First Things
Books in Review
Testing the Medical Covenant
Copyright (c) 1996 First Things 67 (November 1996): 50-54.
Treating the Person
Testing the Medical Covenant: Active Euthanasia and Health
Care Reform. By William F. May. Eerdmans. 146 pp. $14
paper.
Reviewed by Gilbert Meilaender.
If one has time to read only a single book on medical ethics in the near
future, Testing the Medical Covenant: Active Euthanasia and Health
Care Reform would be an excellent choice. As always, William F.
May's writing is characterized by grace and lucidity, and the topics
discussed in four short chapters are timely and important. Quite a few
books these days treat the growing demand for legalized euthanasia, and
quite a few also analyze the pressure for health care reform and some
type of national health care system. Very few authors, however, draw
these two subjects together, exploring their interconnections as May
does. And although I am not as persuaded as he that a single-payer form
of national health care is what we need, May's voice-both distinctively
Christian and generously humanistic-must be taken seriously.
May's four chapters all carry through a theme for which he is already
known: the place and meaning of "covenant" in the practice of medicine.
One of the motive forces in the rise and development of bioethics over
the past quarter century was a strong movement toward patient autonomy.
Paternalistic physicians, so it was believed, were practicing an
overbearing medicine, and, with the new armamentarium of treatment
techniques available to doctors, "overtreatment" seemed to be the
decisive problem. To get medicine off the back of suffering and dying
patients, those patients had to become participants in decisions about
their treatment. Their autonomy could be honored only if their consent
was sought and respected.
Without denying the truth of this account or the significance of patient
participation in treatment decisions, May worries about the way this
emphasis upon self-determination has produced a "contractualist"
medicine. Instead of an authoritarian physician and an obedient patient,
contractualist medicine specifies the terms of the exchange: the patient
has needs, the physician skills. Hence, the physician can agree to put
those skills in service of the patient's desire for healing. Such a
contractualist understanding may overcome physician paternalism to some
extent, but only at a cost. Genuine contracts should presuppose that the
contracting parties are roughly equally informed about the goods and
services they exchange; yet, the patient is never the doctor's equal in
this regard. Contracts are honored in large part because it is in the
interest of the respective parties to do so; covenants are made against
a "more spacious" background in which all know themselves to have
received more than they have given. Contracts specify as precisely as
possible what must be done-and that minimum may easily come to seem
quite sufficient. Covenants commit and engage the whole person, often
carrying one beyond any minimalist understanding of obligation. The
covenanted physician must care for the patient as a whole, not simply
treat a disease. And, most significantly, the covenanted physician
cannot withdraw from the dying patient when he has done all he can or
has agreed to do; he must keep company with the patient in that
dying.
Against the background of this understanding of covenant-language whose
roots are clearly biblical-May turns to the themes of his four chapters.
First he takes up the movement in Western societies toward euthanasia
and assisted suicide, arguing powerfully against the acceptance of such
practices. If, however, we do continue to prohibit euthanasia, we must
ask what sort of healers we need to care for the dying. Therefore, in a
second chapter May outlines what it means to term medicine a
"profession," and he discusses the chief virtues of the physician. Even
covenanted physicians must eventually run up against the limits of their
art, however; hence, the third chapter summarizes and evaluates some of
the recent discussion of the concept of "futility" in medical care.
Finally, in the concluding chapter May connects his two main topics-
euthanasia and health care reform-arguing that we cannot coherently or
compassionately prohibit euthanasia unless we achieve a system of health
care delivery that is both universal and comprehensive in its
coverage.
May's analysis of euthanasia is clear and concise. One terminological
quibble at the outset: May opposes active euthanasia and defends what he
and others sometimes call passive euthanasia. The latter simply means
allowing patients to die when we can no longer ward off that death
without inflicting upon them treatment that is either useless or
exceedingly burdensome. In short, May opposes intentional killing but
approves allowing to die. I think it muddies the waters to use the
language of active and passive euthanasia to mark this distinction.
Ceasing useless treatment is not, properly speaking, a form of
euthanasia.
The first chapter's discussion of euthanasia is set, briefly but
persuasively, within a Christian context. In order to think rightly
about the morality of euthanasia we must, May suggests, learn first to
think rightly about life and death. Life is a good, but not the greatest
good-which is, of course, God. Death and suffering are evils, but not
the ultimate evil-which would be to lose God. Hence, the good of life is
to be cherished but not worshiped. The evil of death is to be resisted,
but this resistance cannot become "our final meaning and resource." We
should therefore join the camp neither of those who struggle to the
bitter end against death nor those who view it as a good sometimes to be
sought and embraced. May's discussion here has clearly been influenced
by the work of Paul Ramsey, who argued that we ought never abandon care
for the dying, but that caring sometimes meant giving up the struggle
against death and "companying" with the dying. In contrast to that
humane wisdom, May discerns in the movement for euthanasia a distinct
irony: "It solves the problem of a runaway technical medicine
by resorting, finally, to technique."
Here I will not attempt to recount fully May's discussion of the
arguments for euthanasia. His own discussion is succinct and clear. He
develops briefly what he regards as the five principal arguments for
euthanasia and then offers, in each case, a counterargument. Certainly
the two chief arguments are those grounded in patient autonomy and in
compassion for the suffering. On the first, May says what needs to be
said: that "respect for a person" should not be confused with "a
readiness to permit or assist him to do whatever he chooses." He also
presses hard on the notion of autonomy, suggesting that patients'
decisions for death are often not as free of external pressures as they
are claimed to be. It is the argument from compassion that constitutes
the connecting link between the two chief themes of the book. "To put it
bluntly," May writes, "a country has not earned the moral option to kill
for mercy in good conscience if it hasn't already sustained and
supported life with compassion and mercy. Active euthanasia could become
a final solution for handling the problem of the aged poor."
In addressing some of the other arguments offered in favor of euthanasia
May offers helpful, critical discussions of our tendency to view death
as a purely private event and our strong desire "to solve the problem of
human existence through control." Granting that all of us seek some
control over our lives, he places that desire in religious context: What
we need, finally, is not control but "a breakthrough to existence and
meaning beyond the urgencies of control."
What sort of physicians can really care for the dying? Only, May
suggests in his second chapter, those who understand medicine not as a
career but as a calling or profession. A "careerist" uses his identity
as doctor to further his purposes in life-money, status, power. A
professional "professes" commitment to the good of healing.
May characterizes a profession in terms of three "marks," each calling
for a particular virtue. The intellectual mark of a profession is its
development of a complex body of knowledge that cannot be learned
through training alone, and the virtue of prudence (understood as
attentive discernment) is needed if this mark is to be attained.
Morally, professionals commit their knowledge to the good of their
patients or clients. Physicians seek not to display intellectual
virtuosity but to serve human need, and the virtue required here is
fidelity to the patient. Such fidelity is important especially because
patients do not share equally in the body of professional knowledge
physicians have mastered. "This imbalance requires that the professional
exchange take place in a fiduciary setting of trust that transcends the
marketplace assumptions about two wary bargainers." If traditional fee-
for-service medicine sometimes tempted physicians to overtreat for the
sake of their own financial gain, the current trend toward health
maintenance organizations and preferred provider organizations may tempt
physicians to undertreat. In the face of such systemic pressures,
fidelity to the patient's good is all the more important. Finally,
professionals organize themselves and seek to maintain discipline within
the profession. This calls for the virtue of public-spiritedness, which
appreciates and acknowledges that becoming a physician is not something
one achieves on one's own. Physicians are indebted to the people who
have supported their study and upon whom they have "practiced" and still
do practice.
May's covenantal understanding of medicine carries with it a certain
danger. As a high and demanding calling, medicine invites us to make of
the doctor a savior whose judgment and decision are final. But all of
us, doctors included, must recognize that at some point treatment may
become "futile." Recent years have seen a burgeoning body of literature
discussing the concept of medical futility. In his third chapter May
briefly summarizes some of the central themes of that discussion and
asks how one ought to respond. If "futility" is essentially a medical
judgment, it might seem that physicians who judge a treatment futile
should be under no obligation to provide it. Indeed, they might even be
obligated not to provide treatment, however strongly a patient or the
patient's family may request it.
May is uneasy, however, with leaving such decisions solely to
physicians, and he examines a number of arguments for doing so, finding
them all wanting. It seems to me, however, that at least one of these
arguments ought to have more appeal for May than it appears to. One
might claim that doctors who judge a requested treatment to be futile
should not provide it precisely in order to defend the integrity of
their profession. A contractualist physician might simply place his
abilities in service of a patient's request, but surely a covenanted
physician has duties not just to patients but to the good of medicine
itself.
May's reason for caution here is, however, an important one. Decisions
about futile treatment made unilaterally by physicians are only
judgments that a certain treatment is futile. Even if it is, the effort
to heal may not be futile in some situations. That is, it may be
important to the patient's family that they participate in the decision
to withdraw treatment and that they be given time to come to terms with
what is happening. Because that is the case, May opposes unilateral
decisions by physicians to withdraw futile treatment, even if that
decision is justified in the name of professional integrity.
Finally May turns to the need for reform of our health care system.
Because the coverage it currently offers is neither universal nor
comprehensive, he believes that it increases the pressure for
euthanasia. In arguing that health care is a fundamental good, May is
careful to grant that it is not the only such good. Societies also need
schools, roads, armies, etc. But just as we would not "limit the
protection afforded by the Defense Department-another fundamental good-
to only those who can afford a private army," so also we "ought not to
limit access to medical care only to those who can hire a platoon of
doctors." For May this claim is grounded not so much in human rights as
in religious vision. "Our three major religious traditions-Protestant,
Catholic, and Jewish-are communitarian. They all insist that we leave no
one out in the cold when naked, starved, or sick."
A good portion of May's argument is taken up with a summary account of
the Clinton Administration's failed attempt to achieve some health care
reform. I myself would have preferred less of this and more of the
theological and moral arguments, but May does, at any rate, situate his
discussion squarely in the midst of current debates. His defense of the
Clinton proposal is of the "two cheers" sort. Clearly, his own preferred
approach would have been a single-payer system something like that used
in Canada. And whatever the defects of such a system, he can argue
fairly persuasively that the bureaucratic cost of our current complex
network of third-party payers is considerable. Whether we really have
reason to hope or believe that a national single-payer system instituted
by the federal government would be better is, however, a question that
deserves more analysis than May offers here.
Still, there might be sound moral wisdom in May's proposals. He himself,
however, wants to press beyond such a moral claim and argue that there
are theological grounds for turning in this direction. What he says here
is said with grace and dignity, but one may doubt whether he says enough
to demonstrate what he claims: that the Church has in the gospel a
certain wisdom about how a health care system ought best be structured.
Can it be true that "nurturing institutions-even of the tax-supported
variety-may sometimes intimate and foreshadow the kingdom of God"?
Let us give May's claim its due. It can indeed be true. In his City of
God Augustine at one point recalls the story of Rome's founding. Rom-
ulus established the city as a place of refuge. Thus, Augustine
suggests, "the remission of sins . . . finds a kind of shadowy
resemblance in that refuge of Romulus, where the offer of impunity for
crimes of every kind collected a multitude which was to result in the
foundation of the city of Rome." Here May follows Augustine's lead.
But, of course, this is not Augustine's only appeal to the story of
Rome's founding. More characteristically, Augustine will say that Rom-
ulus killed Remus because each "sought the glory of establishing the
Roman state," but this was a glory that could not be shared. Human
community is-until the end of history-founded on such fratricide. It may
on occasion provide a "shadow" of what God has in mind for us, but no
clear way leads from that intimation to its realization in the promised
kingdom. All honor therefore to May's attempt to discern the intimations
of God's way in history, but we should be cautious before claiming this
as a wisdom the Church has to offer the world.
Gilbert Meilaender is Professor of Theology at Valparaiso University.
This article provided by First Things Journal.
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