Mental Illness and Voluntary Euthanasia

 

 Canada’s House of Commons has passed a bill which would allow to euthanasia for people suffering from mental illness and a terminal condition, see Bioedge . Let us assume that anyone suffering a great deal of pain and who only is expected to have only short time left to live has a right to assisted suicide provided that she can give competent consent. Let us now consider Andy and Sandra. Andy who has no mental health has an incurable illness from which he suffers greatly. Andy should have a right to assisted suicide. Sandra who has the same illness as Andy and suffers just as much also has mental health problems. It would seem to be unfair to deny Sandra the same right as Andy to end her suffering. What reason could be given to justify this apparent unfairness? It might be suggested that Andy is competent to give consent whilst Sandra isn’t. Let us accept the idea of informed consent is based on respect for autonomy, some might question this assumption, see the doctrine of informed consent and respect for autonomy . Accepting the above might mean the cases of Andy and Sandra differ because Andy can give competent consent to voluntary euthanasia whilst Sandra can’t because Andy is autonomous and Sandra isn’t. If we accept the above it would appear unfortunately that we must accept Sandra’s suffering. I now want to argue that we should permit voluntary euthanasia for some people suffering from terminal illness who also suffer from mental illness. I will accept that only autonomous persons can make a competent decision to accept voluntary euthanasia.

What do we mean by an autonomous decision? Autonomous decisions are decisions we govern ourselves by. What does autonomy in practice? Let us consider a substantive account of autonomy. According to such an account an autonomous decision isn’t simply one the agent freely makes and doesn’t harm others. Let us label such an account as a primitive account. According to a substantive account an agent can only make an autonomous decision if he fully understands any information relevant to his decision and then makes a rational decision based on his best interests. Moreover the substantive element of this account means his best interests are not simply his subjective best interests but must concur with some norms or objective list. If we accept such an account then it seems likely that most mentally ill people wouldn’t be competent enough to consent to voluntary euthanasia and as a result shouldn’t be offered the option. However if we accept a substantive account of autonomy then the substantive element means autonomous decisions must be good decisions. I now want to argue against accepting such a substantive account of autonomy. If autonomous decisions must be a good decisions because they must concur with some accepted norms then it might be questioned whether such an account of autonomy is really doing any useful work. A substantive account of autonomy puts itself out of business because we only need to consider good and bad decisions. We don’t need to consider autonomous decisions at all. Some concerned with medical ethics might be happy to accept the above because they attach great importance to acting beneficently. Do we value autonomy because it helps us make good decisions? I would suggest we don’t. I would suggest that we value autonomy because we value persons. We value being the sort of creatures that can make their own decisions. We don’t respect autonomy because it helps us make good decisions we respect autonomy because respect persons. Respecting persons requires that we accept their decisions and this includes bad decisions. It follows that respect for autonomy means we should accept a non-substantive account. It might be objected that we can respect someone’s autonomy by respecting most of her decisions, but not all, and this means we don’t need to accept a non-substantive account. In response I would point out respect isn’t a part time concept.

Let us accept that that we should permit voluntary euthanasia for persons suffering from terminal who are able to give competent consent. Let us also accept that any autonomous decision using a non-substantive account of autonomy should be regarded as a competent one. What might a non-substantive account of autonomy look like? A random or coerced decision isn’t an autonomous one. An autonomous decision might have no substantive element but the way it is made matters. Autonomy is connected to persons and a person, distinct from a human being, is defined by what he cares about. I would suggest what we care about must have some persistence. (1) It follows that not all freely made decisions are autonomous ones. I would also suggest what we care about depends simply on what we will rather that what it would rational for us to care about, if this wasn’t so we would be returning to a substantive account of autonomy.

What are the implications of adopting the above non-substantive account of autonomy for the mentally ill? Let us accept that mental illnesses differ. For the purpose of this posting I will assume that they can be split into two main types. Mental illnesses which induce mood swings and mental illnesses which cause delusional beliefs. I will consider the effects of both types on someone’s ability to make an autonomous decision.

First let us consider someone whose mental illness means she experiences large mood swings. Such mood swings mean that she has difficulty in making persistent decisions, making autonomous decisions. It follows she has difficulty in making competent decisions. It follows if someone’s mental illness leads to large mood swings that she shouldn’t be offered the option of voluntary euthanasia. The same conclusion cannot be so easily reached if someone’s mental illness leads to delusional beliefs. Her decisions even if they are based on these beliefs might have persistence, reflect her will and if so should be regarded as autonomous and hence competent. At this point it might be objected that it would be absurd to accept as competent any decision based on a delusional belief. In response I would point out that this occurs in medical practice now. Consider a Jehovah’s Witness who needs a blood transfusion without which she will die. She believes that if she permits the transfusion that she will not be admitted to heaven. Because of this belief she refuses the blood transfusion. Her decision would be regarded as a competent one under existing guidelines. However to most people including me such a belief is a delusional one. It seem that in practice a decision based on a delusional belief might be regarded as a competent one. Perhaps then if someone suffering from mental illness makes a persistent decision based on delusion his decision should be regarded as a competent one. Perhaps also someone whose mental illness causes delusions might be competent enough to agree to voluntary euthanasia.

It might be objected that whilst some people have long standing delusions which help define them as persons such as the Jehovah’s Witness. My objector might then point that some people suffering from mental illness might be treated for their mental illness causing them to lose their delusional beliefs. Their delusional beliefs don’t define them as persons. I accept my objectors point but might in turn point out for someone suffering from a terminal illness time is limited and a change in her delusions is unlikely. Someone with a limited expected life span who suffers from long term delusions might be partly defined as a person by her delusions. If such a person has a terminal illness she might well to able to make an autonomous, competent, decision to accept voluntary euthanasia and should be offered the option. My objector might raise another objection to the above. She might suggest that my division of mental illnesses into two main types is flawed. She might point out depression doesn’t fit easily into either type. Once again I am prepared to accept her point. If depression can be quickly cured then someone’s depression doesn’t play a part in defining her as a person. Someone suffering from short term depression might not be able to make competent decisions and should not be offered voluntary euthanasia. However some depression is deep seated and play a part in defining someone as a person. This might be especially true for someone suffering from a terminal illness with a limited expected life span. Someone suffering from a terminal illness with deep depression might well to able to make an autonomous, competent, decision to accept voluntary euthanasia and should be offered the option.

What conclusions can be drawn from the above? First that applied philosophy can be a messy business and that mental illness is a broad concept. It follows not all of those suffering from a terminal disease and mental illness should have the option of voluntary euthanasia.  However those who can make an autonomous decision should. The above highlights the difficulties legislators, such as those in Canada, face when drawing up laws covering voluntary euthanasia. Lastly the concept of autonomy employed should be a non-substantive one.

1.  Harry Frankfurt, 1988, The Importance of What We Care About, Cambridge University Press, page114.

Aspiration

 

People change over time. We become older, bigger and weaker. This posting isn’t concerned with physical changes but changes in what matters to us. We might become a professional sportsperson, a mother or even a priest. These changes often require us to adopt new values and these values help in defining the person we want to be. This posting is concerned with the way in which we acquire these new values. Agnes Callard argues that the way we change our existing values to new ones is by aspiring. In this posting I will firstly outline her idea of aspiration and will then examine an important question what motivates us to aspire.

This examination will be concerned with the choices about values which are connected to character, to the sort of person we are. Some choices are made without reflection, we simply choose the ice cream flavour we prefer. We reflect about other choices. If I want to help my grandchildren flourish I might reflect about how I might assist in this. I use reason to decide which course of action will help me achieve my aim. Now let us assume that I decide to make a major change to the way I live my life. For instance I might decide to become a vegetarian. I can do this for two reasons. I can do so because I believe it is the right thing to do or because I am attracted by the vegetarian lifestyle. If I do so for the first reason then my choice is a result of reflection based on my existing ethical values. It is possible to choose some of our values but I’m not sure that we can choose our ethical values. Let us now assume I make my choice because I’m attracted to the vegetarian lifestyle and that being a vegetarian is not something which I previously valued. In this scenario how do I make my choice? Do I simply decide as I did when choosing an ice cream?  Surely such a big decision shouldn’t be an arbitrary one? Perhaps my choice should be a reflective one based on reason. However a reflective decision is based on our values. If I decide to become a vegetarian then I am changing my values and it might be asked what values I base my decision on. It would seem that I have become dissatisfied with my old values but haven’t yet acquired new ones which could form a basis for my decision. Problems with acquiring new values have lead Agnes Callard to suggest that we acquire these values by aspiration.

What does Callard mean by aspiration? According to Callard,

“The aspirant sees that she does not have the values that she would like to have, and therefore seeks to move herself toward a better valuational condition.” (1)

The aspirant doesn’t decide on better values but tries to move himself towards these values. We usually think of someone as exercising his rational agency if he first considers his values and then decides what to do. Callard wants to reverse this order and say someone when aspiring still exercises his agency by deciding to acquire some different values and throughout the process of acquisition. I’m slightly unhappy about saying an aspirant decides to acquire new values. Aspiration is a process rather a decision perhaps it might be regarded as a smudged decision. Unfortunately there seem to be a problem with how the aspirant comes to aspire to these new values. Perhaps the aspirant glimpses these new values but if this is so what do we mean by glimpse? In the light of this difficulty I will now examine potential alternative means of acquiring new values, perhaps we might not need the idea of aspiration to explain how we acquire new values.

 

Let us accept that values are defined by what we care about. Let us further agree with Harry Frankfurt that what we care about is equivalent to what we love. Love means love in general and not just romantic love. Moreover according to Frankfurt the lover,

“is not free. On the contrary, he is in the very nature of the case captivated by his beloved and his love. The will of the lover is rigorously constrained. Love is not a matter of choice.” (2)

Let us assume that Frankfurt is correct when he asserts that the will of someone is constrained when he comes to acquiring new values. How then might he acquire these values? Perhaps he simply makes an arbitrary choice. I would be reluctant to accept this suggestion for surely acquiring new values which will form a basis for the way someone lives is different from making a choice about flavours of ice cream. It might then be suggested his choice is determined by his character which is linked to his values. This might happen in two ways. First it might be suggested the agent’s choice is determined by his existing character. However if we accept this suggestion it might be questioned whether our agent is really acquiring new values or merely maintaining his existing ones. Secondly it might be suggested that the agent glimpses some character he wants to become. Let us consider Satre’s classic example of someone choosing. He must choose between looking after an ailing mother or joining the French resistance. Did Satre really believe such a choice was completely free? If so we are back to ice cream. Perhaps Satre’s choice was really a choice about what sort of character the agent wanted to become. However the agent hadn’t become that character yet and as yet didn’t have the values of his chosen character. It appears to follow that such a person could best be described as an aspirant. 

It has been suggested above that it is impossible to choose new values based on our current ones. Perhaps our new values emerge from our current ones in some way. This might happen in two ways. Firstly if we seriously reflect on our current values and new values simply emerge. Let us return to our potential vegetarian. Among his current values is not causing unnecessary harm. However he doesn’t value not eating meat. One summer’s day he has time to reflect on his values. He considers causing harm in some detail and comes to believe eating animals harms them. He is well aware that it is unnecessary to eat meat for a healthy diet. He concludes that eating animals causes them unnecessary harm. He becomes a vegetarian and now values not eating meat. It might be suggested that a new value has emerged based on his reflection on his current values. What do we mean by emerged in this scenario? Does it mean he has chosen a new value? I would suggest it doesn’t. The agent has become aware of a value entailed by his current values and becoming aware of a value isn’t the same as choosing a new one. Secondly let us assume that our agent doesn’t reflect very much on his values but that these together with experience of life lead to the emergence of another value. This scenario is similar to the first one. The agent is becoming aware of a value rather than choosing a new one. It appears to follow that it is impossible for somebody to choose new values based on his current ones. Reflection can make us aware of values but it can’t help us choose new ones. Becoming aware of is process but it seems to a different sort of process to the one involved in aspiring. It is of course possible that it is impossible to choose any values by any means because we lack free will. In the light of the above it would seem that provided we can acquire new values and our agency plays some part in this acquisition that Callard’s ideas about aspiration might be helpful in explaining the process.

Unfortunately even if we accept the above a problem remains. Clearly desires can motivate us. According to Frankfurt the things we cares about or love also naturally motivate us. If we don’t act to further what we care about when this is possible then we don’t really care. Let us assume that when we aspire we hope to care about our new beliefs. But new beliefs we have yet to acquire can’t yet motivate. If we aspire to something what motivates us to aspire? Callard suggests that aspiration is a process and that during the course of the process we have a partial grasp of the values we are trying to acquire. Let us agree with Callard that these partially acquired values can motivate us to pursue the acquisition process further. Unfortunately the above problem can be amended. If someone aspires to new values what motivates him to initiate the aspiration process? 

Let us accept that Callard is correct when she suggests that we can’t use our existing values to acquire new values and that we do so by aspiring. However if we do so we must be able to offer an explanation of what initiates the aspiration process. I will now outline two possible explanation. First we aspire because we hope to acquire these new values. What do we mean by hope? Initially someone hoping might described as simply desiring some favoured outcome. Frankfurt points out desires don’t have to have persistence. Hoping seems to have some persistence. Perhaps then if someone hopes means he ‘cares about’ some favoured outcome and ‘caring about’ means that he takes steps to achieve this outcome. Unfortunately a problem remains. Hoping isn’t a mood with no focus. Hoping must be focussed on some specific outcome. If we use hope to explain what motivates us to acquire new values then it cannot be focussed on these new values because we haven’t yet acquired them. Perhaps the above explanation might be modified. Let us accept that one of an aspirants aims is to become a better person. If it is possible to hope to be a better person then this might help to explain what motivates aspiration. It might be objected that the aim of becoming a better person is too vague to be considered as the focus of someone’s hope. Let us now consider a second way in which we might be motivated to aspire. According to John Stuart Mill “it is better to be a human being dissatisfied than a pig satisfied.” Might our dissatisfaction cause us to aspire? Let us also accept that an aspirant is dissatisfied with his current values. It might then be argued that dissatisfaction with his old values rather than these values themselves motivates him to seek new ones. His dissatisfaction motivates him to try and acquire new values. His focus is broad but some of his attempts might allow him glimpse new values which motivates him to aspire further. Aspiration is a process and sometimes as he comes to see these values more clearly he will continue with the process whilst in other cases he might end it.

As we age it seems that we become less concerned with becoming better persons and aspiring and this offers some evidence to support the two explanations offered above. We become more content with our existing values and seek to maintain them rather than acquiring new ones. However many will be unconvinced that the desire to be a better person could initiate the aspiring process. Indeed I am not totally convinced myself. Perhaps then we should reconsider whether it is possible to acquire new values from our existing ones. Perhaps sometimes new experience in conjunction with our existing values might allow us to glimpse new values. Glimpsing these new values doesn’t mean that they are strictly entailed by our existing ones. For instance we might glimpse these new values by the use of analogy. Analogies are never perfect so new values might be suggested by our old values rather than strictly entailed by them. Moreover once we accept these suggested new values and reflect further on them then we might have to change or modify our previous existing values. In in science we are used to the idea of a paradigm shift. Newton’s laws allowed Einstein to develop relativity but once relativity became accepted Newton’s laws had to be modified slightly. Is a paradigm shift in values possible? If so it might be possible to acquire new values which are suggested by our old ones.

What conclusions can be drawn from the above discussion?  Firstly it is at least conceivable that our old values might suggest new ones by analogy and that if we acquire these new values we will be required to amend our old ones.  Secondly we can acquire new values by aspiring. It seems possible that the acquisition process is initiated by a desire to be a better person.

1. Callard, Agnes. Aspiration. Oxford University Press. Kindle Edition, Location 192.
2. Harry Frankfurt, 1999 Necessity, Volition, and Love. Cambridge University Press. Page 135.