John Hardwig

Better public health and medicine have given us a new kind of death and with it, a new fear – the fear that death will come too late and take too long. The generation that is dying now is largely unprepared for this new kind of death, for traditionally, people have always tried to avoid or postpone death. But if we are to avoid a bad death – too slow and too late – many of us with access to 21st century medicine will need to develop a very new art, the art of going to meet death. We will need the wisdom to discern when our lives are over, sometimes even without medical indicators such as a terminal or chronic illness. Then we will need the skill to wrap things up, both within ourselves and with our loved ones, and finally, the courage, decisiveness and resolution to take steps to end our lives.

Most traditional epistemologists see trust and knowledge as deeply antithetical: we cannot know by trusting in the opinions of others; knowledge must be based on evidence, not mere trust. I argue that this is badly mistaken. Modern knowers cannot be independent and self-reliant. In most disciplines, those who do not trust cannot know. Trust is thus often more epistemically basic than empirical evidence or logical argument, for the evidence and the argument are available only through trust. Finally, since the reliability of testimonial evidence depends on the trustworthiness of the testifier, this implies that knowledge often rests on a foundation of ethics. The rationality of many of our beliefs depends not only on our own character, but on the character of others.

W0mcn’s liberation, it is oftcn said, strikes closer t0 home than othcr forms of human liberation. Although basic shifts in attitudes arc required for thc liberation 0f, for example, workers 0r blacks and othcr ethnic minorities, thcsc types of liberation could bc accomplished without fundamental changes in what we call 0ur “privatc" lives or 0ur personal relationships. The liberation 0f blacks 0r workers is largely an affair 0f public roles and institutions, 21 matter 0f socialjusticc, and it is thus carried 0ut relatively impcrsonally and anonymously in the marketplace and workplace, thc university and governmental institutions. Granted, if thc liberation 0f blacks and workers is t0 bc complete, I might have t0 bc willing t0 have some in my club and my suburb. Somc 0f my bcst friends might then bc blacks 0r workers, and I might even have t0 bc willing t0 have my daughter marry 0nc. Nonetheless, it might well be truc that my club and neighborhood, my friendships, and my relationship t0 my daughter could go 0n pretty much as bcforc, 0ncc "thcy” had been admitted.

For all their differences, the “pro-choice” and the “pro-life” views of abortion are largely in agreement about one aspect of abortion decisions: where an abortion is morally legitimate, the pregnant woman should be permitted to decide whether or not to have an abortion. But I argue in this paper that if the man who will become the father of the fetus is known, if he believes that he will not be able (or permitted) to simply walk away from his biological offspring, and if he does not think it would be a good idea for him to a) become a parent, b) with this woman, or c) at this time, then the woman should have an abortion. Given the life-altering moral obligations involved in raising a child, a woman should not decide to make her (sexual) partner a father without his full consent.

find myself believing all sorts 0f things for which I d0 not possess evidence: that smoking cigarettes causes lung cancer, that my car keeps stalling because the carburetor needs LO be rebuilt, that mass media threaten democracy, that slums cause emotional disorders, that my irregular heart beat is premature ventricular contraction, that students} grades are not correlated with success in the ncmacadcmic world, that nuclear power plants are not safe (enough) . . . The list 0f things I believe, though I have no evidence for the truth of them, is, if not infinite, virtually endless. And..

There are good reasons — both medical and moral — for wanting to redistribute health care resources, and American hospitals and physicians are already involved in the practice of redistribution. However, such redistribution compromises both patient autonomy and the fiduciary relationship essential to medicine. These important values would be most completely preserved by a system in which patients themselves would be the agents of redistribution, by sharing their medical resources. Consequently, we should see whether patients would be willing to share before we resort to surreptitiously redistributing their resources or denying medical care to some who want and need it. We should change our health care payments systems to allow patients to donate their medical benefits to those in need.

Amid the controversies surrounding physician-assisted suicides, euthanasia, and long-term care for the elderly, a major component in the ethics of medicine is notably absent: the rights and welfare of the survivor's family, for whom serious illness and death can be emotionally and financially devastating. In this collection of eight provocative and timely essays, John Hardwig sets forth his views on the need to replace patient-centered bioethics with family-centered bioethics. Starting with a critique of the awkward language with which philosphers argue the ethics of personal relationships, Hardwig goes on to present a general statement on the necessity of family-centered bioethics. He reflects on proxy decisions, the effects of elder care on the family, the financial and lifestyle consequences of long-term care, and physician-assisted suicide from the perspective of the family. His penultimate essay, "Is There a Duty to Die?" carries the idea of family-centered ethics to its logical, controversial, conclusion; comments upon this essay from Daniel Callahan, Larry Churchill, Joanne Lynn, and journalist Nat Hentoff offer differing views on this highly charged subject. As advances in medicine prolong patient's lives, the welfare of those ultimately responsible for medical care-the family-must be addressed. Hardwig's courageous and illuminating essays set forth a new direction in bioethics: one that considers the welfare of everyone concerned.

In thc Foundations, Kant draws a distinction bctwccn action which is in accord with duty and action which is done from the motive of duty. This is 21 famous distinction, of course, and thcrc arc many interesting issues concerning it and its implications for ethical thcory. In this paper, I wish t0 focus on just 0nc noteworthy feature of K2mt’s usc of this distinction. Likc any distinction bctwccn logical compatiblcs, this 0nc yields four logically possible classes of action: (1) actions which are both in accord with duty and from duty; (2) actions which arc neither from duty nor in accord with duty; (3) actions which are in accord with duty but not from duty; and (4) actions which are from duty but not in accord with duty. What intcrcsts mc about these four possibilities is that, to thc best of my knowledge, Kant never considers or even mentions the last 0f these possibilities: action from duty but not in accord with duty. This is perhaps surprising in a philosopher with Kant’s intcrcst in logic and passion for thoroughness. Onc would have thought that hc would mention this logical possibility, cvcn if only in order to discount it as not really possible. Beginning with the idea that there arc cases of action from duty but not in accord with duty, I argue in this paper that Kant could not have admitted that thcrc can be actions of this kind, for their cxistcncc un-.

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