tissue for experiments or medical purposes does not fall under the prohibition against experimenting with live fetuses (which we saw in the preceding chapter), because this is dead tissue, no longer a person with rights
Is it all right to use the tissue for research, or for medicines, since fetal cells have properties that are lost later on in human development? There is, for instance, a theory that introducing fetal brain cells into an adult brain with Parkinson's disease might trigger the development of neurons that would correct the problem.
There is no moral problem in itself with using fetal tissue of bodies that have not been killed for the purpose (which would obviously be wrong, since the end does not justify the means), but the Double Effect would permit tissue only from miscarriages, not from abortions.
The reason is that in the real world, the fact that "something useful" can be done with the tissue would provide an incentive for a woman to consider an abortion. Perhaps she would not get an abortion just for that purpose; but it could form a reason which would tip the scales for her. Thus, it tempts people to do what is morally wrong; and since this is the case, it is an evil side-effect of the act, and one serious enough (since it is in fact a temptation to commit homicide) to negate the beneficial side-effects from using the tissue.
If tissue only of miscarriages is used, then this incentive is not present; and hence, there is no problem with using it for experimentation and possible cures.
8.2.3. "Test-tube babies"
Sometimes a woman can't have a baby by normal sexual intercourse (say, because of a blocked fallopian tube); but it is possible for her to gestate a child if an egg is removed and fertilized (in the "test tube"; actually, a Petrie dish), and then placed within her uterus, where he implants and grows. Is there anything wrong with this?
First, there is nothing morally wrong with technologically assisting the act of sexual intercourse from doing what its function is. You just can't contradict any of its functions in the process.
Thus, if a man's sperm is too weak to reach the egg, then sperm deposited in the woman may be propelled by a syringe closer to where the eggs actually are. So the fact of assisting someone by technology in having a baby is not the problem.
The real difficulty here is that in the process of creating the fertilized egg, many eggs must be fertilized, only a very few of which will be implanted. But every one of those fertilized eggs is a person. Thus, many human beings are caused to exist and then let die simply for the satisfaction of the mother's gestating a baby of her own.
The deaths of all the people (the fertilized eggs) involved in the process of external fertilization, while not the means toward the good effect, is an evil effect far outweighing the evil of the woman's disappointment in not having a baby of her own.
Other methods of having a baby, such as artificial insemination, will be discussed in the section on the patient's physical integrity. This one belongs here, because it is a question of ignoring the life of the human being at its beginning.
8.2.4. Monsters and mutants
To form a transition between the beginning and the end of life, let us note that not every birth is of a healthy, normal baby; and some are of things that are so grotesque that it is reasonable to say that they aren't human at all. What are the moral issues here?
Any living organism resulting from the sexual intercourse of two human beings has a presumption in favor of its being a human being (i.e. dynamically organized in a human way), however defective it may appear. Hence, unless there is evidence that this is something so far removed from any human resemblance that there can be no doubt, the organism must be treated as human, under pain of being willing to kill what might in fact be a (defective) human being.
That is, if what is born is simply a leg, then even if it has living cells in it, that's certainly not a human being. But an anencephalic baby (one without anything more than a brain stem inside the skull) might have the human unifying energy, which for some reason was blocked from forming a brain; in which case it would be a human being.
Obviously, this is a matter of the people's conscience. Where some would find a reason to doubt, others would not; and both sides can be justified in extreme cases like this. The point is that the moral course of action is to give the benefit of any doubt to the organism.
This implies the following, however:
No organism which is dubiously human may be killed in order to provide fresh organs for transplants. Even though it might not be killing a human being, it also might be, and so one would have to be willing to commit homicide for a good purpose. This is morally illegitimate.
So the people who have qualms of conscience about "harvesting the organs" of anencephalic children (taking out hearts or livers, etc. while they are still alive) to save others' lives are right on the money. They must be allowed to die naturally (we will discuss this shortly); and if this makes the organs unusable, then so be it. Even if the end is saving lives, it never justifies using a morally wrong means, still less that of choosing to snuff out a life.
8.3. Death and dying
Nowadays, it is more or less taken for granted that death "is" the cessation of brain activity. If that is so, then there are plenty of cases of resurrection from the dead, because it is not uncommon for a person to recover consciousness (and even health) after his brain has stopped acting for a minute or so. "Oh, well," is the answer, "we mean cessation of brain activity for a certain length of time." Clearly, then, it is not the cessation of brain activity which is what the death is, because that would make death be a certain length of time, which is absurd. A length of time is not the opposite of life.
This is the result of "phenomenalism" in science, where the reality is supposed to be (or to be "defined as") the observation which establishes it. But if phenomenalism were true, the sun's color at sunset would be or "be defined as" red, which would mean that the sun really changes color when it sets. But it isn't the sun which changes color (after all, there are people a quarter around the globe who are seeing it at noon, and as its usual yellowish-white), but the fact that some of the light has got filtered out by the thick air on the horizon. No, what something is and how you recognize it are two different things; and confusing them can be significant.
For instance here, to say that death is the cessation of brain activity clearly means that you can't be alive if you haven't got a brain to be active; and so "by definition" embryos aren't alive until they develop their brains. But that's absurd, because it means that plants aren't living things either.
Don't kid yourself; people actually argue this way. It's one of the sophisms by which they justify abortion, for instance.
Then what is death? Once we have the answer, then we can deal with how we recognize when it occurs.
Obviously, death is the cessation of life. But we saw at the beginning of this chapter that a body is living a human life when it is dynamically organized with the human unifying energy.
DEFINITION: The death of a human being is the fact that his body is no longer organized by the human unifying energy.
That's what death is, but it's not very helpful in practice, because the unifying energy, as I said, is not directly observable from the outside; and the parts can be in fact interacting in a human way when the body is asleep or in a coma, and is not exhibiting the common signs of life. In those cases of the first few minutes of "brain death," the body is not showing any sign of life; but it must be alive at least in those cases in which the person recovers.
8.3.1. When death occurs
There is a clue that I gave earlier that will help us. I said that the unifying energy keeps the living body in a high-energy state. So when it is not present, the parts of the body lose energy and decay. As I also said, decay is the sign that the body is no longer alive.
Now there are times when an isolated part of the body can begin to decay without this implying that the unifying energy is not there; when it is for some reason cut off from the rest of the body. For instance, if you cut off the blood supply to your hand, it will begin to decay; but you are still alive. You have to do something fast, though, because this decay can rapidly spread through the body and kill you; and usually what has to be done is to remove the decaying organ to save your life. We will see the morality of removing organs in the next chapter.
But if the part is not isolated, its decay indicates that the body is no longer being maintained in its high-energy condition; and since this is one of the main jobs of the unifying energy, this means that that energy is no longer there.
But organs decay at different rates; and for various reasons, such as taking an organ to transplant it into a sick person who needs it, you want to find out as closely as possible when the decay has actually begun, to remove the organ while it is still as fresh as possible. Ideally, from the point of view of the recipient, this would be while the person is still alive (and there's no decay at all); but in the case of a heart or a lung, this will kill the donor, and the end doesn't justify the means.
It turns out that the brain begins to decay very rapidly; and it is obvious that the body can't function as a unit without the brain (once it is formed, it becomes a necessary condition for human life, even though its activity is not life itself).
The latest information I have is that when an electroencephalogram is used to determine "brain death" (in an adult; in neonates, it is even more complex), it involves taking two readings six hours apart with no brain activity detected--coupled with the absence of certain drugs or low body temperature (as from a victim taken out of cold water) which could depress the brain activity leaving the person still alive.
The point is that it is not perfectly simple in practice to determine when the body is not organized in a human way; and I leave it to the experts in the field to come up with the safest indication that the body is not alive. All I am trying to do here is to say what it is that these procedures are looking to establish.
Of course, in ordinary circumstances, one can be sure death has occurred by the ordinary signs (no heartbeat, breath, eyes dilated and fixed, etc.) After a certain length of time, there is no doubt of death, though it is less easy to come close to the exact moment when it occurred.
In any case, whatever the practical difficulties in discovering this are,
When it is determined that the brain is no longer functioning, one is morally certain that the body is a corpse, and it may be treated as such.
It is possible that one might sometimes make a mistake in such a determination. But the point is that there is no moral guilt in doing so. God is running the universe, and human beings are supposed to act on their human knowledge, and were not created omniscient.
It is possible after death to keep some organs artificially in the high-energy state they are naturally kept in by the body's unifying energy, and so prevent them from decaying, so that they can later be used by another body. There is nothing morally wrong with doing so.
Whether these organs are technically "alive" or not is an interesting speculative question, since if they are left to themselves, they will immediately begin to decay. A living body is one which spontaneously maintains itself in its high-energy state. Machines and so on can be maintained in high-energy states (as when you have your foot on the accelerator of your car, or have your computer plugged in); but they have no internal need or ability to keep themselves at this level; they just run down.
Cells in a tissue culture might be said to be absorbing nutrients from the medium; but this might also be a mechanical sort of activity, and not a strictly high-energy maintenance (although I am inclined to think that it is, but a lower level of life than that of the organism).
But when you get to the level of the organ, the unifying energy of the organ as such does not seem to be a high-energy unification; the high energy is due, it seems, to the unification of the body as a whole.
The point is, of course, that the body is made up of parts that have their own (sub)-unifying energy, which is under the control of the unifying energy of the body as a whole. Whether these sub-unifications are actual living energies (i.e. unnaturally high in terms of physics and chemistry) is not clear; what is clear, however, is that the genetic structure of the organism builds these subunits with their unification.
But since they aren't the human unifying energy, these parts then are just objects, and can be manipulated and transferred to other bodies and so on; because, even though they're made of human cells, they aren't human bodies because they lack the human unification.
8.3.2. Respect for the corpse
But can you morally harvest organs from a corpse? After all, even though it isn't a human being, it's a human body, and you can't just treat it like a lump of garbage, can you?
Even though the corpse used to be a human being, it is now a different kind of thing, and is in itself deserving of no special respect.
The Catholic Church enjoins respect for the corpse on the grounds that it is what used to be a body organized with a spiritual soul, and was a person; and, analogously to defacing a portrait of someone, acting disrespectfully to the corpse insults the person (who is, of course, still alive, though beyond being affected by what goes on in this world).
There is a point to this, and I would not deny it. But it still remains that in itself, the corpse is nothing more than decaying chemicals; and in that sense, it is no more deserving of respect than human excrement (which used to be a part of the body). Obviously, to the extent that contemptuous actions against the corpse imply contempt for the person, this would be a morally wrong expression of a relationship between people. But this need not be the case.
Therefore, corpses may be harvested for useful organs, or cut up and used for experiments, or even examined for medical or artistic training, or used for any reasonable purpose.
You can't use people for such things, because they have rights; but corpses don't have any rights.
Corpses may also morally be disposed of by burning, especially when this would protect people from diseases that might be caught from normal burial.
Nothing that the Catholic Church enjoins is inconsistent with what I just said. It is just that if a person shows the respect that the Church demands, he is doing a good act, beyond what is strictly required by the reality of the situation.
I should point out that the Catholic Church allows cremation, especially in the circumstances of possible infection. Cremation need not be an act of contempt.
I said that a person's self-determination gave him a "right to do wrong," in the sense that if he knowingly wanted to do what was wrong, he is not to be prevented from the act. But perhaps it isn't even morally wrong to kill yourself, if you are in fact the master over your life.
But using "mastery" to say that we can stop living is a fallacy. You don't have "mastery" in the sense that you can act inconsistently with the reality you were given genetically; and one of the "givens" is the fact that you are alive--and that the basic tendency of life, as we saw in the discussion of the life after death in Chapter 3, is to continue indefinitely; and in the human case, this means immortally. So in fact you can't stop living, even though you can stop living as a body. But a person who wants to kill himself wants to stop living altogether, which is impossible.
Hence, it is morally wrong to choose one's own death. But because a person is self-determining, it is moral only to try to persuade him not to kill himself, not to prevent him from doing so.
The persuasion can be pretty forceful, depending on what evidence one has that the person doesn't really realize what he's doing to himself, and what kind of emotional state he is in. In the extreme case,
If the person gives evidence that he is blinded by some emotional problem, then he can be restrained against his will from killing himself, on the grounds that he is not capable of making a rational decision in this state, and in his normal state would choose not to do it.
Thus, the mere fact that a person wants to commit suicide (a fortiori if he is just saying he wants to commit suicide) does not necessarily prevent you from stopping him. Severe depression often carries with it a desire to commit suicide; and even though the person may talk perfectly rationally, what is driving him is a blinding force.
As a clinically depressed person myself (I am on medication for it, because my brain does not produce enough of the chemical that takes one out of a sense of despair), I can vouch for this. There have been times in my life when the urge to kill myself has been all but overwhelming, like the urge of a heroin addict for the drug. Luckily, I was able to say to myself, "This is all based on the way you feel, and it's just a feeling; it's not a fact that things are the way they seem to you." I didn't really believe this in the "conviction" sense of believing; but I knew it was true. I had to train myself to act on abstract knowledge, not conviction.
But this now raises the point of assisted suicide, particularly, physician-assisted suicide. If the person is in his right mind, and says he doesn't want to go on living, and if for some reason he is incapable of killing himself (he's in bed, for instance, and paralyzed, and can't get the pills), does the fact that you have no right to prevent him from killing himself imply that you can or even should help him?
Even if a person has a right to do what is morally wrong, he has no right to ask anyone else to help him do it.
This is obvious when you think of it. If a person wants to rob a bank, and needs you to drive the getaway car, can you drive it, on the grounds that he's the one who's stealing; it's his choice, not yours?
No, because you are willing for the bank to be robbed, and therefore the morally wrong act has entered your choice.
If you assist a person to commit suicide, no matter what the reason, you are willing for him to die, and this is the same in practice as choosing his death--which is morally forbidden, because it violates his right to life.
The fact that he doesn't want to live doesn't deprive him of the right to life, because he has that right as a human being, not because he is a consistent human being. We saw this in discussing self-defense and the alleged "forfeiture of the right to life" on the part of the attacker. You can't forfeit your right to life.
Thus, while it may be compassionate to kill a person and put him out of his misery, and while it may be better that he die now rather than suffer twenty more weeks of agony, blaspheming and cursing God and you for torturing him like this; the end still doesn't justify the means. As I have stressed so often, once you say the good purpose you have allows you to do wrong to achieve it, morality collapses into nonsense.
There are added evil effects to allowing doctors to assist in suicides that make it a very serious wrong to permit such a thing.
The added evils are that a person who is dying realizes that the longer he hangs on, the more of a burden, financially, physically, emotionally, and in every other way he is being to those he loves. And this very fact may tempt him to ask to be killed when he doesn't really want to.
Pressure from family members, who are not necessarily the most loving and unselfish of people, can also coerce consent from someone (particularly when weak from severe disease) which he would not otherwise give. Thus, it is not going to be clear whether it's "his own free choice" or not.
It has also been shown in places where this is allowed that, by a perversion of the argument I gave for saying that people might say they want to die because of emotional problems, sometimes those who actively do not want to die are treated as if they were not in their right minds ("How could he want to live in those conditions? He has to be crazy."). So their "real intention" of doing away with themselves is read into what they say, and they are murdered in the name of "compassionate concern for what their real wish was."
And this leads right up to the "life not worth living" that was the basis of Hitler's horrors. Some bureaucrat decides what kind of life is the kind of life only crazy people would want to continue, and people who have this kind of life are removed from it, kicking and screaming and pleading for mercy. "Compassion," as the Third Reich shows, gets remarkably hard-headed when people don't seem to want to conform to our idea of what's "really" good for them.
And, again taking the Third Reich as the model, it is amazing how many new kinds of life are deemed "not worth living" as time goes on. From clearly insane people, it spreads to deformed, then to the cripples, then to the "misfits," and then to just about anyone society finds a nuisance to have around.
Don't think I'm exaggerating and just telling horror stories. Already in this country, we are killing by starvation babies who have nothing more wrong with them than Spina Bifida and Down Syndrome, who can grow up to live happy, if restricted, lives.
I was once teaching a class in which a nurse was advocating putting such people out of their misery for their own sake and the sake of everyone else. I turned to the man in the front row and asked, "What do you think of this?" He answered, "She would have killed me, because I wasn't crippled this way by an accident. I have just what she was talking about. And I don't want to be killed." "Oh, well," she answered. "You're a special case." Oh, yes?
Just as the permission of abortions has led to the outrageous barbarity of the partial-birth abortion, the callous disregard for life which is inculcated in looking at the value the life has instead of respecting the reality of the living person is bound to do the same thing--just as it has been demonstrated to do historically.
If we keep on the way we are going, we are doomed.
8.3.4. Postponing death
But does this imply that you have to make heroic efforts to keep a person alive, even though you know you are going to fail?
No. Remember, the moral obligation is fundamentally negative; and it translates in this case to, "You must never choose the death of another person," or "You must never be willing for him to die." It does not say, "You must positively choose to keep him alive as long as you possibly can."
But aren't those the same thing? Not at all. Not being willing to harm your health does not mean that you have to get yourself into the best physical shape you could possibly be in; because there are lots of conditions in which, though you can't do all you might be able to do, you're not acting in contradiction to yourself.
Similarly here. If a person is dying, and there's no reason to believe that he's going to survive whatever disease is killing him, then you aren't choosing his death when you refuse to postpone the death by pumping up his body so that he can prolong the agony another six weeks. You haven't avoided the death, merely postponed it. So by not postponing it, it isn't the death that you're choosing, but avoiding the agony.
But we have to make a distinction here; it is a clarification of what is traditionally called "ordinary" and "extraordinary" means of preserving life:
DEFINITION: Life-maintaining measures are those actions done for us which any person needs to keep alive.
DEFINITION: Death-postponing measure are those actions which force the body to do actions it will no longer do by itself.
Whether these actions are "ordinary" or involve "high technology" is really irrelevant. For instance, supplying water to a person is a life maintaining measure; but even for normal people, it is nowadays done by means of elaborate water purification and delivery through sophisticated city water systems. On the other hand, cardio-pulmonary resuscitation (the "kiss of life") doesn't use fancy equipment, but it's clearly a death-postponing action.
So the first moral implication is this:
One cannot refuse life-maintaining measures (even if they involve sophisticated technology) without choosing a person's death.
In the case of refusing life-maintaining measures, you are not "letting someone die," you are taking away from him the way he, like anyone, stays alive. Hence, the act is an act of removal, not an allowing of something to happen; and so it is an act that causes death.
Now true, the act of not feeding or giving water to someone in itself is not morally wrong, since if the person is not starving or dying of thirst, then no harm is done; so one would think it would be possible to use the Double Effect here.
And it is possible but since the act causes death, the only thing that would allow this kind of action is saving a life. That is, you can't do something that causes death unless that same action causes someone else not to die. Otherwise, the evil effect is greater than the good effect. So, for instance, if someone is in terrible pain, and you take his water away from him, you have shortened the time he is in pain, but you have also caused him to die; and in this case, it is the death itself that is compared with the evil of the pain avoided. The fact that "he's going to die anyway" is irrelevant; you would be choosing his death, because it doesn't balance with the evil avoided.
On the other hand,
If a person is dying, then refusal to continue death-postponing measures is possible without choosing the death, using the Double Effect.
Here is where "he's dying anyway" can be relevantly invoked. What the death-postponing measures do is prevent the body from doing what it is trying to do: die. They keep the person alive, to be sure, but not by supplying what the body needs to stay alive, but by taking over some act that the body is no longer performing. Sometimes, the body can be kept alive indefinitely this way, and sometimes these measures are relatively simple, technologically speaking; but the essence of the situation is that they are preventing the body from dying because of what it's not doing (or doing inadequately).
Now then, if these measures are removed, the body dies of whatever with it is killing it. If it is emphysema, from the fact that it can't get enough oxygen by itself; if it is kidney failure, because the kidneys cannot clear the body of poisons; if by removing a pacemaker, because the heart can't pump blood to the rest of the body; and so on.
Thus, the act of removing death-postponing measures is not what causes the death; what causes the death is the disease, which is being held in abeyance by these measures.
Hence, removing death-postponing measures is not of itself performing an act which causes death, even though, by the nature of things, death will in fact result. But in point of fact, what will result from this is not death itself, but the fact that the death occurs sooner than it otherwise would.
Because of this, when removing death-postponing measures, one can now compare, not death with the evil effect avoided, but the shorter with the longer time span before death. If the time before death is happy, productive, and pleasant, but somewhat more expensive than it would be without the disease, it can easily be that to shorten the time involves a greater evil than the expense avoided. But if the only thing that is happening during this time is pain and agony for the patient, as well as expense and anguish for his loved ones, then the evil of a longer period of this is greater than the evil of a shorter one; and so the death-postponing measures may be (and sometimes morally should be) removed. No good purpose is served by them, and a bad one is produced.
A rule of thumb to decide whether the act is one of life maintenance or death postponement is to ask, "What is the patient dying of?" If the measure is removed, and he dies of what he is dying of (e.g. kidney failure), then it is legitimate; if the measure is removed and he dies from its lack (e.g. of starvation or thirst), then it is morally wrong.
Now of course, all of the rules of the Double Effect have to apply. That is, you can't use the fact that your rich uncle is on a respirator and you unplug him so that he'll die and you'll get the inheritance before he changes his will, because, then the death itself is wanted (in this case to avoid the evil of your facing bankruptcy. But the death is what produces this, so you actively want it). Therefore: (1) the act must be the act of removing death-postponement, not life maintenance; (2) there has to be a good effect also from this (you can't do it just for the hell of it); (3) the death itself can't be the means to what you want--it has to be just a question of not prolonging the dying process; (4) you can't have the death as a motive for "pulling the plug"; and finally, (5) the evil of the life as shortened life has to be no greater than the evil of the prolonged life.
Now then, there is one final detail on this matter:
Measures which ordinarily would be life-maintaining can in a given case be death-postponing, if they force the body to take in nutrients when it is either actively rejecting them or incapable of taking them.
That is, just as it is possible to force the body to absorb enough oxygen by putting the patient on a ventilator, it is also possible to force the body to absorb food by, say, a feeding tube introduced into the stomach. Why do you introduce the feeding tube? Because the digestive system has shut down. In this case, the feeding is not simply maintaining the life of the patient; he has digestive-system failure, and you are actively preventing the failure from killing him.
But that was precisely what we meant by death-postponing measures. What does he die of if you remove the tube? In one sense, starvation; but really, he dies of digestive system failure. So by removing the tube, you are not starving him to death, you are allowing him to die. You are not starving him any more than you are choking to death the person you remove from the ventilator.
If, on the other hand, he is dying of cancer, and you stop feeding him, what does he die of? The cancer? No, he dies of starvation. So you have starved him to death. You didn't "allow him to die; you killed him." (Of course, he could be dying both of cancer and of digestive system failure, but you see what I mean.)
The federal courts have recently said that they see no difference between allowing someone to die and killing him. This shows extreme moral obtuseness on their part (not surprising, given the other decisions that have been handed down by them). There is all the difference in the world; in the one case, you can't avoid choosing the death, and you are killing; in the other, you avoid choosing the death, and you are just not fighting nature any longer.
But suppose a person wants to be kept alive as long as possible. Can you "pull the plug" in this case? Well, it depends.
In general, since a person controls his own life, then if he wants to be kept alive by death-postponing measures, his wishes must be respected. The exception to this would be certain times when his use of the equipment would deprive another person, who could be cured, of using it.
That is, if Mr. Jones is dying and wants his life prolonged as long as possible by using the only ventilator available, he must be allowed to use it, though he has no chance of recovery, and all it's going to do is postpone his death another six weeks or so. But if Mr. Smith is also dying unless he uses the ventilator, and Mr. Smith has a good chance of recovery if he uses it, then Mr. Jones may be taken off the ventilator against his will, because in effect his use of it is killing Mr. Smith. In the case in which they are both likely to die anyway, it's first come first served; you can't choose which life is "more important" than which other one.
There are also other extreme cases in which people's death need not be postponed even if they want it to be. If the methods to do so are horrendously expensive, draining resources away from other people who can be cured, while the only thing that is going to happen is that the person's death is put off for another few days, then again his desire to put off the inevitable is causing harm, and the harm can be significant enough to overbalance the evil effect of shortening his life.
This will perhaps be more and more a consideration in years to come. The point is that as long as you are talking about death postponement and not killing or "letting die" in the sense of starving to death, it can be moral to act in this way.
18.104.22.168. The "living will"
Before ending this chapter, I should mention the "living will." It is obviously not a bad thing for a person to declare beforehand that he doesn't want death-postponing measures taken if he is dying and unconscious and incapable of expressing his wishes.
But there are some serious difficulties with putting this into a legal document. It means, for one thing, that the document is what legally acted on unless it is legally revoked. But it's quite possible for you to change your mind between the time you sign the document and the time you wind up in the hospital. But if you tell the doctor, "I want to be kept alive as long as possible. Don't pull the plug," and you just say this and don't revoke the will legally, the doctor is bound by the legal document, and must remove the life support, or face prosecution, in spite of the fact that he knows you don't want him to.
Further, in spite of the turgid and redundant prose of legalese, these documents don't tend to make the proper, precise distinctions, and you may be giving someone permission to kill you. This is true in the State of Ohio in 1996, for instance.
DIRECTIONS FOR MAKING THE OHIO LIVING WILL DECLARATION MORALLY ACCEPTABLE:
(1) On the first page, add what appears in boldface to the paragraph that reads:
In the event I am in a terminal condition, I do hereby declare and direct that my attending physician shall:
1. Administer no life-sustaining treatment except for the provision of artificially or technologically supplied nutrition or hydration;"
(2) On the second page, cross out the whole paragraph that is written in capitals (I will print it below) and initial your crossing. Be sure you don't check the box and initial that. Here's the paragraph:
__________IN ADDITION, IF I HAVE MARKED THE FOREGOING BOX AND HAVE PLACED MY INITIALS ON THE LINE ADJACENT TO IT, I AUTHORIZE MY ATTENDING PHYSICIAN TO WITHHOLD, OR IN THE EVENT THAT TREATMENT HAS ALREADY COMMENCED, TO WITHDRAW, THE PROVISION OF ARTIFICIALLY OR TECHNOLOGICALLY SUPPLIED NUTRITION AND HYDRATION, IF I AM IN A PERMANENTLY UNCONSCIOUS STATE AND IF MY ATTENDING PHYSICIAN AND AT LEAST ONE OTHER PHYSICIAN WHO HAS EXAMINED ME DETERMINE, TO A REASONABLE DEGREE OF MEDICAL CERTAINTY AND IN ACCORDANCE WITH REASONABLE MEDICAL STANDARDS, THAT SUCH NUTRITION OR HYDRATION WILL NOT OR NO LONGER SERVE TO PROVIDE COMFORT TO ME OR ALLEVIATE MY PAIN.
(3) Add the following to the bottom of the document:
This declaration shall be null and void if in the future I explicitly declare, in writing or orally in the presence of witnesses, that I wish life-sustaining treatment to be administered.
The problem with the declaration as it stands is that it uses "life-sustaining" to mean what I called "death-postponing," but it includes also what I called "life-maintaining" actions, as is clear from the omission on the first page of mention of nutrition and hydration when the declarer is in a "terminal condition." If you sign the document as written, you are instructing your physician to starve you to death if you're going to die (of something-or-other) anyway.
Now, as I mentioned, sometimes withdrawing a feeding tube is in fact postponing death; but sometimes it isn't. And the point is that if you're going to "let a person die" rather than kill him, you have to let him die of what he is dying of, not "let him die" of starvation or thirst, unless these are related to (i.e. part of) what he is dying of.
With the changes I mentioned, the document isn't perfect, but it is at least morally acceptable (i.e. as amended, it wouldn't allow the withdrawal of nutrition and hydration when this they are death-postponing; but there's no way you could change it to allow this without adding several pages, and if you're going to be ambiguous, you had better take the morally safest course). Personally, I think it's a good idea to do something like this, because for various reasons (fear of lawsuits), some physicians will go to absurd and torturing lengths to keep their patients alive.
Let me end this long chapter with this remark, connected with what I just said:
The lack of a clear notion of what death is and what postponement of death means has sometimes resulted in actual corpses' parts being kept alive for prolonged periods, days and even months after it is obvious (to anyone who knows) that the body has ceased to be organized as a unit. This is obviously not morally acceptable.
Summary of Chapter 8
A physician is a person who serves other human beings by seeing to their physical health. This chapter deals with the patient's life. A body is alive when its parts are interacting in such a way that it is a functioning unit. The life of the body is the interaction of the parts: the unifying energy. This energy keeps the body in a high-energy state, which is unstable from the point of view of physics and chemistry. Decay is the return to the low "ground-state" energy of the parts when no longer organized by the living unifying energy; so decay is a sign that the body is not alive. The kind of living body is determined by the kind of unifying energy it has; but this energy is not observable from outside, and so one must infer it from evidence.
Distinctively human activity (talking, reading) is a sufficient condition for knowing that something is a human being, but not a necessary one, since humans exist without doing these acts; and the human genetic structure in the cells is a necessary condition, but is not sufficient, since corpses also have this. A human being is a body which is (a) alive, (b) a whole organism, not a part of one, (c) with cells that have the human genetic structure. We can rule out in the human case more than one type of unifying energy at different times, since the organs are adapted from the very beginning to the life outside the uterus: the life, in fact, of the adult. There is thus objective evidence about what a human being is, and so it is not a matter either of personal choice or of what society thinks.
Human sperm and unfertilized eggs are not human; they are organized in a different way. The fertilized human egg/embryo/fetus is not a part of the mother, because parts act for the benefit of the whole, and (a) the mother's body tries to reject implantation, (b) early fetal development often makes the mother sick, (c) the fetus will take nutrients from the mother's body even at the mother's expense, and (d) sometimes the two bloods are incompatible in a deadly way. Thus the egg/embryo/fetus is a foreign body who happens to be inside the mother. This body is a unit, in spite of the possibility of "twinning," because of the organized way it develops; twinning can occur in lesser organisms even at the adult stage, where the body is clearly a unit. And since development is straight to adulthood (with no "caterpillar" stage), then the human being exists from the moment of fertilization. Thus, the human fertilized egg/embryo/fetus is a person, with all his rights, including the right to life.
It is always immoral to choose the death of a fertilized egg/embryo/fetus for any reason whatsoever. But using the Double Effect, an action may be taken which will result in his death but only to save the mother's life. The action is that of removing the non-viable fetus from the mother (whether one removes along with him the organ he is in or not); it is the removal that saves the mother, not the death, the death is not wanted, and if in this case the fetus is not removed, both mother and fetus will die (because he is not capable of surviving without her). If a woman can wait until viability and the fetus can be born, she obviously must do so. In removing the fetus, the manner of doing so must do the least damage to both fetus and mother; this may involve removing the whole uterus, rendering the mother sterile.
Tissue of fetuses dead as the result of a miscarriage may be used for experiments or for medicinal purposes; but there is an evil effect of using tissue from aborted fetuses; the fact that the tissue is going to be used "to save lives" can then be an excuse (if not the whole reason) tipping the scales for a woman to have an abortion; and so this evil effect overbalances the possible benefits of having all this extra tissue available.
If a woman can't naturally conceive, there is nothing wrong with technology's assisting the natural process of reproduction; but no part of the reproductive act may be contradicted in order to have a baby. Thus, a man's weak sperm may be artificially propelled farther into the woman; but there are other assistances that are not morally acceptable. Here we can mention human eggs fertilized outside the mother ("in vitro," "test tube babies"), to be implanted in her. The life-relevant problem here is that in order to do this, many persons must be created, only a few of whom will be implanted, and so have a chance to live. Human lives must not be sacrificed to a woman's desire to have a child of her own.
The presumption is that any living body resulting from the sexual intercourse of two humans is a human being; but there are bodies with genetic defects so severe that sometimes it is obvious, and sometimes it is probable, that they are not human beings. Any dubiously human body must be treated as human, because otherwise (by the rule of doubtful conscience) one would be willing to do harm to a human being. Thus, harvesting organs of living anencephalic babies is morally wrong, even if they might not actually be human beings.
The death of a human being is the fact that his body is no longer organized with the human unifying energy. The sign of death is decay. Since the brain decays rapidly, and since the brain is a necessary condition for unified human functioning, then a significant sign of death is the lack of activity in the brain for enough time that it is morally certain that decay has set in. Then the body is a corpse.
It is morally acceptable to keep parts of a corpse alive artificially, so that they can be used for good purposes (e.g. transplants), because in itself the corpse is simply waste material, to be disposed of. While it may be good to show respect for it because of the person it was, it is not morally necessary to do so, except when not doing so is an actual insult to the memory of the person (who is, of course, still alive, though not as a body).
One's control over oneself does not extend to being able to choose one's own death, because to do so contradicts the given aspect of life as tending to continue indefinitely (and one doesn't actually go out of existence, which is what is wanted). So suicide is morally wrong; but because of a person's control over himself, if he chooses his death rationally and knowingly, he must not be forcibly prevented from carrying out the choice.
Nevertheless, he has no right to have someone help him kill himself, if he can't do it himself, because the killer would also have to choose his death, which is immoral; the fact that he wants it is irrelevant. If doctors assist in suicide, this adds the evils of putting pressure on the sick to agree to assisted suicide, for others to "decide for them" or "in their real interests," which ultimately will lead to many unwilling people being killed because their lives are a burden to others or society.
But a dying person need not postpone death as long as possible, because not to prevent nature from doing what it is doing is not the same as choosing the death itself. Life-maintaining measures are those which any person needs to stay alive (supplying food and water, etc.). Death-postponing measures are those which force the body to do what it will no longer do by itself. One cannot refuse to administer life-maintaining acts (whether technologically simple or complex) without choosing death, except in the case of saving someone else's life, because the act of refusing the measures causes the death; and so the Double Effect requires saving a life to balance it. This is true even if the patient is dying (of something else) anyway.
But if a person is dying, removing death-postponing acts is not what causes the death, but the underlying disease; thus, what is caused by the removal is the shortening of the process of dying, not the death itself. In this case, the evils to be compared are the circumstances of the shorter or longer dying process (e.g. more or less time to continue a happy but doomed life; more or less time of agony and suffering). These circumstances can justify (and even require) the refusal to fight the dying process any longer.
The rule of thumb to decide these cases is "What is the person dying of?" If the person will die of the underlying disease, removal is morally legitimate. If the person dies of starvation or thirst before he has a chance to die of the disease, then this is killing him. Sometimes, measures which are usually life-maintaining can actually be forcing the digestive system to act, when it is shutting down; in this case, the "feeding" is a death-postponing measure, and its removal means the person dies of digestive system failure, and is not starved to death.
If a person wants death-postponing measures to be used, they must be used, unless his use is going to result in the death of someone who could be cured, or unless they are outrageously expensive, taking resources away which imply that many others will be unable to be cured. In that case, the Double Effect can justify stopping the life support even against the patient's wishes.
The "living will" is in itself not morally wrong, if the document makes clear that life-maintaining measures will always be taken, and that a mere oral statement before witnesses will revoke it. As things now stand (at least in Ohio), it in fact instructs doctors to starve the patient to death if he is dying anyway.
Lack of clarity on what death is has led to actual corpses' parts being kept alive for long periods, in the name of "keeping the person alive." This is morally wrong.
Exercises and questions for discussion
1. What of the argument that, even if the fetus is a person, he has no right to use another's body to keep alive, and so the woman may "unplug herself" from this invader of her body, unless she has invited him in by choosing to get pregnant. Hint: consider this in the light of Siamese twins.
2. Does the fact that experiments involving the fertilization of human cells that are going to die imply that there might be some knowledge that is morally forbidden for human beings to acquire?
3. Can a woman have a child in order to use the child's kidney to save his dying brother's life?
4. Suppose a person is in a persistent vegetative state, and life support is removed, and he still lives. How long does he have to be tended, fed, and so on, if he will never recover consciousness?
5. A dying patient is in great pain, but is so weak that giving him enough painkiller to make him comfortable will probably kill him. May he be given the painkiller?
6. Three people are dying, and each needs the only available ventilator. What criteria should be used to determine who gets it. How do you avoid "playing God" in this case?