SPLITTING HAIRS : Morality & self-deception.

Anyone who has taken a course in ethics may well recall, if not fondly, the deployment of numerous concepts and fine distinctions. You may wonder if they matter much, and the suspicion may have crossed your mind that they seem to invite as much obscurantism as clarity. Not until recently, however, did they appear of great importance in public issues, and not simply odd, out-of-the-way cases for classroom debate, such as the rare case of a woman with a potentially lethal fallopian tube pregnancy, a favorite example of the principle of double effect. A broad look at such moral distinctions shows some recent shifts and new imputations of self-deception.

Two old distinctions have been quietly retired. The notion of ordinary and extraordinary treatment, often misunderstood to apply to the complexity of the technology used to sustain a dying person, is now more commonly referred to as the burden of treatment on the patient. This is a judgment of the degree of pain or comfort a specific treatment will bring. Even a technologically simple treatment, such as the use of an antibiotic, can be burdensome if it prolongs the life of someone who is slowly dying of an otherwise painful and fatal condition. Who would want that, and why would any doctor be obliged to prescribe an antibiotic in that circumstance?

The distinction between withholding and withdrawing treatment is another one that is fading. Many doctors had long considered it acceptable not to provide any life-saving treatment when the outlook was poor or hopeless, but not right to withdraw such treatment once initiated. Experientially at least, the latter felt like a killing of a patient in a way that providing no treatment did not. Yet in recent years it has been accepted (even if there is lingering hesitation among some doctors) that there is no meaningful distinction between them. If a patient's condition morally warrants treatment, even if unlikely to succeed, it should be provided, but it can then be withdrawn if the patient fails to improve.

While the principle of double effect still has good standing, and is often invoked in the case of providing drugs such as morphine to relieve pain, critics have begun to appear. The full conditions necessary to invoke the principle are multiple and complex, but the core thrust is that it is morally legitimate to intend to carry out an otherwise morally acceptable act that will have foreseeable--but not intended--wrongful results as a consequence. Tubal pregnancy, which is potentially lethal and which can be dealt with by removing the tube even though it will foreseeably, though not intentionally, kill the fetus, is a classic instance of invoking the principle. So is the use of fatal doses of morphine.

The criticism of the double effect principle takes two forms. One of them argues that it is illogical to distinguish between intended and unintended consequences if both lead to the same practical result, for example, the death of a fetus because of tubal ligation and of a patient given a pain-relieving, but also lethal, dose of morphine. According to these critics, whoever carries out the act that brings about death is morally responsible for the death. "Foreseen but not intended" does not relieve one of direct culpability.

The other criticism goes a step further. This argues that the principle of double effect is not only illogical, but is self-deceptive, allowing people, by a moral sleight-of-hand, to do things they would otherwise consider wrong. I am sympathetic to this criticism, even though I do not share the cynical perspective that some critics (mainly of secular persuasion) bring to it, attributing all-but-deliberate obfuscation to its supporters.

It would be more straightforward to use a principle of lesser evil to judge acts that have both good and bad consequences, taking full responsibility for both, whether intended or only foreseen. In the case of a high dose of morphine, it seems to me morally legitimate to run a foreseeable risk that it will kill the patient, but not a dose so high that it will surely kill him. If the more traditional understanding of the double-effect principle allows a dose that will almost certainly kill the patient--terminal palliation-- then I would reject it, classifying it as a near cousin to euthanasia, that is, the deliberate killing of a patient.

Charges of moral evasion and self-deception are even more pronounced in the case of two other disputed distinctions. One is the difference between "feeding" a patient, taken to be an ordinary duty of care, and providing nutrition to a dying patient by means of a feeding tube. Some conservatives argue that the removal of a feeding tube from such a patient is nothing less than allowing the patient to "starve" to death; and that it is sophistry and self-deception not to see this.

But to me an inability to eat by mouth is clinical evidence of impending death in a patient suffering from a lethal disease, such as Alzheimer's. Tube feeding such a patient should not be confused with feeding by mouth. The latter is the ordinary-language understanding of "feeding." Tube feeding, by contrast, is an invasive technological intervention that will probably bring no benefit to the patient other than to suspend the natural process of dying, and then not necessarily for long. Prior to the invention of modern feeding tubes some thirty years ago, patients unable to eat at the end of their lives were not described as starving to death. Their underlying disease was killing them, not the symptom of that disease manifested by an inability to take food by mouth.

The other distinction under dispute is the most important of all for policy purposes. That is the difference between allowing a patient to die (for example, by turning off a respirator)--once but no longer called "negative euthanasia"-- and the killing of a patient (for example, by lethal injection). A standard move now made by proponents of euthanasia is to argue that, since the result is death in both cases, the distinction is both fallacious and self-deceptive, a kind of conscience salve for physicians opposed to euthanasia. Since termination of treatment for a hopelessly ill terminal patient is a well-established moral practice, logical consistency is said to demand acceptance of euthanasia as well--and not incidentally, it is often added, a quick death by lethal injection would be more merciful than protracted "natural" death from a slow-acting disease.

But the distinction between allowing a patient to die and actively ending a life remains perfectly valid and necessary. Turning off a respirator ordinarily only brings about the death of someone with an underlying lethal disease, which is what biologically causes the death. True, the patient dies sooner than if the respirator had not been turned off--but then the patient would not have been alive at all if the physician had not put him on the respirator.

Even though arguments to cancel or to refine any given moral distinction are conducted in ostensibly neutral and logical language, they are always informed by ideological and moral commitments. Which comes first, the desire to legitimate euthanasia or the nullifying of a distinction between killing and allowing to die? Do I uphold that distinction simply because I am more rational than those who do not? Or do I uphold it because preserving the distinction serves my moral convictions against euthanasia? I cannot tell.

Because rationalization and self-deception are so hard to detect in the use of moral distinctions, it is best not to impute them to those on either side of the debate. I would go even further: Beware of those who so charge others. Be rightfully suspicious of their motives in launching this variant of the ad hominem argument.

I am perfectly prepared to agree that most of us have strong moral feelings, that we have been influenced by the ethical traditions or culture in which we were raised, and that we seek moral reasons to justify our feelings and convictions. Our thinking is shaped by moral distinctions that have been passed on to us by the contexts in which we have been acculturated. Once we are aware of this, we have the obligation to examine those inherited distinctions, to expose them to tough criticism, and to be prepared to amend or reject them if that is where our examination leads us. If we do not, then it is fair to be accused of rationalization, or at least moral blindness. Good ethics cannot do without distinctions, but neither can it do without a willingness to examine them critically. They are nothing but tools of analysis, exceedingly useful if they illuminate real and telling differences, but instantly dispensable if they do not.