No practitioner of medicine wants to turn a person into an object, an object that he subjects to technological manipulation. Yet the pragmatism of medicine focuses on ways to manipulate the physiological body.

Medical scientists of the 1950s and 60s focused their research, not on life in a meaningful sense, but on life defined by the measures of physiological function. The power of technology renders the practitioner forgetful of meaning and purpose. For medicine, then, the important question becomes, Who holds the power over physiological functioning? The debate in medicine has not been about philosophically exploring the ways in which life as such might be meaningful; instead, its focus has been on who can invest meaning back into, and who should exert power over, the meaningless mechanism of the body.

It is at this point that the metaphysical assumptions of modern medicine become most apparent. Medicine as a discipline is mostly concerned with doing and with the effects it brings about in the world. Medicine is a practice ordered toward and by its own practicality - in other words, it collapses into an unthinking pragmatism. Medical information is justified as medical knowledge if one can do something with it in the world.

Means without ends: The metaphysics of medicine

To put this in more thoroughly philosophical terms, medicine's metaphysical stance is a metaphysics of material and efficient causation, concerned with the empirical realm of matter, effects and the rational working out of their causes for the purposes of finding ways to control the material of bodies. That is to say, medicine's metaphysics of causation is one of material and efficient causes at the expense of final causes or purposes.

Among Aristotle's four causes, early modern science - including medical science - historically repudiated (or, at very least, minimized) formal and final causation and elevated material and efficient causation. Newtonian physics thus turned to a philosophy of forces, where the prior cause forces the next effect or series of effects into being; this became the model for medicine, giving birth to a physiology of function, not purpose. There is no formal cause, merely brute force; there is no final cause, merely the post hoc addition of political or individual will.

The problem is that medicine gives no thought to its metaphysics; it might even deny having one. And it gives no thought to its practices, because medicine is about doing, not thinking. For Western medicine, and perhaps for all scientific and technological thinking, the most important problem in the medical world is how to manipulate the body or the psyche in order to get the effects that we desire. Bodies have no purpose or meaning in themselves, except insofar as we direct those bodies according to our desires.

The consequence of medicine's cutting itself free from any purpose or telos is that the questions surrounding medical practice have been recast in terms of power. Thus, patient power is pitted against medical power. Scientific medicine felt compelled to deploy its powerful technologies to master the dying body and maintain life; patients (and their families) felt themselves (or their loved ones) to be patronized and dehumanized.

But rather than rethinking its metaphysics of efficient control, medicine reaffirms it by shifting from exalting the doctor's control to exalting the patient's control. Medicine thus opened a space in which the sovereign patient could embrace death in rejecting the technologies of the ICU. In emphasizing the right of the sovereign decision, one's life and death become one's own-most decision. One either embraces death in rejecting technology, or embraces a life worse than death in embracing technology and forcing life on matter that cannot sustain it of itself. Because there is no robust conception of the formal cause of the living body, there is no real integrity to the life of the body, except insofar as it is forced by a decision.

On this logic, a death is a "good death" only if it is chosen. The logic of sovereign decision thus extends to acts that cause death. On a metaphysics of efficient causation, the sovereign decision is the efficient cause ordered to its terminus, death. The act of rejecting technology is a choice between death and a meaningless life in the ICU, and similarly, the act of embracing doctor-assisted death is couched as a choice between death and a meaningless life of pain. Both are considered decisions for the same kind of action: a decision maker is acting toward his own death.

In this apparatus, doctors become cogs that turn the wheels of embracing or rejecting physiological functioning. Most recently, this sentiment has resulted in ideas that doctors cannot refuse to act even if the doctor finds the decision morally objectionable. On a view such as this, doctors do not engage in moral deliberation at all - because morality is merely a choice, and the doctor does not choose, she or he merely turns the cog of body's mechanism.

Deciding to die

This is nowhere more problematic, or perfidious, than in the case of physician-assisted suicide (PAS), in which the doctor is a mere efficient cause, a cog in a wheel of action that originates in a prior decision. In an older morality, informed by a different metaphysics, one can distinguish between letting someone die - which can be a morally acceptable practice - and PAS - which can never be morally acceptable. These practices historically have been distinguished on the bases of traditional philosophical understandings of causation and moral assessment.

In this regard, the question that forms the title of an essay by Franklin Miller, Howard Brody and Timothy Quill is very telling: "Can physician-assisted suicide be regulated effectively?" Efficiency and effectiveness can be assured by the doctor and by the law. Miller and his co-authors shift the emphasis to the regulative function of the physician, who can efficiently assure proper authorization of death-inducing activity.

The key regulative function of the physician is to ensure effective responses to a patient's decision. The patient's explicit request for death must be judged by the physician to be a free, autonomous request for death. In short, the physician will serve as the procedural regulator of the social apparatus of taking a patient's life. The physician examines and regulates physician-assisted suicide by interrogating the patient's motives and desires, ensuring autonomy in a sea of heteronymous factors. The physician acts as an efficient cause in checking the patient's autonomy. The authors conclude that with the proper social apparatus in place, physicians can efficiently manage the checking of a patient's autonomy.

Efficiency extends not only to the doctor's regulative role in assessing patient decisions for their rationality, but also to the killing action itself. In another essay, Quill and others provide a list of six approaches to patients who opt for noncurative therapy - that is, who decide to die. Four of these practices have traditionally fallen within accepted medical practice, and two fall outside accepted practice. I briefly discuss the six practices to illustrate my point.

Standard pain management: The patient receives quality pain management, including care that may shorten his life, but for which the physician has not traditionally been thought culpable. This employs the rule of double effect. Forgoing life-sustaining therapy: The patient may choose not to undergo major curative interventions should he find them cumbersome. Physician involvement is necessary insofar as the physician must cease and desist. Time to death depends on the aggressiveness of the disease. Voluntary Stopping of Eating and Drinking (VSED): The patient, of his own accord, chooses to stop eating and drinking. No physician involvement is really needed. This requires tremendous will power on the part of the patient, and thus it is clear that the patient chooses this method of his own accord. Time to death is anywhere from one to three weeks, and the lengthiness of time to death makes this option less than optimal because the patient's clarity of cognition may "raise questions about whether the action remains voluntary." Quill and others see this practice as potentially problematic, on the one hand because the doctor might undermine the patient's resolve not to eat or drink by continually offering him food and drink; on the other hand, if the palliative care team does not continue to offer food or water to the patient, the physician cannot continue to ensure that the choice is autonomous. Moreover, the physician is not present (assuming the patient is at home) to continue the regulative function, and thus "palliation of symptoms may be inadequate, the decision to forgo eating and drinking may not be informed, and cases of treatable depression may be missed." While I agree that many of these issues are important, the point remains that in Quill's assessment, the physician must be present to assure the efficiency of the process of dying. Terminal Sedation (TS): A continuous infusion of a medication, usually a benzodiazepine, is given in such quantities as to induce complete sedation. The goal is to increase the infusion until such time as the patient appears to be comfortable. Quill and others suggest that with TS, medical practitioners are in a better position to ensure that the patient's decision is voluntary, given that the regulative aspects of most medical practices are extensive; this ensures that the patient is repeatedly questioned about her desire to continue with this intervention. Physician-Assisted Suicide (PAS): In this practice the physician writes a prescription for a large dose of barbiturates; the patient decides when or if to take them. These medications induce deep sleep and finally suppress respirations, resulting in death. The patient is the main actor here, as the physician plays a more passive role (though Quill and others state that the physician plays an indirect role - a confusion of traditional moral terminology). In addition to violating some traditional medical mores, this practice is "not always effective," as stated by Quill and others, and potentially messy, as it may induce vomiting. Without the physician present, the patient's family may lose heart or become frightened, taking the patient to the emergency room, where he may be resuscitated and receive unwanted therapeutic interventions. Voluntary Active Euthanasia (VAE): Here, the physician takes a much more active role than in the first five approaches. After receiving a strong sedating agent, the patient receives a lethal dose of medication, usually a paralytic agent, possibly followed by a bolus of potassium chloride to stop the heart. "VAE has the advantages of being quick and effective." Physicians again can ensure the voluntary nature of the act right up to the time of death, thus fulfilling the regulative function for the social apparatus.

The most remarkable aspect of this list of practices is that the distinctions of traditional morality have vanished. There is no mention of intention or the moral integrity of the physician. There is little mention of patient intention, and then only in terms of decision and choice. The physician's role is to ascertain that the patient's agency, her sovereignty, is intact. The actions are only assessed in terms of the final effect - death - and the efficient means to achieve it.

The moral distinctions between these six actions are removed precisely because Quill and others accept a metaphysics of efficient causation, where a dualism is set up between the decision (the will to power) and matter. On this schema, these practices are part of a continuum of comprehensive care caused by the prior patient decision and directed to the same final effect, death. The main concern of Quill, Miller and their co-authors is the efficiency and effectiveness with which this continuum of care can be implemented, including both the efficiency of the social apparatus and the efficiency of the process of death-inducing activity. The effectiveness of death-inducing activity takes centre stage.

Notice that death here becomes the most rational of choices because, in the efficiency of the social apparatus, death - the final effect of all causes and effects - is the focal point of the picture. And so death, which had been hidden deep in the body, hidden by technological medicine, rears its head once again, this time in the machine of the social apparatus.

Rather than being subjected to the sovereignty of doctors, patients are told that they are their own sovereigns capable of subjecting themselves to their own deaths, first by rejecting the machinery of medicine and, more recently, by embracing either Jack Kevorkian's death machine - the thanatron, as he calls it - or the social machinery of legally sanctioned PAS.

Thus, the issue is framed as a choice between a life without meaning in the ICU (or a meaningless life of suffering) and a death chosen and owned by the patient, who has been reassured by the social apparatus that her death is autonomously chosen and is therefore moral. The sovereign decision is therefore not really a decision welling up deep from within the self, but is instead moulded and shaped by a medico-legal social apparatus. Death, and by extension, life that resists death, are fully ensconced in this apparatus.

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This drive to think practically, mechanically and efficiently is not merely where medicine has gone. It is where Western cultures have gone. Medicine both produces and is produced by the metaphysics of efficient causation rampant in Western cultures. This metaphysics of efficient causation is also what drives modern liberal governments bent on efficient control of bodies, living and dying. It reduces life to its mechanisms of control, at both the level of the body and at the level of the body politic.

Since in this metaphysics, life comes from nowhere (no meaningful formal causation), is headed nowhere and has no particular purpose (no final causation), we are left with bodies caught in the social apparatuses of liberalism. On this Western metaphysics of efficient causation, we are little more than corpses figuring out when to embrace death.

Jeffrey Bishop is the author of The Anticipatory Corpse: Medicine, Power, and the Care of the Dying. He directs the Albert Gnaegi Center for Health Care Ethics at Saint Louis University and holds the Tenet Endowed Chair in Health Care Ethics.