On the Other Hand

By my lights, those who publicly take up ethical issues often seem to claim clarity and certainty where I am most struck by ambiguity and ambivalence. It's a feature both of much theoretical discussion and of much professional and political debate. I suspect this is partly a result of underlying theoretical suppositions (which seem shaky to me) about the nature of moral reasoning and the status of moral judgments. I suppose it is also an inevitable feature of any exchange of views that bears on policy or might be subject to legal scrutiny. A person who makes a bedside decision to withdraw care from a dying loved one cannot but feel some ambivalence about the decision, even if they are convinced it is the right or best decision, all things considered, but it is difficult to express this ambivalence without seeming to draw back from the decision.

Some of the contributions to this issue of the Report are especially noteworthy, however, for the pains they take to recognize complexity and ambiguity. In one of the essays, Joseph Fins explains the recent advances in the physiology of brain injury and recovery that have complicated the process of deciding whether a patient is in a vegetative state—one of the sources of ambiguity in these cases. Fins is critical of neurologists, who misdiagnose cases of MCS as vegetative states "at rates that would be intolerable in other clinical domains," but also of right-to-life advocates and journalists, who have sometimes deliberately ignored the distinctions between the multiple disorders of consciousness. (Fins believes that Terri Schiavo, who as of this writing has just entered the seventh day since her feeding tube was removed, is genuinely vegetative.)

The feature articles in this issue also take up complexity of various sorts, and in various ways. In the second article, Rebecca Kukla argues that respecting a patient's autonomy does not mean, contrary to the received wisdom, that the patient makes all of her own health care decisions. Sensible patients don't want to and won't try to. What respecting a patient's autonomy means, rather, is that the patient adheres to health care regimens in which she is in some measure in control of her care, making her own decisions, but also in some measure dependent on her physicians, deferring to their views. Her physicians also inculcate her into her health care regimen in the first place and hold her morally accountable for adhering to it. But then, "to turn the corkscrew yet again," as she writes, patients are supposed to internalize the physicians' health care standards—to endorse them, for good reasons, not merely to obey them blindly—and they should also be able, in principle, to step back, question, or explain their reasons for endorsing those standards. The result is a very complex and sophisticated account of how autonomy is related to self-determination.

In the lead article, Paul Lauritzen writes that stem cell interventions, if they materialized along the lines described by their more avid proponents, might upend our current ethical commitments, or at least undercut our commitment to them, in part because they might incline us to regard nature, including human nature, as having the status of mere artifact. He draws on contemporary artwork to explore this notion. Part of what is interesting about turning to artwork is that art is an imprecise way of registering reaction to a social issue. It is perfect for expressing ambivalence.