Beyond paternalismDragan Pavlovic

Department of Anesthesiology, Greifswald University, Germany

What happened in Heringsdorf in 2010

Thanks to Porfessor Thomas PapadimosProfessor Steven Gabbe, and Ohio State University

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• What do European citizens think about the old?

Are people 70+ a burden for health care services?

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EU29 BE BG CZ DE DK UK GR HU NL NO SK

70 + burden for health service (1=no burden 10=great burden

Copyright © 2010 Prof van den Heuvel

Demographic change and intergenerational justice.

Health Care Cost[€ p.c.,p.a.]

Can we affort an aging society?

Prof. Dr. Steffen Fleßa, heringsdorf 2010

It is likely that there is a potential moral problem.

Paternalism: We decide for the patient, and this is justified.

We claim to know better what is to do.

But, if our claim is not true?

3. The physical (medical) state of a patient in terminal care is NOT decisive.

1. The absence of the clear link between universal and concrete particulars imposes need for permanent moral judgements and disagreements. 2. We must also face permanent sorites where our decision will be dependent on arbitrariness.

Tentative conclusions

4. The emotional concerns of some other actors in the patients close emotional circle, could also be important for decisions. If in our everyday lives we base the value of our life in great deal on the relation with other human beings, then they should take part in the end-of life decisions 5. The “asymmetry” : the rights in forbidding life termination should be greater than the rights to contribute to the decisions to terminate life.

Tentative conclusions

I would therefore like to make three points:

I. Not only facts but interests count as well: Moral judgment indeterminacy

II. Our moral judgment is based ALSO on our emotions, intentions and our concerns: Theory of concerns

III. The principles are often asymmetrical

Kant and Putnam. on moral wit. (in DERMOT MORAN: HILARY PUTNAM AND IMMANUEL KANT: TWO ‘INTERNAL REALISTS’? Synthese 123: 65–104, 2000.) p. 70)

I. Not only facts but interests count as well: Moral judgment indeterminacy – FIRST PROBLEM

“Putnam rejects Kant’s idea of a transcendent structure of reason which prescribes the categories once and for all, and fixes our conceptual choices in advance. For Putnam, on the contrary, our conceptual choices remain tied to our interests, but our interests are changing and evolving.”

Putnam on interests and Kant (Ethics Without Ontology. Cambridge, Mass.: Harvard University Press, 2004.) p. 4:

“Few moral problems can be solved by treating them as mere instances of a universal generalization.”

SECOND PROBLEM

Transmission problem from general to particular (macro to micro)

Good moral thinking, as Kant said, requires “mother wit” (or “healthy human understanding”), and there is no algorithm for healthy human understanding (Ethics Without Ontology, p. 4)

SECOND PROBLEM

Ethics Without Ontology (P 24) For Levinas: none of us can help all of the other suffering human beings, and the obligation to help a particular human being may be overridden by the obligation to help what he calls “the third.” But not to feel the obligation to help the sufferer at all, not to recognize that if I can, I must help, or to feel that obligation only when the suffering person I am confronted with is nice, or sympathetic, or someone I can identify with, is not to be ethical at all, no matter how many principles one may be guided by or willing to give one’s life for.

Related PROBLEMS-1

(Ethics Without Ontology p 27-28) Most ethicists, however, down to the present day, still opt for one or another of the concerns I have listed, or perhaps opt simply for the Utilitarian concern with maximizing pleasure (the greatest pleasure of the greatest number for the longest period of time, or some successor to that formula) and try either to deny the ethical significance of the other.  Koncept of Table with many legs.

Related PROBLEMS-1

Koncept of “table with many legs”.

But the problem from of transition from universal to particular remains

Related PROBLEMS-1

Solution to the FIRST PROBMEM - How the social theories explain macro-micro transition: macro-micro transition

(i) macro factors serve as filters for psychological prerequisites for the event we are explaining, neutralizing all prerequisites which are irrelevant for the event (Robert Nozik: Anarchy, State and Utopia, Basil Blackwell, 1988, p. 22);

(ii) macro factors produce psychological prerequisites for these events (Louis Althusser: Reading Capital, New Left Books, 1970, p.180),

(iii) macro factors program conditions for realization of the event we are explaining, augmenting its possibility (Frank Jackson and Philip Pettit:'Structural Explanation in Social Theory', in:David Charles and Kathleen Lennon, Rediction, Explanation and Realism, Claredon Press, 1992).

(iv) Some other theoreticians (methodological individualism) favor micro factors (Jon Elster: Explaining Technical Change, Cambridge University Press, 1983).

(v) Finally, some researchers, respecting significance of both micro and macro factors, propose a complex, compromising solution (James Bohman: New Philosophy of Social Science, Problems of Indeterminancy, Polity Press, 1991).

Solution to the FIRST PROBMEM

There is a link Macro – Micro, but the link is not a deduction par excellence

DN (deductive nomological) model does not suit to draw conclusions

Neither Deontic logic has yet offered more precise model that could be used.

Why moral judgments are not clear deductions? Not only because these laws are kind of positive laws.

May be because the argument cannot be completely described and a moral problems often finish as a perfect SORITES (Eubulides).

Related PROBMEMS-2

Professor Scruton on value of life and “others”(Roger Scruton, Timely Death, Journal für Anästhesie und Intensivbehandlung, Nr. 3-2010 – S. 24)

Yet another thought is this: the worthwhile life is not something that we understand or realise alone. Life becomes worthwhile through relations with others, in which mutual affection and esteem lift our actions from the realm of appetite and endow them with significance – significance for the others who observe them and acknowledge them as worthy.

II. Solution of the SECOND PROBLEM - Our moral judgment is based ALSO on our emotions, intentions and our concerns: Theory of concerns

(Roger Scruton, Philosophy, principles and problems, Continuum, 1996., p. 113.)

“A society ordered entirely by the moral law, in which rights, duties and justice take precedence over all interests and affections, would alienate the mere human beings who compose it, and soon fall apart. For it would make no distinction between neighbours and strangers, between the alien and the friend. People need the safety promised by the moral law, and by the habit of negotiation. But they also need something more: the nexus of affection and sympathy which binds them to their neighbours, which creates a common destiny, and which leads people to share one another’s sorrows and joys.”

It is complementary and should not be forgotten what Cicero wrote (On Friendship, 44 BC, from “Cicero’s Offices”, Everymen’s Library, 1909, p. 207; transl. by Thomas Cockman (1966)):

“ It is an error, therefore, that leads to the most pernicious consequences to imagine that the laws of friendship supersede those of moral obligation, and justify a participation with licentiousness and debauchery. Nature has sown the seed of that social affection n in the heart of man for purposes far different; not to produce confederation of vice, but auxiliaries in virtue.”

Direct and Indirect Concerns

Direct and Indirect ConcernsOur world, as we perceive it, is inhabited by other minds, animals, plants and things, i.e. material objects, as well as mental objects (worlds, 1, 2,3 – Popper). All of these may deserve our direct (primarily other people, i.e. other minds) or indirect (the rest of our perceived world) moral (or other) concern, this depending on the degree by which they may relate to the other minds, other human beings (persons). However, the primary and direct subject of morality and our moral concern are human beings.

OUR WORLD. One builds multiple relations with one’s surroundings. One likes or dislikes the objects, facts or persons; what they do or not do, approve or disapprove of. All kinds of intellectual and psychological relationships are established. Whether these be cognitive, behavioural, automatic responses or attachments to the objects or persons, all generate a vast variety. These concerns vary in intensity and kind. Many of our relations can be described in terms of the pleasure they foster. This may be simple, physical pleasure (i.e., taking a warm bath) or artistic pleasure (enjoying a piece of art), to name a couple. There may be a combination of ”pleasures”, such as watching or doing sports. Participating in sport, fosters a corporal satisfaction, as well as, a mental satisfaction, which is not only related to the feeling of movement of one’s own body, but, also, to the visual satisfaction while performing or seeing a performance of movements.

Regarding the many concern types, the possibilities are endless. Only one group of concerns are moral concerns. The others are our aesthetic concerns, intellectual or social concerns (dependent on activities which are subject to a person’s preferences and values; what one discourages/encourages and what one [dis]approves of). In addition, one cares about one’s own life, the lives of others, the existence of objects, other living beings, and our “world”.

In general, our concerns will be positive or negative, direct or indirect. Positive would mean that we approve of doing something, like doing something, or, even, believe that we have to/ought to do something. The opposite would be true of the negative concerns. We experience pleasure or pain in a number of them; though, not in all. Given the substantial number of our concerns, their fulfillment or lack of fulfillment does not necessarily produce pleasure of pain. We may be quite indifferent to them.

In general, direct concerns would be about those objects/subjects we care about; not because of some other reason; but for the object itself.

Indirect concerns are equally important. We are concerned about the concerns of other people or living beings (even those of animals) and sympathize with them. Our concerns about the concerns of other people (other minds) are particularly strong. But we sympathize only if we can recognize their concerns. As Hume puts it: “sympathy with persons remote from us, (is) much fainter than that with persons near and contiguous”. We are capable of recognizing “concerns” which animals may have. Indeed, we, for example, recognize that animals may experience pain or pleasure and, often, admit to caring very much about them. Our concerns about other minds’ concerns or about the concerns or feelings of other living creatures could be, also our moral concerns. We may therefore even indirectly care about some physical objects which concern others.

We, also, strongly sympathize with people who are anxious about their existence. On the other hand, we are prepared to not care about animal lives if we are aware that animals do not have such concerns. In general, we are able to not sympathize with living beings (including humans), thereby excluding moral concerns. Our moral concerns need objects of concern and we need the capability to sympathize with these objects.

As we have seen above, sympathy is important for, both, direct and indirect concerns, although largely independent of the nature of the objects. Whether the object of our concerns is a person or not is not particularly decisive. When the justification of animal killing is in question, it seems to be of little relevance whether the animal is a mammal or not. Our human relationship with a particular animal seems to be of more importance in fostering eventual sympathy and inciting such in other people. Enormous numbers of highly developed animal species are killed just for food and, this, without much hesitation, as long as no human being is suffering because of that act.

Simon Blackburn’s theoryRuling Passions (…) I did not want to discuss here, since Simon is, probably present. But I feel that a lot what he says is close to my concerns, or inverse.

There is however an important asymmetry in the meaning of the principle of autonomy and of paternalism: while being quite permissive, when applied in cases of an eventual decision in favour of life, they are quite limited when applied as principles of conduct for decisions concerning the termination of life.

Also, the consequentialist arguments lose power when finality is at issue.

III. The principles are often asymmetrical

Residual problems

The problem with concerns is that in the end of life decisions they are sometimes not taken seriously enough A solution would be to find and introduce the mechanisms that would ensure that concerns are taken into account in these decisions.

Pessimist’s argument If it is true that, in moral arguments, generalisations cannot be directly applied to the particularsThen it must always be judged de novo

But on the basis of what? If the individual interests are that basisIf our concerns govern our decision tooThen there are no (or just a few) universal moral principles that universally apply.Then our aspiration for Justice and Morality that will be simple inferences from some principles is in vain. Antigone’s call for higher justice - an empty illusion

Cultural crash is inevitable and cultural relativism is of course evident. H. Tristram Engelhardt, Jr. Finitude, Scarce Resources, and End-of-Life Decision-

Making, Journal für Anästhesie und Intensivbehandlung Nr. 3-2010 – S. 19.

“End-of-life decisions and the project of planning for a life marked by aging will continue to be matters of which the battles in the culture war are made. Following the battles around abortion, a new fault line in the culture wars is thus now opening, bearing on decisions at the end of life, and with respect to care for the aged in particular.”

Conclusions 1. The absence of the clear link between universal and concrete particulars imposes need for permanent moral judgements and disagreements. 2. We must then face permanent sorites (Eubolides) where our decision will be dependent on arbitrariness. 3. The physical (medical) state of a patient in terminal care is NOT decisive.

4. If in our everyday lives we base the value of our life in great deal on the relation with other human beings, and if they do the same too, then they may have right to take part in the decisions of the value of our life, and should take part in the end-of life decisions (when we are incapacitated to do it ourselves). This should apply to the relatives but not only to the relatives.

The emotional concerns of some other actors in the patients close emotional circle, could also be important for decisions. If we would fail to reach a rational decision, then it must be accepted that the “pro vita” decision cannot be refuted and that probably some forms of encouragement to accept advanced forms of life maintenance should be offered to the patients. 5. The “asymmetry” should here apply also: what would mean that the rights in forbidding life termination should be greater than the rights to contribute to the decisions to terminate life. Similar would apply to the principle of autonomy which would be much larger when deciding to live, and much more restricted when applied to the decisions for life termination.

Thank you very much.

Next year?