The Burdens of “Choice”

Beyond Price: Essays on Birth and Death

  • J. David Velleman
  • Open Book Publishers, 2015; 232 pages, £29.95

It is interesting that in a time of seemingly unprecedented opportunities for unfettered individual choice, when few of the social constraints traditionally indicted as barriers to human happiness remain in place, two of our more pressing political campaigns are for recreational marijuana use and physician-assisted suicide. Increasingly, it seems, we are seeking to escape, either temporarily or permanently.

In regards to the latter, five states in the U.S. now permit medical doctors to assist individuals in taking their own lives. The latest to change its laws in this regard is California. After a very public wrestle over the assisted suicide bill, Governor Jerry Brown announced he would sign it. His rationale was deeply personal: “I do not know what I would do if I were dying in prolonged and excruciating pain. I am certain, however, that it would be a comfort to be able to consider the options afforded by this bill. And I wouldn’t deny that right to others.”

J. David Velleman, who teaches philosophy at New York University, has thought deeply about this issue and suggests that having such a choice may lead to less comfort than the governor, and those activists he is responding to, assume.

In “Against the Right to Die,” one of the essays in Beyond Price, Velleman explains why having uninhibited choices is not an unmixed blessing. He uses the example of a cashier given the combination to the store’s safe. The choice to open or not to open the safe is a burden. He points out that this is true for the person offered the choice of suicide: “Just as options can subject one to pressure from an opponent in negotiation, for example, they can subject one to pressure from other sources as well.”

How so? Well, “even if the option of euthanasia won’t alter a patient’s existential situation, it will certainly alter the way in which his situation is generally perceived.” This creates problems for the elderly or disabled patient, problems created “not just by having options but by being seen to have them”: 

Once a person is given the choice between life and death, he will rightly be perceived as the agent of his own survival. Whereas his existence is ordinarily viewed as a given for him—as a fixed condition with which he must cope—formally offering him the option of euthanasia will cause his existence thereafter to be viewed as his doing. . . . Forcing a patient to take responsibility for his continued existence may therefore be tantamount to confronting him with the following prospect: unless he can explain, to the satisfaction of others, why he chooses to exist, his only remaining reasons for existence may vanish.

We have reason to believe that this is precisely what does happen for those faced with the prospect of euthanasia. Since Oregon adopted an assisted suicide law, 40% of those who committed suicide with the help of a doctor mentioned concerns about being a burden on family, friends, and caregivers.

This problem is exacerbated by the fact that “our culture is extremely hostile to any attempt at justifying an existence of passivity and dependence. The burden of proof will lie heavily on the patient who thinks that his terminal illness or chronic disability is not a sufficient reason for dying.” Thus, Oregon’s Public Health Division notes that the most frequent end of life concern was “loss of autonomy” (reported by 91.4%).

It is not hard to see how this pressure to exercise the choice to die would exist even if it were not overt (though there is evidence that overt pressure is also often at work):

In practice, however, friends and relatives of a patient will not have to utter a word of encouragement, much less exert any overt pressure, once the option of euthanasia is offered. For in the discussion of a subject so hedged by taboos and inhibitions, the patient will have to make some assumptions about what they think and how they feel, irrespective of what they say. And the rational assumption for him to make will be that they are especially sensible of the considerations in favor of his exercising the option. . . . Thus, even if a patient antecedently believes that his life is worth living, he may have good reason to assume that many of the people around him do not, and that his efforts to convince them will be frustrated by prevailing opinions about lives like his, or by the biases inherent in their perspective. Indeed, he can reasonably assume that the offer of euthanasia is itself an expression of attitudes that are likely to frustrate his efforts to justify declining it.

In sum, “to offer the option of dying may be to give people new reasons for dying.”

Dr. Velleman’s collection of essays is not meant to address political issues as such. In fact, the majority of the essays in this book address philosophical topics without obvious implications for political and social controversies. But his careful and thorough analysis of a range of ethical topics yield challenging insights that invite us to think more deeply about ethical obligations at the points of birth and death, and also offers some fascinating thoughts about family histories. Many readers will find compelling and all will find challenging these careful and incisive essays responding to calls for upending traditional assumptions about killing and creating life.

The desires for autonomy to which Dr. Velleman responds prize individual choice and have as their subtext the notion of a person radically separated from any kind of family ties or obligations not strictly “chosen.” He tells of a time when this recognition came as he was undergoing cancer treatment and heard another philosopher speak in a cavalier way about his choice to smoke. Velleman immediately called to mind something he had learned after only a few months with cancer: “a tumor rarely invades a region smaller than an extended family.” While he knew that the bone marrow threatened by the cancer was his “sole source of blood cells, and my life depended on it . . . so did the life of my sons’ father, my wife’s husband, my parents’ son, my brothers’ brother, and I was never sure who among us would suffer the greater harm if that life ran out of gunk.”

This understanding, he explains, is precisely what is missing “in so many discussions of euthanasia and assisted suicide: a sense of something in each of us that is larger than any of us, something that makes human life more than just an exchange of costs for benefits, more than just a job or a trip to the mall. I miss the sense of a value in us that makes a claim on us—a value that we must live up to.”

This sense of atomistic individualism is manifest not only in ways we think about death and the killing of those whom we assume are living a life they would not choose to prolong, but also in new ways we have devised to create life. Specifically, Velleman discusses the practice of creating children with “donor” sperm or eggs so that an adult may raise a child with no relationship with that child’s other parent. He contends, “donor conception is wrong” because “the act of procreation generates parental obligations that cannot be contracted out to others, except when doing so is in the best interests of the child.”

He argues “that life is not a gift, and that ‘giving’ it to a child is wrong if the child will be severed from half of its ancestry.” This argument does not impugn the value of adoption, since an adopted child “needs to be parented by someone, and it cannot or should not be parented by its biological parents, for reasons that would outweigh any value inhering in biological ties. An ideology belittling the value of such ties is not needed to justify entrusting this child to adoptive parents.”

Of course, we have always had a way of encouraging the ideal for children:

Some truths are so homely as to embarrass the philosopher who ventures to speak them. First comes love, then comes marriage, and then the proverbial baby carriage. Well, it’s not such a ridiculous way of doing things, is it? The baby in that carriage has an inborn nature that joins together the natures of two adults. If those two adults are joined by love into a stable relationship—call it marriage—then they will be naturally prepared to care for the child with sympathetic understanding, and to show it how to recognize and reconcile some of the qualities within itself. A child naturally comes to feel at home with itself and at home in the world by growing up in its own family.

The wisdom inherent in this ideal is now threatened for some children because “our society has embarked on a vast social experiment in producing children designed to have no human relations with some of their biological relatives. Conceived of anonymously donated sperm or eggs, these children are permanently severed from all or part of their biological past.” Dr. Velleman explains that this experiment “is supported by a new ideology of the family, developed for people who want to have children but lack the biological means to ‘have’ them in the usual sense.” In these cases,

That this child cannot be parented by one or both of its biological parents is not a disadvantage that its custodial parents volunteer to mitigate; it was a desideratum that guided them in creating the child, to begin with. Not being attached to a partner with whom they could be fertile, they needed a child who was correlatively unattached, a child already disowned by at least one of its biological parents. Rather than adopt a child whose ties to its biological parents had been ruptured after conception, they intentionally created one for whom those ties were ruptured antecedently. This choice would be morally problematic if biological ties were genuinely meaningful. Hence the need for an ideology that denies their meaning.

Regardless of how much “we love disadvantaged children, we rightly believe that people should not deliberately create children who they already know will be disadvantaged.” Thus, in our public discussions of these issues, the question ‘Is this a good way to get a child?’ cannot dominate the question ‘Is this a good way for a child to have been gotten?’”

There is a serious irony at work here. Adults turn to gamete donation rather than “adoption precisely because of the parents’ interest in biological ties—an interest that they choose to further slightly in their own case by creating a person for whom the same interest will be profoundly frustrated.” Velleman sees this choice as “morally incoherent.” In these cases,

whereas the parent will be just as fully related to the child as any mother or father, the child will know only half of its biological parentage. Surely, we don’t believe that parents are entitled to make themselves slightly better off in some fundamental dimension by impoverishing their children in the same dimension. Why, then, should they be entitled to enlarge their own circle of consanguinity by creating children whose circle will be broken in half?

Fundamentally, Dr. Velleman questions the “the new ideology of the family” which posits that “any adult is in a position to satisfy this requirement, since a family is whatever we choose to call by that name.” He argues instead: “The right to procreate is conditional on the ability to provide the resulting child with a family; what counts as providing the child with a family in the relevant sense is a question that must be settled prior to any claim of procreative rights.” A safer and morally coherent approach is to assume that “those who create a child thereby incur an inalienable obligation to provide the necessary assistance.”

The essays in Beyond Price require us to think more carefully about why we value certain choices related to birth and death, particularly those that create burdens on others that are unnecessary and could, indeed, be cruel. In this way, it is a powerful corrective to the reflexive atomistic individualism at the root of our sometimes callous discussion of these topics.

William C. Duncan is Director of the Marriage Law Foundation.