In this essay, we appeal to conceptual and empirical research to establish that autonomy and meaningfulness, when understood concretely and realistically, remain possible for frail and dependent elders. Contrary to ageist cultural attitudes, relationships render frailty and dependence compatible with the exercise of autonomous agency and with a life of meaning. This conclusion is important not only for the goal of supporting frail elders but also for developing a realistic understanding of the way relationships and spirituality are required for autonomy and meaning in the life of any human person, regardless of what state of dependence or independence they may be in. Each of us develops and continues to exist in radical dependence on others. Seeing the way autonomy and meaning manifest in the context of frailty and dependence thus helps us better appreciate what these crucial aspects of being human mean for all of us. In other words, we can learn important lessons about autonomy, meaningfulness, and relationship from the experience of our elders, and in particular from those who experience significant frailty and dependence.
The moral significance of the distinction between killing and allowing to die has played a key role in debates about euthanasia and physician assisted suicide. Since the withdrawal of life-sustaining treatment is held as morally permissible in the medical community, it follows that if there is no morally significant difference between killing and allowing to die, then there is no morally significant difference between withdrawing life-sustaining treatment or administering a lethal injection to end a patient’s life. Consistency then requires that voluntary active euthanasia (VAE) is also morally permissible. The debates over whether the distinction is morally significant have carried on for decades with little hope of consensus. We begin by surveying the literature to identify common argumentative strategies used in defending or rejecting the distinction’s significance. We observe, based on our review, that many of these strategies operate in ways that are conceptually removed from the concrete clinical situation of physicians involved in practices that lead to patient death (by withdrawal of treatment or VAE). We conclude by arguing for a novel way of moving the debate forward indicated by our reading of the literature, namely, by paying careful attention to the moral experience of physicians involved in end-of-life interventions to understand how they experience these practices. Exploring physician experience can reveal how the distinction may or may not be useful for moral deliberation and can provide the needed context to theorize about the distinction in a more empirically informed and practically useful way.
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