Correspondence
CORRESPONDENCE Killing or allowing to die? AN EXCHANGE OF VIEWS Cost-benefit decisions New Orleans, La. To the Editors: I take it to be the main point of Daniel Callahan's essay ("Vital...
...Doyle seems to think blame and responsibility mean the same thing...
...What Callahan warns us about does not seem to be a matter of general concern, much less political agitation...
...Let us examine the Oregon case...
...To the Editors: Dennis M. Doyle has seriously misrepresented my views in his article on "The Meaning of AIDS" [June 3...
...Mill New York, N.Y...
...LORETTA M. KOPELMAN Chair, Department of Medical Humanities School of Medicine East Carolina University The author replies: After a close rereading of Professor Kopelman's article, I stand by the brief remarks that I made...
...Callahan is persuaded that the American public is as committed to preserving life as it is to refraining from taking it, because it cannot quite manage, morally speaking, to grasp the difference...
...So would all sorts of measures to avert deaths caused by exposure, malnutrition, toxification of the environment, felonies, and fires...
...There are many other legitimate and urgent demands upon them...
...If, as an alternative, we decide to exclude from entitlement programs some therapies that the rich can buy, we set up a two-tier system...
...He proposes in its place John Stuart Mill's proscription against a person's abdication of liberty...
...We do not yet have that kind of power...
...In the context of a voter-established limit, I think it was reasonable to spend the money on prenatal care...
...This should not be confused with the question of active euthanasia, which Mr...
...I say in my article that educational programs on AIDS and other illness are important and that people should take responsibility for their behavior...
...But my main point was to distinguish between causality and culpability...
...Rather than continuing to contribute to the conflation that he deplores, I hope that in his future work Mr...
...What I am suggesting is that in her trenchant analysis of the contradictions inherent in the punishment concept of disease, she performs an overkill that becomes insensitive to the legitimate concerns of those with whom she disagrees...
...As Dr...
...The issue of allocation, especially of very expensive and efficacious medical procedures, is a real problem and will almost certainly become more urgent...
...One may be responsible even when one is not at fault (as parents are for children and as supervisors or editors may be for their agents' handiwork...
...He will perhaps forgive me if I suggest that he is in part responsible for that confusing conflation...
...DENNIS M. DOYLE...
...During the year that state officials were denying a life-saving bone-marrow transplant to a young boy, they were also refunding a multi-million dollar surplus in the state's treasury to taxpayers...
...There is a difference between moral and medical judgment...
...Permit me to suggest that a "vital distinction" is missing here...
...They do not...
...Pragmatically, the appeal to Mill's dubious theory is likely to be less politically effective in our society than an acknowledgment of transcendent authority and communal responsibility...
...He is undoubtedly right in believing that the discussion in which he is engaged has intensified and will become even more painfully intense in the years ahead...
...There was no implication in that statement that this "is a particularly ugly way to terminate life" or that the doctor who made such a decision would be deliberately killing such a patient rather than (as I would judge the matter) allowing the patient to die from the underlying disease that created the inability to eat...
...Whose life is worth living," he says, is a moral judgment, whereas what constitutes "meaningful personal life" is in the category of the medical...
...Given the monopoly of medicine in our economy it will, I think, be difficult to persuade the public that funding restrictions of the kind Callahan recommends represents a step that ought to be taken before the taking of other, more fundamental steps towards a just distribution of medical resources...
...Such a mentality would have no more reason to manifest itself in providing life-sustaining technology to patients in hospitals than in being equally lavish with other ordinary means of keeping people alive...
...For example, Mrs...
...RICHARD JOHN NEUHAUS The Center on Religion & Society Politics of transplants Emeryville, Calif...
...I do not at all intend to suggest that Kopelman self-consciously holds the absurd position that people should not take responsibility for their behavior or that the morality of AIDS-transmitting behaviors should not be discussed...
...There are plenty of exceptions to this generalization but, in the case for instance of organ transplants, it was originally the affluent who got them...
...I strongly emphasized that some such decisions could be wrong and thus morally culpable...
...His rationale is that society cannot be held hostage to medical advances, and that other claims on the treasury may have precedence...
...And given current sensitivities to the widening gap between rich and poor, such are likely to be angry reflections...
...First, nowhere in her article does she directly say that people should take responsibility for their behavior...
...Higgins and Mr...
...JAMES GAFFNEY Religion vs...
...I also have no doubt that his voice will continue to be important in that discussion...
...Otherwise, we fall into the trap I mentioned, that of thinking we are such powerful creatures that our omissions become physical causes...
...Public and legislative outrage at that situation, however, eventually led many states to require their availability to all...
...My point, however, is that we ought not to blame people for their illnesses, but take care of them in a compassionate and sympathetic way as best we can to the limit of our abilities and resources...
...As one who has been critical of that book, I welcome Mr...
...I am not persuaded that it makes any sense to call the termination of artificially provided nutrition and hydration causes of death, however much it might be true that to do so would be morally culpable...
...The point is a morally valid and socially important one...
...It points the way to a time when being kept alive by American medicine will constitute one more of the privileges of the wealthy...
...Callahan, hunger and thirst are not the "underlying disease that brings that life to an end...
...I argued that it is dangerous to do so because we do not know well enough who is to blame for their illness, and because it would endanger promoting empathy from doctors and nurses to patients...
...Neither is an attractive choice, but I suspect the latter would make more sense than the former...
...But look almost anywhere in our society, except where Callahan is looking, and letting people die on the basis of cost-benefit analysis in public spending is practically habitual...
...the proposal met with overwhelming opposition not only in the Legislature, but also from the public...
...The larger question seems to me two-fold: should voters establish hard-and-fast expenditure limits, and could it be reasonable, under some circumstances, to deny "life-saving medical care...
...Gaffney seem to imply) everyone should receive whatever lifesaving care the rich can get, then we will, of course, set the general level of care at an extraordinarily high level, one that will become increasingly insupportable...
...Second, in her article she discusses AIDS-education as a dimension of social health policy, not as an entirely separate category...
...He was the signer of a prominent 1987 statement ("Feeding and Hydrat-ing the Permanently Unconscious and Other Vulnerable Persons") which stated that" if it is really useless or excessively burdensome to provide someone with nutrition and hydration, then these means may rightly be withheld or withdrawn...
...He undermines that purpose by defining artificial feeding and hydration as "medical treatment'' which can be withdrawn in order to "let the patient die...
...If the decision to terminate is admissible, neater and quicker means will be employed...
...If we do not admit (at least in principle) that this is possible, we will be held hostage to medical progress, which will find more and more expensive ways to keep us alive...
...DANIEL CALLAHAN AIDS & social policy Greenville, N.C...
...What is likely to have hindered its reception by our society...
...A vital distinction between the two issues should be made as sharply as possible, while acknowledg-(Continued on page 541) CORRESPONDENCE (Continued from page 514) ing that some of the same questions are engaged by each...
...Accordingly, it was decided to allocate funds to additional prenatal care rather than organ transplants...
...Preventive medicine would have at least as strong a claim...
...Higgins notes, that Oregon refused to pay for organ transplants in the face of a budget surplus (of $200 million...
...The logical outcome of such thinking would be public policies as earnest and energetic about preventing death as about avoiding homicide...
...However, the denial of life-saving medical care by any state in this affluent America is invidious discrimination on the basis of wealth...
...As I understand the matter, however, that money could not be spent on transplants (or any other purpose) because of a voter-imposed expenditure limit...
...To the Editors: Although Dan Callahan's article ["Vital Distinctions, Mortal Questions," July 15] is a valuable and lucid piece, I disagree with him in one important respect...
...Contra Mr...
...John Kitzhaber, a physician and president of the Oregon Senate noted (in the Oregonian, Nov...
...Thus is the invitation offered to the active euthanasia that Mr...
...To the Editors: I take it to be the main point of Daniel Callahan's essay ("Vital Distinctions, Moral Questions," July 15) that our society should not unreservedly commit its public resources to providing medical patients with everything technology has and will have to offer as effective means for preserving life...
...It cannot be morally supported, and it is not good public policy...
...Even in an affluent country, to allow claims to life-saving care to take precedence over other legitimate social needs would not always be justifiable...
...Callahan is taking his argument to an illogical extreme...
...What Kopelman claims in her letter differs from her article on at least three points...
...Callahan's probings toward greater clarity...
...Thus, I reject Doyle's interpretation of my view...
...Callahan wants to oppose...
...I have no quarrel with Callahan's argument that individuals in a permanent vegetative state should not necessarily have their medical care paid by the state...
...Leary was responsible, but not to blame, for the fire that burned down Chicago when her cow kicked over a lantern...
...I am a bit baffled by Pastor Neuhaus's letter...
...In his discussion of the allocation debate, he writes approvingly of state decisions, such as the Oregon case, which deny organ transplants to Medicaid recipients, even when they are life-saving...
...Kopel-man's otherwise excellent article illustrates well my point that people in various parts of the spectrum need to be more aware of how their arguments might sound to those who do not share their presuppositions...
...The question I was addressing in my article, "The Punishment Concept of Disease," was whether social policy should take blame into consideration in the allocation of health care...
...Callahan wants to oppose...
...Gaffney's position, my impression from the historical record of American health care is that what is initially available for the rich eventually comes to be given to the poor as well...
...Yet Callahan's proposal will, I imagine, encounter resistance and suspicion...
...In question here is not whether Kopelman formally holds the position that the morality of AIDS-transmitting behaviors should not be discussed, but whether the overall thrust of her article devalues any such consideration...
...I believe the answer to the first part is no, and to the second yes...
...I find this explanation implausible...
...THOMAS HIGGINS Editor, Healthweek The author replies: It is true, as Mr...
...Callahan correctly notes that the idea of state funding of every medical possibility is a formula for disaster...
...That kind of pattern leaves us with a terrible problem: if (as both Mr...
...Callahan will make a "vital distinction" between the legitimate issue of allocation and the debate over euthanasia...
...Was this a justifiable decision...
...I do think we should discuss morality of behaviors and discuss the meaning of AIDS...
...I do thank him, however, for saying that I have pointed out the contradictions of the religious and secular versions of the punishment concept of disease...
...29, 1987), "While some legislators . . . advocated the repeal of this limit...
...Did this refund, much of it to corporations and wealthy individuals, have a superior moral claim over a life-saving medical procedure, albeit an expensive one...
...Not, I think, what Callahan supposes...
...Public resources are limited...
...Third, throughout her article she consistently, and without qualification, warns against the dangers of insinuating either responsibility or blame in the transmission of the disease, including in educational and preventive health contexts...
...even if she did, however, such would hardly constitute an explicit discussion of the morality of behaviors such as drug abuse or casual sex...
...It is a particularly ugly way to terminate a life...
...Increasingly, the average American's habitual attitude towards the medical profession is one of moral indignation, and that is an unpropitious mood for hearing recommendations of what sounds like self-denial, even when they are as sensible and potentially beneficial to society as I believe Callahan's to be...
...My article was saying no more than this: a justifiable decision to cease nutrition and hydration should not be classified as direct killing, but as allowing to die...
...There are several concerns that I believe he and his readers might well ponder...
...More persuasive is an ethic of communal responsibility, which significantly recasts the entire discussion of, for example, patients' "rights...
...To the Editors: In "Vital Distinctions, Mortal Questions" [July 15], Daniel Callahan continues to feel and think his way through the questions that prompted his recent and controversial book, Setting Limits...
...Callahan writes of a "conflation of the allocation and euthanasia issues...
...But surely the decision is to terminate a life by letting the patient die of hunger and thirst...
...In arguing against euthanasia, he says the "religious" argument that life belongs to God is not publicly persuasive...
...Contrary to Mr...
Vol. 115 • October 1988 • No. 17
