12.1 Introduction

Climate change is happening, and human activity is the cause. What are we going to do about it? Bill McKibben calls this “the most important question that there ever was.” It is a practical question, but it also raises some philosophical issues. My goal in this chapter is to examine these philosophical issues. They include matters of self-interest and rational choice, and they include moral issues about the value of nature, the nature of human values, and difficult issues about international justice and intergenerational morality.

A number of writers have pointed out that climate change has remarkable spatial and temporal characteristics. It is a global problem and a paradigm of what game theorists call the Prisoner's Dilemma. The fundamental characteristic of a Prisoner's Dilemma is that if each agent successfully pursues its rational best interests, the result is collectively worse for each of them than some other possible result. I will discuss this issue in Section 12.3 below.

The temporal problem is an illustration of intergenerational asymmetry, or what some philosophers call the “tyranny of the present.” In each generation, people must decide whether they will collectively accept some costs in order to reduce greater harms and costs in the future or continue to pursue short-term gains and pass the problem on to the next generation. Because future people do not exist, they cannot bargain, reciprocate, compensate, reward, or punish us for what we do. I will discuss the implications of this asymmetry in intergenerational morality in Sections 12.4 and 12.5.

Both of these philosophical problems are familiar, and I will have little to add to the technical analysis of them. Once one understands and accepts the central facts about climate change, moreover, it is easy enough to formulate principles that tell us what we must do to avoid causing the worst harms and to mitigate the future harms we have already caused.

Informed consent is a fundamental component of moral justification. It distinguishes love-making from rape, employment from servitude, and life-saving surgery from felonious assault with a deadly weapon, to mention just a few examples. At a more general level, consent distinguishes democratic from authoritarian governments, and it justifies a capitalist economic system. Efficiency is important, but freedom is what makes capitalism most appealing, as producers choose what to produce, and consumers choose what to buy. Consent is required to justify activities that impose a risk of harm or death on others. This is true of dramatic and newsworthy instances, such as trying to site a nuclear waste disposal facility, but it may also be true of activities as mundane as driving cars. When I drive a car in a city, I impose a risk of injury or death on innocent pedestrians. I also contribute to pollution and climate change, which imposes further risks on others. I do not know how the consent process works that permits me to engage in this kind of risk-imposing activity, but it seems reasonable to think that some sort of tacit consent must be at work to justify our using automobiles.

When disparities of power or the effects of new technologies threaten the effectiveness of consent, democratic governments intervene with regulations aimed at reinforcing the conditions of consent or establishing procedures for obtaining it.

Individuals and organizations often have powerful incentives to shape our preferences, influence our judgments, and get us to make choices that serve their interests, whether or not they serve our own. We depend on our rational instincts, democratic institutions, and other rules and procedures to protect us from being exploited by these forces. To the ex-tent that our preferences are shaped in non-rational ways, however, and to the extent that others can find ways to bypass our rational faculties, we need to worry about our susceptibility to manipulation. If our nonrational tendencies are deep and pervasive, this worry may be justified, even when we have in place procedures and robust institutions aimed at steering us toward rational deliberation, and even when we want and try to act reasonably. This chapter is an examination of the grounds for this worry.

One of the central aims of behavioral decision theory is to discover and analyze the causal processes of preference formation. Behavioral decision theory is not a single theory but an amalgamation of findings, hypotheses, and research projects in different areas of the social sciences, which are united by their interest in discovering the empirical bases of judgment and choice. Some of the most interesting research in this area comes from psychologists who show how preferences are often determined in predictable but nonrational ways, with the implication that most of us can easily be led to make choices that we would also admit are not rationally justifiable.

The moral permissibility of patients forgoing life-sustaining medical treatment has come to be widely accepted. The issue of forgoing life-sustaining food and water, however, has only very recently gained attention in public policy discussions. One source of resistance to extending this acceptance of a general right to forgo life-sustaining treatment to the case of food and water has explicitly philosophical origins: for a physician to withhold food and water might seem to be not merely to allow the patient to die, but to kill the patient, and therefore wrong. A closely related moral worry is that for physicians to withhold food and water would be to make them the direct cause of their patients' deaths, which also would be wrong. And finally, many worry that providing food and water is ordinary care, not extraordinary or “heroic,” and so must be obligatory.

In each case, a distinction is drawn – between killing and allowing to die, causing or not causing death, and withholding ordinary or extraordinary care – and in each case it is claimed that the former, though not the latter, is morally forbidden. I consider appeal to the intrinsic moral importance of these distinctions to be confused, both in general and as applied to food and water. In the hope of reducing the impact of these moral confusions in the policy debate about forgoing food and water, I will address here both the general meaning and the putative moral importance of these distinctions, as well as their specific application to the case of food and water.

A dominant theme in both public and policy-making discussions of health care in recent years has been the need to control relentlessly escalating health care costs. One widely perceived and important cause of this problem has been the “graying” of America – recent and anticipated increases in life expectancy and in the proportion of the population over age 65, and especially the even more rapid increase in the “old old” population. The increased numbers of elderly in turn make disproportionately large use of health care. In response to any proposals to limit the availability to the elderly of resources generally, and health care resources in particular, their advocates have added the charge of “ageism” to the more familiar charges of racism and sexism. From the other side and in the face of the daunting political power of the elderly wielded by such lobbying groups as the American Association of Retired Persons, the argument is increasingly heard that making Social Security or Medicare programs relatively immune from the budget cuts suffered by other domestic programs is creating intergenerational injustice – that the welfare of children and working-age Americans is being wrongly sacrificed for the benefit of the elderly. The intensifying policy debate over health care and other social support programs serving the elderly is forcing a rethinking of questions of intergenerational justice and the claims of the elderly on social resources.

In what types of cases that arise in the practice of medicine is it morally permissible to kill human beings? My discussion of this question will largely involve working out some implications of a particular type of normative moral theory for the question of terminating human life in medical settings. However, the very substantial and often heated disagreement that arises over these issues amounts to more than simply disagreement over the implications of the kind of view I shall develop. Rather, it arises in large part because participants in the disputes hold general moral views of fundamentally different sorts. In the emotionally charged context in which these discussions often take place, and where the specifics of particular cases often occupy much of the attention, the deeper sources of the moral disagreement encountered are often obscured. I shall begin then with a brief attempt to illuminate some of those sources.

How one divides and distinguishes substantive moral theories is largely a matter of convenience, in the sense that it depends on the purpose of the inquiry at hand and the usefulness to that inquiry of carving up the geography of normative ethics in that particular way. No general distinctions between types of normative theories which delineate broad categories of such views are the correct distinctions or categories; any quite general distinctions will at the very least blur differences that are important in other contexts.

The two central aims of the requirement that medical care cannot be given to competent patients without their informed consent are illustrated by the following two cases, in which that requirement is violated.

INTRODUCTION

This essay addresses a narrowly circumscribed aspect of justice and the elderly. What health care and expenditure of resources on health care are owed on grounds of justice to the severely demented elderly? This is not an entirely accurate specification of the group of patients with whom I am concerned in several respects. In the great majority of cases, the severely demented are among the elderly, understood here as the over age 65 population, but in a minority of cases dementia can progress to this stage in younger persons. In that respect, my argument here will apply to the claims to care of some non-elderly as well. The effects of dementia that are my special concern here are the erosion of memory and other cognitive functions that attack and, I shall argue, ultimately destroy personal identity and personhood in the patient. While senile dementia of the Alzheimer's type is probably the most common cause of cognitive disability of the specific form that erodes personal identity, it may have other causes as well. Thus, the implications of my argument here will extend to some other severely cognitively disabled patients besides the severely demented, though for convenience I shall generally refer simply to the severely demented.

In recent decades medicine has gained dramatic new abilities to prolong life. Patients with kidney failure can be placed on renal dialysis; patients who have suffered cardiac arrest can sometimes be revived with advanced life-support measures including drugs, electric shock, airway intubation and closed or open heart massage; patients with pulmonary disease can be assisted by mechanical ventilation on respirators; and patients unable to eat or drink can receive nourishment and fluids intravenously or with tube feedings. These are only some of the most dramatic and well-known additions to medicine's armamentarium for staving off death in the gravely ill. While these and other life-sustaining treatments often provide very great benefits to individual patients by restoring or prolonging functioning lives, they also have the capacity to prolong patients' lives beyond the point at which they desire continued life support or are reasonably thought to be benefitted by it. Thus, where once nature took its course and pneumonia was the “old man's friend,” now increasingly someone must decide how long a life will be prolonged and when death will come. This chapter addresses some of the principal moral issues and arguments in current debates about life support. First, I address very briefly a related issue: the definition of death.

INTRODUCTION

Shared treatment decision making, with its division of labor between physician and patient, is a common ideal in medical ethics for the physician-patient relationship. Most simply put, the physician's role is to use his or her training, knowledge, and experience to provide the patient with facts about the diagnosis and about the prognoses without treatment and with alternative treatments. The patient's role in this division of labor is to provide the values – his or her own conception of the good – with which to evaluate these alternatives, and to select the one that is best for himself or herself. As a rough guide to practice, this is a reasonable conception; most of the time it is likely to produce sound treatment decisions. However, as an ideal it is too simplistic, and is subject to several challenges that I will explore in this essay.

Some challenges relate to the physician's role. This facts/values division of labor seems to assume that the physician can and should provide the facts about treatment alternatives in a value-neutral form. But some have questioned whether the sciences on which medicine is based are, or can be, value-free. Moreover, the concepts of health and disease, and of the normal and pathological, are held by many to be value-laden.