perspective
Officers of The Center – 2015
field notes Planning for disaster. Some of my friends and relatives wonder why I want to spend my time thinking about social inequities in the context of natural disasters. To answer that question, I have tried to explain the importance of understanding how humanity’s responses mitigate or worsen the human toll of “acts of God.” It seems as though every month another environmental disaster is devastating the lives of hundreds or thousands. A recent example is April’s 7.8 magnitude earthquake in Nepal, which has sprung suggestions from international disaster insurance to sustainable building. I laud the writers who respond to Nepal’s tragedy by continuing to write about sustainability and potential solutions. Natural disasters bring near-instant devastation, affecting large groups of people and razing societies. It can be difficult to innovate and think of answers in the face of what seems to be an overwhelming flood of bad news. Many times it may seem as though the relevance and gravity of one’s thoughts are lost in a twelve-hour news cycle and the Internet’s sugary nonsense that can crowd out productive ideas. Disaster ethics presents its own unique set of challenges. First, there are likely to be a number of criticisms about how any particular disaster is managed, but the validity and relevance of those criticisms for future disasters is limited. No two disasters are exactly the same, which makes it possible to tear apart any analogy of safety or preparedness made between them. This presents difficulties for government bodies and individual communities to respond to natural disasters and invest in infrastructure that has the potential to vastly improve lives. Second, disasters often trigger a “state of emergency,” which leads to an implementation of temporary legal orders that may not apply in other cases. The decision-making that occurs during a disaster by humanitarian aid officials—whether from the Federal Emergency Management Agency, the United Nations, or the American Red Cross—is the product of an emergency situation. Pondering the ethics is often an afterthought since management and containment to safeguard vulnerable people are primary concerns. Yet, much as it is certain that there will be another earthquake that devastates Nepal, Japan, or Southern California, there will always be insights available about how to better address safety and health. Bioethics has a great deal to add to the smaller but similarly interdisciplinary field of disaster ethics. One example is to utilize human flourishing as a model for disaster management. Another is to promote communitarian values. In April 2015, an Institute of Medicine report on health and well-being during and after catastrophic events emphasized that community solidarity is a key component in resilience after a disaster. The IOM found that “pre-disaster planning and post-disaster recovery are part of an ongoing cyclical process of community improvement.” Additionally, the social determinants of health that limit individuals, such as racial and socioeconomic inequalities, have a greater effect during these crises. In order for disaster management to continue to improve, it must keep a notion of the good life at its core. This includes examining the injustices within our society that are already making people vulnerable and preventing them from living healthy lives. —Mohini P. Banerjee Former Research Assistant
David L. Roscoe
Chair Mildred Z. Solomon
President and Chief Executive Officer Harriet S. Rabb
Secretary
Thinking All Wrong about How You Die
Andrew S. Adelson
Treasurer
BY MARGARET P. BATTIN
Board of Directors – 2015 Andrew S. Adelson Liza Bailey Daniel Callahan (ex officio) Edgar Cheng The World-Wide Investment Co., Ltd. Rebecca Dresser (ex officio) Washington University School of Law Joseph J. Fins Weill Cornell Medical College Alan R. Fleischman Albert Einstein College of Medicine Willard Gaylin (ex officio) Francis H. Geer St. Philip’s Church in the Highlands Thomas B. Hakes C/S Group Geoffrey R. Hoguet GRH Holdings, LLC Kim Kamdar Domain Associates Patricia Klingenstein Ilene Sackler Lefcourt Sackler Lefcourt Center for Child Development Robert Michels Weill Cornell Medical College Michele Moody-Adams Columbia College Gilbert S. Omenn University of Michigan Michael E. Patterson Richard Payne Duke Divinity School Robert Pearlman (ex officio) National Center for Ethics in Health Care University of Washington VA Puget Sound Health Care System Harriet S. Rabb Rockefeller University Eve Hart Rice David L. Roscoe Michael Roth Wesleyan University Blair L. Sadler Institute for Healthcare Improvement Mildred Z. Solomon (ex officio) Francis H. Trainer, Jr.
H
ow do we approach our deaths? By avoidance, for Can we recover some form of the ancient understandings one thing—death, especially our own death, is of death? Yes, if we are clear-eyed about what is to come hard to talk about, think about, even imagine in at the end. When your physician says, “We can keep you the dimmest way. Or we dwell on it, that black, feared vor- comfortable,” that’s not the issue. The issue is, what counts tex that will eventually engulf us, swallowing our identity as a good death for you? How can you get what most nearly and personhood. Mostly, we distract ourselves with things approximates your preference to actually happen? of the moment; no need to dampen today with thinking After all, you cannot pretend that the question is not diabout the distant future. rected at you. We all die—we already know that—but what But in our rational moments we make preparations. we don’t always understand is that about three-quarters of We write advance directives. We execute durable pow- us will die of diseases with long downhill courses. Of course, ers of attorney. We give instructions to loved ones about a few folks will die like Bing Crosby, who had a massive and our care when we get cancers or heart attacks or kidney instantly fatal heart attack while walking in from the eighor liver failure or Alzheimer’s or whatever will eventu- teenth hole of a favorite golf course (he had just said to his ally carry us away. “No tubes, no golf partners, “That was a great game machines,” we write piously. “I apof golf, fellas!”), but in the present state n point my friend. . . . . I want comfort of things, in the high-tech developed care. . . .” world, that isn’t what’s in store for most That’s the wrong approach, I think. of us. For most Americans, dying ocHere’s the problem: all this stuff we put curs in health care facilities, the last together doesn’t guarantee that what frame in a photomontage of cognitive we say we want will actually happen or and corporeal defeats. n that we’ll have what we’d call a “good Suppose you could make your own death”—what you would think of as a choices, arrange things so that the way good death for you. That’s for two reasons: we frame our you’d like to die would be your most likely end? Would you wishes mostly in terms of the things that we don’t want— like to be conscious and alert right at the end? Or to just pain, suffering, obtundation—and we have to put our dy- go to sleep and not wake up? Raging against the dying of ing in the hands of others. the light, with every life-sustaining medical effort still being So how might we approach death differently so that our made? Unaware of the approach of death, at the conclusion deaths might go better? Suppose we started with a different of gradually deepening dementia? Or still capable of closing question—not how we don’t want to die, but how we want scenes, like the ancients’, to bestow blessings, pass on wisto die? dom, make peace with whatever god you recognize? These How we die is important. We have lost the ancient He- can require different settings, different timing, and different brew, Greek, and medieval senses that the last moments of medical and caregiving choices, from passive refusal of treatdying are deeply, crucially spiritually important. For the ment, to continuing aggressive management, to palliative ancient Hebrews, this was a time for bestowing (or not) sedation, to an actively assisted end. blessings (think of Jacob with Joseph and his other sons). Your death doesn’t have to be the standard defeat by For Socrates, it was a time for conveying wisdom. For the whatever illness you’re succumbing to as it finally kills you. medievals, there was an entire ars moriendi of final confes- You don’t have to issue only instructions that leave your dysion, absolution, making peace with God. Today, instead, ing in the hands of others. Let’s start thinking about our we have bought ourselves prolonged deaths that often end deaths proactively, so to speak, in ways that will get us closer in effacement, as efforts to control pain and other symp- to our own authentic choices for our last moments here. toms cloud or even deliberately obliterate consciousness.
Reinventing ars moriendi
Margaret P. Battin is a professor of philosophy at the University of Utah and a Hastings Center fellow. DOI: 10.1002/hast.473
Officers of The Center – 2015
field notes Planning for disaster. Some of my friends and relatives wonder why I want to spend my time thinking about social inequities in the context of natural disasters. To answer that question, I have tried to explain the importance of understanding how humanity’s responses mitigate or worsen the human toll of “acts of God.” It seems as though every month another environmental disaster is devastating the lives of hundreds or thousands. A recent example is April’s 7.8 magnitude earthquake in Nepal, which has sprung suggestions from international disaster insurance to sustainable building. I laud the writers who respond to Nepal’s tragedy by continuing to write about sustainability and potential solutions. Natural disasters bring near-instant devastation, affecting large groups of people and razing societies. It can be difficult to innovate and think of answers in the face of what seems to be an overwhelming flood of bad news. Many times it may seem as though the relevance and gravity of one’s thoughts are lost in a twelve-hour news cycle and the Internet’s sugary nonsense that can crowd out productive ideas. Disaster ethics presents its own unique set of challenges. First, there are likely to be a number of criticisms about how any particular disaster is managed, but the validity and relevance of those criticisms for future disasters is limited. No two disasters are exactly the same, which makes it possible to tear apart any analogy of safety or preparedness made between them. This presents difficulties for government bodies and individual communities to respond to natural disasters and invest in infrastructure that has the potential to vastly improve lives. Second, disasters often trigger a “state of emergency,” which leads to an implementation of temporary legal orders that may not apply in other cases. The decision-making that occurs during a disaster by humanitarian aid officials—whether from the Federal Emergency Management Agency, the United Nations, or the American Red Cross—is the product of an emergency situation. Pondering the ethics is often an afterthought since management and containment to safeguard vulnerable people are primary concerns. Yet, much as it is certain that there will be another earthquake that devastates Nepal, Japan, or Southern California, there will always be insights available about how to better address safety and health. Bioethics has a great deal to add to the smaller but similarly interdisciplinary field of disaster ethics. One example is to utilize human flourishing as a model for disaster management. Another is to promote communitarian values. In April 2015, an Institute of Medicine report on health and well-being during and after catastrophic events emphasized that community solidarity is a key component in resilience after a disaster. The IOM found that “pre-disaster planning and post-disaster recovery are part of an ongoing cyclical process of community improvement.” Additionally, the social determinants of health that limit individuals, such as racial and socioeconomic inequalities, have a greater effect during these crises. In order for disaster management to continue to improve, it must keep a notion of the good life at its core. This includes examining the injustices within our society that are already making people vulnerable and preventing them from living healthy lives. —Mohini P. Banerjee Former Research Assistant
David L. Roscoe
Chair Mildred Z. Solomon
President and Chief Executive Officer Harriet S. Rabb
Secretary
Thinking All Wrong about How You Die
Andrew S. Adelson
Treasurer
BY MARGARET P. BATTIN
Board of Directors – 2015 Andrew S. Adelson Liza Bailey Daniel Callahan (ex officio) Edgar Cheng The World-Wide Investment Co., Ltd. Rebecca Dresser (ex officio) Washington University School of Law Joseph J. Fins Weill Cornell Medical College Alan R. Fleischman Albert Einstein College of Medicine Willard Gaylin (ex officio) Francis H. Geer St. Philip’s Church in the Highlands Thomas B. Hakes C/S Group Geoffrey R. Hoguet GRH Holdings, LLC Kim Kamdar Domain Associates Patricia Klingenstein Ilene Sackler Lefcourt Sackler Lefcourt Center for Child Development Robert Michels Weill Cornell Medical College Michele Moody-Adams Columbia College Gilbert S. Omenn University of Michigan Michael E. Patterson Richard Payne Duke Divinity School Robert Pearlman (ex officio) National Center for Ethics in Health Care University of Washington VA Puget Sound Health Care System Harriet S. Rabb Rockefeller University Eve Hart Rice David L. Roscoe Michael Roth Wesleyan University Blair L. Sadler Institute for Healthcare Improvement Mildred Z. Solomon (ex officio) Francis H. Trainer, Jr.
H
ow do we approach our deaths? By avoidance, for Can we recover some form of the ancient understandings one thing—death, especially our own death, is of death? Yes, if we are clear-eyed about what is to come hard to talk about, think about, even imagine in at the end. When your physician says, “We can keep you the dimmest way. Or we dwell on it, that black, feared vor- comfortable,” that’s not the issue. The issue is, what counts tex that will eventually engulf us, swallowing our identity as a good death for you? How can you get what most nearly and personhood. Mostly, we distract ourselves with things approximates your preference to actually happen? of the moment; no need to dampen today with thinking After all, you cannot pretend that the question is not diabout the distant future. rected at you. We all die—we already know that—but what But in our rational moments we make preparations. we don’t always understand is that about three-quarters of We write advance directives. We execute durable pow- us will die of diseases with long downhill courses. Of course, ers of attorney. We give instructions to loved ones about a few folks will die like Bing Crosby, who had a massive and our care when we get cancers or heart attacks or kidney instantly fatal heart attack while walking in from the eighor liver failure or Alzheimer’s or whatever will eventu- teenth hole of a favorite golf course (he had just said to his ally carry us away. “No tubes, no golf partners, “That was a great game machines,” we write piously. “I apof golf, fellas!”), but in the present state n point my friend. . . . . I want comfort of things, in the high-tech developed care. . . .” world, that isn’t what’s in store for most That’s the wrong approach, I think. of us. For most Americans, dying ocHere’s the problem: all this stuff we put curs in health care facilities, the last together doesn’t guarantee that what frame in a photomontage of cognitive we say we want will actually happen or and corporeal defeats. n that we’ll have what we’d call a “good Suppose you could make your own death”—what you would think of as a choices, arrange things so that the way good death for you. That’s for two reasons: we frame our you’d like to die would be your most likely end? Would you wishes mostly in terms of the things that we don’t want— like to be conscious and alert right at the end? Or to just pain, suffering, obtundation—and we have to put our dy- go to sleep and not wake up? Raging against the dying of ing in the hands of others. the light, with every life-sustaining medical effort still being So how might we approach death differently so that our made? Unaware of the approach of death, at the conclusion deaths might go better? Suppose we started with a different of gradually deepening dementia? Or still capable of closing question—not how we don’t want to die, but how we want scenes, like the ancients’, to bestow blessings, pass on wisto die? dom, make peace with whatever god you recognize? These How we die is important. We have lost the ancient He- can require different settings, different timing, and different brew, Greek, and medieval senses that the last moments of medical and caregiving choices, from passive refusal of treatdying are deeply, crucially spiritually important. For the ment, to continuing aggressive management, to palliative ancient Hebrews, this was a time for bestowing (or not) sedation, to an actively assisted end. blessings (think of Jacob with Joseph and his other sons). Your death doesn’t have to be the standard defeat by For Socrates, it was a time for conveying wisdom. For the whatever illness you’re succumbing to as it finally kills you. medievals, there was an entire ars moriendi of final confes- You don’t have to issue only instructions that leave your dysion, absolution, making peace with God. Today, instead, ing in the hands of others. Let’s start thinking about our we have bought ourselves prolonged deaths that often end deaths proactively, so to speak, in ways that will get us closer in effacement, as efforts to control pain and other symp- to our own authentic choices for our last moments here. toms cloud or even deliberately obliterate consciousness.
Reinventing ars moriendi
Margaret P. Battin is a professor of philosophy at the University of Utah and a Hastings Center fellow. DOI: 10.1002/hast.473
