Rediscovering community at the core of the human condition and social covenant.

Community is a core value for end of life care. It could not be otherwise. Dying confronts us with questions that go to the heart of what it means to be alive and human. Looking at these questions, we find that, fundamentally, human beings are social animals. Indeed, humanness may have little meaning without a context of relationships with others. Vanderpool asserted, "Being part of a community is essential for the development of consciousness and individuality and is characterized by communication, mutuality, and the ethical ideals of fidelity, gratitude, reciprocity, justice, and love." (1) At its most rudimentary level, society is about people choosing an alternative to isolation and competition. The primal social compact is about offering cooperation and accepting responsibility; self-interest rooted in mutual obligation. This fundamental contract--or is it a covenant?--was the initial impetus for society and remains a sustaining force today. Writing in that tradition, philosopher Norman Daniels has identified "equality of opportunity" as the foundation stone of justice and has outlined principles to guide policy decisions and enable a moral assessment of proposed health care systems. Several years ago Daniels and fellow philosopher Dan Brook wrote this about the Clinton administration health plan: "We are members not only of a national community but also of many other communities that flourish within our society: religious, racial and ethnic, as well as the neighborhoods, towns and cities in which people share a sense of common life. Fundamental to all these different communities is a shared concern and responsibility for one's fellow members, especially those suffering misfortune and in need of help." (2) Applied to situations of illness-related suffering, disability and dying, these core values suggest basic components of care that we are obligated to extend: Providing shelter from the elements. Metaphorically, we say to the other person, "We will keep you warm and dry." Maintaining hygiene. "We will keep you clean." Assisting with elimination. "We will help you with your bowel and bladder function." Offering food and drink. "We will always offer you something to eat and drink--and help you to do it." Keeping company non-abandonment. "We will be with you. You will not have to go through this time in your life entirely alone." Alleviating suffering. "We will do whatever we can, with as much skill and expertise as available, to lessen your discomfort." Obligations and expectations of care find little place within the prevailing contractual framework of patient-provider relations that emphasizes individuals, rights and liberties. If, however, the fundamental social compact is a covenant, by extension, we must incorporate covenantal values and principles within our caring and our ethical analyses. One reason for doing so is that many people prefer for their proxies to make decisions about their care in ways that are, as Joseph Fins has argued, more covenantal than contractual. (3) Inherent limitations of a contractual model carry profound clinical and social implications. Fins notes that the contractual decisionmaking is founded on underlying distrust and requires external strategies such as advance directives, which assign responsibilities, rules and restrictions on surrogates. Protection of autonomous individuals from unwanted intrusion is the highest value. This insight sheds light on the "right to die" as a logical extension of the contractual model as applied to illness, suffering, and dying. It is the right to avoid being protected from oneself. In this context, "assisted suicide" seems a misnomer, a contradiction in terms. Suicide is by nature a solitary act. The act of suicide by an ill person (successful or not) represents not only a rejection of care but an attempt to unilaterally sever the social contract. Traditionally, hospice has operated from an alternative covenantal and community-based approach. …