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Age and Death: A Defence of Gradualism

Published online by Cambridge University Press:  06 March 2015

JOSEPH MILLUM
JOSEPH MILLUM*
Affiliation:
Clinical Center Department of Bioethics and Fogarty International Center, National Institutes of [email protected]
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Extract

According to standard comparativist views, death is bad in so far as it deprives someone of goods she would otherwise have had. In The Ethics of Killing, Jeff McMahan argues against such views and in favour of a gradualist account according to which how bad it is to die is a function of both the future goods of which the decedent is deprived and her cognitive development when she dies. Comparativists and gradualists therefore disagree about how bad it is to die at different ages. In this article I examine two prominent criticisms of gradualism and show that both misconstrue McMahan. I develop a related criticism that seems to show that a gradualist cannot coherently relate morbidity and mortality. This criticism also fails, but has an instructive implication for how policy-makers setting priorities for health care investments should regard choices between life-saving interventions and interventions against non-fatal diseases in the very young.

Type
Research Article
Information
Utilitas , Volume 27 , Issue 3 , September 2015 , pp. 279 - 297
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This is a work of the U.S. Government and is not subject to copyright protection in the United States.
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Copyright © Cambridge University Press 2015

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References

1 See Nagel, T., ‘Death’, Noûs 4 (1970), pp. 73–80CrossRefGoogle Scholar; Feldman, F., ‘Some Puzzles about the Evil of Death’, The Philosophical Review 100 (1991), pp. 205–27CrossRefGoogle Scholar.

2 McMahan, J., The Ethics of Killing: Problems at the Margins of Life (New York, 2002), pp. 165–85CrossRefGoogle Scholar.

3 Murray, C. J., ‘Quantifying the Burden of Disease: The Technical Basis for Disability-Adjusted Life Years’, Bulletin of the World Health Organization 72 (1994), pp. 429–45, at 429Google ScholarPubMed.

4 Many other considerations, including the cost of available interventions and the distributive consequences of different policy choices, are, of course, relevant to actual priority-setting decisions.

5 See, e.g. DeGrazia, D., ‘The Harm of Death, Time-relative Interests, and Abortion’, Philosophical Forum 38 (2007), pp. 57–80, at 66–8CrossRefGoogle Scholar. DeGrazia regards the ability of McMahan's alternative account of the badness of death to explain our intuitions about these cases as the central reason to adopt it. This counter-intuitive implication of comparativist accounts of the badness of death has also motivated attempts to incorporate alternatives into summary measures of the burden of disease (see Jamison, D. T., Shahid-Salles, S. A., Jamison, J., Lawn, J. E. and Zupan, J., ‘Incorporating Deaths Near the Time of Birth into Estimates of the Global Burden of Disease’, Global Burden of Disease and Risk Factors, ed. Lopez, A. D., Mathers, C. D., Ezzati, M., Jamison, D. T., and Murray, C. J. L. (Washington DC, 2006), pp. 438–9)Google ScholarPubMed.

6 McMahan, Killing, pp. 74–5.

7 McMahan, Killing, p. 170.

8 McMahan writes: ‘The relation that is constitutive of identity – sufficient physical and functional continuity of the areas of the brain in which consciousness is realized in order for those areas to retain the capacity to support consciousness – is both a necessary and a sufficient condition of a minimal degree of rational egoistic concern. Beyond that, the degree of egoistic concern that it is rational to have about the future may vary with the degree of physical, functional, or organizational continuity in the brain (or, to be more exact, those areas of the brain in which consciousness is realized)’ (McMahan, Killing, p.79). See also his discussion at pp. 267–78.

9 Singer, P., Practical Ethics, 2nd edn. (New York, 1993), p. 95Google Scholar.

10 Feinberg writes: ‘in respect at least to welfare interests, we are inclined to say that what promotes them is good for a person, in any case, whatever his beliefs or wants may be. . . . Welfare interests, however, normally achieve their status as interests in virtue of their being generalized means, often indispensable ones, to the advancement of more ulterior interests. . . . In respect to these interests, wants seem to have an essential role to play, for it is difficult at best to explain how a person could have a direct stake in certain developments without recourse to his wants and goals’ (Feinberg, J., Harm To Others (Oxford, 1984), p. 42Google Scholar). Compare Ronald Dworkin's distinction between experiential and critical interests (Dworkin, R., Life's Dominion: An Argument About Abortion, Euthanasia, and Individual Freedom (New York, 1994)Google Scholar, pp. 204f.).

11 He writes: ‘The badness of death thus varies with a great many factors. But the various factors are strongly correlated with age.’ When a foetus or infant dies, ‘the loss is great and the victim has so far gained little or nothing from life. But the misfortune is greatly diminished by the virtual absence of potential psychological connections to the life that is lost, the absence of narrative structure in the life, the absence of investment in the future, the absence of desert, and the absence of categorical desires for future goods. The badness of the loss must be discounted for the absence of each of these factors’ (McMahan, Killing, p. 184).

12 Nelson Textbook of Pediatrics, ed. R. Kliegman et al., 19th edn. (Philadelphia, 2011); Centers for Disease Control and Prevention, ‘Developmental Milestones’, <http://www.cdc.gov/ncbddd/actearly/milestones/> (2012).

13 For a contrary view, see McMahan, Killing, p. 184. McMahan concedes: ‘Exactly where the peak is, and whether the peak is actually a plateau, are questions that it is difficult to answer with confidence . . . And there is certainly a case to be made for the view that the peak comes even before adolescence.’

14 Depending on the specific account of interests that one adopts, the age at which it starts to be bad for an individual that she dies will vary. For example, if it were necessary for someone to be self-conscious in order to have an interest in her continuing existence, then death would start to be bad for people at a much later age than if mere sentience were sufficient. I have assumed that it can be bad to die as soon as one is sentient, but I have not argued for this claim. For the purposes of this article, the point at which death starts to be bad for a creature does not matter: the objections and my responses to them apply equally well to any function of the form represented in figure 1 no matter how we shift its starting point along the x-axis.

15 Bradley, B., ‘The Worst Time to Die’, Ethics 118 (2008), pp. 291–314, at 297Google Scholar.

16 McMahan, Killing, p. 105.

17 Bradley, ‘Worst Time’, p. 292. In his book Bradley calls it the Difference-Making Principle (DMP), which is ‘the account that the overall value of an event for a person is equal to the difference between the value of her actual life and the value of the life she would have had if the event had not happened’ (Bradley, Ben, Well Being and Death (Oxford, 2009), p. 113CrossRefGoogle Scholar; see pp. 50–2 for a precise characterization).

18 This is true only if we begin to exist at conception. If we begin to exist at a later point – for example, when we become sentient – then that point will be the worst time to die, according to the Life Comparative Account. Again, it seems implausible that the death of a barely sentient foetus is as bad for him as the death of an infant or young child is for her. Gradualist accounts can explain why.

19 McMahan, Killing, pp. 165–6.

20 McMahan, Killing, p. 171, cited in Bradley, ‘Worst Time’, p. 297.

21 Bradley, ‘Worst Time’, p. 297. Compare Bradley, Well Being, pp. 121–2.

22 Bradley briefly questions P2 on the grounds that it might in fact be bad to fail to come into existence. I can, for example, consider possible worlds in which I do not exist and note that in those worlds I do not experience any pleasure. Bradley claims that we ‘might conclude that an event that brought about these sorts of negative facts about me would be harmful to me at that world, even though I never exist there’ (Bradley, ‘Worst Time’, p. 298). But in the cases we are considering, denying P2 is very implausible. It would imply that preventing people from coming into existence in this world is bad for them and therefore imply that the use of contraception is harmful.

23 Bradley, ‘Worst Time’, pp. 298–9.

24 Bradley, ‘Worst Time’, p. 299.

25 Bradley, ‘Worst Time’, p. 299.

26 Note that McMahan does not think that differences in moral status affect how (morally) bad it is for an individual to die, even though he thinks that how wrong it is to kill someone depends on whether or not they are a person (see McMahan, Killing, pp. 183–4 for the factors that he thinks are relevant to the badness of death simpliciter).

27 Suppose that the LCA is correct, but that harms matter morally in proportion to moral status. Then, if the moral status of a foetus develops in degrees, how much it matters that someone dies at an age will vary in a very similar way to the way that McMahan suggests. Thus, for the purposes to which an account of the badness of death might be put, such as deciding how much weight to give to the prevention of deaths in setting priorities for health care spending, it would give very similar results.

28 Bradley also very briefly suggests a possible objection to P4: ‘I can imagine someone taking issue with P4, in the following way: Coming into existence is a big deal in someone's life. Many things are true of a person after she comes into existence that weren't true before. One of those things is that she can die. Another is that she can be harmed. Insofar as we care about preventing harms to people, then, we must think it is important to prevent someone from coming into existence if she would otherwise die shortly after coming into existence’ (Bradley, ‘Worst Time’, pp. 297–8). Since the argument that I reconstruct on McMahan's behalf does not require P4, I do not consider it here.

29 Bradley, ‘Worst Time’, p. 300.

30 Bradley, ‘Worst Time’, p. 300.

31 Bradley, ‘Worst Time’, p. 297. Jeff McMahan called my attention to a passage later in his book, where he explicitly recognizes this point. In that passage, responding to an argument of Michael Lockwood's, McMahan notes that: ‘the evil of being deprived of further life is not appropriately avoided by ensuring that the possible victim gets no life at all. It is not that kind of evil. . . . Even if causing a fetus to exist condemns it to a tragically premature death, it does not follow that causing it to exist is bad for it’ (McMahan, Killing, pp. 369–70).

32 To back this up with some statistics, in the United States up to 50 per cent of fertilized eggs are estimated to die and among women who know themselves to be pregnant 15–20 per cent of pregnancies end in miscarriage, usually before seven weeks gestational age (PubMed Health A.D.A.M., ‘Miscarriage’, Medical Encyclopedia, <http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002458/> (2012)). In 2008, in the United States, there were 1,118,000 foetal losses (i.e. miscarriages and stillbirths) while there were 2,471,984 total non-foetal deaths (A. M. Miniño et al., ‘Deaths: Final Data For 2008’, National Vital Statistics Reports 59.10 (2011)). The U.S. National Institutes of Health, which is the largest publicly funded health research institution in the world, has an annual budget of almost $31 billion. Approximately $1.3 billion is appropriated to the National Institute of Child Health and Development, which in turn spends a small fraction of its budget on research into the prevention of miscarriages. (National Institutes of Health, ‘Appropriations History by Institute/Center (1938 to Present)’, <http://www.officeofbudget.od.nih.gov/approp_hist.html> (2012)).

33 Note that McMahan's arguments do not rely on the claim that there is no harm to the foetus, just that the harm is not as bad as the harm to a young adult who dies. It is at least plausible that later miscarriages and stillbirths are bad in virtue of their effects both on the mother and on the foetus (see J. Phillips and J. Millum, ‘Valuing Stillbirths’, Bioethics (forthcoming)).

34 J. Broome, Saving Lives (Oxford, 2004), p. 250.

35 Broome, Saving Lives, p. 251.

36 Broome, Saving Lives, p. 251.

37 Note that this is not committing to a view about when death harms the person who dies. Rather, it concerns when in someone's life we should evaluate her interest in not dying. (On the question of when death harms the decedent see Feit, N., ‘The Time of Death's Misfortune’, Noûs 36 (2002), pp. 359–83CrossRefGoogle Scholar; Bradley, B., ‘When Is Death Bad for the One Who Dies?’, Noûs, 38 (2004), pp. 1–28CrossRefGoogle Scholar; and for an overview of the debate see S. Luper, ‘Death’, Stanford Encyclopedia of Philosophy, <http://www.plato.stanford.edu/entries/death/> (2009).)

38 We can make similar judgements about cases in which a person did not yet exist, but we know will come to exist independent of our actions. Holding all else constant, the person who plants a bomb in a kindergarten that will go off tomorrow and the person who plants a bomb that will go off in six years’ time are equally guilty of murder, despite the fact that the latter's victims do not yet exist. They exist and matter morally at the time of their deaths, and that is what is relevant to our moral judgement.

39 This is stated simplistically for the sake of making clear the contrast between morbidity and mortality. It might be that lifetime well-being is not a simple sum of one's well-being at each time one is alive, but that more global features of one's life, such as the diachronic distribution of well-being, matter too (see, e.g. Velleman, J. D., ‘Well-Being and Time’, Pacific Philosophical Quarterly 72 (1991), pp. 48–77CrossRefGoogle Scholar).

40 The arbitrary choice of these numbers is irrelevant. The apparent paradox and the implication I note in the next section can be generated provided that the disvalue of losing future life at a young age is discounted by a multiplier of less than 1. In that case, there will be some level of disability that is better than being dead, but sufficiently bad that the DALYs associated with the disability over a lifetime will be greater than those associated with dying at that young age.

41 The structure of this problem is not an artefact of the way that DALYs are constructed. A similar problem can be generated if we use a positive measure of health, such as a quality-adjusted life year (QALY) where one QALY is equal to the value of a year of life lived in perfect health. A newborn who dies thereby misses out on 80 QALYs. According to the gradualist, however, those QALYs should be discounted, so that saving her life is valued at 20 QALYs. A lifetime lived with the disability will be worth 40 QALYs, so that preventing the disability would be worth 40 QALYs. Again, the loss to the individual is twice as much if she has the disability than if she dies.

42 McMahan, Killing, p. 185.

43 McMahan, Killing, p. 187.

44 Note that this does not straightforwardly entail that we should treat the newborns who would be blind over those who would die. The newborns who would otherwise die are, plausibly, worse off than those who would live anyway. Prioritarian considerations would therefore provide countervailing reasons to prevent the deaths. The correct verdict in any specific case will depend on the relative importance of maximizing valuable life years versus prioritizing the worse off, as well as the specific disability weights given to the diseases that could be prevented. Thanks to Doug Mackay for this point.

45 For helpful comments and feedback, I would like to thank Jeff Brand, Steve Campbell, David DeGrazia, Michael Garnett, Jeff McMahan, Daniel Sharp, Alex Voorhoeve, Alan Wertheimer, and audiences at the Clinical Center Department of Bioethics, the 2013 Three Rivers Philosophy Conference and the New Scholars in Bioethics 2nd Annual Symposium. Disclaimer: The views expressed are the author's own. They do not represent the position or policy of the National Institutes of Health, U.S. Public Health Service or the Department of Health and Human Services. Funding Support: This work was supported, in part, by intramural funds from the National Institutes of Health Clinical Center.