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Open Access 01-09-2018 | Scientific Contribution

Relieving one’s relatives from the burdens of care

Author: Govert den Hartogh

Published in: Medicine, Health Care and Philosophy | Issue 3/2018

Abstract

It has been proposed that an old and ill person may have a ‘duty to die’, i.e. to refuse life-saving treatment or to end her own life, when she is dependent on the care of intimates and the burdens of care are becoming too heavy for them. In this paper I argue for three contentions: (1) You cannot have a strict duty to die, correlating to a claim-right of your relatives, because if they reach the point at which the burdens of care are larger than you can reasonably expect them to take, the natural conclusion is that their duty ends. (2) They may be prepared, however, to go on caring for you beyond that point. In that case your responsibility for their wellbeing may require you to refuse this care, even if this results in a situation for you in which death will be preferable to continued life. (3) If this is the correct understanding of your responsibilities, the objection that in the context of family life the burdens of care attached to one family member’s valued existence can never be ‘too heavy’, fails. It postulates unlimited concern on one side and a total lack of concern on the other.

Landelijk Platform Ouderenmishandeling (2009). For a cross-national study, based on reports of GP’s, see Pivodic et al. (2014). These GP’s considered caregivers who provided long-term care at the end of life to be physically or emotionally overburdened in 28% (Belgium), 30% (the Netherlands), 35% (Spain) and 71% (Italy) of the cases. In 8% (Spain), 14% (Belgium), 36% (the Netherlands) and 43% (Italy) of the cases GP’s reported difficulties in covering care-related costs. Cf. Hardwig (2013, p. 115), for some details about the extent of family caregiving in the USA.

See the American case described by Hardwig (1997, p. 37).

Hardwig (1997, 2000, 2013). My discussion in this paper is restricted to the context of personal care. The possibility of a ‘duty to die’ has also been discussed in the context of the just distribution of scarce health care resources (cf. Battin 1987, 2000; Menzel 1990, 2000), interview with Mary Warnock in Beckford (2008).

Levvis and Levvis (2012).

Cf. Anderson (2000).

In some cultural environoments children are supposed to have fixed duties to their parents that are virtually independent of the behaviour of those parents. It is a difficulty question whether such social norms can have any ‘true’ moral authority. It is beyond the scope of this paper to discuss that question.

That a care-recipient may have to limit the demands made on a care-provider has occasionally been observed in discussions of the ethics of care (e.g. Tjong Tjin Tai 2006, p. 75; Kittay 2013, pp. 82–84) on being ‘overdemanding’.

The argument against Hardwig presented by Cholbi (2010), goes astray by failing to distinguish between these two senses of ‘duty’. He observes that according to Hardwig it can be ‘impermissible’ for you to fail to decide to die in your relatives’ interests, and objects that in that case they would have the right to kill you. But they clearly don’t have such a right. Therefore you have no ‘duty’ to die.

Let alone a duty corresponding to a right of them to kill him, as Cholbi (2010) suggests. Even if Oates would have had a strict duty to die, his comrades would, perhaps, not have wronged him by killing him, but that doesn’t mean that they would have had the right to kill him. For there might be reasons of public trust to prohibit such killings, or impersonal moral considerations. Or the mere fact that the law forbids them could have moral significance.

It is controversial whether implementing that decision by itself would have been a suicide. The actual way in which Oates implemented his decision, by walking into the blizzard in order to save his comrades the agony of the decision to leave him behind, certainly amounted to a suicide for altruistic reasons. But he didn’t have decisive moral reasons to act in that particular way, it was a supererogatory act.It has been objected that even in such cases one does not commit suicide because one would be all too happy when, miraculously, one survived. But that depends on a definition of suicide in terms of intention rather than foreknowledge and endorsement, that can be criticized (cf. Cholbi 2011, chap. 2), for an excellent discussion.

I therefore agree with Cholbi (2010) that there is an important difference between the case of Captain Oates and the cases to which Hardwig’s argument applies. But I don’t believe that the difference can be explained in terms of proportionality, see footnote 25 below.

Cf. English (1992). But I disagree with her view that children never ‘owe’ their parents anything.

Hardwig (2013), cf. Churchill (2000, p. 154).

Cf. Spellecy (2000, p. 210).

As proposed by Drebuschenko (2000).

Kittay (2013, p. 81).

It may be highly praiseworthy to do the right thing, if it requires making great sacrifices. That doesn’t mean, however, that we need a new category of ‘forced supererogation’, as proposed by Cohen (2013). Relieving your relatives from the burdens of care is one of his examples. Such acts may seem to be supererogatory because there is no strict duty, owed to someone else, to perform them.

Joiner (2005, p. 99).

If the perception of being a burden to others is prominent among the reasons for requesting euthanasia in the Netherlands in a particular case, physicians will, for such reasons, be reluctant to grant the request, Haverkate et al. (2000). Although the emotional and physicial burdens of care increase significantly towards the end of the care-recipient’s life, most care-providers do not perceive this as a problem because they consider caring a rewarding task, De Korte-Verhoef et al. (2014).

Callahan (2000), cf. Spellecy (2000). To some extent Hardwig invited this kind of criticism by insisting that the decision should be made by the family collectively.

Harris (1985, pp. 93–94).

Callahan (2000), Kass (1993, p. 271, cf. 281), footnote 1: Kass confesses to be tempted to save his family from the crushing burdens of care, but then asks: “What principle of family life am I enacting and endorsing with my ‘altruistic’ suicide?”

Kittay (2013, pp. 81–84) argues that “both refusing care and making incommensurate demands are strategies by which we deny our dependency on another.”

Callahan (2000).

If only for this reason Cholbi’s argument that, irrespective of the burdens, we always ask too much if we ask people to surrender the benefit of life, does not succeed, Cholbi (2011, pp. 109–111), cf. the appeal to a principle of proportionality to explain why you cannot have a duty to die in order to relieve your relatives from the burdens of care, Cholbi (2010), cf. also Drebuschenko (2000) for a similar but more limited claim. The benefits of life are not the same for everyone and for some are very modest. Cholbi’s view is a variant of what Hardwig calls ‘medical vitalism’, the idea that prolonging life is always the highest personal value. Interestingly, it is the essence of much of Daniel Callahan’s work to deny this, see for example Callahan (1987).

Anderson, S. L. 2000. Do we ever have duty to die? In Is there a duty to die, eds. J. M. Humber and R. F. Almeder, 177–190. Totowa, NJ: Humana Press.CrossRef

Battin, M. P. 1987. Age rationing and the just distribution of health care: Is there a duty to die? Ethics 97: 317–340. Reprinted in The least worst death: Essays in bioethics on the end of life. New York: Oxford University Press 1994, 58–79.

Battin, M. P. 2000. Global life expectancies and the duty to die. In Is There a Duty to die? eds. J. M. Humber and R. F. Almeder, 1–22. New York: Oxford University Press.

Beckford, M. 2008. Baroness Warnock: Dementia sufferers may have a “duty to die.” Telegraph. September 18. http://www.telegraph.co.uk/news/uknews/2983652/Baroness-Warnock-Dementia- sufferers-may-have-a-duty-to-die.html.

Callahan, D. 1987. Setting limits: Medical goals in an aging society. Washington: Georgetown University Press.

Callahan, D. 2000. Our burden upon others: A response to John Hardwig. In Is There a Duty to die? And other essays in medical ethics, eds. J. Hardwig et al., 139–145. New York: Routledge.

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Drebuschenko, D. 2000. How could there be a duty to die? In Is there a duty to die? eds. J. M. Humber and R. F. Almeder, 159–176. New York: Oxford University Press.CrossRef

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Title: Relieving one’s relatives from the burdens of care
Author: Govert den Hartogh
Publication date: 01-09-2018
Publisher: Springer Netherlands
Published in: Medicine, Health Care and Philosophy / Issue 3/2018
Print ISSN: 1386-7423
Electronic ISSN: 1572-8633
DOI: https://doi.org/10.1007/s11019-017-9815-9

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