The Value of Life

6The value of life: who decides andhow?

Consider the following case.

The case illustrates the relevance of question-ing the value of a life, if for no other reasonthan that some people come face-to-face withthe reality of asking this question about theirown lives. The key consideration in end of lifechallenges is how that life is valued. In the caseof James Brady (see p. 91), it became clear thatBrady placed little value on his life as hishealth began to fail. On balance, he preferredto die rather than continue to live with thequality to which his life had deteriorated. Thecourts made the same decision for JanetJohnstone after recommendations from her

109

Questions about the value of life involve someof the most important considerations made inthe fields of medicine and medical ethics,including treatment and management deci-sions in all areas of life and death. Placing avalue on a given life is significant in antenatalcare, infant care, childhood, adulthood andinto old age. It is relevant to congenital birthdefects and genetic conditions, as well as tomid-life accidents and senile dementia. Howwe make decisions regarding the value of agiven life, and who ought to make these deci-sions, is difficult to discern (Fig. 6.1). Perhapsmost importantly of all, why are we eveninterested in assessing the value of a life?

Figure 6.1The title of this installation piece – ‘2ndclass male, 2nd class female’ – raises thequestion of whether it is ever appropriateto place a value on life. The company thatsold these skulls for educational purposeshad labelled them ‘second class’ becausethey were considered to be of pooreducational quality. (‘2nd class male, 2ndclass female’ Christine Borland 1996. ©Christine Borland. Courtesy of the artistand Howard and Donna Stone, Chicago.)

Case 23The value of life

Katherine Lewis is an intelligent, unmarried, 40-year-old woman suffering from Guillain–Barré’ssyndrome, a painful neurological illness thatleaves its sufferers paralysed for unpredictablelengths of time. Many people recover from thesyndrome more or less completely and live long,relatively healthy lives. However, Katherine hasbeen paralysed for 3 years and, 10 months ago, itwas recognized that she was unlikely to be able tomove or breathe on her own again because of theextent of damage to her nerves and muscles; shenow needs a ventilator to help her breathe.

You explained this to Katherine in a gentle butclear manner. Last week Katherine asked tospeak with you privately. She told you that she had considered her options and decided that sheno longer wanted to live. She said her life held novalue for her if it meant being in constant pain andwithout the freedom to move or even breathe onher own. She told you that she has discussed thiswith her family and that they have accepted herwishes to have the ventilator removed.

family and doctors (see p. 96). Similarly,Katherine Lewis, in the case above, made along-considered decision about the value ofher own life. So the issue is relevant. Neverthe-less, how the value of a life is determined is sofar unanswerable, although there are someuseful ideas and principles to consider.

In this section we will consider first howdecisions about the value of life are madeand, second, who is, and ought to be,involved in these decisions. The first questionwill be resolved by exploring concepts ofquality, quantity and sanctity of life. We willalso examine the differences involved whenmaking decisions about individual lives asdistinct from making general decisions aboutthe value of types of lives (in other words, wewill distinguish decisions made at the microand macro levels). The second aspect willexplore the differences between stakeholdersand decision makers, and ask who has alegitimate stake in the decisions about valueof life and who ought to be permitted tomake those decisions. We will ask:

• how do we place value on life?• who are the relevant stakeholders and

decision-makers?

How do we place value on life?There are essentially three elements toconsider when determining the value of life:

• quality• quantity• sanctity.

Quality

The first criterion that springs to mindregarding the value of life is usually thequality of the life or lives in question:

The quality of life ethic puts theemphasis on the type of life being lived,not upon the fact of life. Lives are not all

of one kind; some lives are of greatvalue to the person himself and toothers while others are not. What thelife means to someone is what isimportant. Keeping this in mind it is notinappropriate to say that some lives areof greater value than others, that thecondition or meaning of life does havemuch to do with the justification forterminating that life.1

Those who choose to reason on this basishope that if the quality of a life can be meas-ured then the answer to whether that life hasvalue to the individual can be determinedeasily. This raises special problems, however,because the idea of quality involves a valuejudgement, and value judgements are, bytheir essence, subject to indeterminate rela-tive factors such as preferences and dislikes.Hence, quality of life is difficult to measureand will vary according to individual tastes,preferences and aspirations. As a result, nogeneral rules or principles can be assertedthat would simplify decisions about thevalue of a life based on its quality.Nevertheless, quality is still an essential cri-terion in making such decisions because itgives legitimacy to the possibility thatrational, autonomous persons can decide forthemselves that their own lives either areworth, or are no longer worth, living. To dis-regard this possibility would be to imply thatno individuals can legitimately make suchvalue judgements about their own lives and,if nothing else, that would be counterintu-itive.2 In our case, Katherine Lewis had spent10 months considering her decision beforeconcluding that her life was no longer of atolerable quality. She put a great deal ofeffort into the decision and she was compe-tent when she made it. Who would be betterplaced to make this judgement for her thanKatherine herself? And yet, a doctor facedwith her request would most likely be uncer-tain about whether Katherine’s choice istruly in her best interest, and feel trepidationabout assisting her. We need to know which

Medical ethics: a case-based approach110

considerations can be used to protect thepatient’s interests.

The quality of life criterion asserts that thereis a difference between the type of life and thefact of life. This is the primary differencebetween it and the sanctity criterion dis-cussed on page 115. Among quality of lifeconsiderations rest three assertions:

1. there is relative value to life2. the value of a life is determined

subjectively3. not all lives are of equal value.

Relative valueThe first assertion, that life is of relativevalue, could be taken in two ways. In onesense, it could mean that the value of a givenlife can be placed on a scale and measuredagainst other lives. The scale could be a socialscale, for example, where the contributions orpotential for contribution of individuals aremeasured against those of fellow citizens.Critics of quality of life criteria frequentlyname this as a potential slippery slope wherelives would be deemed worthy of saving, oreven not saving, based on the relative socialvalue of the individual concerned. So, forexample, a mother of four children who is apractising doctor could be regarded ofgreater value to the community than anunmarried accountant. The concern is thatthe potential for discrimination is too high.

Because of the possibility of prejudice andinjustice, supporters of the quality of life cri-terion reject this interpersonal construction infavour of a second, more personalized,option. According to this interpretation, thenotion of relative value is relevant notbetween individuals but within the context ofone person’s life and is measured against thatperson’s needs and aspirations. So Katherinewould base her decision on a comparisonbetween her life before and after her illness.The value placed on the quality of a lifewould be determined by the individualdepending on whether he or she believes thecurrent state to be relatively preferable toprevious or future states and whether he orshe can foresee controlling the circumstancesthat make it that way. Thus, the life of anathlete who aspires to participate in theOlympics can be changed in relative value byan accident that leaves that person a quadri-plegic. The athlete might decide that the rela-tive value of her life is diminished after theaccident, because she perceives her desiresand aspirations to be reduced or beyond hercapacity to control. However, if she receivestreatment and counselling her aspirationscould change and, with the adjustment, shecould learn to value her life as a quadriplegicas much or more than her previous life. Thisillustrates how it is possible for a person toadjust the values by which they appraisetheir lives. For Katherine Lewis, the decisionwent the opposite way and she decided thata life of incapacity and constant pain was ofrelatively low value to her.

It is not surprising that the most vocifer-ous protesters against permitting people inKatherine’s position to be assisted in termi-nating their lives are people who themselvesare disabled. Organizations run by, and thatrepresent, persons with disabilities maketwo assertions in this light. First, they claimthat accepting that Katherine Lewis has aright to die based on her determination thather life is of relatively little value is demean-ing to all disabled people, and implies thatany life with a severe disability is not worth

The value of life: who decides and how? 111

Write a list of three things that makeyour life worth living and ask someoneelse to do the same.

Compare your lists.

Are they identical? Why?

Are they not identical? Why not?

living. Their second assertion is that withproper help, over time Katherine would beable to transform her personal outlook andfind satisfaction in her life that wouldincrease its relative value for her.

The first assertion can be addressed byclarifying that the case of Katherine Lewismust not be taken as a general rule.Deontologists, who are interested inknowing general principles and duties thatcan be applied across all cases would not be very satisfied with this; they wouldprefer to be able to look to duties that wouldapply in all cases. Here, a case-based,context-sensitive approach is better suited.Contextualizing would permit freedom toact within a particular context, without theimplication that the decision must hold ingeneral. So, in this case, Katherine mightdecide that her life is relatively valueless. Inanother case, for example that of actorChristopher Reeve, the decision to seekother ways of valuing this major life changeled to him perceiving his life as highly valu-able, even if different in value from beforethe accident that made him a paraplegic.This invokes the second assertion, thatKatherine could change her view over time.Although we recognize this is possible insome cases, it is not clear how it applies toKatherine. Here we have a case in which arational and competent person has had timeto consider her options and has chosen toend her life of suffering beyond what shebelieves she can endure. Ten months is along time and it will have given her plentyof opportunity to consult with family andprofessionals about the possibilities open toher in the future. Given all this, it is reason-able to assume that Katherine has made awell-reasoned decision. It might not be adecision that everyone can agree with but ifher reasoning process can be called intoquestion then at what point can we say thata decision is sound? She meets all the cri-teria for competence and she is aware of theconsequences of her decision. It would bevery difficult to determine what arguments

could truly justify interfering with herchoice.

Subjective determinationThe second assertion made by supporters ofthe quality of life as a criterion for decision-making is closely related to the first, but withan added dimension. This assertion suggeststhat the determination of the value of thequality of a given life is a subjective determi-nation to be made by the person experiencingthat life. The important addition here is thatthe decision is a personal one that, ideally,ought not to be made externally by anotherperson but internally by the individualinvolved. Katherine Lewis made this decisionfor herself based on a comparison betweentwo stages of her life. So did James Brady.Without this element, decisions based onquality of life criteria lack salient informationand the patients concerned cannot giveinformed consent. Patients must be given theopportunity to decide for themselveswhether they think their lives are worthliving or not. To ignore or overlook patients’judgement in this matter is to violate theirautonomy and their freedom to decide forthemselves on the basis of relevant informa-tion about their future, and comparative con-sideration of their past. As the deontologicalposition puts it so well, to do so is to violatethe imperative that we must treat persons asrational and as ends in themselves.

It is important to remember the subjectiv-ity assertion in this context, so as to empha-size that the judgement made about the valueof a life ought to be made only by the personconcerned and not by others. Of course, thispresumes that the person deciding is con-scious and competent to make the decision atall, which is especially complicated in caseswhen the patient is unconscious, immature orsuffering from a mental illness, such asdepression, that could distort their decision-making abilities. Thus, seeking patient choiceis not always a viable option. Not all patientsare capable of choosing for themselves. InJanet Johnstone’s case, and in the similar case


of Tony Bland, the decision was made exter-nally, by people involved in their care. Insuch situations, family or practitioners havebeen known to make the decision on behalfof the incompetent patient, usually becausethey claim to know what the patient in ques-tion would have wanted. Relatives anddoctors of Janet Johnstone argued that hercondition lacked the dignity and control shevalued, and that her situation would notimprove. Under the circumstances, the judgedecided the quality of her life was so dimin-ished that her life was no longer worth livingand that Ms Johnstone herself would havereached the same conclusion.

The same sort of proxy decision makingoccurs when a woman, or couple, decide toterminate a pregnancy based on antenatalscreening and testing. Here, parents make thedecision on behalf of a fetus or a child.

In such cases the parents must decide if, onbalance, their child’s life is worth living giventhe possibility of pain and suffering or suchinhibited interaction with the world that itwould be of no value to the person living it.Needless to say, this is a difficult and tryingdilemma for anyone to face. It also introducesa concern that underlies all prenatal screeningprogrammes, in that these are supported bythe social values implied by screening, whichdirect women towards termination of positive

tested pregnancies.3 In the past, women werebarred from screening and testing for similarconditions if they had previously decided thatthey would not terminate a pregnancy if thefetus carried the genetic condition. Hencescreening was meant to be followed by testing,and positive results were meant to be followedby termination of pregnancy. The conclusionthis yields, like it or not, is that our screeningprogrammes carry with them an implicationthat the lives of those who are affected withcertain conditions ought to be terminatedbecause they are of comparatively less valuethan the lives of those who are not. This is sup-ported in law by Wrongful Life suits in whichparents of people born with screenable geneticconditions, such as spina bifida, have success-fully sued doctors for the burden involved incaring for those born with such conditions.4

The problems associated with screening will bediscussed elsewhere in Chapter 8 (p. 146–147).They are significant here because they eluci-date the third assertion made by supporters ofquality of life considerations in the medicalcontext.

Equal or unequal value?The third assertion is that, as a result of sub-jective and relative determinations about thequality of a life, lives can be seen to be ofunequal value. At the extreme, it follows thatit is possible to describe a life as valueless,especially when it is compared with the valueof a life that has greater quality. In the case ofthe unborn fetus affected by a debilitatinginherited condition, the welfare of the parentsand their other children can be invested withgreater value than the potential good of apotential child born with a severe disability.This allows us to make relative judgementsamong or between lives of individuals orgroups. This is especially useful in healthcareeconomics, where decisions about distribu-tion of resources rely on comparative infor-mation of the effectiveness of treatments. Inthis way it can be determined that resourceswill be made available for treatments that aremore effective at improving quality of life in


Case 24Screening/testing for Downsyndrome

A 42-year-old woman presented at an antenatalclinic with her husband to discuss the results ofher recent amniocentesis. In addition to Downsyndrome, echocardiography of the fetusshowed cardiac abnormalities, includingatrioventricular septal defect. After extensivediscussion between the parents and theobstetrician, the parents decided that the fetushad too many problems and that it would beunfair to the unborn child and to their other fourchildren to continue with the pregnancy.

particular conditions and not where thequality of life is not improved or so dimin-ished that improvements are too small tojustify.

This point will be developed more fully inthe section on quality-adjusted life-years(QALYs) and rationing in Chapter 9 (p. 163).Here, it is important to point to the possibil-ity of making comparative judgements basedon assessments of the quality of life and toemphasize that such judgements can be usedto inform decisions about distributing andrationalizing scarce resources. As a result,there is a concern about quality of life deci-sions being made for others without theirparticipation, and about decisions imposedwithout their consent. Both these concernsare tempered by the second assertion of thequality of life ethic. This states that valuemust be personally assessed by the individ-ual concerned, and imposed externally onlyin extreme circumstances where patients areunable to decide on their own behalf andtheir wishes can be reasonably determined.An advance directive can be highly useful inthe latter case. If a balance is made betweenboth subjective determination and compara-tive decisions, we can avoid classifying a lifeas of comparatively low value where theperson possessing it does not agree.

Basing value of life decisions on quality oflife has strong advantages. It:

• Is subjective: takes seriously personalassessments made by individuals about thequality of their own lives

• Is flexible: recognizes the possibility that thesubjectively determined value of one’s lifecan change

• Is comparative: recognizes that the way onelife is valued need not impose the identicalvalue on a similar life condition

• Permits rational suicide: recognizes that onecan legitimately assert the relatively lowvalue of one’s own life.

No one denies the importance of a goodquality of life, or one that is acceptable to the

person who has to live it. However, someargue that it is not the sole criterion uponwhich to base value of life decisions. Thesepeople include considerations of quantityand sanctity in their determination.

Quantity

The value of the quantity of a life should notbe underestimated. In the past, so muchemphasis was placed on the quality of lifelived that quantity was virtually forgotten.More recently, attitudes have changed andconsideration is given to the possibility thata long life of diminished quality could be ashighly valued as a short life of high quality.In some senses the comparison seemsabsurd, unless we consider cases in whichpatients have refused complicated or ago-nising treatments that they perceived wouldexacerbate their suffering rather than extendtheir lives. Other patients prefer to extendtheir lives at any cost or risk to thembecause they value their existence so muchthat they will sacrifice quality in favour ofquantity. This indicates that quantity oughtnot to be mistaken for quality and that pro-longing a patient’s life might be nothingmore than a burdensome and painful exten-sion of suffering for them and their lovedones. However tempting it is for doctors toprovide whatever care they are capable ofproviding, there is a responsibility to ensurethat the treatments are actually useful to thepatient and not unnecessarily burdensome.This means that a cost–benefit analysis canbe usefully applied to a care managementplan for an individual patient. The aim is todetermine the extent to which treatment willbe helpful and where the healing stops andthe burden begins.

Quantity might not be identical withquality but, often, increased quantity in med-icine can be equal to cure or control ofdisease and hence does enhance quality oflife. The Compression of Morbidity principlecited by Downie and Calman is useful forguiding these decisions:


Compression of morbidity principle: theobjective of increasing life-span shouldbe associated at the same time with anincreasing quality of life or reduction ofdisability.5

So, provided quality of life is maintained orenhanced, quantity is a positive factor inhealthcare.

There is a sense in which quality of lifejudgements are made in a wider context andnot just as they pertain to particularpatients. Health economists have long triedto determine the appropriateness of costlytreatments on the basis of their burdensomeness and effectiveness. Themost famous of these is a system known asQALYs. QALYs stand for quality-adjustedlife-years, and are a means of making com-parisons between health states. Equally con-cerned with quantity and quality, QALYscan be applied to a ‘relative health states’scale. The problem is that these scales arethemselves value-laden. Such issues will becovered in Chapter 9, where the idea ofQALYs will be discussed as they relate torationing and distribution of resources. Theyare introduced here because they show howa model for decision making can include thenotions of quality and quantity discussed inthis chapter. QALYs help decide whichhealthcare needs will be met by identifyingwhich yield:

• the greatest amount of good for• the greatest amount of time for• the greatest number of people.

However, this utilitarian approach alsoinvolves a degree of casuistry: patients’QALYs are assessed and decisions are madeon the basis of how well a treatment workedfor them. The treatment with the mostacceptance can then be applied exclusively.But all patients are unique, so what works formany will not work for all individuals. Thisis the classic problem with inductive argu-ments where particulars are used to implygenerals.

Sanctity

Supporters of the sanctity of life ethic dismissconsiderations about quality and quantitybecause, they assert:

• all life is worth living under any conditionbecause of

• the inherent value of life.

The upshot of the theory is that quality oflife, although desirable, is irrelevant toassessing the value of a life because all life isinherently valuable. Many supporters of thesanctity of life criterion say this is true only ofhuman life, but there are religious groupswho claim sanctity extends to all life. Eitherway, the sanctity of life principle states thatall human life is worthy of preservation andhence eliminates the justifiability of abortion,euthanasia and rational suicide and, atextremes, withdrawal of futile treatment:

The sanctity of life ethic holds thatevery human life is intrinsically good,that no life is more valuable thananother, that lives not fully developed(embryonic and fetal stages) and liveswith no great potential (the sufferinglives of the terminally ill or the patheticlives of the severely handicapped) arestill sacred. The condition of a life doesnot reduce its value or justify itstermination.6

So, whereas to determine the value of a lifeon its quality asserts that there is a relevantdifference between the type of life and the factof life, this distinction is rejected by sanctityarguments as irrelevant.

The sanctity criterion tends to beassociated with religious beliefs. The Judeo-Christian rationale is usually thatlives are inherently valuable because theyare gifts from God and not ours to end as wewish. In a sense, our lives are on loan to usand, as such, must be treated with respect.In Islam, the suffering associated withreduced quality of life is also considered adivine endowment and therefore ought to


be borne without assistance, as the sufferingis said to lead to enlightenment and divinereward.

However, religious arguments are notrequired to defend sanctity beliefs. It isenough simply to say that all human lives aredeserving of equal respect not because ofwhat they have to offer or have offered orpotentially will offer, but because they exist.The notion of inalienable human rightsattributes force to the value of human lifewith the assertion that it needs nojustification. This is the primary merit of thesanctity of life ethic – that a life requires nojustification – but justification is required forthe premature termination of that life. In thissense, the principle acts as a forceful bulwarkagainst devaluing human life. Article 3 of theUnited Nations Declaration of Human rightsasserts simply that:

Everyone has the right to life, libertyand security of person.7

No argument is made to justify this claimbecause no argument is necessary. However,it will be necessary to justify any violation ofthis right.

The sanctity of life criterion is appealingbecause it appears to resolve a number ofethical quandaries. To accept it would entailrejection of so many of the problematicissues faced by practitioners and ethicists.For instance, it will mean rejecting abortionat any stage of pregnancy because of theinherent value of the life of the fetus. Thisseems like an easy solution to the problemof abortion, except in cases where a preg-nancy might be terminated to save the life ofthe mother. In such cases, sanctity of lifecannot inform the decision of which lifeshould be saved. On the one hand, we mightchoose to save the mother’s life because sheis already viable and independent and shemight have responsibilities that give her lifeadded value. On the other hand, we couldsave the fetus which, although only a poten-tial life, has not had the opportunity to livethat the mother has had, and so deserves a

chance. The list of reasons can be given onbehalf of either life, but this is no solution.In fact, all it does is present us with reasonsto use quality and quantity criteria forresolving the dilemma. This is a seriouspractical shortcoming of the sanctity crite-rion. Other problems will be discussedbelow.

Problems faced by thequality, quantity andsanctity criteriaQuality of life problems

There are two major concerns about thequality of life criterion for assessing thevalue of life. The first is that it is a value-laden and judgement-relative alternative.The second problem is that it relies on sub-jective rather than objective decision-making, so it is difficult to know when weare getting it right.

Quantity of life problems

There is really only one problem with thisposition and that is that it cannot work inisolation. Length of life is not identical witha good or valuable life, so quality of lifequestions emerge.

Sanctity of life problems

Judgements on the basis that life is sanctifiedleave no room for personal judgement aboutthe value of one’s own life, let alone the livesof others. It cannot account for the fact thatsome of us do feel we have reached the pointof suffering beyond endurance or that ourlives have so diminished in dignity that onlydeath can restore its value. Disturbingthough it is, some people will reach thispoint. The assumption that all life issanctified would remove the right of the suf-fering individual to choose how and when itshould end:


Different people, of different religiousand ethical beliefs, embrace verydifferent convictions about which way ofdying confirms and which contradictsthe value of their lives. Some fightagainst death with every weapon theirdoctors can devise. Others will donothing to hasten death even if they prayit will come soon. Still others…want toend their lives when they think thatliving on, in the only way they can,would disfigure rather than enhance thelives they had created. Some peoplemake the latter choice not just to escapepain. Even if it were possible to eliminateall pain for a dying patient – andfrequently that is not possible – thatwould not end or even much alleviatethe anguish some would feel atremaining alive, but intubated, helpless,and often sedated near oblivion.8

The stakeholders – whoought to decide?Where individuals are capable of estimatingthe value of their own lives we encounterproblems of whether they are competentenough to do so and of ensuring that depres-sion or fear is not interfering with their eval-uation. The subject is further complicatedwhen decisions are made for people who arenot competent to judge for themselves thevalue of their own lives. In either case thequestion becomes who ought to decide?

External arbiter

An external arbiter is usually believed to beobjective and capable of having a clearpicture of the person and the context of his orher life. However, the arbiter might not beobjective, to the extent that all judgementsare based on values and external arbiters willbe affected by their own values in making thedetermination. In addition, given that this

person is not the same person whose life isunder consideration, he or she might not beable to truly know what is best for thepatient. Generally speaking, it feels like acounterintuitive imposition to assume thatany one person can make a decision aboutthe value of another person’s life.

The main concern is that decisions aboutthe value of another person’s life would de-teriorate into general assertions about thedevaluation of similar lives, as expressed bythe concerns in this quote about the value oflife of a disabled child:

I cannot accept [the parent’s] view thatStephen would be better off dead. If it isto be decided that ‘it is in the bestinterests of Stephen Dawson that hisexistence cease’, then it must be decidedthat, for him, non-existence is the betteralternative. This would mean regardingthe life of a handicapped child as notonly less valuable than the life of anormal child, but so much less valuablethat it is not worth preserving. I trembleat contemplating the consequences ifthe lives of disabled persons aredependent upon such judgements.9

The example of parenthood reveals that itmight be impossible to escape the need for anexternal arbiter when individuals are not com-petent to decide for themselves. Neonates,severely disabled or demented persons andpeople in a persistent vegetative state will notbe able to make this choice for themselves.10

Parents and loved ones are frequently left withthe burden of deciding what to do in thesetragic situations. In certain cases these deci-sions clash with established expectations, asthey did in the following case.


Case 25Who decides? Samuel Linares11

Five-month-old Samuel Linares aspirated a blueballoon at a birthday party on 2 August, 1988.Paramedics removed the balloon with forceps.

The problem of who decides is madepoignantly clear by the seemingly somewhatexaggerated case of the Linares family, butthe events described are true. It is not the firsttime that the best interests of the patient werenot obvious, or where agreement could noteasily be found.

Internal

Permitting individuals to determine thevalue of their own lives preserves autonomyand reduces the likelihood of coercion.However, it could be too subjective, espe-cially when the person is hindered frommaking a rational decision by fear and

illness. Nevertheless, it is the best choicebecause no one can decide for another personwhat is the best quality of life.

Perhaps the ideal is to let people maketheir own decisions about the way the qualityof their lives affects what quantity they haveleft. If they perceive their own lives to besanctified despite any diminishment inquality then that is their own decision. If theyprefer to see their lives of such low qualitythat they seek to reduce or eliminate it alto-gether, then they ought to be given the assis-tance they require to ensure that it improvesor at least meets the values and hopes theydesire. Related reflections are made inChapter 5 on end of life issues.

ConclusionWe have considered the ideas of quality,quantity and sanctity as they relate to thevalue of life. These were revealed to haveadvantages and disadvantages in theirapplication.

Consideration was also given to who oughtto determine the value of a given life. Externaland internal arbiters were considered with theconclusion that it is always safest to permitpeople to judge for themselves what value togive to their own life.

Notes and references1 Weber LJ. Who shall live? In: Walter J, Shannon T,

eds. Quality of life: the new medical dilemma. NewYork: Paulist Press; 1990:111–118.

2 Dworkin R et al. Assisted suicide: the philosopher’sbrief. New York Review of Books; 27 March 1997.Available from On-line Archives:http://www.nybooks.com:6900/nyrev/WWWfeatdisplay.cgi?1997032741F@p1

3 MacIntyre S. Social and psychological issuesassociated with the new genetics. Phil Trans R SocLondon B 1997; 352:1095–1101.

4 See Fish v. Wilcox and Gwent Health Authority; Court ofAppeal. [1994] 5 Med LR 230, 13 BMLR 134 as cited inNelson-Jones R, Burton F. Medical negligence caselaw. 2nd edn. London: Butterworths; 1995:332–333.


Samuel was left comatose and respirator-dependent in a persistent vegetative state atChicago’s Rush–Presbyterian–St-Luke’s Medical Center. When the prognosis becameclear, the family asked that the respirator bedisconnected and their son allowed to die.

Although the physicians were sympathetic,the hospital’s lawyer read federal law to requirethe hospital to continue treatment to avoidliability for ‘murder or child abuse’. The hospitaldoes not have an ethics committee or ethicsconsultant.

Samuel Linares was going to be moved to anursing home, despite his family’s protests. On25 April 1988, the night before Samuel was tobe moved the distraught father went to thehospital. Mr Linares removed his son from theventilator, revealing a .357 Magnum whennurses attempted to intervene. Saying, ‘I’m nothere to hurt anybody’, he allowed staff toremove three children from the ICU. His son died in his arms 10 minutes later. Mr Linaresconfirmed the death with a stethoscope that adoctor slid across the floor. The weeping fathersurrendered the baby and the gun. Later hesaid, ‘I did it because I love my son and my wife.’

Consider how a deontologist and aconsequentialist would have respondedunder similar circumstances.

5 Downie R, Calman K. Healthy respect. Oxford:Oxford University Press; 204.

6 Weber LJ. Who shall live? In: Walter J, Shannon T,eds. Quality of life: the new medical dilemma. NewYork: Paulist Press; 1990:111–118.

7 United Nations High Commissioner For HumanRights: Universal Declaration of Human Rights.Available: http://www.unhchr.ch/udhr/lang/eng.htm

8 Dworkin R et al. Assisted suicide: the philosopher’sbrief. New York Review of Books; 27 March 1997.Available from On-line Archives:

http://www.nybooks.com:6900/nyrev/WWWfeatdisplay.cgi?1997032741F@p1

9 Justice McKenzie BC. Quoted in: Thomas J,Waluchow W. Well and good: case studies inbiomedical ethics. Peterborough, Ontario: BroadviewPress; 1990.

10 McHaffie HE, Fowlie PW. Life, death and decisions:doctors and nurses reflect on neonatal practice.Hochland & Hochland Ltd; 1996.

11 Miles SH. Hastings Centre Report. July/August1989:4.


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The Value of Life