Lydia at Right Reason makes a number of startling claims...
(1) A person's past wishes are [always?] outweighed by their present ones. "If a person does agree [to refusal of medical treatment including feeding tubes] but later cries, 'Water!' that wish should be answered with water, not with morphine."
(2) The present wish need not be "a fully coherent thought about 'wanting to stop dying'... Even if the person is simply feeling--rather like an animal under similar circumstances--an inarticulate and overwhelming desire for water, should not that count as a relevant stand-in for the person's 'wanting water'?"
(3) "a person in great pain will want the pain to stop... Therefore, giving pain medication under these circumstances has as one of its effects that it prevents a patient who has previously agreed to death by dehydration from changing his mind and wishing for food and water."
Working backwards... #3 is a simply atrocious argument. It effectively says that, by failing to make a desired event or process unpleasant, we thereby "prevent" the person from changing their mind and disliking said event/process. This is so patently ridiculous that I'm not sure how to respond. I think I will simply lift my jaw from the ground and move on.
#2 is a serious threat to personal autonomy. By ignoring the structure of our desires, it fetishizes the satisfaction of urges over the genuine preferences of the agent. According to #2, we should take along a keg of beer to an Alcoholics Anonymous meeting, since apparently an "inarticulate and overwhelming desire" for alcohol should indicate that this is what they really want - never mind their higher-order preferences!
Besides, an animal craving for water may not be so much an intrinsic desire for the object of water itself, as a desire that the pain of dehydration go away. In any case, desire frustrations can be avoided by either fulfilling the desire, or else getting rid of it entirely. Which is better will be determined by the person's higher-order preferences. Do I want to feel thirst and have it satisfied, or would I rather have the pain medication and thus avoid the cravings altogether? Well, I'm happy drinking, but the patients we're talking about here have expressed their preference for the latter. We should respect that preference. The fact that a patient is in pain (and wants it to stop) in no way implies that they want to live. Lydia seems to have missed this obvious point.
#1 is the really interesting issue for me. So let's forget about the earlier problems, and assume that a patient has genuinely changed their mind (or what's left of it) and wants to live a life that they had previously judged "not worth living".
There are cases where past desires become irrelevant once superceded, e.g. a child's desire to be a fireman. But other times they seem more important. Take the case of a devout atheist who strongly wishes for (almost) his entire life that no priest be present at his deathbed -- and impresses upon you that you ought to ignore any later request he may make to the contrary. But, lying on his deathbed, he has a moment of weakness, and asks you to send for a priest. Would doing so make his life go best? I think in such a case his past desire, being a 'global preference' that is central to the integrity of his life, takes precedence. The same seems true of the person with a strong and informed desire to forgo artificial life support and "die with dignity" rather than rot away in a hospital bed for the rest of their life.
But this one, at least, is not clear cut. Someone may have a genuine change of heart. If they actually change their global preferences, so that they now consider the hospitalized life to be well worth living, then it would be a grevious wrong to go ahead and kill them. That would be murder. But if their new desire is merely due to a temporary bout of 'weakness of the will', or a lower-order urge of the sort discussed in #2, then it seems more plausible to take their earlier choice as the authentic expression of the agent's preference. (How to tell the difference between these two cases is an extremely important practical question, of course -- but I'm much more interested in theory.)
Here's the central question, as I see it: Given a conflict between past and present desires, what determines which ought to take precedence? My tentative answer is appeal to the structure of one's desire-set, and in particular one's global desires. But I'd love to hear some alternative suggestions (or elaborations of the present one).
Update: Don't miss the excellent discussion in the comments below.
Friday, April 22, 2005
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My view is that a person's surroundings influences their values and new surroundings and conditions will then in turn ifluence new values but if a person's older values are thrown out the door by a sudden set of news ones due to a sudden change of influences then I believe the older set of values and decisions take priority.
ReplyDeleteRichard, I found this claim of yours jarring: "If they actually change their global preferences, so that they now consider the hospitalized life to be well worth living, then it would be a grevious wrong to go ahead and kill them. That would be murder."
ReplyDeleteMurder is a serious charge, and not one that you want to toss out against someone who is trying to figure out the wishes of a chronically ill person who has considered ending it all. I presume that you wanted your concession to be something less aggressive, like "That would be homicide."
On to the substance. I agree with your responses to #3 & #2. On the subject of past vs. present desires, I think that past desires are irrelevant. Only the present matters. However, what matters in the present is not just the one isolated wish, but the totality of the person's psychology. A person's past desires could be a good cue to this totality, so our knowledge of a person's past is useful when we try to figure out what to make of their cry for water. I think that this is roughly the same thing that you're saying with your appeal to the structure of their desire set and your consideration of whether there is a genuine change of heart.
There are other indirect ways in which past desires are relevant. We want to create a society in which people believe that their desires about the end of their life will be respected so that they can have as much peace of mind as possible when considering their future. Particularly if the patient is already pretty far gone, acting in accordance with their past desires rather than their present desires may be a better way of promoting this sort of society. People may find it easier to follow this recommendation, though, if they think of it as acting out of respect for the person that this used to be, rather than in order to benefit society.
Blar, thanks for the interesting comment.
ReplyDeleteRegarding the "murder" accusation, I should clarify the sort of case I had in mind. I was thinking of a person who still had full command of their mental faculties, and could still communicate reasonably well, but simply happened to be severely physically injured (such that they could not live without life support, say).
If a such a person lucidly expressed their carefully considered desire to go on living, and someone went ahead and killed them anyway (based on their earlier wishes), then yes, I think that would be wrongful homicide -- murder.
Your other comments do sound plausible to me, and resonate nicely with my appeal to 'structure', as you noticed. But I do have some concerns about disregarding past desires entirely.
a) What are you to do when the person's mind has degraded to the point where they no longer have any structurally 'higher' concerns -- would you just grant their base desires, no matter their earlier preferences?
b) It would make all our desires about the future irrelevant to our well-being. But this seems wrong, especially if one cannot provide a principled reason to exclude such desires from consideration. After all, desire theorists believe that we are still affected when the fulfilment or frustration of our desires occurs behind our backs. Why is distance in time any more significant than distance in space?
c) It leaves no room for posthumous harm. But events after our deaths can (retroactively) influence whether we succeeded in our goals, and thus how well our lives went. See my comments over at Universal Acid.
But this is certainly a controversial issue. In the old discussion at PEA Soup, the consensus seemed to be against past desires. On the other hand, I have Derek Parfit on my side, so perhaps that balances things out ;)
Richard, I agree that disregarding past desires can cause some problems, but I think some of your specific concerns can be answered by those who hold a view like Blar's.
ReplyDeleteFor instance, you say that to disregard past desires "would make all our desires about the future irrelevant to our well-being." I don't think this is completely right. Suppose that right now I desire that in the year 2015 I will climb a mountain. Blar can say that my PRESENT well-being is increased if it is the case that, 10 years from from now, I will climb a mountain. But now suppose that it is 2015. I've changed my mind; I no longer have any desire to climb a mountain. Blar's commitment is just to say that my NOW-present well-being is not increased if I climb the mountain.
A few other observations:
1. I think it is likely that whether a person is "autonomous" is determined solely by the "totality" the person's "present psychology," as Blar puts it. In other words: I'd argue that autonomy is an attribute which attaches to a person solely in virtue of states of affairs which obtain at the present moment.
2. However, I think it is likely that there is some value in satisfying past desires. Suppose that, 10 years ago, I wanted to climb a mountain, but I no longer have that desire. I will probably choose not to climb the mountain. Still, I think I will have to admit that it would be _a good thing_ if my present self and my 10-years-prior self could somehow both get what they want. The thing is that, when there's a conflict between my old desires and my new ones, I choose the new ones; but that's just because satisfying the new ones brings about _more_ value, not because satisfying the old ones wouldn't have any value at all.
3. What I think this means is that (for instance) when we satisfy posthumous desires, we should not do so because, by doing so, we respect the dead person's autonomy. There's no autonomy, because autonomy is a function of a person's present psychology, and there's no present person there at all. Instead, I think we should satisfy posthumous desires simply because satisfying past desires is a good thing; there's something nice about a past self getting what he wants.
Richard, I think that I just have more internalist intuitions than you with regard to b) and c). Maybe I'm just crudely hedonistic. It seems like your original account also leans in this direction, though. Are you giving past desires a role consistent with your b) and c) when you let a genuine change of heart override all previous desires?
ReplyDeleteFor a), when all that's left of a person's desires are a few basic urges and the person's experience is severely limited, that is when the person's desires become less important and interpersonal issues, like the role of end-of-life care in society and the family's need to come to terms with the situation, take on a relatively greater weight.
David, what you describe in your 2nd paragraph sounds more like my view than Blar's. I agree that fulfilling a past desire doesn't bestow any present benefits upon one. Rather, the benefit is retroactive: it makes one's past self better-off.
ReplyDeleteRegarding your point #3, why not say that we are respecting the past person's autonomy? Isn't that at least part of the reason why we carry out someone's "last will and testament" -- because we recognise that they have a right to decide what is done with their property after they die? (That's not to deny that there are also pragmatic reasons to support the practice.)
Blar asks: "Are you giving past desires a role consistent with your b) and c) when you let a genuine change of heart override all previous desires?"
Admittedly, I think that very few past desires remain relevant once superceded. (I don't really think David is benefitted by climbing the mountain, for example.) But I think this can be explained by appeal to structurally 'higher' desires. Most desires about the future are what Parfit would call "conditional" on their own persistence. That is, we only want the desire to be fulfilled if we still hold the desire at the time of its fulfilment.
To demonstrate: I ask David, "Suppose I were to tell you that in 2015 you wouldn't want to climb the mountain. Do you now, in 2005, still prefer that your future self go ahead and climb the mountain anyway?"
I think most people in that sort of situation would answer "no", at least for most of their normal desires. This shows that forcing oneself to (unwillingly) fulfill past "desires" often doesn't really satisfy one's past preferences anyway!
The exceptions are cases where the past self would want the desire to be fulfilled even against their future self's wishes. Here I think of the dying atheist, or the brain-damaged euthanasia advocate.
But what about if the euthanasiac has a "genuine change of heart"? Well, ask their earlier self: "Suppose you found yourself bed-ridden for life, yet realised that you still considered that life well worth living. Would you still want us to kill you?"
Surely the answer for most people would be "no". But let's imagine (for sake of argument) that some stubborn euthanasiac would have answered "yes". It's then true that we benefit their past self by killing their present/future self. However, it does not follow that we ought to kill their present self. For surely the harm to the present self is much greater than the benefit to their past self.
In fact, after a serious change of heart, the person might be so psychologically different that we would do best to consider them an entirely new person. (This is especially plausible given Parfit's reductionism about personal identity.) The past person would thus have no moral authority over their future self -- you cannot kill a person just because someone else wants them dead!
Anyway, I hope my various suggestions here sound vaguely coherent. Feel free to point out any inconsistencies you find!
First point: the higher-order desire stuff does not seem to provide reasonable solutions. The problem is that being higher-order is just a formal property of desire, and there is no reason why a corresponding axiological property should correspond to it. I may have a very trivial higher order desire, such as the desire not to desire to eat strawberry ice-cream, and there is no reason why this desire should be taken more seriously for the simple fact that it is higher order.
ReplyDeleteThen there is an example (I heard this from Akeel Bilgrami) when I have an higher-order desire that is more "neurotic" than the desire that it is its object. (Neurotic means: less integrated/coherent with the overall set. Bilgrami thinks this sort of coherence is normative, and has a normative value). For example, a man may have developed a higher order desire not to desire doing a job involving politics in any way, out of being burned out of unsuccessful political activity. He may decide to dedicate himself to metaphysics, for example, rather than political philosophy. Still, it may be true of that person that he is being untrue to himself; by the use of this "continental sounding" expression I mean: the man still feels all the attraction of political issues and political debates; his forcing himself not to indulge with it is the "neurotic" desire, rather than the opposite (in terms of the test of overall coherence).