A World of Ideas; 120; Leon Kass Part 2 of 2

BILL MOYERS' WORLD OF IDEAS Leon Kass -Part II

BILL MOYERS: [on camera] Good evening. I'm Bill Moyers. Last night you met Leon Kass, the philosopher, he and I discussed the health of the soul and the lessons of mortality and morality. Tonight, in Part Two of our conversation, you'll meet Leon Kass the scientist and the physician, as we explore how his philosophy applies to specific problems facing the doctor and the patient.

[voice-over] Leon Kass is by rearing a moralist, by education a generalist, by training a physician and biochemist, by vocation a teacher and student of philosophy, and by choice a lover of serious conversation. He teaches at the University of Chicago, and has also been a senior fellow at the National Institutes of Health and a research professor at the Kennedy Institute of Ethics at Georgetown University. In his writings, Dr. Kass explores the relationship between morality and the revolutionary technologies of modern science. Breakthroughs that have given us the power to create new life forms, to make perfect babies, and prolong life. But they also raise excruciating ethical questions for doctors and patients.

{interviewing] What would you say to a badly crippled woman in great misery, suffering from terminal cancer, in a hospital room, as she begged you to help her die?

LEON KASS: A short answer, especially if this question is put to me as a physician, is that I couldnít, in conscience and in loyalty to what it means to be a physician, be the administerer of deadly poison. It violates, as I understand it, the inner meaning of the art of healing. In fact, it's only because I know that I'll never kill my patients that I'm willing to get in there close to them and struggle with them as they face these agonies of the end of their life. And know that I'm never going to give up on them and say, "I can't cure you, I might as well kill you." I mean, that's-to have that power denied me as a physician is, I think, absolutely indispensable to everything humanly I need to do for my patients. Now, that might seem, on the face of it, too short and too insensitive to the real agony of my patients. And I don't for a minute deny that there are many people who, at the end of life, are in not only painful conditions, but in reduced and degraded and humiliated conditions of life in which they couldn't imagine themselves living. And I understand the very powerful pressures for this kind of easy technical solution.

BILL MOYERS: The pain is terrible, Dr. Kass, I-

LEON KASS: Well, I-

BILL MOYERS: Nothing could be worse than staying alive in the way-in the condition I'm in right now.

LEON KASS: Well, let's speak about the pain for a moment, because friends of mine who work in pain management and who work in hospices, I think, have provided some rather powerful evidence that pain management -the pain aspect of terminal illness -is, in almost all cases, really manageable if, in fact the physicians are willing to take the trouble to do it properly.

BILL MOYERS: The alternatives are not just cure and kill?

LEON KASS: That's right. I mean, the relief of suffering, if one's talking about bodily physical pain, for this we are increasingly sophisticated and successful in our ability to deal with it. Now that's not to say in all cases that one will be able to do it, but in the vast majority of cases, with the judicious and aggressive use of medications, one can control this kind of agonizing pain. Now, it's a very different thing if you're talking about dementia, or you're talking about the horror that one feels compelling one's loved ones to visit one and see one in this condition.

BILL MOYERS: The prolonged years of a woman suffering Alzheimer's, unable to recognize, respond, react, reach out to or receive love, affection. Lying there, sitting there, all curled up. The soul is gone. By your own-

LEON KASS: The soul is mostly gone. If she's still breathing or he or she is still breathing on their own, and still responsive in some way, it's flickering, it's not all out. But let me grant your point And here we face, I think, a very delicate and difficult practical problem which is-the boundaries of which are, in a way, roughly easy to describe but in practice exceedingly difficult to do right. And that is to say, look, precisely because one thinks that death is not always the enemy and that the meaning of a life includes a fitting conclusion, that physicians, families and patients ought gracefully to desist from certain kinds of useless efforts to prolong life that in fact

only prolong degradation or suffering, and so on.

On the other hand, one still would draw the line, I think, at the willful and direct, deliberate taking of life, especially on the part of physicians.

BILL MOYERS: Because a physician is?

LEON KASS: Well, for a number of reasons. I mean, pan of the argument is that the physician as physician, I think, cannot directly and deliberately intend and cause the death of a patient I think the physician can perfectly conscientiously give adequate pain medication that might run the risk of shortening life. I mean, to give proper doses of morphine might, in fact, run the risk of respiratory depression and hastening death, but the doctor isn't trying to kill the patient, the doctor is trying to relieve the patient's suffering. To intend the good of the patient presupposes the patient will continue to exist in order to experience the good that you're doing for them. And it's, in a way, it-physicians are not terribly good at standing in there in those last moments with words of encouragement, with those gentle speeches. And, in fact, they are going to be tempted and a very angry society is going to push them into the temptation of saying, "Look, you guys, you've kept us alive longer than we want. You can't cure us. You've put us into this mechanized and dehumanized environment. Get rid of us, please."

And we know we've got the precedent in Holland, where the physicians have already begun to do this. Very nearly in California this November, there would have been a voter initiative to legalize euthanasia, and it just barely failed. We're going to have a lot of pressure for this in this country, and I think we need to try to find a way to walk the line between standing back, allowing to die, even giving patients permission to die, and holding the line at deliberate and willful killing. Not only because, it seems to me, undermines the meaning of what it is to be a physician, but because we're not going to be able to hold the line between voluntary and involuntary euthanasia, it's just impossible to hold the line there.

BILL MOYERS: If one can make a case for mercy killings, one can also find people in the name of mercy killings committing murder?

LEON KASS: Well, we've already seen the precedent for this in the withdrawal of treatment, and it goes like this. The early cases permitting people to refuse life-sustaining treatment were all people who were conscious and who asked that the doctor should leave them alone. And the courts upheld their right to refuse treatment. Next batch of cases, people come along and sue in coon in the name of the comatose, who cannot make the request for themselves, saying, look, equal protection of the laws. Why should someone be denied a right to refuse treatment just because they're too comatose to claim it for themselves? We will speak in their name. And the courts have already upheld the right of some people to select for other people the fact that their life is no longer worth living.

Now, I'm not faulting this, but one has, in away, already established the principle at law that we're going to go from the clearly voluntary cases to those cases which are not involuntary, but nonvoluntary, in which someone else has got to say this is really not a life worth living. And I'm not faulting so much the wish for it, but one sees that the vast majority of cases for which the Euthanasia Society and others want euthanasia are not the small number of voluntary cases whose pain can't be controlled, and they own up to this in print. It's the Alzheimer's, it's the people who are in reduced conditions.

BILL MOYERS: So even if you were contributing to the relief of a dying person seeking escape from his or her agony, you would also be contributing -if you followed the policy of euthanasia, and

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society came in your wake -you'd be contributing to a change in the attitude of culture, of society, toward human life itself. And you don't want to have that unintended consequence.

LEON KASS: No, absolutely. There are a number of circumstances in which the power of the plea for some kind of humane assistance is very great, but to give in to it for perfectly good reasons

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would be to embrace consequences for future generations, the cost of which we can't even begin to imagine. I think that there would be a considerable weakening of our respect for life and a weakening of the hard-won reluctance to take innocent life, if we really made killing patients a therapeutic option.

BILL MOYERS: But if I were your patient, and I had terminal cancer, and I said, "Leon, I know you can't cure me, and I know you won't kill me, but Leon,let me die. Just go away and let me die," would you be morally offended by that?

LEON KASS: I would say we'd have to talk concretely about it. I would say, look, I'm not going to abandon you. You are my patient, a human being I care about until you are no more. If you got an infection, and you said to me, "You know, his infection is likely-is this infection likely to take me?" And if in my best judgment I said to you, "I really think it is," and then you were to say to me, "Look, if you cure this infection, is there any easier and gentler way that I'm liable to get out of this life?" And I say, "No, this is probably the best." And then you said to me, "Look, Leon, we've been together for a number of years. If I get his kind of pneumonia, do me a favor and stand aside. No antibiotics," I'd say, "Well, are you sure about this, and can we talk about it with your family?" and so on. But I think in principle I'd be willing to do that, if I were persuaded that, you know, where was clear understanding that there isn't subtle coercion, that this isn't the fellow who's asking for death not because he really wants to die, but because he thinks it's unseemly to stick around because everybody else is choosing death.

BILL MOYERS: But when you do that, you're playing God.

LEON KASS: If what?

BILL MOYERS: If you're trying to analyze the motives. 1

LEON KASS: No, but one's got to be very careful. If it becomes fashionable, or even permissible, for people to plead for death and the profession is willing to go along with it, we're going to sweep ) up in this not only people who have deliberately and freely and knowingly chosen that they want no more, but all kinds of other people who are not tired of life but who think other people are tired of them, or other people who really would like to live but they think it's son of cowardly to do so, given that choosing death is an option. One would have to be fairly confident, and so, 1 mean, the attempt to reduce all of this to statements and writing is no substitute for this kind of conversation that you as my patient and 1 would have over a number of years.

BILL MOYERS: But 1 would plead with you, I think, to let me take the early train.

LEON KASS: Well, if 1 knew this was you talking and not the despair of a particular episode, part of your present debility.

BILL MOYERS: But despair is a natural part of life, the despair at the end.

LEON KASS: Well, if it were indeed the end, you'd have no trouble from me.

BILL MOYERS: What if the family came to you and said, "Dr. Kass, our mother is 89 years old. Nine years she's had Alzheimer's. There's nothing left there except the biological function. Let her go, you know, let's don't feed her any more"?

LEON KASS: Well, the feeding and hydration is a complicated one, because it's on the boundary between what's obviously therapy and what is the mere sustenance that is, in a way, owed to a human being this side of the grave. And I know that the AMA has flip-flopped on this, and now regards artificially administered food and water as therapy, and therefore optional. And I suppose there are cases in which I could be persuaded to do that. I would much rather say we'll wait for the infection and do nothing, because we are, in a way, it would be useless to do something there. But I wouldn't be saying, "Look, I intend this person's death." I don't see how someone can withhold food and water and pretend that they're doing anything other than intending to kill the patient. And I don't think that one can preserve the trust in the medical profession once that age-old restraint is lifted.

Now, that means that I am in this awkward position of having to say to certain people, "Look, this is not what any of us hoped for. 1bis is a terrible situation, and it's -without abusing the word -tragic." But it would be perhaps even more tragic to acquiesce in the request for certain kinds of relief from this. When the infection comes-certainly, no heroic measures, no operations, and even foregoing antibiotics, and maybe, if you make a case to me, that the patient won't feel, if I know that the person won't feel the starvation, feel the process of dehydration, that I won't be inflicting additional suffering, maybe you might persuade me, but I'm-I'm very worried about this.

BILL MOYERS: It strikes me that life is not a moral choice for the person who is invested with life. We come into this world without our permission. You're saying that death is not really a moral choice, either.

LEON KASS: Well, 1 think that's very nicely put. There is a notion very popular that what counts, humanly speaking, is what's called the person, or consciousness. And that when that goes, everything valuable about us goes. And I have seen enough of such instances where you would say, you know, "Grandfather really died five years ago. We're just burying him now, when the rest of him left" But I think the respect for consciousness, for personhood, for everything that

we would call the distinctively human in human life, we only find that when it's connected with a living, breathing, digesting body, and for the society to place itself in opposition to life is - and even to the mere circulation and breathing - is to commit an affront against the whole of our being, and the whole of our dignity.

BILL MOYERS: All of a sudden it seems we are confronted by these very big ethical questions, from whether the state should require people to be tested for AIDS before they get married, to whether the cells of a fetus should be used for the study of Alzheimer's disease, whether the courts can order a woman to have a Caesarean operation in an effort to save the life of a fetus, whether one Siamese twin should be "sacrificed" -with quotes around it -in a risky operation that might save the other Siamese twin for a normal life -who's going to make these decisions?

LEON KASS: Well, some of these questions are, in fact, social and political questions. It's sometimes said that these are moral questions, and therefore have no place in our political life, that they are moral and religious questions and therefore are outside the realm of politics. But politics is always about moral questions, we're always trying to figure out what the better or the just or the right or decent thing to do is. And while I'm not naive about what kind of results we will achieve through this process, I do think that for better and for worse, in a liberal democracy, those expressions of the beliefs and practices and values of the community are best expressed communally through serious discussion with the populace, in the legislatures, in local communities, in hospitals, and so on. I think. that there are probably a rather small number of such matters that do require legislation, and not everything that I think is of dubious propriety ought to be a matter of illegality. I mean, enforcing certain kinds of laws has its own cost that might be higher than the harm that one is trying to root OUL The public health needs, for example, of dealing with the AIDS problem and pursuing carriers has to be balanced against the invasion of privacy and the use of the police power in order to get compliance in the tracing of contacts, and this is a very delicate subject But I do think that ours is a moral community as well as it is an economic one, and that the media, the schools, the legislative bodies are the place for the airing of some of these questions. To be sure, the individual judgments about when to stand aside from life prolonging treatment is unlikely to be a matter for legislation. One's never going to do away with the need for the prudent judgment of decent people on the spot, and the attempt to provide rules and institutions to solve these problems, I think, is -however well-intentioned -finally foolish. I mean, one's finally got to have room for judgment and conscientiousness, and maybe not a perfect judgment, but the best under the circumstances.

BILL MOYERS: You've said that reproductive technologies are especially dehumanizing. Why are they, in particular?

LEON KASS: The reproductive technologies encourage us to rationalize and make a matter of will and an this deeply ingrained activity whereby we perpetuate ourselves into the next generation. Everybody understands the desirability of family planning. Everyone understands the wish to satisfy the desire to have a child of one's own. One even understands the desire that children should be born healthy. But the more one intrudes into this process to produce what one obstetrician called "the optimum baby," the more one is going to move procreation from the womb and the home into the laboratory, the more it will be transformed from a natural and human activity into one of production and manufacture. And there will be, however much we welcome the benefits in terms of quote, the product, there will be some cost in the dehumanization of the process.

BILL MOYERS: You ask, what, for example, does the word "mother" mean if one woman donates the egg, another houses it for insemination, a third hosts the transferred embryo and gives birth to the baby, a fourth nurses it, a fifth rears it and a sixth has legal custody? Now, thatís an extreme case, an extreme statement.

LEON KASS: A very extreme case.

BILL MOYERS: But he point is?

LEON KASS: Well, the point is that one of the unexpected consequences of these new technologies to cure infertility is that it's now possible to shuttle eggs and embryos around, introducing a certain kind of confusion about one's biological lineage. And the extreme case that we face now, for example, are in these surrogate wombs or surrogate pregnancies, which I think-I feel fairly strongly, this is something I think we really ought not to practice at all. I think that it comes dangerously close to degrading people to allow their bodies to be used merely as incubators for other people's babies.

BILL MOYERS: But the other side of it, Dr. Kass, is that being a mother is not merely -and not always ways -a biological act. It's a-you know, mothers and fathers are born of love, and not just the womb and seed.

LEON KASS: No, to be sure. And one could cite -as both of us would be thinking of -the case of adopted children, much loved and very well-reared. On the other hand, we don't deliberately set out to produce all kinds of babies for the sake of adopting them and to, I think, come close to what is really a kind of market in babies, I think risks certain kinds of degradation of the whole activity of engendering of giving birth, and of connecting sex, procreation, marriage and rearing in a kind of package, which, modern prejudices aside, I think is perhaps the deepest meaning of this aspect of our humanity.

BILL MOYERS: It could make an economic transaction out of what ultimately is a moral affair.

LEON KASS: Yes. And I think, I mean, there are some people who criticize this practice of surrogate motherhood not because they think there's anything intrinsically wrong with it, but because they feel that poor women, especially, are going to be exploited. to take advantage-to make money by this use of, by this service. But if there were really nothing wrong with the practice, there would be nothing wrong with making a living at all. I mean, you don't object to people working for a living; you object when they're, in a way, compelled to put their bodies to the use of other people's wills for a living.

BILL MOYERS: We face some hard choices, don't we?

LEON KASS: We certainly do. And it's an old Chinese curse, "May you live in interesting times." That happens to be, in a way, our dilemma. It's also an opportunity to -thanks to these new technologies that cause us so many hard choices -perhaps to rethink the meaning of our own humanity under the pressure of these new biological possibilities.

BILL MOYERS: From the University of Chicago, this has been part two of a conversation with Leon Kass. I'm Bill Moyers.