Why Being Alive Matters

People in "suspended states." "Slippery state" people. A category to conjure with, according to Elysa R. Koppelman (2003), one that avoids our society's misguided attention to whether a person is alive or dead and instead focuses on furthering that person's interests. But perhaps her proposed new focus is less helpful than one might think.

Why We Care about Whether a Person Is Alive

Koppelman suggests that the rule she proposes is somehow "good for" persons in a persistent vegetative state (PVS), that she is "furthering" their interests and eliminating the "disrespect" shown them by the dead donor rule. This conclusion is far from obvious. Indeed, if we examine her rule in the context of related situations, it appears that she might be doing just the opposite of what she claims.

To understand why this might be so, we need to first recognize something she says relatively little about: that the line between life and death is used by society for a number of purposes, not all of them designed to "maximize" the autonomy of persons who are alive. In 49 of the states we don't let people end their lives with the "active" assistance of a physician, even if the person has a miserable life and is sure to be dead within days or at most weeks. This rule is embodied in the laws against homicide, which criminalize actively hastening a person's death even if this is what that person, competently exercising his or her own autonomy, desperately wishes.

One is left to wonder about how this rule will apply to the people in Koppelman's new category. She is quite eager to empower them by giving them a new "right" to actively end their lives by altruistically donating their vital organs, a "right" the rest of us don't have. Yet she says nothing about their right to actively end their lives for more mundane nonaltruistic reasons; for example, just because they don't want to be kept alive in their current condition. Will a person who is in a persistent vegetative state be allowed to die by lethal injection if he or she requested this in an advance directive? ("After being kept alive for one year, if I am then diagnosed as being in PVS, I want a lethal injection.") Presumably, this is as rational a choice for such a person as choosing to donate their organs. I suspect I am not alone in having encountered families of patients in PVS who kept them alive largely because the only way to allow them to die would be to withdraw hydration and nutrition and wait the needed one to two weeks (Tresch et al. 1991). These family members might well resent society's denying their loved ones a near-instant way to die (and their beliefs might well have been shared by the patients themselves).

If Koppelman is truly interested in furthering the autonomy of the "suspended state" people, it is curious that her entire article concentrates on something that most of us would consider an act of altruism (donating organs) and says nothing about providing the right to physician- assisted suicide that would more directly allow them to control their well-being. If it is so important to avoid "disrespecting" them by failing to let them donate vital organs, wouldn't it be even more respectful to let them control their lives for their own selfish purposes (Menikoff 2002)? And, of course, both of these rights are rights we do not give to "fully alive" people, raising exactly the issue of whether these people aren't effectively being turned into a subclass of "less than whole" persons.

Yet, reading Koppelman's article, one is left with the incorrect impression that the issue of physician-assisted suicide has nothing to do with her proposal. In fact, she is proposing a limited variant: physician-assisted suicide by organ donation. It is telling to note that in...