In response to a comment on my earlier post on Terri Schiavo and the Law, I tried to amplify my thoughts on the broader ethical issues relating to medical treatment, artificial nutrition and hydration, and PVS. I thought this was worth a separate post.
The philosophical / theological underpinnings of my view are set forth in my two earlier posts (here and here) on this issue. Essentially, I don’t think a monistic view of personhood — that personhood is coequal with the physical body — is Biblical. I’m also not a dualist (personhood consists of two separate components of body and soul). I hold a conditional unity view of personhood. Personhood has different aspects, including body, mind, and soul, and these different aspects are part of a unified whole.
In conjunction with this condition unity view of personhood, I apply the Biblical concept of humans as created in the “image of God.” What is the image of God? Most Biblical scholars agree that it is not a physical image. Rather, it has something to do with our capacity to reason, relate, communicate and create.
Finally, I apply what I believe is a Biblical understanding of death. Death temporarily separates body from the other aspects of personhood, pending the Resurrection — hence the “conditional” aspect of the unity of personhood. The aspects of our person that reflect the image of God continue to exist and one day will be reunited with a body. The current physical aspects of our personhood — the body — is no longer connected to our “person.” We treat physical remains with respect, but we appropriately dispose of them through burial or cremation, knowing that the “person” is no longer present in the body.
If these views of personhood, the image of God, and death are Biblical, and I belive they are, then it is possible, given modern medical technology, that a body could continue to be maintained even though the person has gone on to the intermediate state pending the Resurrection.
As an extreme example, imagine a person whose brain was completely removed from her body, while the heart, lungs and other organs were maintained through artificial respiration, circulation, nutrition and hydration. I think most Christians probably would agree that the “person” in that circumstance has died, and that our technology was merely keeping some parts of the body from decay. If you wouldn’t agree to that, I’d ask how much of the body needs to be maintained before the “person” is gone. For example, if we take the heart from a person who has recently died and transplant it into another person, does the “person” who recently died still exist in this life?
The persistent vegitative state (PVS) is several steps back from my “brainectomy” hypothetical, but the principle is the same. At some point, when there is nothing left of most of the brain but liquid, and there is no remaining capacity or potential for the attributes of communication, relationship, and creativity that reflect the image of God, I believe the “person” has gone on to the intermediate state, and nothing is left but the mortal body.
The commenter to my eariler post asked why, if I hold this view, it would be unethical to terminate a PVS patient through lethal injection or immediate cremation. Here, I believe an ethical distinction remains between actively terminating bodily functions and removing artificial medical support for those functions. A lethal injection or cremation before cessation of all bodily functions would constitute an affirmative act that would betray a lack of respect for the bodily aspect of personhood. Therefore, I would not be comfortable with that kind of action.
However, the removal of artifical medical support is a different matter. In that case, we are allowing the body to take its natural course. I should note here that I don’t see any material distinction between turning off a respirator and removing artificial nutrition and hydration. In either instance, a fundamental requirement for bodily function — air, hydration, or nutrition — is being provided by technological means — a respirator, or tubes inserted by medical professionals into the gatric tract through which nutritional serum and water are metered by a machine. And, in either case, the removal of those technological life supports will result in the cessation of bodily functions. In my view, under these circumstances, turning off a respirator or an artificial nutrition and hydration system is a withdrawal of medical treatment that allows the body to take a natural course. This, in my view, is ethically different than assisted suicide or euthanasia.
As I’ve said before, none of this settles the question whether it was ethical to remove Terri Schiavo’s ANH. If there is a material doubt about whether the patient truly is in a PVS, ANH should not be withdrawn. But, that is exactly the kind of factual determination, I think, that trial courts are best equipped to make. Moreover, I don’t think any medical treatment, including ANH, should be withdrawn if the patient’s wishes were equivocal or to the contrary. But, again, determining what the patient’s wishes were, in the absence of a clear, written advance health care directive (a living will), is, in my judgment, an appropriate function of the trial courts.
2 replies on “More on Personhood, Medical Treatment, and PVS”
I appreciate your thoughtful response to this question, and I read the previous posts that you referred to. It’s nice to see Christians thinking this through in a more systematic (and theologically grounded) way.
I do come from the conservative Catholic position on this issue, and the two major problems I have with your position is as follows:
1) I’m still not sure how the notion of “conditional unity” differs from dualism, or maybe I’m just not clear how it works. You seem to be suggesting that under the conditions where such unity is present, there is a monistic view of personhood and under the conditions where the unity is absent, there is a dualistic view (or maybe I’m misunderstanding). I certainly respect the serious thought you’ve put into this, but the position still seems less philosophically and rationally tenable than the monistic position. Here is a post of mine dealing with this issue:
http://whatstherumpus.blogspot.com/2005/03/terri-schiavo-and-sneerbots.html
In it, I quote extensively from Robert P. George’s book, “The Clash of Orthodoxies,” which, I think, nicely sets forth the argument for monism (and against body/person dualism). I suppose one of the questions I would ask about your position is, when the conditions for unity are present, do you still consider the body to be a subpersonal entity?
[If you do read the post, I hope you understand that my reference to “sneerbots” was aimed at the explicitly anti-religious commenters on the Terri Schiavo case — like Christopher Hitchens — and not at thoughtful Christians like you.]
2) The idea of conditional unity seems to me to open the personhood of late-stage Alzheimer’s patients and severely disabled newborns, for instance, to more interpretation than some are willing to admit. It seems to me that once you reject the notion that personhood begins at conception and ends at bodily death, then the position of someone like Peter Singer becomes “arguable,” and that’s not necessarily a bad thing, I guess (having to argue against Singer), but I don’t know that I trust society to argue these issues once we accept a more “conditional” framing of the problem.
Thanks for the interesting comments. I appreciate Robert George greatly, and I agree with his criticism of a mind / body dualism that sees the “person” essentially as the conscious mind that happens to inhabit a body, making the body merely a “sub-personal instrument.” My conditional unity view does not hold such an instrumental view of the body. The body is as integral to personhood as the mind or “soul.”
I don’t think, however, that this should lead to the monistic view that “to be human is to be or have a body.” (This is how Millard Erickson, from whose Systematic Theology text I derive the conditional unity view, defines monism.) Here I’d go back to my “brainectomy” hypothetical and ask whether you think a body with no brain is truly still a “person.” And, I’d go back to my heart transplant hypothetical and ask how much of the body must remain to constitute a “person.” The heart that beats in the transplant patient, after all, is a living component of someone else’s body. It seems to me that a purely monistic view of personhood is readily challenged by this sort of reductio ad absurdum argument.
What the conditional unity view recognizes is that, although the body is not merely an instrumentality of personhood, there will come a time for all persons when they will be temporarily separated from their bodies by physical death. As Erickson describes it,
Some Biblical support for this view can be found in Jesus statement to the thief on the cross (“today you will be with me in paradise”)(Luke 23:43), the parable of the rich man and Lazarus (Luke 16:19-31), Paul’s statement that we should prefer to be “away from the body and at home with the Lord” (2 Cor. 5:8) and Jesus statement in Mathew 10:28: “Do not be afraid of those who kill the body but cannot kill the soul.”
It seems to me, then, that philosophically, observationally, and scripturally, a purely monistic view doesn’t work.
As to your concerns about Alzheimers’ patients, newborns, fetuses and such, I understand the concern and share it. But, unlike a true PVS patient, newborns, fetuses, and even Alzheimers’ patients still possess some capacity and/or potentiality to reason and relate.
The potentiality principle is a key adjunct to my views on bioethics arising out of the conditional unity view of personhood. If there is any capacity or potentiality for the aspects of the imago Dei that separate mere tissue from a person, we are dealing with a “person” and it is immoral and unethical to terminate the person’s life. The science of PVS as we understand it tells us that in true PVS cases, all such capacity and potentiality are irrevocably lost. In my view, this changes the moral and ethical considerations.