Human selves, chronic illness, and the ethics of medicine.

Human Selves, Chronic Illness, and the Ethics of Medicine One of the rare pleasures of being at The Hearings Center and involved in discussions of medical ethics is that occasionally we are shaken to our philosophic boots. Amidst our deliberations, we come to the sudden and stunning realization that we do not really know what we are talking about. We rediscover that medical ethics hovers over a philosophic abyss. Fortunately this does not happen often, or we would not be able to carry on with our work. Ordinarily we are like the Harlem Globetrotters of old. We emerge from our offices, the bioethicist's locker room, gather around the conference table, and toss around our cherished ethical principles, autonomy, beneficence, and justice. We twirl them on our fingers, bounce them off our lips, and dribble them through our legs. Ignoring the abyss, we put on a great show and skillfully employ our conceptions, assuming both that they are adequate and that we all know what they mean and imply. This is "Sweet Georgia Brown" ethics, and it is lively, interesting, and usually serves us well. But occasionally the music stops, and we become mired in philosophic quandary. Consider one of our fundamental ethical values: respect for persons and individual autonomy. We ethically require our health care providers to obtain our informed consent, either direct or substituted, before they practice their medicine on us. But who and what are these professionals finally supposed to respect? Is it our rational decision-making capacities? Our individual bodily integrity and historical, biographical, temporally deep selves? Our lives amidst immediate family and friends? Or our active lives pursued within particular and concrete wordly settings, cultural and natural? How we answer this question importantly determines our particular ethical duties. However, such an answer depends on our conception of a human self, of who we are. This, in turn, determines what in practice we want respected or cared for, and what individual human autonomy, may concretely mean. It is precisely here, with the human self, that we stare into the philosophic abyss. "You would not find out the boundaries of the soul, even by traveling along every path: so deep a measure (Logos) does it have." Thus spoke the presocratic Heraclitus (Fragment 45). After all these years, we still lose ourselves along the footpaths of the soul. No doubt it is difficult enough to understand the enigmatic Heraclitus, yet there is one thing we can learn from his aphoristic arrows. The understanding of the self is not a matter of scientific or empirical knowledge that can be decided once and for all. It is a task for philosophic or speculative interpretation, and is essentially open-ended. It is a metaphysical question finally requiring bold fights of rational imagination, always tentative, aiming at an adequate conceptual elucidation of who we are and what we experience and endure. In our ongoing efforts to understand ourselves adequately, we moderns are importantly undermined by recent metaphysical speculation. We poorly comprehend the essential relation of our concrete selves to our organic bodies and to the world abroad. The chief philosophic culprit is arguably the modern conception of "substance," originally fashioned in the great period of substance and genius, the seventeenth century. Here is the crucial point from which critical and speculative reflections should commence. We must begin, of course, with Descartes and his famous and fateful partition of reality into three types of substance--God, Res Extensa, and Res Cogitans: the Divine Being, extended or physical things, and thinking things. A substance is conceived as that which requires nothing else in order to exist, an entity that can be alone by itself, in need of no other in order to be. For example, a human individual's mind does not require a body in order to exist, nor does a body need a human mind, and God requires neither. …