Published in: Hastings Center Report
27, no. 2 (1997): 34-42.
When Richard Lamm made the statement that old people have a duty to
die, it was generally shouted down or ridiculed. The whole idea is just
too preposterous to entertain. Or too threatening. In fact, a fairly common
argument against legalizing physician-assisted suicide is that if it were
legal, some people might somehow get the idea that they have a duty to
die. These people could only be the victims of twisted moral reasoning
or vicious social pressure. It goes without saying that there is no duty
But for me the question is real and very important. I feel strongly
that I may very well some day have a duty to die. I do not believe that
I am idiosyncratic, morbid, mentally ill, or morally perverse in thinking
this. I think many of us will eventually face precisely this duty. But
I am first of all concerned with my own duty. I write partly to clarify
my own convictions and to prepare myself. Ending my life might be a very
difficult thing for me to do.
This notion of a duty to die raises all sorts of interesting theoretical and metaethical questions. I intend to try to avoid most of them because I hope my argument will be persuasive to those holding a wide variety of ethical views. Also, although the claim that there is a duty to die would ultimately require theoretical underpinning, the discussion needs to begin on the normative level.
I will use "duty," "obligation," and "responsibility" interchangeably, in a pretheoretical or preanalytic sense, , as is appropriate to my attempt to steer clear of theoretical commitments.
CIRCUMSTANCES AND A DUTY TO DIE
Do many of us really believe that no one ever has a duty to die? I suspect
not. I think most of us probably believe that there is such a duty, but
it is very uncommon. Consider Captain Oates, a member of Admiral Scott's
expedition to the South Pole. Oates became too ill to continue. If the
rest of the team stayed with him, they would all perish. After this had
become clear, Oates left his tent one night, walked out into a raging blizzard,and
was never seen again. That may have been a heroic thing.
This is a very unusual circumstance--a "lifeboat case"--and lifeboat
cases make for bad ethics. But I expect that most of us would also agree
that there have been cultures in which what we would call a duty to die
has been fairly common. These are relatively poor, technologically simple,
and especially nomadic cultures. In such societies, everyone knows that
if you manage to live long enough, you will eventually become old and debilitated.
Then you will need to take steps to end your life. The old people in these
societies regularly did precisely that. Their cultures prepared and supported
them in doing so.
Those cultures could be dismissed as irrevelant to contemporary bioethics;
their circumstances are so different from ours . But if that is our response,
it is instructive. It suggests that we assume a duty to die is irrelevant
to us because of our wealth and technological sophistication have purchased
exemption for us . . . except under very unusual circumstances like Captain
But have wealth and technology really exempted us? Or are they, on the
contrary, about to make a duty to die common again? We like to think of
modern medicine as all triumph with no dark side at all. Our medicine saves
many lives and enables most of us to live longer. That is wonderful, indeed.
We are all glad to have access to this medicine. But our medicine also
delivers most of us over to chronic illnesses and it enables many of us
to survive longer than we can take care of ourselves, longer than we know
what to do with ourselves, longer than we even are ourselves.
The costs -- and these are not merely monetary -- of prolonging our
lives when we are no longer able to care for ourselves are often staggering.
If further medical advances wipe out many of today's "killer diseases"
-- cancers, heart attacks, strokes, ALS, AIDS, and the rest -- then one
day most of us will survive long enough to become demented or debilitated.
These developments could generate a fairly widespread duty to die. A fairly
common duty to die might turn out to be only the dark side of our life-prolonging
medicine and the uses we choose to make of it.
Let me be clear. I certainly believe that there is a duty to refuse
life-prolonging medical treatment and also a duty to complete advance directives
refusing life-prolonging treatment. But a duty to die can go well beyond
that. There can be a duty to die before one's illnesses would cause death,
even if treated only with palliative measures. In fact, there may be a
fairly common responsibility to end one's life in the absence of any terminal
illness at all. Finally, there can be a duty to die when one would prefer
to live. Granted, many of the conditions that can generate a duty to die
also seriously undermine the quality of life. Some prefer not to live under
such conditions. But even those who want to live can face a duty to die.
These will clearly be the most controversial and troubling cases; I will,
accordingly, focus my reflections on them.
THE INDIVIDUALISTIC FANTASY
Because a duty to die seems such a real possibility to me, I wonder
why contemporary bioethics has dismissed it without serious consideration.
I believe that most bioethics still shares in one of our deeply embedded
American dreams: the individualistic fantasy. This fantasy leads us to
imagine that lives are separate and unconnected, or that they could be
so if we chose. If lives were unconnected, things that happened in my life
would not or need not affect others. And if others were not (much) affected
by my life, I would have no duty to consider the impact of my decisions
on others. I would then be morally free to live my life however I please,
choosing whatever life and death I prefer for myself. The way I live would
be nobody's business but my own. I certainly would have no duty to die
if I preferred to live.
Within a health care context, the individualistic fantasy leads us to
assume that the patient is the only one affected by decisions about her
medical treatment. If only the patient were affected, the relevant questions
when making treatment decisions would be precisely those we ask: What will
benefit the patient? Who can best decide that? The pivotal issue would
always be simply whether the patient herself wants to live like this and
whether she herself would be better off dead. "Whose life is it, anyway?"
we ask rhetorically.
But this is morally obtuse. We are not a race of hermits. Illness and
death do not come only to those who are all alone. Nor is it much better
to think in terms of the bald dichotomy between "the interests of the patient"
and "the interests of society" (or a third-party payer), as if we were
isolated individuals connected only to "society" in the abstract or to
the other, faceless members of our health maintenance organization.
Most of us are affiliated with particular others and most deeply, with family and loved ones. Families and loved ones are bound together by ties of care and affection, by legal relations and obligations, by inhabiting shared spaces and living units, by interlocking finances and economic prospects, by common projects and also commitments to support the different life projects of other family members, by shared histories, by ties of loyalty. This life together of family and loved ones is what defines and sustains us; it is what gives meaning to most of our lives. We would not have it any other way. We would not want to be all alone, especially when we are seriously ill, as we age, and when we are dying.
A BURDEN TO MY LOVED ONES
But many older people report that their one remaining goal in life is
not to be a burden to their loved ones. Young people feel this, too: when
I ask my undergraduate students to think about whether their death could
come too late, one of their very first responses always is, "Yes, when
I become a burden to my family or loved ones." Tragically, there are situations
in which my loved ones would be much better off -- all things considered,
the loss of a loved one notwithstanding -- if I were dead.
The lives of our loved ones can be seriously compromised by caring for
us. The burdens of providing care or even just supervision twenty-four
hours a day, seven days a week are often-overwhelming. When this kind
of caregiving goes on for years, it leaves the caregiver exhausted, with
no time for herself or life of her own. Ultimately, even her health is
often destroyed. But it can also be emotionally devastating simply to live
with a spouse who is increasingly distant, uncommunicative, unresponsive,
foreign, and unreachable. Other family members' needs often go unmet as
the caring capacity of the family is exceeded. Social life and friendships
evaporate, as there is no opportunity to go out to see friends and the
home is no longer a place suitable for having friends in.
We must also acknowledge that the lives of our loved ones can be devastated
just by having to pay for health care for us. One part of the recent SUPPORT
study documented the financial aspects of caring for a dying member of
a family. Only those who had illnesses severe enough to give them less
than a 50% chance to live six more months were included in this study.
When these patients survived their initial hospitalization and were discharged,
about 1/3 required considerable caregiving from their families, in 20%
of cases a family member had to quit work or make some other major lifestyle
change, almost 1/3 of these families lost all of their savings, and just
under 30% lost a major source of income.
If talking about money sounds venal or trivial, remember that much more
than money is normally at stake here. When someone has to quit work, she
may well lose her career. Savings decimated late in life cannot be recouped
in the few remaining years of employability, so the loss compromises the
quality of the rest of the caregiver's life. For a young person, the chance
to go to college may be lost to the attempt to pay debts dure to an illness
in the family, and this decisively shapes an entire life.
A serious illness in a family is a misfortune. It is usually nobody's
fault; no one is responsible for it. But we face choices about how we will
respond to this misfortune. That's where the responsibility comes in and
fault can arise. Those of us with families and loved ones always have a
duty not to make selfish or self-centered decisions about our lives. We
have a responsibility to try to protect the lives of loved ones from serious
threats or greatly impoverished quality, certainly an obligation not to
make choices that will jeopardize or seriously compromise their futures.
Often, it would be wrong to do just what we want or just what is best for
ourselves; we should choose in light of what is best for all concerned.
That is our duty in sickness as well as in health. It is out of these responsibilities
that a duty to die can develop.
I am not advocating a crass, quasi-economic conception of burdens and
benefits, nor a shallow, hedonistic view of life. Given a suitably rich
understanding of benefits, family members sometimes do benefit from suffering
through the long illness of a loved one. Caring for the sick or aged can
foster growth, even as it makes daily life immeasurably harder and the
prospects for the future much bleaker. Chronic illness or a drawn-out death
can also pull a family together, making the care for each other stronger
and more evident. If my loved ones are truly benefitting from coping with
my illness or debility, I have no duty to die based on burdens to them.
But it would be irresponsible to blithely assume that this always happens,
that it will happen in family, or that it willb e the fault of my family
if they can not manage to turn my illness into a positive experience. Perhaps
the opposite is more common: a hospital chaplain once told me that he could
not think of a single case in which a family was strengthened or brought
together by what happened at the hospital.
Our families and loved ones also have obligations, of course -- they
have the responsibility to stand by us and to support us through debilitating
illness and death. They must be prepared to make significant sacrifices
to respond to an illness in the family. I am far from denying that. Most
of us are aware of this responsibility and most families meet it rather
well. In fact, families deliver more than 80% of the long-term care in
this country, almost always at great personal cost. Most of us who are
a part of a family can expect to be sustained in our time of need by family
members and those who love us.
But most discussions of an illness in the family talk as if responsibility were a one-way street. It is not, of course. When we become seriously ill or debilitated, we too may have to make sacrifices. To think that my loved ones must bear whatever burdens my illness, debility, or dying process might impose upon them is to reduce them to means to my well-being. And that would be immoral. Fammily solidarity, altruism, bearing the burden of a loved one's misfortune, and loyalty are all important virtues of families, as well. But they are all also two-way streets.
OBJECTIONS TO A DUTY TO DIE
To my mind, the most serious objections to the idea of a duty to die
lie in the effects on my loved ones of ending my life. But to most others,
the important objections have little or nothing to do with family and loved
ones. Perhaps the most common objections are: 1) There is a higher duty
which always takes precedence over a duty to die. 2) A duty to end one's
own life would be incompatible with a recognition of human dignity or the
intrinsic value of a person. 3) Seriously ill, debilitated, or dying people
are already bearing the harshest burdens and so it would be wrong to ask
them to bear the additional burden of ending their own lives.
These are all important objections; all deserve a thorough discussion.
Here I will only be able to suggest some moral counterweights -- ideas
that might provide the basis for an argument that these objections do not
always preclude a duty to die.
An example of the first line of argument would be the claim that a duty
to God, the giver of life, forbids that anyone take her own life. It could
be argued that this duty always supersedes whatever obligations we might
have to our families. But what convinces us that we always have such a
religious duty in the first place? And what guarantees that it always supersedes
our obligations to try to protect our loved ones?
Certainly, the view that death is the ultimate evil cannot be squared
with Christian theology. It does not reflect the actions of Jesus or those
of his early followers. Nor is it clear that the belief that life is sacred
requires that we never take it. There are other theological possibilities.
In any case, most of us -- bioethicists, physicians, and patients alike
-- do not subscribe to the view that we have an obligation tob preserve
human life as long as possible. But if not, surely we ought to agree that
I may legitimately end my life for other regarding reasons, not just for
Secondly, religious considerations aside, the claim could be made that
an obligation to end one's own life would be incompatible with human dignity
or would embody a failure to recognize the intrinsic value of a person.
But I do not see that in thinking I had a duty to die I would necessarily
be failing to respect myself or to appreciate my dignity or worth. Nor
would I necessarily be failing to respect you in thinking that you had
a similar duty. There is surly also a sense in which we fail to respect
ourselves if in the face of illness or death, we stoop to choosing just
what is best for ourselves. Indeed, Kant held that the very core
of human dignity is the ability to act on a self-imposed moral law, regardless
of whether it is in our interest to do so. We shall return to
the notion of human dignity.
A third objection appeals to the relative weight of burdens and thus,
ultimately, to considerations of fairness or justice. The burdens that
an illness creates for the family could not possibly be great enough to
justify an obligation to end one's life -- the sacrifice of life itself
would be a far greater burden than any involved in caring for a chronically
ill family member.
But is this true? Consider the following case: An 87-year old woman
was dying of congestive heart-failure. Her APACHE score predicted that
she had less-than a 50% chance to live for another six months. She was
lucid, assertive and terrified of death. She very much wanted to live and
kept opting for rehospitalization and the most aggressive life-prolonging
treatment possible. That treatment successfully prolonged her life (though
with increasing debility) for nearly two years. Her 55-year-old daughter
was her only remaining family, her caregiver, and the main source of her
financial support. The daughter duly cared for her mother. But before her
mother died, her illness had cost the daughter all of her savings, her
home, her job and her career.
This is by no means an uncommon sort of case. Thousands of similar cases
occur each year. Now, ask yourself which is the greater burden:
(a) To lose a 50% chance of six more months of life at age 87?
(b) To lose all your savings, your home, and your career at age 55?
Which burden would you prefer to bear? Do we really believe the former
is the greater burden? Would even the dying mother say that (a) is the
greater burden? Or has she been encouraged to believe that the burdens
of (b) are somehow morally irrelevant to her choices?
I think most of us would quickly agree that (b) is a greater burden.
That is the evil we would more hope to avoid in our lives. If we are tempted
to say that the mother's disease and impending death are the greater evil,
I believe it is because we are taking a "slice of time" perspective rather
than a "lifetime perspective."  But surely the lifetime perspective
is the appropriate perspective when weighing burdens. If (b) is the greater
burden, then we must admit that we have been promulgating an ethic that
advocates imposing greater burdens on some people in order to provide smaller
benefits for others just because they are ill and thus gain our professional
attention and advocacy.
A whole range of cases like this one could easily be generated. In some,
the answer about which burden is greater will not be clear. But in many
it is. Death -- or ending yourown life -- is simply not the greatest evil
or the greatest burden.
This point does not depend on a utilitarian calculus. Even if death
were the greatest burden (thus disposing of any simple utilitarian argument),
serious questions would remain about the moral justifiability of choosing
to impose crushing burdens on loved ones in order to avoid having to bear
this burden oneself. The fact that I suffer greater burdens than others
in my family does not license me to simply choose what I want for myself,
nor does it necessarily release me from a responsibility to try to protect
the quality of their lives.
I can readily imagine that, through cowardice, rationalization, or failure of resolve, I will fail in this obligation to protect my loved ones. If so, I think I would need to be excused or forgiven for what I did. But I cannot imagine it would be morally permissible for me to ruin the rest of my partner's life to sustain mine or to cut off my sons' careers, impoverish them, or compromise the quality of their children's lives simply because I wish to live a little longer. This is what leads me to believe in a duty to die.
WHO HAS A DUTY TO DIE?
Suppose, then, that there can be a duty to die which grows out of the
burdens that will fall upon our loved ones if we live on. WHO has a duty
to die? And WHEN? To my mind, these are the right questions, the questions
we should be asking. Many of us may one day badly need answers to just
But I cannot supply answers here, for two reasons. In the first place,
answers will have to be very particular and contextual. Our concrete duties
are often situated, defined in part by the myriad details of our circumstances,
histories, and relationships. Though there may be principles that apply
to a wide range of cases and some cases that yield pretty straightforward
answers, there will also be many situations in which it is very difficult
to discern whether one has a duty to die. If nothing else, it will often
be very difficult to predict how one's family will bear up under the weight
of the burdens that a protracted illness would impose on them.
Secondly and perhaps even more importantly, I believe that those of
us with family and loved ones should not define our duties unilaterally,
especially not a decision about a duty to die. It would be isolating and
distance-creating for me to decide without consulting them what is too
much of a burden for my loved ones to bear. That way of deciding about
my moral duties is not only atomistic, it also treats my family and loved
ones paternalistically. They must be allowed to speak for themselves about
the burdens my life imposes on them and how they feel about bearing those
Some may object that it would be wrong to put a loved one in a position
of having to say, in effect, "You should end your life because caring for
you is too hard on me and the rest of the family." Not only will it be
almost impossible to say something like that to one you love, it will carry
with it a heavy load of guilt. On this view, you should decide by yourself
whether you have a duty to die and approach your loved ones only after
you have made up your mind, to say good-bye to them. Your family could
then try to change your mind, but the tremendous weight of moral decision
would be lifted from their shoulders.
Perhaps so. But I believe in family decisions. Important decisions for
those whose lives are interwoven should be made TOGETHER, in a family discussion.
Granted, a conversation about whether I have a duty to die would be a tremendously
difficult conversation. The temptations to be dishonest could be enormous.
Nevertheless, if I am contemplating a duty to die, I and my family should,
if possible, have just such an agonizing discussion. It will act as a check
on the information, perceptions, and reasoning of all of us. But even more
importantly, it affirms our connectedness at a critical juncture in our
lives and our life together. Honest talk about difficult matters almost
always strengthens relationships.
However, many families seem unable to talk about death at all, much
less a duty to die. Certainly most families could not have this discussion
all at once, in one sitting. It might well take a number of discussions
to be able to approach this topic. But even if talking about death is impossible,
there are always behavioral clues -- about your caregiver's tiredness,
physical condition, health, prevailing mood, anxiety, financial concerns,
outlook, overall well-being and so on. And families unable to talk about
death can often talk about how the caregiver is feeling, about finances,
about tensions within the family resulting from the illness, about concerns
for the future. Deciding whether you have a duty to die based on these
behavioralclues and conversation about them honors your relationships better
than deciding on your own about how burdensome you and your care must be.
I cannot say when someone has a duty to die. Still, I can suggest a
few features of one's illness, history, and circumstances that make it
more likely that one has a duty to die. I present them here without much
elaboration or explanation.
CAN THE INCOMPETENT HAVE A DUTY TO DIE?
Several mental deterioration springs readily to mind as one of the situations
in which I believe I could have a duty to die. But can incompetent people
have duties at all? We can have moral duties we do not recognize or acknowledge,
including duties that we NEVER recognized. But can we have duties we are
UNABLE to recognize? Duties when we are unable to understand the concept
of morality at all? If so, do others have a moral obligation to help us
carry out this duty? These are extremely difficult theoretical questions.
Our notions of moral agency are severely strained by mental incompetence.
I am tempted to simply bypass the entire question by saying that I am
talking only about competent persons. But the idea of a duty to die clearly
raises the specter of one person claiming that another -- who cannot speak
for herself -- has such a duty. So I need to say that I can make no sense
of the claim that someone has a duty to die if the person has never been
able to understand moral obligation at all. To my mind, only those who
were formerly capable of making moral decisions could have such a duty.
But the case of formerly competent persons is almost as troubling. Perhaps
we should simply stipulate that no incompetent person can have a duty to
die, not even if she affirmed belief in such a duty in an advance directive.
If we take the view that formerly competent people may have such a duty,
we should surely exercise extreme caution when claiming a formerly competent
person would have acknowledged a duty to die or that any formerly competent
person has an unacknowledged duty to die. Moral dangers loom regardless
of which way we decide to resolve such issues.
But for me personally, very urgent practical matters turn on their resolution.
If a formerly competent person can no longer have a duty to die (or if
other people are not likely to help her carry out this duty), I believe
that my obligation may be to die while I am still competent --BEFORE I
become unable to make and carry out that decision for myself. Surely it
would be irresponsible to evade my moral duties by temporizing until I
escape into incompetence. And so I must die sooner than I otherwise would
have to. On the other hand, if I could count on others to end my life after
I become incompetent, I might be able to fulfill my responsibilities while
also living out all my competent or semi-competent days. Given our society's
reluctance to permit physicians, let alone family members, to perform aid-in-dying,
I believe I may well have a duty to end my life when I can see mental incapacity
on the horizon.
There is also the very real problem of sudden incompetence due to a serious incompetence -- due to a serious stroke or automobile accident, for example. For me, that is the real nightmare. I suddenly become incompetent, I will fall into the hands of a medical/legal system that will conscientiously disregard my moral beliefs and do what is best for me, regardless of the consequences for my loved ones. And that is not at all what I would have wanted!
SOCIAL POLICIES AND A DUTY TO DIE
The claim that there is a duty to die will seem to some a misplaced
response to social negligence. If our society were providing for the debilitated,
the chronically ill, and the elderly as it should be, there would be only
very rare cases of a duty to die. On this view, I am asking the sick and
debilitated to step in and accept responsibility because society is derelict
in its responsibility to provide for the incapacitated.
This much is surely true: there are a number of social policies we could
pursue that would dramatically reduce the incidence of a duty to die. Most
obviously, we could decide to pay for facilities that provided excellent
long-term care (not just health care!) for all chronically ill, debilitated,
mentally ill or demented people in this country. We probably could still
afford to do this. If we did, sick, debilitated, and dying people might
still be morally required to make sacrifices for their families. I might,
for example, have a duty to forgo personal care by a family member who
knows me and really does care for me. But these sacrifices would only rarely
include the sacrifice of life itself. The duty to die would then be virtually
I must not, then, live my life and make my plans on the assumption that social institutions will protect my family from my infirmity and debility. To do so would be irresponsible. More likely, it will be up to me to protect my loved ones.
A DUTY TO DIE AND THE MEANING OF LIFE
A duty to die seems very harsh, and often it would be. It is one of
the tragedies of our lives that someone who wants very much to live can
nevertheless have a duty to die. It is both tragic and ironic that it is
precisely the very real good of family and loved ones that gives rise to
this duty. Indeed, the genuine love, closeness and supportiveness of family
members is a major source of this duty: we could not be such a burden if
they did not care for us. Finally, there is deep irony in the fact that
the very successes of our life-prolonging medicine help to create a widespread
duty to die. We do not live in such a happy world that we can avoid such
tragedies and ironies. We ought not to close our eyes to this reality or
pretend that it just doesn't exist. We ought not to minimize the tragedy
in any way.
And yet, a duty to die will not always be as harsh as we might assume.
If I love my family, I will want to protect them and their lives. I will
want not to make choices that compromise their futures. Indeed, I can easily
imagine that I might want to avoid compromising their lives more than I
would want anything else. I must also admit that I am not necessarily giving
up so much in giving up my life: the conditions that give rise to a duty
to die would usually already have compromised the quality of the life I
am required to end. In any case, I personally must confess that at age
fifty-six, I have already lived a very good life, albeit not yet nearly
as long a life as I would like to have.
We fear death too much. Our fear of death has lead to a massive assault
on it. We still crave after virtually any life-prolonging technology that
we might conceivably be able toproduce. We still too often feel morally
impelled to prolong life -- virtually any form of life -- as long as possible.
As if the best death is the one that can be put off longest.
We do not even ask about meaning in death, so busy are we with trying
to postpone it. But we will not conquer death by one day developing a technology
so magnificent that no one will have to die. Nor can we conquer death by
postponing it ever longer. We can conquer death only by finding meaning
Although the existence of a duty to die does not hinge on this, recognizing
such a duty would go some way toward recovering meaning in death. 1) Paradoxically,
it would restore dignity to those who are seriously ill or dying. 2) It
would affirm the connections required to give life (and death) meaning.
I close now with a few words each of these points.
First, recognizing a duty to die affirms my agency and also my moral
agency. I can still do things that make an important difference in the
lives of my loved ones. Moreover, the fact that I still have responsibilities
keeps me within the community of moral agents. My illness or debility has
not reduced me to a mere moral patient (to use the language of the philosophers).
Though it may not be the whole story, surely Kant was onto something important
when he claimed that human dignity rests on the capacity for moral agency
within a community of those who respect the demands of morality.
By contrast, surely there is something deeply insulting in a medicine
and a bioethics that would ask only what I want (or would have wanted)
when I become ill. To treat me as if I had no moral responsibilities when
I am ill or debilitated implies that my condition has rendered me morally
incompetent. Only small children, the demented or insane, and those totally
lacking in the capacity to act are free from moral duties. There is dignity,
then, and a kind of meaning in moral agency, even as it forces extremely
difficult decisions upon us.
Secondly, recovering meaning in death requires an affirmation of connections.
If I end my life to spare the futures of my loved ones, I testify in my
death that I am connected to them. It is because I love and care for precisely
these people (and I know they care for me) that I wish not to be such a
burden to them. By contrast, a life in which I am free to choose whatever
I want for myself is a life unconnected to others. A bioethics that would
treat me as if I had no serious moral responsibilities does what it can
to marginalize, weaken, or even destroy my connections with others.
But life without connection is meaningless. The individualistic fantasy,
though occasionally liberating, is deeply destructive. When life is good
and vitality seems unending, life itself and life lived for yourself may
seem quite sufficient. But if not life, certainly death without connection
is meaningless. If you are only for yourself, all you have to care about
as your life draws to a close is yourself and your life. Everything you
care about will then perish in your death. And that -- the end of everything
you care about -- is precisely the total collapse of meaning. We can, then,
find meaning in death only through a sense of connection with something
that will survive our death.
This need not be connections with other people. Some people are deeply
tied to land (e.g., the family farm), to nature, or to a transcendent reality.
But for most of us, the connections that sustain us are to other people.
In the full bloom of life, we are connected to others in many ways -- through
work, profession, neighborhood, country, shared faith and worship, common
leisure pursuits, friendships. Even the guru meditating in isolation on
his mountain top is connected to a long tradition of people united by the
same religionus quest.
But as we age or when we become chronically ill, connections with other
people usually become more restricted. Often only ties with family and
close friends remain and remain important to us. Moreover, for many of
us, other connections just don't go deep enough. As Paul Tsongas has reminded
us, "when it comes time to die, no one says, 'I wish I had spent more time
at the office.'"
If I am correct, death is so difficult for us partly because our sense
of community is so weak. Death seems to wipe out everything when we can't
fit it into the lives of those who live on. A death motivated by the desire
to spare the futures of my loved ones might well be a better death for
me than the one I would get as a result of opting to continue my life as
long as there is any pleasure in it for me. Pleasure is nice, but it is
meaning that matters.
I don't know about others, but these reflections have helped me. I am now more at peace about facing a duty to die. Ending my life if my duty required might still be difficult. But for me, a far greater horror would be dying all alone or stealing the futures of my loved ones in order to buy a little more time for myself. I hope that if the time comes when I have a duty to die, I will recognize it, encourage my loved ones to recognize it too, and carry it out bravely.
I wish to thank Mary English, Hilde Nelson, Jim Bennett, Tom Townsend, the members of the Philosophy Department at ETSU and anonymous reviewers of the REPORT for many helpful comments on earlier versions of this paper. In this paper, I draw on material in Hardwig J. "Dying at the Right Time; Reflections on (Un)Assisted Suicide" in LaFollette, H. Practical Ethics(London:Blackwell), 1996, with permission.
1. Given the importance of relationships in my thinking,"responsibility"
-- rooted as it is in "respond" -- would perhaps be the most appropriate
word. Nevertheless, I often use "duty" despite its legalistic overtones,
because Lamm's famous statement has given the expression "duty to die"
a certain familiarity. But I intend no implication that there is a law
which grounds this duty, nor that someone has a right corresponding to
2. For a discussion of the Oates case, see Tom L. Beauchamp,
"What Is Suicide?" in Tom L. Beauchamp & Seymour Perlin, eds.,
Ethical Issues in Death and Dying, (Englewood Cliffs, NJ: Prentice-Hall,
3. Most bioethicists advocate a "patient-centered ethics" --
an ethics which claims only the patient's interests should be considered
in making medical treatment decisions. Most health care professionals have
been trained to accept this ethic and to see themselves as patient advocates.
For arguments that a patient-centered ethics should be replaced by a family-centered
ethics see John Hardwig, "What About the Family?" Hastings Center
Report 20, no. 2 (1990): 5-10; Hilde L. Nelson & James L. Nelson,
The Patient in the Family, (New York: Routledge, 1995).
4. A good account of the burdens of caregiving can be found in
Elaine Brody, Women in the Middle: Their Parent-Care Years (New
York: Springer Publishing Co., 1990). Perhaps the best article-length account
of these burdens is Daniel Callahan, "Families as Caregivers; the Limits
of Morality"> in Nancy Jecker, ed., Aging and Ethics: Philosophical
Problems in Gerontology, (Totowa NJ: Humana Press, 1991).
5. Kenneth E. Covinsky, Less Goldman et al., "The Impact of
Serious Illness on Patients' Families" 272 (1994): 1839-1844.
6. Larry Churchill, for example, believes that Christian ethics
takes us far beyond my present position: "Christian doctrines of stewardship
prohibit the extension of one's own life at a great cost to the neighbor.
. . And such a gesture should not appear to us a sacrfice, but as the ordinary
virtue entailed by a just social consicence." Larry Churchill, Rationing
Health Care in America (South Bend, IN: Notre Dame University Press,
1988), p. 112.
7. Kant, as is well known, was opposed to suicide. But he was
arguing against taking your life out of self-interested motives. It is
not clear that Kant would or we should consider taking your life out of
a sense of duty to be wrong. See Hilde Nelson, "Death with Kantian Dignity,"
Journal of Clinical Ethics, 7(1996): 215-21.
8. Obviously, I owe this distinction to Norman Daniels. Normal
Daniels, Am I My Parents' Keeper? An Essay on Justice Between the Young
and the Old (New York: Oxford University Press, 1988). Just as obviously,
Daniels is not committed to my use of it here.
9. Daniel Callahan, The Troubled Dream of Lif (New York: Simon & Schuster, 1993).