“Person”, “Personal Property” and “Personal Act”: How to Use Philosophical Notions in Ethical Decision-Making at Terminal-Ill Patients
In this paper I want to address the problem of using the notion of “person” or “personhood” in the biomedical ethics. I want to do this in four steps: In the first step I want to argue that there is a need to distinguish between persons and human beings as the medical science advances, this poses an ethical challenge for today’s philosophers; in the second part two different kinds of explicating “person” should be presented; in the third part I want to present another solution to the challenge, not the difference between “person” and “human being” plays the center role, but the notion of “enabling personal acts” should be the regulative principle of medical treatments; and in the last part I want to survey the consequences of the thesis.
This paper aims at ethical decision-making for terminal-ill patients, if the thesis here is accepted, it will have consequences for other parts of biomedical ethics as well, but I won’t address them here.
1. The need to distinguish between “person” and “human being”
It is a well-known fact that through the advance of modern medical science, physicians can now save lives where this was not possible in earlier times. The deeper knowledge of biological functions, mechanisms of regulations and other vital processes allows physicians to intervene with the biological organisms and by doing so to prolong human lives. The medical treatment with dialyzers, PEG-Tubes and Heart-Lung-Machines are just examples of these modern medical achievements.
The other side of this technical achievement lies in its ethical implications. There are cases in which it does not seem reasonable to prolong human lives. Life sustained by modern techniques does not seem fulfilling; for many people such a life is not an option to natural, biological life. The life quality seems to be so low that some people would even favor the death than the “prolonged dying”. For this reason many have plead for the passive euthanasia; not only patients, their relatives and physicians are among them, even the Catholic Church in its “Declaration on Euthanasia” (Sacred Congregation for the Doctrine of the Faith 1980) from 1980 speaks about the “dignity of death”. Though the Catholic Church does claim that the human life is given by God and so it is not to be given away easily, the human death has dignity too and has to be treated carefully.
I think there is a general agreement that human lives are precious and that we should only give up a life of a patient under special circumstances and that most everyone condemns taking the life of a human being (even her own life) without adequate reasons. On the other side there are (good) arguments for the (passive) euthanasia, as stated above. In the light of these two positions we have a (moral) conflict: On the one hand prolonging life is not always reasonable, so under certain circumstances letting a patient die should be morally permitted; but on the other hand we should try to save every life because (human) lives are precious. If we agree to both positions, the following moral dilemma is the crucial question:
[Q1] Under what circumstances can a physician let go a patient’s life?
Sometimes there is just nothing can be done to prevent the death of a patient. Sometimes the question of clinical allocation arises. Within this paper these two situations should be neglected. I will focus on those cases where medical professionals are able to prolong the life of a patient, but it is nevertheless morally allowed to let go her life. With this restriction and under the premise that we are talking about human beings [Q1] can be reformulated into the following question.
[Q2] What kind of human beings can be let die?
Logically speaking: answering [Q2] is equal to making a subclass within the class of human beings: The members in the subclass are of special kind, we should try to save their lives, while it is morally allowed to let those human beings die which do not belong to this subclass.
Different kinds of answers to [Q2] are possible: We could take medical/physiological facts about a patient as a criterion to see whether it is allowed to let her die. Though medical facts make important parts of an adequate answer to [Q2], arguments are provided by philosophers that medical propositions alone cannot be the sole ground upon which a moral judgment is based. Beside the medical propositions philosophical considerations are necessary parts within an adequate answer to [Q2].
1.1 Medical propositions alone cannot ground an answer to [Q2]
Usually medical answers are expected to [Q2]: E.g.: “… elderly patients with underlying chronic cardiopulmonary disease or metastatic cancer …” (Le Conte et al. 2004). But this does not seem satisfactory. When the medical science advances, physicians are able to save more lives even under worse conditions. This fact shows that physiological parameter beyond which the patient cannot be saved are changing quickly; and thus they are not suitable as an answer to [Q2].
Another critic to a “medical approach” to [Q2] comes from the moral philosophy: Since [Q2] is a question about the right- or wrongness of an action, factual propositions alone are not sufficient to ground an answer. If one can only give factual propositions as an answer to [Q2], she is committing a “naturalistic fallacy”: We cannot know what we should do from just the facts alone, there should be at least one ethical proposition (e.g. “it is morally allowed to let somebody die, if you cannot save her” or “keeping the cost for health care down is morally imperative”) in the premises.
Though medical propositions cannot be the sole component of the answer to [Q2], they can (and even have to) be part of the answer. The other part must come from the moral philosophy, since [Q2] is an ethical question. At best moral philosophy should provide physicians with ethical criteria or principles which could be of help during the process of making end-of-life-decisions.
1.2 The distinction between “person” and “human being”
Ever since Peter Singer’s Practical Ethics (Singer 1970) the philosophical part of an answer to [Q2] is the notion of “person”. Singer introduced this notion within his preference utilitarianism to sort out a special class of entities. Persons are not only objects of the utilitarian ethics, but they are also subjects. While non-persons will to live on can be put into utilitarian considerations and therefore be neglected out of utilitarian calculations, persons are different. Their preferences to live on is of so much weight that they can only be counter-weighted with the will to live on of other persons, not with any other utilitarian calculations.
While the results of Singer’s considerations (e.g. “active euthanasia” and “animal rights”) are heavily discussed and his notion of personhood becomes one permanent subject of philosophical debates, the role this notion plays is seldom doubted: Persons are special subjects and objects of ethical considerations: If one entity is a person, then she is to treated in a different kind than other entities which are not persons. Applying this thinking to [Q2], the answer could be [A1]:
[A1] Those human beings are to be saved, if they are (still) persons. If they are not persons (anymore), they can be let die.
If [A1] is correct then the criteria for personhood will decide over life or death of a patient. Since the notion of person is a philosophical – precisely ontological – concept, we now have a shift from an ethical question [Q1] to an ontological question for the personhood. The next step will be to look into the debate on personhood in the philosophy.
2. Two different kinds of “person”
Although there are many different concepts of “person”, we can sort them into two different groups: The so-called “simple view of personhood” and the so-called “complex view of personhood” (cf. Quante 2002, Chap. 2)1. Before we can survey the difference between the two views, let me first introduce the following philosophical terms: “substance” and “property”.
2.1 Substances, properties and dispositional properties
In the Aristotelian Metaphysics the notion “substance” denotes primarily those entities which can exist independently (cf. Hoffman/Rosenkrantz 1997). Paradigmatic examples for substances are individual cats, dogs, roses and human beings. It is important to note that each cat is one substance. Aside from this “first substance” there is also a notion of “second substance”. Examples of the second substances are “being a cat”, “being a dog”, “being a rose” and “being a human being” (but not “being beautiful”). The second substance names the kind to which an individual substance belongs to. It is important to note that although there are similarities between second substances and properties, second substances are not properties.
Philosophers calls “being beautiful”, “being red”, and “being anxious” properties, as opposed to substances. Within the Aristotelian Metaphysics properties are entities which cannot exist alone, independently from the substances. Substances are bearers of properties.2 While an individual stays – as long as it exists – the same substance, its properties can be changed. While a cat is always a cat, as long as it exists, it can change its properties from “being hungry” to “being not-hungry” from time to time.
Dispositional properties are a special kind of properties. Examples for dispositional properties are “being able to play piano”, “being dissolvable in water”, and “being capable of flying”. The main problem with these properties lies in their verifiability: Though we think that a concert pianist always has the ability to play a piano, when she is not playing the piano, we cannot be sure that she still has that ability. Though we think that sugar is dissolvable in water, if it is not solved in water, we cannot verify this thesis. And sometimes these dispositions can be even lost: If the concert pianist suffers from a stroke, it is possible that she cannot play piano anymore.
Now let us come back to the two different views of personhood.
2.2 The simple view
The simple view of personhood regards the notion of person as a kind of second substance.3 According to those philosophers committed to the simple view, being a person is the necessary condition for having typical personal properties. So if you experience an entity having one of the personal properties, then et ceteri paribus it is a person. While when a thing lacks personal properties, then we cannot say that it isn’t a person just out of this experience. We would need other evidences to prove that a thing is not a person.
I think there are good arguments for the simple view: In my opinion the simple view catches the everyday intuition of the people best. When we use the word “person”, it seems to refer to an individual substance, and not to some properties. Normally you would say “she is a person”, but not “she is personal”.
But there are also good arguments against the simple view: For the subject of this paper, the uncertainty whether a patient is (still) a person or not would pose the greatest threat. Just because someone is (currently) lacking personal properties doesn’t mean that he is not a person (anymore). The simple view does not provide us with any criteria to recognize a person as such.
2.3 The complex view
On the other hand, philosophers committed to the complex view regards “person” as a kind of a (complex) property. To them “being a person” is equal (or analyzable) to “actualizing one or more of personal properties”.
The best thing about the complex view is that if it is true, then it is possible that we can know whether an entity is a person or not just by looking at whether it is actualizing those personal properties. The epistemic certainty of this view is a great help with the end-of-life decision.
The bad thing about the complex view is that its plausibility depends on the person-concept of each philosopher (or even physician): Since every philosopher has a (slightly) different concept of personhood, sometimes the same entity would be classified as a person by one, but not by another philosopher. In the supermarket of philosophical concepts, how can we sort out the right from the wrong ones?
The most troublesome feature of the complex view is that there are entities which do not have (or even had) any personal properties, e.g. an embryo, but some of us still regard it as a person.
2.4 Personal properties
Although both view points contradict with each other, they both agree that “person” is not an empty notion. Persons are special entities which must be treated differently in ethical considerations. They also agree on that persons have special properties which non-persons lack, which are those “personal properties” I mentioned earlier.
Philosophers certainly do not agree on which properties should be called personal. Many suggestions have been made: Different concepts on personhood suggest different sets of personal properties. Peter Singer (Singer 1970) regards self-consciousness and rationality as eminent properties of personhood. For Günter Pöltner (Pöltner 2002) relations to other persons (“Beziehungen zu den Mitmenschen”), the ability to be called upon (“Ansprechbarkeit”), the relation to the world (“Weltbezug”) and the relation to time (“Zeitbezug”) are the most important personal properties. For Michael Quante (Quante 2002, 19f) personal properties are being a mental subject, being able to refer to itself, having a consciousness of time, having a consciousness on one’s identity over time, having logical and instrumental rationality and being able to communicate with other personal beings.
To complicate the view, philosophers do not agree on whether the (mere) actualizing one of these personal properties is a necessary or sufficient condition for personhood, and whether non-persons can also have some of these properties. Take Quante (Quante 2002) as an example, he suggests that having some of those properties in a sufficient high grade is enough for personhood. For Robert Spaemann (Spaemann 1991) being a human being alone is enough to be qualified as person. And Daniel Dennett (Dennett 1976) cannot even be sure that something which fulfills all of his conditions for personhood is a person.
2.5 Actus personalis
One interesting thing about these personal properties is that most of them are dispositional properties. As stated in [2.1], dispositional properties are capacities which can be if some conditions are met. While one condition for personhood could be the rationality, she does not need to be rational at every single moment of her life. When she is asleep, she is probably not rational, but she has nevertheless the capacity to be rational. Similar things can be said to other personal properties like “capacity to use language”, “self-consciousness” or “to be conscious of time”.
Whenever a certain substance S has a dispositional property D to be P, we can distinguish between two states of S: (1) S has D, but S is not actualizing P; and (2) S has D and S is also P. When we are talking about persons and personal properties, then I think it is suitable to call a person not only having a personal property, but is also actualizing this property that she is exercising her personal power. She is doing an actus personalis, a personal act.
3. “Enabling personal acts” as a principle of medical treatment
While the philosophical debate on the notion of personhood is really an interesting and important topic within the biomedical ethics, it is also very confusing. Having heard the debate physicians who are confronted with end-of-life-decisions will still not know what to do with terminal-ill patients. As we can see, if [A1] is the right answer, then these ontological considerations are crucial. But since there is no clear ontological answer, [A1] (especially when it comes to its application) remains unclear. Should we therefore drop the notion of personhood and claim that we should take other considerations instead of an approach through the notion of person if we wanted to answer [Q2]? Perhaps we should take a further look into what physicians are doing.
3.1 The aim of medical treatment
The notion of person developed here is less well-known among physicians. When we look the way they work, they normally do not ask ontological questions, but they ask the following question:
[Q3] What can be done to help the patient in this situation?
But what does the word “help” mean here? The answer to this question is normally quite clear: Trying to cure the patient. When this cannot be done, physicians will try to treat the patient in such a way that her “life quality” improves. But when it comes to the end-of-life-decision, the question for “life quality” seems inappropriate: If the question is really about the improvement of life quality, then allowing someone to die will not be an option, since if one has died, the life quality cannot possibly be improved. So another approach must be taken here. In my opinion the ontological debate on “person” can throw some light here.
As stated in [2.4] and [2.5] both views of personhood agree on the thesis that only persons can have personal properties. And since most of these properties are dispositional properties, we can call the actual realization of these properties personal acts. As also stated in [2.5] persons do not always actualize the personal properties; and the personal acts are bounded to some conditions. A person can only communicate through language under the condition that parts of her body are functioning (normally) and that there are other persons to whom she can talk.
If this is true, then it is possible to see the medical treatment as a way to setup the (physical) conditions for the patient so that she can perform personal acts again. Though this thesis might not be the best description of medical treatments, it is in my opinion at least a possible description. So “helping a patient” would be equal to “recreating the physical conditions for the patient, so she can perform personal acts”. Let us call the recreation of the physical conditions the “enabling of personal acts”.
If the thesis about “enabling the personal act” is correct, then [Q3] can be reformulated to [Q4]:
[Q4] What can be done to enable the patient for personal acts again?
As one can easily see [Q4] is mostly a medical, not an ontological question. For answering [Q4] knowledge of the medical science is needed while just a “light weight” philosophical background is necessary to understand the question.
3.2 Enabling personal acts as a regulatory principle
As far as now I have stated that it is possible to reformulate the aim of medical treatments, namely they aim at the enabling patients for actus personales. Now I want to formulate this as a regulative principle for medical care in general.
What is a regulative principle in medical ethics? A regulative principle has the form: “You ought to try to achieve p“, while p is a type of states. A principle of this kind is formulated without any conditionals, but it has also less normative potency. Under certain circumstances it is possible to neglect a principle. In this case the regulative principle could be this:
[P1] Physicians ought to try to achieve a physiological state in which the patient can perform personal acts!
This principle is grounded on two premises: First, with respect of an entity which has the special power to perform personal act performing personal acts is (in any sense) better then not-performing personal acts. Second, to enable someone for personal acts is a good personal act itself.
To be able to apply this principle a physician has to know some premises: She must know which (physiological) conditions are necessary for a human being to perform personal acts, and what she could do (or omit) to recreate these conditions. What she does not need to know is the ontological status of the patient as person, and which of the concepts on personhood is the right/true one. What matters is what she can do to enable the patient for personal acts.
4. An alternative answer
But can the “principle of enabling patients for personal act” also tell the physician, when she can withhold or withdraw a therapy and let the patient die? For sure, since [P1] is a regulatory principle for actions of physicians, [P1] is not suitable for applying [A1]. Whether the patient is still a person or not cannot be found out by using [P1].
[P1] cannot answer [Q2] or even [Q1] directly. But I think this principle, when accepted, makes the following answer [A2] plausible.
[A2] Physicians are allowed to let a patient die, if there isn’t any treatment physicians can apply to enable the patient for performing a personal act.
4.1 [P1] is not counter-intuitive and can be applied to standard cases.
I want to show that most physicians already apply [P1] intuitively.
Let us first take a rather fortunate case: There has been an accident and a patient was seriously injured and taken to the emergency room. The well-trained physicians knew what they had to do and were able to save the life of the patient. Since they knew that they had chance to save her life, they wouldn’t even start to think about letting her die. In terms of personal acts the physician in this case did their best to enable a patient for personal act.
What about a patient who is seriously injured? The physicians first try out the most promising therapy but soon realize that even with this therapy the patient would not regain consciousness again. In this case they will normally give up the patient’s life and withdraw from every therapy they have started. We do not think that the physicians act morally unjustified. In terms of personal we can describe this situation as one in which physicians cannot do anything to enable the patient for personal acts and so let her die.
It seems that this principle does not contradict with standard cases. Within these cases it does not seem to be counter-intuitive. What about complicated situations where the intuitions and arguments among the physicians and philosophers are different?
4.2 Problematic cases
First there are cases of indirect euthanasia. With ‘indirect euthanasia’ I mean a situation in which a physician eases the pain of a patient with means which shorten her life. It is controversially discussed, whether indirect euthanasia is morally justified. If my principle is accepted, the physician is allowed to do this: Since a human being suffering less pain can perform personal acts better than in times when the pain is unbearable, the physician ought to give him analgesics to relieve his pain. He will try to find out the best dose, in which the pain is more bearable, but not so much that he will not be able to act again.
What to do with patients in PVS (‘persistent vegetative state’) is a subject in heavy debate. Should physicians let them die? I think there are both advocates and rejecters among physicians and philosophers. People who reject allowance of withdrawal from therapy sometimes argue with the uncertainty of the person status of patients suffering from PVS. But since this argument depends on the ontological framework of the philosopher, it cannot be sound to everybody. Within my argument these patients can be let die, since physicians cannot do anything to enable them for personal acts. Since this is still controversial, I cannot claim to be right. But I think I can prove that with [P1] there is a clear answer to this topic. And there are other good arguments which also lead to the same consequence.
The active euthanasia is also controversially discussed. Since the usage of physics to cause someone’s death is definitively not an action to enable a patient for personal act, the active euthanasia cannot be justified with this principle. But provided with an additional premise physician assisted suicides might be allowed. If it is agreed that suicide itself can be a personal act, then it will be possible for a physician under [P1] to assist a patient in her suicide, e.g. providing her with physics which will lead to her death. But it isn’t at all clear that with [P1] the physician assisted suicides should be allowed. I want to point out, that in the foregoing argument a special knowledge of personal acts – namely whether suicidal acts can be counted as personal acts or not – is needed. On the contrary to this we do not need to specify the personal acts in standard cases. So there is a difference between physician assisted suicides and those standard cases, and the presented argument using [P1] to justify physician assisted suicides might be flawed.
There is also need to discuss which role advance directives should play in the end-of-life-decision. If there is an advance directive to withhold any therapy, should physicians still try to save the patient’s life?4 I think from this regulative principle alone we must infer that advance directives should not play a role. There is still an amended argument, though. Out of the respect for autonomy we can formulate an argument that physicians should respect advance directives. Physicians should enable patients for personal acts, not to interfere with them. So if there isn’t anything suggesting the contrary a physician must think of an advance directive of a patient as a personal act of the same patient. Similar to the “amended argument” provided earlier for the physician assisted suicides this argument is also based on a special knowledge of personal acts. But since the personal act is already committed (giving a directive in advance), it is not a personal act in the future. So this argument might be a convincing one.
5. Conclusion remark
I think the principle proposed here [P1] can really help physicians in the end-of-life-decisions and does not lead to any rather counter-intuitive conclusions. The only requirement for this principle is a vague notion of ‘person’; and for this an intuitive understanding of personhood is sufficient, knowledge of the ontological debate on personhood is not necessary for the decision-making. On the other side, [P1] can also be used to point out why these debates are necessary and why the notion of person can be used not only to ground the ethics, but also to provide regulatory principles for medical decisions.
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1 To be exact: Quante distinguishes not between different concepts of personhood, but rather different concepts of (ontological) personal identity. Prima facie a philosopher who defends the simple view of personal identity will also defend a simple view of personhood; and a philosopher who defends a complex view on personal identity will also defend a complex view of personhood. I think it is rather difficult to defend a mixed concept, e.g. a simple view on personal identity but a complex view on personhood or a complex view on personal identity with a simple view on personhood.
2 In the modern philosophy ontological concepts have been developed in which properties can exist without “bearers” (cf. Campbell 1990). As for the argument in this paper, since I am using the Aristotelian Metaphysics “merely” to make the differences between substances and properties more clearly, I don’t think this kind of ontology would harm my argument substantially.
3 Though not every philosopher committed to the simple view would agree on this, this is actually the result of the analysis. If one accepts that “second substance” is not a (special kind of) property, then there should be no difficulties regarding “person” as “a second substance”.