Monday, 26 April 2010

Legal Right to Die Comfortably for the Lethally Ill or Injured finally Confirmed in Sweden – but the Line Between Palliation and Murder is Still Undefined...

Today the Swedish National Board of Health and Welfare (NBHW), my country's highest authority on the application of health care law and associated ethical codes, delivered its ruling on a publicised case where a 31 year old woman, totally physically incapacitated since 6 years of age, appealed for the right to have the respirator keeping her alive since 25 years turned off and then to receive palliative care powerful enough to effectively ameliorate the resulting pain and anxiety.

To grant such wishes has indeed been established practice within Swedish health care since at least a decade back, not least in the case of old people who decline nutrition and liquid. The received opinion among doctors, officials and ethicist alike has been that the acceptability of this practice is a logical consequence of the principle of respect for personal autonomy in health care, combined with the approval of palliation as a legitimate medical aim by itself. However, a recent criminal prosecution against a neonatal doctor at the Karolinska Hospital, where surprisingly high amounts of the rests of powerful sedative drugs where found after an autopsy of a newborn child following a decision to terminate neonatal intensive care treatment that had been judged to be medically meaningless, has cast doubt on the legality of the established practice. Legal scholars, as well as the National Council of Medical Ethics, has pointed out that the aim of palliation after withdrawal of life-saving treatment may conflict with established criminal law regarding killing, since palliation necessarily brings a risk for hurrying death along, especially so with powerful palliation and in the case of fragile patients in a terminal stage. And Swedish criminal law statutes regarding, e.g., manslaughter do not mention imminent death by natural causes as a factor that excludes an act from falling under the legal ban. As an effect, doctors treating severely, chronically ill patients who wished to have life-support withdrawn and to receive effective palliation up to the time of death, became hesitant to grant these wishes. This is the background to why the woman appealed to NBHW; to ask it to let her doctor of the hook created by the uncertain legal situation.

The ruling is most welcome just due to the need for having the legalities straightened out, and even more so due to its content. NBHW had two alternative positions to choose from, besides the one actually taken: (1) to deny people suffering from deadly diseases or injuries the right to have their personal autonomy respected; and effectively to grant the right of the state to force adult and fully decision competent people to undergo very burdensome medical procedures for indefinite times, or (2) to grant the medical professions a right to effectively torture their patients, by affirming the rule of respecting autonomy while denying palliation as a legitimate medical aim. The NBHW instead states clearly that adult, decision competent patients have an unequivocal legal right to have ongoing medical treatment terminated (and unwanted treatment never to be initiated), even when the treatment has a life-supporting function. It moreover rules that dying patients have a right to effective palliation within the limits set by the established practice within this branch of medicine – thereby licensing the use of anesthetics besides, e.g., morphine.

Within the palliative medical practice and profession (and, evidently, within the NBHW), it is well-established that all palliative drugs, pain- and anxiety-killing as well as sedative, bring some risks of a slightly shortened life-span. Thus,  the ruling implies the legal acceptance of medical procedures that bring such risks without being balanced by the reduction of other risks for a shortened life-span. The palliative effect is recognised as a sufficiently important factor by itself. However, the question still remains how far this reasoning can be taken before the above-mentioned potential conflict with criminal manslaughter statutes is actualised. For the job of the NBHW is not to apply criminal law, only administrative law governing health care and medicine and, should there be a conflict, legal principles are clear: criminal law trumps any sort of administrative ruling.

Currently established palliative drugs and dosage can presumably cover most needs arising in this area of medicine. Especially so since the use of anesthetic for palliative purposes is a part of this practice since many years. One may hope, therefore, that an actualised legal conflict will never occur. However, the theoretical room is there, and it would take just one unforeseen case to reopen the can of worms.

Thursday, 22 April 2010

Celibacy is not the problem: the core of Catholic ideology on the family is

Following the avalanche of revelations regarding sexual child abuse within the Roman Catholic Church, the suggestion has been recurring recently that the root of the problem is to be found in the – by all means silly, dated and inhuman – prescription of celibacy for priests and members of congregations. See, e.g., this, this, this and this. I believe that this idea is a side-track of a serious kind – averting attention from what is really the source of what we have seen revealed during the last few years. The Roman catholic child abuse scandal is, I conjecture, the effects of certain key elements in the core of the Roman Catholic ideology with regard to human reproduction and the family.

First, to my knowledge, there is no credible evidence whatsoever that sexual child abuse is more common within the Roman Catholic social context than in other comparably large social or institutional settings. In particular, there is no such evidence with regard to settings where celibacy is not proscribed practice. But this is hardly the issue! What is the issue is what has been pressed by Richard Dawkins and Christopher Hitchens, among others recently: the fact that the institution of the Roman Catholic Church has (presumably for many centuries) embodied a conscious and organised cover-up of the cases of sexual child abuse occurring within the confines of this church, especially when perpetrated by priests. This may look as an analysis close to satire such as this one, but hang on a minute and you'll see it's more to it than that!

What is the issue is not that some Catholics, or even some professional Catholic representatives, are child abusers. Child abusers are to be found all around the human block! What is the issue is the way in which the Roman Catholic Church, condoned by their highest leaders, has systematically shielded the abusers to the detriment of the victims, and set the preservation of the institution before the interests of real human being. I've blogged before of what becomes of the Christian message of love when unchecked by secular rationality – this is another example. However, in this case, there is a sinister connection to some of the core ingredients of ideology on which the Roman Catholic Church builds its power over people, nations and ideas.

A recurring theme in Catholic teaching is the sanctity and impenetrable integrity of "the family" – a teaching that has been inherited from Judaism and preserved also in other versions of Christianity, as well as taken over within the Islamic faith. As a matter of fact, this dogma, as observed by feminist philosophers like Alison Jaggar and Susan Moller Okin, has been transported into sizable portions of secular liberal democratic societies, perhaps best evidenced on the theoretical side by the uncritical way in which John Rawls awarded  "the family" an unmotivated shielded position as an autonomous "sub-society" in his otherwise outstanding political thinking (said by a moral philosophical opponent, mind you).

A recurring theme in Catholic preaching is the notion of the dignified family, i.e. the heterosexual (properly) married couple who have sex only to glorify the master plan of the creator to have humans fill up the earth and who, accordingly, have hordes of children. This ideal reflects several central themes in catholic moral dogma: the sinfulness of all sorts of sex that lack procreative potential (hence, the alleged sinfulness of contraceptives, masturbation, oral sex, petting, homosexual sex....), the sinfulness of even potentially procreative sex outside the context of (Catholic) marriage, the sinfulness of procreation (even for a married couple) that is not the result of sex (hence the critical view on assisted reproductive technologies), the impossibility of dissolving marriage no matter what failures with regard to caring duties married partners engage in, etcetera. In this teaching, human beings are mere instruments for the institution allegedly installed merely for the sake of being obedient to a supposed supreme authority – what Catholic ethicists and propagandists usually refer to as human dignity. This is why, for the Roman Catholic Church, the family is not for society to meddle in, it is the business of the church. This is what explains what for non-Catholics like myself has always come out as the most superbly bizarre preoccupation with sex you might find among anti-sex extremists. Well, you know all about this, I reckon, so what's the connection to the child abuse you might ask?

Well, here you are. We already know that, regarding ordinary families, the official Roman Catholic attitude to sexual child abuse is to have the preservation of the family as the highest priority, not the well-being of the victim. Confession and atonement for the torturer is the prescribed medicine, not the rescue of victims of torture. This is not changed by the opaque rhetoric about children's best interest always being about not being separated from their family - this empty and cynical gesture is hardly believed by anyone nowadays besides the Congregation of the Doctrine of the Faith (if you have some time, please study the teachings of this virtual central committee of the Roman Catholic Church) and a few fanatical followers. Now: the institutional attitude towards sexual child abuse within the Roman Catholic Church itself perfectly reflects this very attitude at a grander level. For, in Catholic ideology, the Church is more or less a perfect analogue of a family - it is God's family. Thus, the family has to be preserved whatever the cost to its members. Thus, the institution goes before the well-being of people. Thus, shielding the abusers even at the cost of facilitating further abuse is perfectly in line with core Roman Catholic teaching, and so is lying your head off in the face of allegations you know to be perfectly true. So much for human dignity.

Sunday, 18 April 2010

Time for rational systematics rather than demagogic self-serving in the atheism-religion discourse?

This is a theme I have been thinking about a lot during the last few years, and I have been sketching on a blog piece without yet having come to a publishable result. However, my Australian colleague Russell Blackford has, so awaiting my results, please check out what he writes, as well as the comments!

Tuesday, 6 April 2010

War - Why Not? That's Why!

The film showing how an US military helicopter without any prior warning guns down a number of journalists, other civilians, eventual rescuers and - perhaps - some armed individuals in Iraq in 2007 has been waltzing around the world's news-desks this day. We can hear the heli-crew's jovial chatting over the radio as they identify the carrying of bags, cameras and phones as the equivalent of being "armed" and jolly reactions to the result of their own response to this observation: "Right through the windshield!" the gunner exclaims happily as he has just massacred some people coming to rescue in a car. Here is the video (from the NBC news website, since the youtube posting has been blocked unless you log in):


The reactions I have seen in commentaries are all about outrage, horror and amazement. I, for my part, is not at all surprised at what the video shows, but actually by this reaction. I've touched on this subject before in relation to the Swedish public reaction to the fact that Swedish soldiers are in fact being killed in Afghanistan. But this time, then, it is about the killing being done by soldiers in a war. Why, I ask, be surprised or amazed?

Not that I believe the US armed forces to be particularly sinister or evil - not at all. The behavior of the crew is what we should expect of any military unit in a similar situation. This is what war is about. This is what soldiers are for. Making war and engaging the military is when we lay to a side all normal hesitations and restrictions in the pursuit of our political goals. In a soldier's logic there is only the objective: balancing benefits and burdens, cost-benefit analyses, weighing of ends and means - all that is for the jujumen higher up to do before they choose to send the soldiers to war. For a soldier, to speak in technical terms, there is no such thing as efficiency, there is only efficacy (although the end pursued may not seem valuable to others when considering the costs). If the objective is to engage and exterminate "enemy combatants", this is what the soldier does, accepting that there will be masses of "collateral damage". This is what we spend all those tax money in the defense budget on: to teach our soldiers that lesson; to make them able to execute its practical implications on the battlefield.

This is also why war so seldom (if anytime) solve any problems, although military objectives may be accomplished. For, as Iraq so saliently illustrates, all that collateral damage inevitably invites new aggression as well as social chaos. Unless, of course, the war ends in the way that colonel Kurtz in Coppola's Apocalypse Now realised that it has to end if there is to be an end: "We have to exterminate them! Village after village, pig after pig, cow after cow" - "Drop the bomb, destroy them all!", as the final scribble in Kurtz's journal reads, echoing his namesake's "Exterminate all the brutes!". Not that this has to mean actual physical slaughter of every single human being, but the people, the nation, the culture, the group - the very institution that is attacked - has to be finally broken into total defeat and to accomplish that (as the WW2 defeat of Germany showed) takes a lot of killing - a lot. Wars with such objectives can indeed be won! But if we want a war with moderation, with human restraint, with moral consideration - forget it! This is why Apocalypse Now is the greatest anti-war movie ever made. This is why the very idea of a just war - while logically conceivable - is a practical misnomer, unless you accept the military logic that achievement of the objective - whatever it is - is worth just about any cost.

Admittedly, in very rare, extreme circumstances, even a winnable war may seem worth it to a decent person. In that case, we may accept that we have to lay off our normal cloak of decency and restraint in order to prevent the worst. This is why politicians keen of attaining a legacy as leaders in times of war and conflict always do their best to create the public image of such circumstances being the actual situation before taking action. Knowing or sensing that people, even under the influence of such manipulation, are normally quite unwilling to have masses of uncontrollable violence and destruction unleashed, our leaders most often also convey messages about the war being undertaken in a controlled, moderated, restrained and considerate manner. Also this is a part of the idea of the just war and when preaching this doctrine they lie. Of course, they lie. This is why the US army tried to cover up the event shown in the 2007 film: it exposes their and their leaders lies.

But back to the Iraq-footage from 2007. My simple point is: you went to war, what the heck did you expect? If you go to war, it is perfectly normal to have people gun each other down for no better reason than that they assemble in a group, wear certain clothes or carry cameras, phones or handbags. For all those things might be what that soldier in the film reports over the radio: firearms, bombs, grenades, scouts, infiltrators, you name it! He did his job, he assumed the worst and acted accordingly. If you still feel that there is some wrong that has been committed here, you need to look further; to the original decision to make war in the first place.