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Health Insurance

by James M. Humber and Robert F. Almeder, (editors)
Humana Press, 2000
Review by Howard B. Radest, Ph.D. on Oct 16th 2001

Is There a Duty to Die?While relevant to the general discussion of death and dying, a "duty to die" raises different questions from those posed by physician-assisted suicide, terminal sedation, refusal or withdrawal of treatment, etc. These matters focus on personal choice and a "right to die." Their underlying value is autonomy. Duty, on the other hand, is communally rooted (duty to another) and legally or morally coercive: i.e. a duty is not optional; failure to do one's duty calls for moral sanction or legal punishment or both.

The question of "duty to die" is already in play in today's biomedical world and will surely be with us more urgently tomorrow. Access to health care -- and not just in the U.S.-- is a dilemma in all industrialized nations. Access is a crisis in the third-world which the AIDS epidemic only highlights. And from the looks of things, no solutions are readily available. Socialist and social insurance schemes (Canada, Great Britain, Europe) meet many of the same difficulties as our confused and ineffective market-based efforts. Everywhere, population growth, increasing numbers of the aging, technological innovation, competition for limited funds and resources, the changing nature of professionalism, the indefinitely expanding social expectations here and evolving social expectations elsewhere join to create a biomedical crisis. Perhaps, the most dramatic way of putting this is to recognize that we, in this country, already have a "trillion-dollar problem" (what we actually spend from all sources on health care). Within the decade this will grow into a "two-trillion-dollar" problem with no end in sight. In a sense, we could afford to meet the cost as we demonstrate when forced to go to war. But, other legitimate social needs -- education, defense, housing, infrastructure, etc. -- would obviously have to be neglected.

Prophetically, in 1987, Margaret P. Battin (philosophy, University of Utah), raised the question of a duty to die in an essay, " Age Distribution and the Just Distribution of Health Care: Is There a Duty to Die?" [Ethics, 97(2):317-340]. Similarly, former Governor Lamm of Colorado spoke to the issue of "rationing," a word which neither politicians nor practitioners dare to utter. More recently, John Hardwig wrote, "Is There A Duty To Die" (1997, Hastings Center Report, 27{2}: 34-42) The present volume is an analysis of and response to Hardwig (and by implication, the others), from 12 philosophers. Naturally, the book ranges in method from technical analysis (the meaning of duty, comes in for careful scrutiny) to characterizing relationships (to whom is the duty owed -- family, community, society, even international community) and why might this be so. While Hardwig's essay focused the issue on the intimacies of a mother-daughter relationship, the authors in this collection demonstrate, convincingly in most cases, that duty, if such there be, cannot be encapsulated within family or nation. At the same time, they expose the moral and policy difficulties, practical and theoretical, raised by taking a "duty to die" seriously. Who enforces it; how will the duty be communicated within a family whose members care for each other, what criteria will justify invoking the duty, why focus only on age and terminal illness. Are not handicaps, deadly birth defects, incurable chronic illnesses, or psychological depression candidates for invoking such a duty? In other words, as the pressures of finitude increase around us, must the "duty to die" become a generalized moral commandment and ultimately a social policy?

Absent from the book, fortunately, is moralistic and religious preachment. To be sure, the essays lack a sense of humor. I would wish for a modern Jonathan Swift whose "A Modest Proposal" you will recall advised solving the Irish famine by means of cannibalism. So, one can fault the text for a certain ponderousness. Moreover, it would have helped if the essayists had acknowledged the metaphoric and not the just literal intent that, I think, moved Hardwig. In common -- whatever their differences -- they take Hardwig's question at face value without recognizing the utility of stirring conscience and consciousness with a rhetorical device like a "duty to die." About half of the essays essentially deny Hardwig's "duty" and the other half, even while accepting it, do so with reservations. Unfortunately -- and a significant weakness of the text -- Hardwig's own voice is absent. The book would have benefited from his response.

I was grateful for the "abstracts" which preceded each chapter. In a tightly written text (essays were apparently limited to about 12 pages each), they provided a map and a mnemonic tool for keeping track of what could have been -- in some cases -- tough going. The book is part of a continuing series, Biomedical Ethics Reviews, which enables relatively speedy responses to the issues and problems that appear almost daily it seems in a rapidly developing field of inquiry and practice. Given the limitations which such a project imposes -- in particular the need to move very quickly -- we should be grateful for the series and for this text. But, given the complexity of the issue of death and dying in a world of limits, it is only an introduction to the hard work ahead of us.

HOWARD B. RADEST, PHD, is Adjunct Professor of Philosophy at The University of South Carolina-Beaufort. He is Ethics Consultant to Hilton Head Hospital and Chair of its Biomedical Ethics Committee. He is the Dean Emeritus of The Humanist Institute, a member of the Council of Ethical Culture Leaders and of the Highlands Institute for American Religious and Philosophic Thought. Dr. Radest was the founder and chairman (1983-1991) of the University Seminar On Moral Education, Columbia University. He is a member of the Board of the North American Committee for Humanism. From 1978-88 he was Co-Chair of The International Humanist and Ethical Union. He is on the editorial boards of The Humanist, Religious Humanism, and Free Inquiry. His books include Toward Common Ground (Ungar, 1968), Can We Teach Ethics? (Praeger. 1989), The Devil and Secular Humanism (Praeger, 1990), Community Service: Encounter With Strangers (Praeger, 1993), Humanism With A Human Face (Praeger, 1996), Felix Adler: An Ethical Culture, (Peter Lang, Publishers, 1998) and From Clinic to Classroom (Praeger, 2000}.

Dr. Radest received his B.A. at Columbia College, his M.A. in Philosophy and Psychology at The New School For Social Research and his Ph.D. in Philosophy at Columbia University. He is listed in Who's Who.

This review first appeared online Oct 1, 2001