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Terra es animata: on having a life.

For the past quarter century bioethics has been a booming business in this country. In part that may be because humanists found here a field in which they could compete with scientists for grant money. In larger part, it is surely because medical advance has forced certain problems upon our attention. But, at least in part, it must also be because some of the concerns of bioethics impinge upon everyday life--upon the lives of most people, and at some of the crucial moments of life, in particular birth and death. Bioethics could not have boomed as it has were it not a reflection of some of our central concerns.

I will examine some of the issues that have emerged in bioethical discussions of death, dying, and care for the dying as a way of thinking about what it means to have a life. In particular, I will focus on a concept that has risen to great prominence in our thinking: the concept of a person. Two competing visions of the person--and the relation of person to body--have unfolded as bioethics has developed, and in my view, the wrong one has begun to triumph. We have tried to handle our substantive disagreements on this question by turning to procedural solutions--in particular, advance directives--trusting that they presume no answer to the disputed question. We are, however, beginning to see how problematic such a procedural solution is, how flawed and even contradictory much thinking about advance directives has been. What we need, I will suggest, is to recapture the connection between our person and the natural trajectory of bodily life.

That will be the course of my argument. But, as a way of framing the issues, I begin in what is likely to seem a strange place: with the thought of some of the early Christian Fathers about heaven and the resurrection of the dead. They were attempting to relate the body's history to their concept of the person's optimal development. In so doing, they provide a different and illuminating angle from which to see our present concerns.

Patristic Images of the Resurrection of the Body

In his City of God Saint Augustine describes the human being as terra animata, "animated earth."[1] Such a description, contrary in many ways to trends in bioethics over the last several decades, ought to give pause to anyone inclined to characterize Augustine's thought simply in terms of a Neoplatonic dualism that ignores the personal significance of the body. It may, in fact, be our own constant talk of "personhood" that betrays a more powerful tendency toward dualism of body and self.

This same Augustine, however, found himself puzzled at the thought of the resurrected body. What sort of body will one who dies in childhood have in the resurrection? "As for little children," Augustine wrote, "I can only say that they will not rise again with the tiny bodies they had when they died. By a marvelous and instantaneous act of God they will gain that maturity they would have attained by the slow lapse of time" (22.14). This is, in fact, a question to which a number of the Church Fathers devoted thought.[2]

Origen, for example, understood that throughout life our material bodies are constantly changing. How, then, can the body be raised? He appealed (in good Platonic fashion) to the eidos, the unchanging form of the body. Despite the body's material transformations, its eidos remains the same as we grow from infancy, through childhood and adulthood, to old age. (For Origen this eidos is not the soul; it is the bodily form united with the sold in this life and again in the resurrection. J.N.D. Kelly comments that Origen was charged with having held that resurrected bodies would be spherical; he may have held such a view, in keeping with the Platonic theory that a sphere is the perfect shape.)

From here it is not a long step to suppose that since the eidos of each resurrected body will be perfect, it will in every instance be identical in qualities and characteristics. Thus, Gregory of Nyssa, though differing from Origen in some respects, held that in the resurrection our bodies will be freed from all the consequences of sin--including not only death and infirmity, but also deformity and difference of age. This is a view not unlike Augustine's. Bodies may have a (natural) history, but the bodily form is unchanging. That form is the human being at his or her optimal stage of development, the person as he or she is truly meant to be. (I write "he or she" not simply to conform to current canons but because Augustine, for example, took trouble to note that the sexual distinction--but not the lust which, in our experience, accompanies it--would remain in the resurrection. All defects would be removed from the resurrected body, but "a woman's sex is not a defect" [CD 22.17]. And although intercourse and childbirth will be no more in the resurrection, "the female organs . . . will be part of a new beauty." This is perhaps what C. S. Lewis had in mind when he wrote of the resurrection: "What is no longer needed for biological purposes may be expected to survive for splendour."[3])

Against Origen's notion that the resurrected body would be a purely spiritual eidos, Methodius of Olympus held that the body itself--not just its form--would be restored in the resurrection. He based his claim less on a developed philosophical argument than on the resurrection of Jesus, who was raised in the same body that had been crucified (complete, we may recall, with the nail prints in his hands).

Such issues continued to occupy the attention of theologians for centuries to come. For Saint Thomas, the form of the body is the rational soul, and the body reunited with that soul in the resurrection need not reassume all the matter that had ever been its own during temporal life. Rather, as Thomas suggests in the Summa contra gentiles, the resurrected man "need assume from that matter only what suffices to complete the quantity due."[4] The "quantity due" is whatever is "consistent with the form and species of humanity." This means that if one had died at an early age "before nature could bring him to the quantity due," or if one had suffered mutilation, "the divine power will supply this from another source" (4.81.12). Saint Thomas is emphatic--against what may have been Origen's view--that our risen bodies will not be purely spiritual. Like Christ's they will have flesh and bones, but in these bodies there will not be "any corruption, any deformity, any deficiency" (4.86.4). Nor, it appears, will there be differences of age; for all will rise "in the age of Christ, which is that of youth [young adulthood], by reason of the perfection of nature which is found in that age alone. For the age of boyhood has not yet achieved the perfection of nature through increase; and by decrease old age has already withdrawn from that perfection" (4.88.5).

Modern Images of the Resurrection

At least to my knowledge, this sort of speculation becomes much rarer after the Reformation--perhaps because Protestants were less inclined to go beyond biblical warrants, even when an intriguing and potentially significant question beckoned. In the fifteenth and last of his charity sermons, Jonathan Edwards does say of heaven: "There shall be none appearing with any defects either natural or moral."[5] And more recently Austin Farrer has approached these questions by asking how it is possible for us to "relate to the mercy of Cod beings who never enjoy a glimmer of reason."[6] If there never was a speaking and loving person, Farrer asks, where is the creature for God to immortalize? He is less troubled by those who have lost the speaking and loving personhood that once was theirs; God can immortalize them, though Farrer does not tell us whether they are immortalized free of defects or even age differences. But what of those in whom reason never developed? "The baby smiled before it died. Will God bestow immortality on a smile?" Farrer contemplates, without being satisfied by, the possibility that "every human birth, however imperfect, is the germ of a personality, and that God will give it an eternal future"--a speculation not entirely unlike that of some of the early Fathers. And he realizes that there may be some who, though retarded, are not completely without reason--though he never asks, then, what sort of eternal future might be theirs.

If we can overcome both our Enlightened bemusement at such speculation and our Protestant refusal to learn from questions that admit of no answer, if instead we enter into the spirit of such questioning, we may find ourselves rather puzzled. Could such a monochromatic heaven really be heavenly? All of us thirty-five-years old, well endowed with (identical?) reasoning capacities? If each of the saints is to see God and to praise the vision of God that is uniquely his or hers, and if the joy of heaven is not only to see God but to be enriched by each other's vision, then why should we not look through the eyes of persons who are very different indeed? Is not the praise of a five-year-old different from that of a thirty-five-year-old, and, again, from that of a seventy-five-year-old? Why should not these distinct and different visions be part of the vast friendship that is heaven? Perhaps it is easier to understand the tendency to eliminate any defects from heaven, but even there, when they closely touch personal identity, we may find ourselves rather puzzled. Edwards was, for example, confident that there would be neither moral nor natural defect in heaven. Yet he was willing to grant that friends will know each other there. But if the stump that should have been my leg has shaped the person who I am, the person who has been your friend for forty years, it is hard to know exactly what our heavenly reunion is to be like when the stump is replaced by a perfectly formed leg. "Will God bestow immortality on a smile?" As likely, I should think, as that the mother of that child will meet one upon whom God has, in Augustine's words, bestowed in "a marvelous and instantaneous act . . . that maturity they would have attained by the slow lapse of time." We might set against Farrer's view the comment of his fellow Anglican David Smith, who writes that "at the very least it would be hard for Anglicans to hold that a being who might be baptized was lacking in human dignity."[7]

Perhaps I begin to wax too enthusiastic in my own speculations, but the point is worth pondering. To live the risen life with God is, presumably, to be what we are meant to be. It is the fulfillment and completion of one's personal history. To try to think from that vantage point, therefore, is to imagine human life in its full dignity. And to try, however clumsy the speculation, to adopt this vantage point for a moment is to think about what it means to have a life. The questions I have been considering invite us to think about our person, our individual self. Does it have a kind of timeless form? A moment in life to which all prior development leads and from which all future development is decline? A moment, then, in which we are uniquely ourselves? Or is our person simply our personal history, whether long or short, a history inseparable from the growth, development, and decline of our body?

There is some reason to think--or so I shall suggest in what follows--that much contemporary thought in ethics has a great deal in common with Origen. In an age supposedly dominated by modes of thought more natural and historical than metaphysical, we have allowed ourselves to think of personhood in terms quite divorced from our biological nature or the history of our embodied self. In the words of Holmes Rolston, our "humanistic disdain for the organic sector" is "less rational, more anthropocentric, not really bio-ethical at all," when compared to a view that takes nature and history into our understanding of the person.[8] Or, put in a more literary vein, the view I will try to explicate is that expressed by Ozy Froats in Robertson Davies's novel, The Rebel Angels. Froats, a scientist, is discussing his theories about body types with Simon Darcourt, priest and scholar. Froats believes there is little one can do to alter one's body type, a dismaying verdict for Darcourt, who had hoped by diet and exercise to alter his tendency toward a round, fat body. Froats says of such hopes:

To some extent. Not without

more trouble than it would probably

be worth. That's what's

wrong with all these diets and

body-building courses and so

forth. You can go against your

type, and probably achieve a good

deal as long as you keep at it. . . .

You can keep in good shape for

what you are, but radical change

is impossible. Health isn't making

everybody into a Greek ideal; it's

living out the destiny of the body.[9]

Terra es animata.

Ozy Froats's notion of having a life is not, however, the vision that seems to be triumphing in bioethics. And, to the degree that developments in bioethics both reflect and shape larger currents of thought in our society, those developments merit our attention.

Contra Ozy Froats

The language of personhood has been central to much of the last quarter century's developments in bioethics. It was there at the outset when, in 1972, in the second volume of the Hastings Center Report, Joseph Fletcher published his "Indicators of Humanhood: A Tentative Profile of Man." The language had not yet solidified, since Fletcher could still use |human' and |person' interchangeably. But the heart of his view was precisely that which would, in years to come, distinguish clearly between the class of human beings and the (narrower) class of persons.

Among the important indicators (by 1974 Fletcher would declare it fundamental[10]) was "neo-cortical function." Apart from cortical functioning, "the person is non-existent." Having a life requires such function, for "to be dead |humanly' speaking is to be ex-cerebral, no matter how long the body remains alive." And, in fact, being a person has more to do with being in control than with being embodied. Among the indicators Fletcher discusses are self-awareness, self-control (lacking which, one has a life "about on a par with a paramecium"), and control of existence ("to the degree that a man lacks control he is not responsible, and to be irresponsible is to be subpersonal"). Human beings are neither essentially sexual nor parental, but the technological impulse is central to their being. ("A baby made artificially, by deliberate and careful contrivance, would be more human than one resulting from sexual roulette.")

Even if, in the briskness with which he can set forth his claims, Fletcher makes an easy target, he was not without considerable influence--and it may be that he discerned and articulated where bioethics was heading well before the more fainthearted were prepared to develop the full consequences of their views. Certainly the understanding of personhood that he represents is very different from Augustine's "animated earth" or Ozy Froats's sense that one must live out the destiny of the body. Views of that sort have generally been labeled "vitalism," and their inadequacy assumed.

This is especially evident in our attitude toward death and toward those who are dying. To confront our own mortality or that of those we love is to be compelled to think about our embodiment and about what it means to have a life.[11] How we face death, and how we care for the dying, are not just isolated problems about which decisions must be made. These are also occasions in which we come to terms with who we are, recognizing that we may soon be no more. The approach of death may seem to mock our pretensions to autonomy; at the least, we are invited to wonder whether wisdom really consists in one last effort to assert our autonomy by taking control of the timing of our death. Contemplation of mortality reminds us that our identity has been secured through bodily ties--in nature, with those from whom we are descended; in history, with those whose lives have intertwined with ours. We are forced to ask whether the loss of these ties must necessarily mean the end of the person we are. Such issues, fundamental in most people's lives, have been involved in arguments about how properly to care for the dying, as we can see if we attempt to bring to the surface two contrasting views within bioethics about what it means to have a life.

Having a Life: View 1

For some time the distinction between "ordinary" and "extraordinary" care dominated bioethical discussions of care for the dying. It provided categories by which to think about end-of-life decisions. When this language began to be widely used--and, indeed, it did filter quite often into ordinary, everyday conversation--its chief purpose was a simple one. The perception, in many ways accurate, was that patients needed moral language capable of asserting their independence over against the medical establishment. They needed to be able to have ways of justifying treatment refusals, ways of resisting overly zealous--even if genuinely concerned--medical caregivers. A widespread sense that patients found themselves confronting a runaway medical establishment lay behind arguments that "extraordinary" or "heroic" care could rightly be refused and that no one had a moral obligation to accept such care. Over against a runaway and powerful medical establishment, this language sought to restore a sense of limits and an acceptance of life's natural trajectory. The language proved inadequate, however, meaning too many different things to different people. But it was not simply inadequate; it was also a language that did not, taken by itself, lend stature to the increasingly prominent concept of personhood. And that concept has been used to broaden significantly the meaning of "useless" or "futile" treatment, by divorcing the person from the life of the body.

In recent years we have seen a spate of articles seeking to define futility in medical care. Care that is futile or useless has in the past been considered "extraordinary" and could be refused or withheld. But what do we mean by futility? Years ago, when I was younger and more carefree, I used to enjoy going out at night in the midst of a hard snowstorm to shovel my driveway. In a sense, this was far from futile, since its psychological benefits were, I thought, considerable. But if the aim was a driveway clear of snow, it was close to futile. Well before I had finished, if the snow was coming hard, the driveway would again be covered. Sometimes I'd do it again before coming in, though aware that those inside were laughing at me. But if the goal was a driveway clear of snow, it just could not be accomplished, no matter how hard I worked while the snow was falling. "In Greek mythology, the daughters of Danaus were condemned in Hades to draw water in leaky sieves. . . . A futile action is one that cannot achieve the goals of the action, no matter how often repeated."[12]

This sense of futility we all understand, even if we realize that it may be difficult to apply with precision in some circumstances. Thus, for example, the comatose person (unlike the person in a persistent vegetative state) is reasonably described as "terminally ill." Because the cough, gag, and swallowing reflexes of the comatose patient are impaired, he or she is highly susceptible to respiratory infections and has a life span usually "limited to weeks or months."[13] Because these reflexes are not similarly impaired in the PVS patient, he or she may live years if nourished and cared for. It makes sense, therefore, to describe most medical care for the comatose person as futile, and we understand readily, I think, the language of futility in that context. It is not as obvious, however, that the same language is appropriate in referring to the PVS patient.

Recent discussions make clear that, in light of such problems, "futility" has gradually come to mean something else--and something quite different. If the sense of futility described above is termed "quantitative" (referring to the improbability that treatment could preserve life for long), a rather different sense of futility is now termed "qualitative." Thus, some have argued, treatment that preserves "continued biologic life without conscious autonomy" is qualitatively futile.[14] It is effective in keeping the earth that is the body animated--effective, but, so the argument goes, not beneficial because what is central to being a person cannot be restored.

How ambivalent we remain on these questions becomes evident, however, when we contrast that view with a recent article, "New Directions in Nursing Home Ethics."[15] The authors argue that the standard view of autonomy that has governed so much of our thinking about acute care in the hospital context is not applicable to the nursing home patient. There we need a new notion of "autonomy within community." This may not be the best language to make their point, however, since the authors want to do more than just envision the person within his community of care. They are also concerned to see his medical condition, his chronic needs, his dependence, as internal to the person. Thus, they seek a

notion of moral personhood that

is not abstracted from the individual's

social context or state or

physical and mental capacity. . . .

For now the caring constitutes the

fabric of the person's life . . . and

the reality of the moral situation is

that the person must embrace dependency

rather than resisting it

as a temporary, external threat.

The aim here is no longer to fend off the threat external to his person and return the patient to an autonomous condition; instead, the aim is to rethink autonomy, to take into it a loss of self-mastery, to accept dependence in order "to give richer meaning to the lives of individuals who can no longer be self-reliant." Perhaps we might even say that the aim is to help the chronically ill person live out the destiny of the body.

How can it be, in essentially the same time and place where this argument is put forward, that we should be moving rapidly away from such an understanding of the person in so many discussions of "futile" medical care? When Dr. Timothy Quill assisted his patient Diane to commit suicide, he did it, he said, to help her "maintain . . . control on her own terms until death." The hands are the hands of Dr. Quill, but the voice is that of Joseph Fletcher, an increasingly powerful voice in our society.

Having a Life: View 2

Around the time that Fletcher was publishing his indicators of humanhood, one of the other great figures in the early years of the bioethics movement, also a theologian, was writing that the human being is "a sacredness in the natural biological order. He is a person who within the ambience of the flesh claims our care. He is an embodied soul or an ensouled body."[16] In those words of Paul Ramsey the vision of the human being as terra animata was forcefully articulated. As "embodied souls" we long for a fulfillment never fully given in human history, for the union with God that is qualitatively different from this life--which longing can never, therefore, be satisfied by a greater quantity of this life. But as "ensouled bodies" our lives also have a shape, a trajectory, that is the body's. Our identity is marked, first, by the bodily union of our parents, a relationship that then gradually takes on a history. We are a "someone who"--a someone who has a history--and though we may long for that qualitatively different fulfillment, we never fully transcend the body's history in this life. To come to know who we are, therefore, one must enter that history.

It is a history that may be cut short at any time by accident or illness, but in its natural pattern it moves through youth and adulthood toward old age and, finally, decline and death. That is the body's destiny. As Hansjonas has suggested, we exist as living bodies, as organisms, not simply by perduring but by a constant encounter with the possibility of death.[17] We constantly give up the component parts of our self to renew them, and our continued life always carries within itself the possibility that these exchanges may fail us. Eventually we are worn down, unable any longer to manage the necessary exchanges. The fire goes out, and we are no longer "animated" earth.

To point to some moment in this history as the moment in which we are most truly ourselves, the vantage point from which the rest of our life is to be judged-not just another of the many moments in which we are persons, but a moment at which, presumably, we have personhood--is to suppose that we can somehow extricate ourselves from the body's natural history, can see ourselves whole. It is even, perhaps, to suppose that in such a moment we are rather like God, no longer having our personal presence in the body.

It is not too much to say that two quite different visions of the person--Fletcher's and Ramsey's--have been at war with each other during the three decades or so that bioethics has been a burgeoning movement. But it is equally clear that one view has begun to predominate within the bioethics world and perhaps within our culture more generally. Among the peculiarities of our historicist and purportedly antiessentialist age is the rise to prominence of an ahistorical and essentialist concept of the person. On this view, it is not the natural history of the embodied self but the presence or absence of certain capacities that makes the person. Indeed, we tend to think and speak not of being a person but of having personhood, which becomes a quality added to being. The view gaining ascendancy does not think of dependence or illness as something to be taken into the fabric of the person and lived out as part of one's personal history. It pictures the real person--like Origen's spherical eidos--as separate from that history, free to accept or reject it as part of one's person and life. Moreover, to be without the capacity to make such a decision is to fall short of personhood.

This view is not required by any of the standard approaches to bioethical reasoning or any of the basic principles (such as autonomy, beneficence, and justice) so commonly in use. What we do with such principles depends on the background beliefs we bring to them. Those beliefs determine how wide will be the circle of our beneficence and whether our notion of autonomy will be able to embrace dependence. The problems we face lie less with the principles than with ourselves. We have lost touch with the natural history of bodily life--a strange upshot for bioethics, as Holmes Rolston noted. How wrong we would be to suppose that ours is a materialistic age, when everything we hold central to our person is separated from the animated earth that is the body.

Embodied Souls sans Competence

It might be, however, that I have overlooked something important. If in some cases we judge care futile when the capacity for independence is gone, and if in other cases of chronic illness we take the need for continual care into the very meaning of personal life, perhaps--one might suggest--the difference lies in what different people want, how they choose to live. One patient chooses to live on; another sees no point in doing so. Hence, the key is autonomous choice, which remains at the heart of personhood. All we need do is get people to state their wishes--enact advance directives--while they are able. Then, if the day comes when others must make decisions for them, we will not have to delve into disputed background beliefs about the meaning of personhood. We will have a procedure in place to deal with such circumstances.

In the wider sweep of history, living wills are a very recent innovation, but the debate about their usefulness or wisdom coincides with the quarter century in which bioethics has grown as a movement.[18] And when we are told that, within a month after the Supreme Court's Cruzan decision, 100,000 people sought information about living wills from the Society for the Right to Die, we can understand that this is not an issue for specialized academic disciplines alone. The term |living will' was coined in 1969, and the nation's first living will law (in California) was passed in 1976--prompted, it seems, by the Karen Quinlan case. By now most states have enacted laws giving legal standing to living wills, and in 1991 the federal Patient Self-Determination Act went into effect, requiring hospitals to advise patients upon admission of their right to enact an advance directive. In a relatively short period of time, therefore, the idea of living wills (and other forms of advance directives, such as the health care power of attorney) seems. to have scored an impressive triumph. If we have no substantive agreement on what it means to be a person or have a life, the living will offers a process whereby we can deal with substantive disagreement. Each of us autonomously decides when our life would be so lacking in personal dignity as to be no longer worth preserving, and we pretend that such a process masks no substantive vision of what personhood means.

But it does, of course. Such a procedural approach brings with it a certain vision of the person: to be a person is to be, or have the capacity to be, an autonomous chooser, to take control over one's personal history, determining its bounds and limits. This substantive view turns out to have a life of its own and--we are beginning to see--can lead in several quite different directions. For a time, perhaps, all choices of once autonomous patients are honored. You choose to die when your ability to live independently and with "dignity" wanes; I choose to live on even when my rational capacities are gone. Each of us is treated as we have stipulated in advance. But then a day comes--and, indeed, is upon us--when the vision of the person hidden in this process comes to the fore.

The Paradox of Autonomy

If the person is essentially an autonomous chooser, then we will not forever be allowed to choose to live on when our personhood (so defined) has been lost. Living wills had, for the most part, been understood as a means by which we could ensure that we were not given care we would no longer have wanted, care that preserved a life regarded as subpersonal and no longer worth having. But in principle, after all, the process could be used to other ends. One could execute a living will directing that everything possible be done to keep oneself alive, even when one's "personal" capacities had been irretrievably lost. What then?

In a case somewhat like this, Helga Wanglie's caregivers answered that question by seeking a court order to stop the respirator and feeding tube that were sustaining her life. Mrs. Wanglie was an eighty-seven-year-old woman who, because of a respiratory attack, lost oxygen to her brain. She did not recover and remained in a persistent vegetative state. Although the costs of her care were covered by the family's insurance policy, the hospital still sought permission to remove life support. In some relatively minor ways, her case does not fit perfectly the hypothetical situation I considered above, for she had no living will. What she had, though, was a husband who was her guardian and who refused to consent to the withdrawal of treatment, believing she would not have wanted him to do so. Also, the medical caregivers went to court challenging her husband's suitability as guardian, rather than directly seeking court approval to terminate treatment.[19] But as Alexander Morgan Capron notes, when the caregivers first announced their intention to go to court, they stated that "they did not |want to give medical care they described as futile.'"

Thus, in the Wanglie case, at least in the minds of the caregivers, personhood defined in terms of the right autonomously to determine one's future gave way to personhood defined in terms of the present possession of certain capacities.[20] For those who lack such rational capacities, further care is understood as futile-whatever they might previously have stipulated while competent. Similarly, when Schneiderman and his colleagues develop their "qualitative" understanding of futility, they make clear its impact on cases like this one. "The patient has no right to be sustained in a state in which he or she has no purpose other than mere vegetative survival; the physician has no obligation to offer this option or services to achieve it."[21] Ironies abound here. At the heart of the bioethics movement has been an assertion of personal autonomy for patients, which was, of course, ordinarily understood as ensuring their ability to be rid of unwanted treatment. But having built autonomy into the center of our understanding of personhood, having indeed (after Roe v. Wade) claimed that such autonomy flows from our right of privacy and may be asserted on our behalf even by others when we are unable to assert our wishes, having used patient autonomy as a hammer to bludgeon into submission paternalistic physicians, we suddenly rediscover the responsibility of physicians to consider what is really best for the patient, to make judgments about when care is futile. We suddenly do an about face. Against past autonomous patient choice for continued treatment even after "personhood" has been lost, we now assert medical responsibility not to provide present care that is "futile."

Helga Wanglie's caregivers and those who would assert a "qualitative" notion of personhood are both light and wrong--though not in the ways they suppose. They are right in that there is no reason to think that my physicians should forever be bound by what I stipulate (when I am forty-five and in good health) about my future care. That is, they are right in thinking that autonomy alone is far too thin an account of the person and that physicians must concern themselves with patients' best interests, not just their requests or directives. But they are wrong in supposing that care for me becomes futile simply because I have irretrievably lost the higher human capacities for reasoning and self-awareness. They are also confused; for the vision of the person guiding them where they are right is incompatible with the vision of the person at work where they are wrong. In supposing that care for me becomes futile when I have lost my powers of reason (even though I may not be terminally ill), they express a vision of the person that divorces personhood from organic bodily life. They decline to take into their understanding of the person defect, dependence, or disability. But in judging that caregivers need not be bound forever by directions I have stipulated in advance, when my condition was quite different from what it has now become, they accept the need to live out the body's history, and they decline to give privileged status to the person's existence at one earlier moment in time.

Rethinking the Eidos

If we could develop an increased sense of irony about the course the bioethics movement has taken, we might be well positioned to think about the important questions for everyday life with which it here deals. The ironies are a clue to our confusions. Is it not striking that just at the moment when the idea of living wills seems to have triumphed, when federal law has required hospitals to make certain we know of our right to execute an advance directive, bioethicists should begin to wonder whether living wills are not themselves problematic? Having gotten what we thought we wanted--a law under-girded by a certain vision of the person--we begin to discern problems.

Thus, for example, John A. Robertson has had "Second Thoughts on Living Wills."[22] There are, he notes, spheres of life in which we do not hold a person to an understanding he or she had previously stated. We do not, for example, hold surrogate mothers to contracts. Yet, we are reluctant to recognize that when Meilaender becomes incompetent--severely demented, let us say--his interests may well shift. We prefer to suppose that his person was complete and perfect at some earlier point in his development--when, say, at age forty-five he executed a living will. We hesitate to consider that what the forty-five-year-old Meilaender thought should be done to and for a demented Meilaender may not be in the latter's best interest. His life circumstances have changed drastically; he has become more simply and completely organism and less neocortex. If we would care for him, we must take that into account. And if we do not take it into our reckoning, if we blindly follow whatever directions the forty-five-year-old Meilaender gave, it is not clear that we can really claim to have the best interests of this patient--the Meilaender now before us--at the center of our concern.

Something like that is Robertson's argument, and it makes good sense. For it essentially denies that we should think of the person as a perfect eidos captured at a moment in time, and, less directly, it invites us to think of the person as a someone who has a history, as animated earth. But that is not really Robertson's intent. He sees that the living will has become essentially "a device that functions to avoid assessing incompetent patient interests," but his real aim is to encourage us to take up "the difficult task of determining which incompetent states of existence are worth protecting." This can only land him back in the muddle from which he is trying to escape. He is back to thinking of personhood as something added to existence--and well on his way, therefore, to the conception of personhood that gave rise to an emphasis on autonomy, which in turn suggested the living will as a useful way to exercise our autonomy, which--or so he thinks--is a path strewn with "conceptual frailties." He wants us not to live out the destiny of the body but to escape it.

Life as "Someone Who"

To have a life is to be terra animata, a living body whose natural history has a trajectory. It is to be a someone who has a history, not a someone with certain capacities or characteristics. In our history this understanding of the person was most fully developed when Christians had to make sense of the claim that in Jesus of Nazareth both divine and human natures were joined in one person.[23] Christians did not wish to say that there were really two persons (two sets of personal characteristics) in Christ; hence, they could not formulate his personal identity in terms of capacities or characteristics. They could speak of his person only as an individual with a history, a "someone who." The personal is not just an example of the universal form; rather, the general characteristics exist in and through the individual person. And we can come to know such persons only by entering into their history, by personal engagement and commitment to them, not by measuring them against an ideal of health or personhood.

Perhaps such an understanding of the person is also available to us through reflection upon our life as embodied beings. "Embodiment is a curse only for those who believe they deserve to be gods."[24] If Origen's account of the resurrected body seems to have lost much of what we mean by embodiment, he had at least this excuse: he genuinely believed that God intended to make humankind divine. That bioethics--and our culture more generally--is in danger of losing the body in search of the person is harder to understand, unless in our own way we believe that we deserve to be gods.

James Rachels, arguing that ethics must and can get along quite well without God, has recently distinguished between biological and biographical life, arguing that only the second of these is of any value to us.[25] Biological life has instrumental value, since apart from it there is no possibility of realizing biographical life, but biological life without the possibility of self-consciousness and self-control can be of no value to us. In such a state we no longer have any interest in living, and we cannot be harmed if our life is not preserved.

Perhaps, though, such arguments do not take seriously enough the terra of which we are made. What Rachels never explains, for example, is why one's period of decline is not part of one's personal history, one's biography. As John Kleinig suggests, "Karen Ann Quinlan's biography did not end in 1975, when she became permanently comatose. It continued for another ten years. That was part of the tragedy of her life."[26] From zygote to irreversible coma, each life is a single personal history. We may, Kleinig notes, distinguish different points in this story, from potentiality to zenith to residuality. But the zenith is not the person. "Human beings are continuants, organisms with a history that extends beyond their immediate present, usually forward and backward. What has come to be seen as |personhood,' a selected segment of that organismic trajectory, is connected to its earlier and later phases by a complex of factors--physical, social, psychological--that constitutes part of a single history."

Indeed, it is not at all strange to suggest that even the unaware living body has "interests." For the living body takes in nourishment and uses it; the living body struggles against infection and injury. And if we remember "the somatic dimensions of personality, as expressed for instance in face and hands,"[27] we may recognize in the living body the place--the only place--through which the person is present with us. This does not mean that the person is "merely" body; indeed, in such contexts the word "merely" is always a dangerous word. As bodies we are located in time, space, and history; yet, we also transcend that location to some degree. Indeed, from the Christian perspective with which I began, it is right to say that, precisely because we are made for God, we indefinitely transcend our historical location. But it is as embodied creatures that we do so, and our person cannot be divorced from the body and its natural trajectory. This is not vitalism; it is "the wisdom of the body" (p. 358). It is the wisdom to see that every human life is a story and has a narrative quality--a plot to be lived out. That story begins before we are conscious of it, and, for many of us, continues after we have lost consciousness of it. Yet, each narrative is the story of "someone who"--someone who, as a living body, has a history.

Caught as we are within the midst of our own life stories, and unable as we are to grasp anyone else's story as a single whole, we have to admit that only God can see us as the persons we are--can catch the self and hold it still. What exactly we will be like when we are with God is, therefore, always beyond our capacity to say. But it will be the completion of the someone who we were and are, and we should not, therefore, settle for any more truncated vision of the person even here and now.

References

[1.] St. Augustine, De civitate Dei, trans. Henry Bettenson (New York: Penguin Books, 1972), 20.20. Future citations will be given by book and chapter number within parentheses in the body of the text. [2.] For much of what follows about the early Fathers I draw upon J.N.D. Kelly, Early Christian Doctrines (New York: Harper & Row, 1960), pp. 464-79. I am indebted to Robert Wilken for drawing my attention to Kelly's discussion. [3.] C. S. Lewis, Miracles (New York: Macmillan, 1947), p. 166. [4.] Saint Thomas Aquinas, Summa contra gentiles, trans. Charles J. O'Neil (Notre Dame: University of Notre Dame Press, 1975), 4.81.12. Future citations will be given by book, chapter, and paragraph number within parentheses in the body of the text. [5.] Jonathan Edwards, Works, vol. 8, Ethical Writings, ed. Paul Ramsey (New Haven: Yale University Press, 1989), p. 371. [6.] Austin Farrer, Love Almighty and Ills Unlimited (Garden City, N. Y.: Doubleday & Company, 1961), p. 166. For his discussion more generally, see the Appendix, "Imperfect Lives," pp. 166-68. [7.] David H. Smith, Health a Medicine in the Anglican Tradition (New York: Crossroad, 1986), p. 10. [8.] Holmes Rolston 111, "The Irreversibly Comatose: Respect for the Subhuman in Human Life," Journal of Medicine and Philosophy 7 (1982): 337-54. [9.] Robertson Davies, The Rebel Angels (New York: Penguin Books, 1983), pp. 249ff. [10.] Joseph Fletcher, "Four Indicators of Humanhood: The Enquiry Matures," Hastings Center Report 4, no. 6 (1974): 4-7. [11.] I have discussed this from another angle in chapter 8 of Faith and Faithfulness (Notre Dame: University of Notre Dame Press, 1991). [12.] Lawrence J. Schneiderman, Nancy S. Jecker, and Albert R. Jonsen, "Medical Futility: Its Meaning and Ethical Implications," Annals of Internal Medicine 112 (June 1990): 949-54. [13.] Ronald E. Cranford, "The Persistent Vegetative State: The Medical Reality (Getting the Facts straight)," Hastings Center Report 18, no. 1 (1988): 27-32. [14.] Schneiderman et al., "Medical Futility," 952. [15.] Bart Collopy, Philip Boyle, and Bruce Jennings, "New Directions in Nursing Home Ethics," special supplement, Hastings Center Report 21, no. 2 (1991): 1-16. [16.] Paul Ramsey, The Patient as Person (New Haven: Yale University Press, 1970), P. xiii. [17.] Hans Jonas, "The Burden and Blessing of Mortality," Hastings Center Report 22, no. 1 (1992): 34-40. [18.] For the historical information that follows I rely upon George J. Annas, "The Health Care Proxy and the Living Will," NEJM 324 (25 April 1991): 1210-13. [19.] Alexander Morgan Capron, "In Re Helga Wanglie," Hastings Center Report 21, no. 5 (1991): 26-28. [20.] My distinction here bears some similarities to James Childress's distinction between autonomy as an end state and autonomy as a side constraint. Cf. his Who Should Decide? Paternalism in Health Care (New York: Oxford University Press, 1982), p. 64. [21.] Schneiderman et al., "Medical Futility," p. 952. [22.] John A. Robertson, "Second Thoughts on Living Wills," Hastings Center Report 21, no. 6 (1991): 6-9. [23.] 1 have discussed this point more fully (and acknowledged my indebtedness for it to Oliver O'Donovan) in Faith and Faithfulness, pp. 4547. [24.] Leon R. Kass, Toward a More Natural Science (New York: Free Press, 1985), p. 293. [25.] James Rachels, Created from a Animals: The Moral Implications of Darwinism (New York: Oxford University Press, 1990), pp. 198ff. [26.] John Kleinig, Valuing Life (Princeton: Princeton University Press, 1991), p. 201. [27.] Rolston, "Irreversibly Comatose," p. 352.
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Author:Meilaender, Gilbert
Publication:The Hastings Center Report
Date:Jul 1, 1993
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