In both these philosophical approaches, the self is a psychological ego, occupying an inner space in which the essential “I “exists as separate from the external world of others.244 The features of this psychological self245 are
strongly individualistic, with an emphasis on the independence and uniqueness of each identity.246 Personal existence becomes a project, to map
and occupy an interior space in which the person can exist, by functioning psychically and rationally. Thus, the ontological criterion (philosophically or theologically considered) of personal being becomes increasingly replaced by the criteria of function.
243 Paola Cavalieri and Peter Singer, "The Great Ape Project," in Unsanctifying Human Life, ed. Helga Kuhse, (Oxford: Blackwell Publishers, 2002), 136
244 Graham Ward, Theology and Contemporary Critical Theory , ed. David Jasper, 2nd ed., Studies in Literature and Religion (Basingstoke, Hampshire: MacMillan Press, 2000).
245 Steven Collins, "Categories, Concepts or Predicaments? Remarks on Mauss's Use of Philosophical Terminology," in The Category of the Person: Anthropology, Philosophy, History , ed. Michael Carrithers, Steven Collins, and Steven Lukes, (Cambridge: Cambridge University Press, 1985), 66
246 J. S. La Fontaine, "Person and Individual: Some Anthropological Reflections," in The
Category of Person: Anthropology, Philosophy and History , ed. Michael Carrithers, Steven Collins, and Steven Lukes, (Cambridge: Cambridge University Press, 1985), 124
From this point of view, consider Nancy Crick, an autonomous, rational person, who sought to end her life and to involve others in her decision. Her independent choice, not the basis of her choice, was taken to be the determining factor. It is irrelevant to this way of thinking that Nancy Crick was not terminally ill, nor that she was ignoring sound medical advice. We might justifiably presume that neither Kant nor Descartes would have held that Crick was acting rationally. Nonetheless, the way that “reason” might be currently interpreted from a perspective of Cartesian or Kantian individualism would suggest that she was not acting irrationally: the patient in this case had made an “autonomous decision”. When the focus is on the rational, autonomous person in the Cartesian or Kantian tradition, the autonomy of rational persons can be so exalted that any request they make must be acted on, as is argued in positions favouring voluntary euthanasia and assisted suicide. However, matters are never so straight forward. On the one hand, a person expressing a desire for self-harm would usually be considered to be exhibiting signs of mental instability or incapacity. On the other hand, if one claims that life is intolerable due to a real or perceived health condition, then this is automatically assumed to be a rational choice. In the former instance, the choice would be considered unreasonable, and it may even be deemed appropriate to restrain the person from acting on their choice/request. In the latter instance, the current pro-euthanasia position argues that the choice should always be acted on. The Crick case has sharply
divided the community on the issue of “the right to die”. According to pollsters, a majority of the community supports voluntary euthanasia.247
However, the reaction to the Crick case suggests that proof of the illness being terminal is required.248
The case of Nancy Cruzan is also instructive in this regard. Cruzan was a young woman in a persistent vegetative state for eight years following a car accident. She was unable to respond or even to swallow, but did not require ongoing mechanical respiration. As a result she was provided with nutrition and hydration via a nasal-gastric tube. Cruzan’s parents had attempted to have their daughter’s feeding tube removed. The State of Missouri took the view that in the absence of evidence of what the patient would have wanted, the state has an obligation to preserve her life. The “proxy consent” of parents on behalf of children was deemed not to apply in this case, despite the general presumption that parents have the best interests of their children at heart. If Cruzan was genuinely alive, then any act which would result in her death could not be in her interest; if she were not alive, then she had no interest to defend.249 It was determined by the U. S. Supreme Court that
feeding and hydration could only be ceased if there were “clear and
247 Ian Ireland, Choice, Quality of Life and Self-Control: Summary Arguments in Support of
Euthanasia (Canberra: Parliamentary Library, 1996-1997), 10, Research Note 12
248 M. Otlowski, "Discussion: The Nancy Crick Case," Monash Bioethics Review 21, no. 3 (2002). 249 John Robertson, "Cruzan: No Rights Violated," Hastings Center Report 20, no. 5 (1992).
convincing evidence” that this is what the patient would have wanted.250
Following the Supreme Court judgement, several members of Cruzan’s family and some of her friends recalled her comments suggesting that she would not want to be kept alive in such a situation. Singer, commenting on this case, argues that the choice of Cruzan’s parents should have been sufficient to cease feeding her.251 While not supporting this line of argument,
the case does reinforce the Kantian position on rational autonomy, but limits it to the actual person concerned and does not extend it to proxy consent.
All of the above serves to indicate that philosophy has practical consequences; and in this case, the narrowness of its conceptions of personal existence is not the resource needed in moral dilemmas that have arisen. Similarly, while neither philosophical tradition advocates abortion,252 their respective
emphasis on autonomous rationality, irrespective of a larger social setting, can be used to justify terminations based on a the right of the mother to choose the fate of what is regarded as her personal property or, at least, as her exclusive sphere of responsibility. Clearly, radical philosophical and existential options are involved. The confused philosophical inheritance that implicitly or explicitly affects health care and its morality is in need of further critique and clarification.
250 Gregory E. Pence, Classic Cases in Medical Ethics (New York: McGraw-Hill, Inc., 1995). 251 Singer, Rethinking Life & Death: The Collapse of Our Traditional Ethics.
6. Conclusion
Moral decisions rely on assumptions concerning ways of reasoning applicable to any case in question. More fundamentally, the nature of the human person becomes an urgent question. Anthropological assumptions determine decisions and outcomes. If it is assumed that patients are persons definable as rational agents, then it must be allowed that they are capable of understanding the information given,253 that they are free to give consent to
any procedure which they believe to be in their best interests, and that the decision is theirs alone. But on this presumption, a consideration of the relational aspect of the person concerned is not apparent. Indeed, in Australia, the National Health and Medical Research Council policy states that family members should not be used as interpreters.254 While this is no
doubt aimed at precluding the possibility of wrong information being given and conflicts of interest arising, the implication is that the personal relationships of patients have no direct bearing on the decisions made. I have already cited Carl Elliot’s reflections on the damage this assumption can cause, when he cites the case of his grandfather, dying separated from those
253 National Health and Medical Research Council Health Care Committee, Guidelines for
Medical Practitioners on Providing Information to Patients (Canberra: National Health and Medical Research Council, 1993)
254 Health Care Committee, Guidelines for Medical Practitioners on Providing Information to
he cared about and who cared for him.255 The situation of the conjoined twins,
Rosie and Gracie, is similar. Little consideration was shown by the medical professionals involved of the relational implications of their choices. While some of the judges in the case alluded to the complex relationships involved, these were ultimately discounted.256 A very individual and rationalistic view
of the human person was presumed. If, however, greater attention is paid to more relational types of philosophy, while calling on explicitly theological positions, it is possible to enrich the theory and practice of health care with a new vision as to what constitutes a human person, which, in turn, will enrich the context in which moral decisions are made. The next chapter lays the foundation for the task of developing a relational theology of personhood by exploring the contributions of John Macmurray, Emmanuel Levinas and Alistair McFadyen. These thinkers provide the more relational philosophies which inform this practical theology of health care.
255 Elliott, A Philosophical Disease.
256 "In Re a (Children)," in Ward, LJ. Brooke, LJ. Walker, LJ. (Supreme Court of Judicature Court of Appeal (Civil Division) on Appeal from Family Division, 2000)
CHAPTER FOUR: PERSON AS RELATIONAL SUBJECT:
PHILOSOPHICAL AND THEOLOGICAL BASES
In this chapter, I elaborate the relational character of the human person as integral to the vision and values of health care. I proceed then to consider what must certainly be of paradigmatic significance for any health care system, the relational reality of the persons involved, either as agents or patients within it. To this end, I have selected three thinkers who have notably contributed to a more relational understanding of the human person. In so doing, this thesis is an exercise in practical theology as it presents and applies aspects of philosophical and theological theory to the concrete circumstance of health care. The philosophic emphasis follows a well- established tradition in Catholic theology. For example, von Balthasar, who devotes two of the seven volumes of The Glory of the Lord257 to metaphysics,
explains,
For although theology thinks and develops on the basis of its own presuppositions, it makes use of the human-philosophical forms of consideration and results of investigation at every step on this path… The entire fullness—the gold, frankincense, and myrrh of human thought–is not too much to be presented to the Word of God which has become nature.258
257 H. U. von Balthasar, The Glory of the Lord: A Theological Aesthetics, ed. J. and Riches Fessio sj, J., trans. various translators, 7 volumes vols. (San Francisco: Ignatius Press, 1982 - 1991). 258 H. U. von Balthasar, "On the Tasks of Catholic Philosophy in Our Time," Communio 20 (1993).
Indeed, he concludes the fifth volume of his great work with a chapter, “The Christian Contribution to Metaphysics,” in which he argues that the Christian is called to be the guardian of metaphysics, responsible for the development of a comprehensive and contemporary metaphysics for our time.259 That is
evidently an ambitious undertaking, but in this present instance, my aim is more modest: in the context of health care, to elaborate and apply the meaning of personhood in its fullest relational expression.
After an introductory remark on the all-pervasive relational character of reality, I will present the relational understanding of the human person as it is elaborated in the writings of John Macmurray, Emmanuel Levinas and Alistair McFadyen in turn. In the next chapter I present an explicitly theological grounding of this approach, and then proceed to the practical implications of such philosophical and theological positions for the cases already mentioned, and a number of others as well. Hence, the chapter will be presented under the following five headings: