John Hardwig

We are beginning to recognize that the prevalent ethic of patient autonomy simply will not do. Since demands for health care are virtually unlimited, giving autonomous patients the health care they want will bankrupt our health care system. We can no longer simply buy our way out of difficult questions of justice by expanding the health care pie until there is enough to satisfy the wants and needs of everyone. The requirements of justice and the needs of other patients must temper the claims of autonomous patients.

Most professions rest on the expertise of their members. Professionals are professionals primarily because they know more than most of us about something of importance to our society or to many members of it. Professionals are given power, respect, prestige, and above average incomes. If professionals are worthy of this status, it is largely because of their special knowledge and the way they use it. And if professionals have special rights and responsibilities, it is also primarily because of the social positions they occupy due to their presumed expertise.

We need to understand, and on a philosophical level, our consumer mentality. For ours is a consumer society. Yet (pace environmental philosophers) philosophers have had almost nothing to say. This paper is a start toward a normative philosophy of consumption. It explores a distinction which, if viable, has far-reaching implications — the distinction between ownership and what I call “possession.” This distinction marks two different senses in which a good or service can be mine. I argue that an approach to consumption oriented around possession rather than ownership would support the conclusion that there are prudential or self-interested, not only moral or environmental, limits to rational consumption. That would be a very desirable conclusion given that we often exceed these other limits of rational consumption.

A 78 year old married woman with progressive Alzheimer's disease was admitted to a local hospital with pneumonia and other medical problems. She recognized no one and had been incontinent for about a year. Despite aggressive treatment, the pneumonia failed to resolve and it seemed increasingly likely that this admission was to be for terminal care. The patient's husband (who had been taking care of her in their home) began requesting that the doctors be less aggressive in her treatment and, as the days wore on, he became more and more insistent that they scale back their aggressive care. The physicians were reluctant to do so, due to the small but real chance that the patient could survive to discharge. But her husband was her only remaining family, so he was the logical proxy decisionmaker. Multiple conferences ensued, and finally a conference with a social worker revealed that the husband had recently proposed marriage to the couple's housekeeper and she had accepted.

When Richard Lamm made the statement that old people have a duty to die, it was generally shouted down or ridiculed. The whole idea is just too preposterous to entertain. Or too threatening. In fact, a fairly common argument against legalizing physician-assisted suicide is that if it were legal, some people might somehow get the idea that they have a duty to die. These people could only be the victims of twisted moral reasoning or vicious social pressure. It goes without saying that there is no duty to die