While relevant to the general discussion of death and dying, a
“duty to die” raises different questions from those
posed by physician-assisted suicide, terminal sedation, refusal
or withdrawal of treatment, etc. These matters focus on personal
choice and a “right to die.” Their underlying value
is autonomy. Duty, on the other hand, is communally rooted (duty
to another) and legally or morally coercive: i.e. a duty is not
optional; failure to do one’s duty calls for moral sanction or
legal punishment or both.

The question of “duty to die” is already in play in
today’s biomedical world and will surely be with us more urgently
tomorrow. Access to health care — and not just in the U.S.–
is a dilemma in all industrialized nations. Access is a crisis
in the third-world which the AIDS epidemic only highlights. And
from the looks of things, no solutions are readily available.
Socialist and social insurance schemes (Canada, Great Britain,
Europe) meet many of the same difficulties as our confused and
ineffective market-based efforts. Everywhere, population growth,
increasing numbers of the aging, technological innovation, competition
for limited funds and resources, the changing nature of professionalism,
the indefinitely expanding social expectations here and evolving
social expectations elsewhere join to create a biomedical crisis.
Perhaps, the most dramatic way of putting this is to recognize
that we, in this country, already have a “trillion-dollar
problem” (what we actually spend from all sources on health
care). Within the decade this will grow into a “two-trillion-dollar”
problem with no end in sight. In a sense, we could afford to meet
the cost as we demonstrate when forced to go to war. But, other
legitimate social needs — education, defense, housing, infrastructure,
etc. — would obviously have to be neglected.

Prophetically, in 1987, Margaret P. Battin (philosophy, University
of Utah), raised the question of a duty to die in an essay, ”
Age Distribution and the Just Distribution of Health Care: Is
There a Duty to Die?” [Ethics, 97(2):317-340]. Similarly,
former Governor Lamm of Colorado spoke to the issue of “rationing,”
a word which neither politicians nor practitioners dare to utter.
More recently, John Hardwig wrote, “Is There A Duty To Die”
(1997, Hastings Center Report, 27{2}: 34-42) The present
volume is an analysis of and response to Hardwig (and by implication,
the others), from 12 philosophers. Naturally, the book ranges
in method from technical analysis (the meaning of duty,
comes in for careful scrutiny) to characterizing relationships
(to whom is the duty owed — family, community, society, even
international community) and why might this be so. While Hardwig’s
essay focused the issue on the intimacies of a mother-daughter
relationship, the authors in this collection demonstrate, convincingly
in most cases, that duty, if such there be, cannot be encapsulated
within family or nation. At the same time, they expose the moral
and policy difficulties, practical and theoretical, raised by
taking a “duty to die” seriously. Who enforces it; how
will the duty be communicated within a family whose members care
for each other, what criteria will justify invoking the duty,
why focus only on age and terminal illness. Are not handicaps,
deadly birth defects, incurable chronic illnesses, or psychological
depression candidates for invoking such a duty? In other words,
as the pressures of finitude increase around us, must the “duty
to die” become a generalized moral commandment and ultimately
a social policy?

Absent from the book, fortunately, is moralistic and religious
preachment. To be sure, the essays lack a sense of humor. I would
wish for a modern Jonathan Swift whose “A Modest Proposal”
you will recall advised solving the Irish famine by means of cannibalism.
So, one can fault the text for a certain ponderousness. Moreover,
it would have helped if the essayists had acknowledged the metaphoric
and not the just literal intent that, I think, moved Hardwig.
In common — whatever their differences — they take Hardwig’s
question at face value without recognizing the utility of stirring
conscience and consciousness with a rhetorical device like a “duty
to die.” About half of the essays essentially deny Hardwig’s
“duty” and the other half, even while accepting it,
do so with reservations. Unfortunately — and a significant weakness
of the text — Hardwig’s own voice is absent. The book would have
benefited from his response.

I was grateful for the “abstracts” which preceded each
chapter. In a tightly written text (essays were apparently limited
to about 12 pages each), they provided a map and a mnemonic tool
for keeping track of what could have been — in some cases —
tough going. The book is part of a continuing series, Biomedical
Ethics Reviews, which enables relatively speedy responses
to the issues and problems that appear almost daily it seems in
a rapidly developing field of inquiry and practice. Given the
limitations which such a project imposes — in particular the
need to move very quickly — we should be grateful for the series
and for this text. But, given the complexity of the issue of death
and dying in a world of limits, it is only an introduction to
the hard work ahead of us.

HOWARD B. RADEST, PHD, is Adjunct Professor of Philosophy at The
University of South Carolina-Beaufort. He is Ethics Consultant to Hilton
Head Hospital and Chair of its Biomedical Ethics Committee. He is the
Dean Emeritus of The Humanist
Institute, a member of the Council of Ethical Culture Leaders and of
the Highlands Institute for American Religious and Philosophic Thought.
Dr. Radest was the founder and chairman (1983-1991) of the University Seminar
On Moral Education, Columbia University. He is a member of the Board of
the North American Committee for Humanism. From 1978-88 he was Co-Chair
of The International Humanist and Ethical Union. He is on the editorial
boards of The Humanist, Religious Humanism, and Free Inquiry. His books
include Toward Common Ground (Ungar, 1968), Can
We Teach Ethics? (Praeger. 1989), The
Devil and Secular Humanism (Praeger, 1990), Community
Service: Encounter With Strangers (Praeger, 1993), Humanism
With A Human Face (Praeger, 1996), Felix
Adler: An Ethical Culture, (Peter Lang, Publishers, 1998) and From
Clinic to Classroom (Praeger, 2000}.

Dr. Radest received his B.A. at Columbia College, his M.A. in Philosophy
and Psychology at The New School For Social Research and his Ph.D. in Philosophy
at Columbia University. He is listed in Who’s Who.

This review first appeared online Oct 1, 2001

Categories: Philosophical, Ethics

Tags: Grief and Bereavement Issues, Mental Health Policy and Advocacy