In a recent article by Walter Sinnott-Armstrong and Franklin G. Miller, the argument is made that ability should be the metric of value among human life and thus the determining factor on what constitutes moral harm when killing. Someone who has permanently lost all abilities no longer has value and killing them would not only fail to add more harm and it would also fail to take away any more value.

In the authors' case, to say that "Betty is not worse of dead" is to presume knowledge about death. It's taken for granted what the authors believe about death is true: a descent into non-existence and nothingness. However, we cannot say whether it is better to become nothing than to be conscious and totally and irreversibly disabled mainly because we have experienced neither, and we have no ability to comprehend what it would be like to "be nothing" (a contradictory phrase, but one that captures the farce in making the claim that someone is "not worse off dead" if one presupposes nothing after death). I certainly don't believe that we descend into nothingness when we die, and indeed the things that happen after we die could be much worse than our present life, but I'm only using the authors' own views to determine that they aren't justified to say that Betty is not worse off dead; even if she were, it would be a matter of personal preference toward either nothingness or total and irreversible disability.

Furthermore, the authors divorce morality from truth when they say "one advantage of this position is that it simplifies the structure of morality." Either that which is most simple is always true, or else morality and truth have no relationship and we pursue that which is most useful to us, regardless of its veracity. Why should simplicity win on the merit of simplicity alone? The authors identify the simplification of morality as an advantage of this perspective, regardless of whether that simplification is born out of truth: is it actually true that it is wrong to kill a universally and irreversibly disabled person? The truth, it seems, doesn't matter as much as the simplicity of the moral system.

The authors also assume that it is worse to cause a person to be deaf and blind rather than only blind. However, this begs the question, for this is only worse in their system of morality in which abilities are the metric of value. In that system, it makes sense that it is worse to deprive a person of two abilities rather than one. However, in other systems, depriving a person of any abilities ("without adequate reason") reaches maximum heinousness and to add increasing quantities of ability deprivation to that doesn't make it any more wrong, but only more tragic. The authors' example here, then, isn't helpful to them because it assumes the system of value they're trying to establish.

The rebuttal to the objection regarding God's commandment is superficial. First, it assumes that the strength of God's commandment is in the reason that justifies his commandment and not the command itself. This is not evidenced throughout Judeo-Christian theology, the theology that I would be prepared to assert and defend; instead, God should be obeyed because he is God. This is why Lot's wife was turned into a pillar of salt: because she disobeyed God. It doesn't matter what God's reasons were for commanding her not to look back on the destruction of Sodom and Gomorrah. What matters is that he commanded it at all and his commands are self-justifying because he is God. This leads us into a discussion regarding the sovereignty of God and epistemology, which isn't the main topic at hand, but suffice it to say that the authors dismiss this objection without actually rebutting it.

The authors go on to further establish, in their rebuttal of the anticipated objection by secular theorists, how they are begging the question in their argument. The main question of their paper may be, "Why is life valuable in this extreme case when it includes no ability?" They're trying to show in their argument that killing people in this state is not wrong because lack of ability constitutes total loss of value. To dismiss this objection by assuming that the metric of value is ability is to beg the question in the rebuttal.

They reduce moral theory to a matter of preference when they write, "these arguments will have no force at all for those of us who prefer our moral theories to be independent of religion." Therefore, it doesn't matter what is actually true; what matters is what one prefers. They further support this idea by stating that it is problematic to depend on religious belief in philosophical theory as well as public policy. They imply that what is good is an agreeable solution for all, even if that means that the agreeable solution isn't what's actually true. Is this right or even good? Unfortunately that small question alone is irrelevant to those who do not care about what's right but instead only what serves their preferences! Thus this discussion cannot even begin until we deal with moral relativism, a discussion unto itself.

They go on to nearly refute their entire argument when addressing concerns regarding whether using ability as the metric of value would lead to the assignment of variable values to humans with non-zero quantities of ability.

For their first response regarding possession of abilities greater than plants, why would that be the case? Why plants in particular? If one is going to hold the "minimal ability threshold" stance, does that mean a human with, say, one ability is equivalent to a chimpanzee with one ability? Indeed, under this view, why aren't chimpanzees and humans equivalent, or any non-plant life? The authors fail to flesh out this rebuttal to make it consistent with the rest of their argument. Furthermore, they establish earlier in their argument that if it is wrong to remove one ability, it is more wrong to remove two, and maximally wrong (indeed, equivalent to murder) to totally and irreversibly disable someone. Their argument cannot be paired with this objection because this objection assumes that abilities do not have individual value but only the trait of "ability possession" (in which a person may only possess one ability) is what actually grants value.

Their second response (that it would be morally wrong to treat people differently based on their different abilities) does a good job of overturning the argument for which the paper was written. Are we not treating the totally and irreversibly disabled person differently based on their lack of ability? Yet the authors argue that one could rebut the aforementioned objections by declaring that it's wrong to do just that.

The third response is antiquated: quality- and disability-adjusted life years (QALYs and DALYs) are already used to compare people with different disabilities and sets of abilities. This is not a perfect system, but it's what's being used for any number of purposes now. If one is going to respond in this way, one would have to make the point of doing away with QALYs and DALYs.

The fourth response is essentially what the authors are doing in this paper. They're insisting that ability should be the metric of value, yet they haven't established why that should be the case and they've done a poor job of dealing with the anticipated objections. Indeed, if ability is the metric of value, then a myriad of questions are raised that the authors don't address: for someone who is reversibly disabled, how many abilities must they recover to gain value again and thus pull themselves from the chopping block? What if they can follow simple commands? Write their name? Speak? Maintain urinary and bowel continence? Do abilities differ in value, as this would become a real concern in determining whether to harvest someone's organs? If not, would it be accurate to say all who are disabled at all are equally disabled?

The fifth and final response is essentially selling the agenda; somehow get people to believe that what is wrong isn't that wrong, or what is wrong is actually good. When variable value is assigned to humans, such that some are worth less than others, that is the stuff out of which tyrannies, discrimination, eugenics and persecution are made. It is not hyperbole to indicate this because that is precisely the philosophy of historical figures like Adolf Hitler: some people were worth more than others during the Third Reich and some people were worth so little and so detrimental to society that they were better off exterminated. This, of course, is the extreme conclusion of the authors' argument, but the authors' argument sets the precedent for it; it paves the way for other arguments to march, one step at a time, toward that conclusion.

In stating that it is bad to shorten life and thus worse to shorten it more in killing younger or healthier individuals, the authors assume that quantity is what gives life value; in this particular point, not just quantity of abilities, but quantity of years left to live. They neglect the possibility that life, regardless of the quantity remaining, maintains maximum value until death. An analogy would be currency: whether you have $1000 or $1, a dollar is still worth a dollar (putting aside inflation and other economic confounders). Thus, as you spend your money, your money doesn't lose value. By the time you're down to your last dollar, it's not worth $0.10 or some other amount; it's still worth a dollar. The subjective value of that dollar to its owner may be greater (it becomes more precious to its owner because the owner does not have the other $999), but the objective worth of it is still one. If anything, as life shortens, it becomes more precious (particularly for the atheist, who believes that this is all we get!), so it may be more wrong kill people with less time left to live.

In discussing violations of the dead donor rule, the authors miss the mark in clearly establishing what death is. Brain death is merely a surrogate marker for determining death proper. What we actually care about is whether the organism itself, the person, is dead. We use brain death as a marker for the organism's inability to maintain cohesion of its various systems to the benefit of itself. According to Maureen Condic, a neurobiologist at the Universty of Utah, when an organism can no longer "act in a coordinated manner for the continued health and maintenance of the body as a whole," it's considered dead (Condic, M. Life: Defining the Beginning by the End. First Things. 2003). This appears to be the most intuitive, holistic definition of death. The reason why we look for brain death is because we care whether we're using machines to artificially prolong the survival of an organism that can no longer perform this fundamental function; it is not strictly to determine whether higher-order brain function is lost. Thus Condic explains:

"It is often asserted that the relevant feature of brain death is not the loss of integrated bodily function, but rather the loss of higher- order brain activities, including consciousness. However, this view does not reflect the current legal understanding of death. The inadequacy of equating death with the loss of cognitive function can be seen by considering the difference between brain death and "persistent vegetative state" or irreversible coma. Individuals who have entered a persistent vegetative state due to injury or disease have lost all higher brain functions and are incapable of consciousness. Nonetheless, integrated bodily function is maintained in these patients due to the continued activity of lower-order brain centers. Although such patients are clearly in a lamentable medical state, they are also clearly alive; converting such patients into corpses requires some form of euthanasia."

Therefore if one is brain dead, one is properly dead because brain death is a marker for the organism's permanent inability to coordinate the maintenance of all its various sub-systems into a cohesive whole. The authors' ignore the implication that brain death is being used as a surrogate marker for the death of the organism in light of the fact that we can use machines to keep the cellular processes of the organism going without the organism ever being able to recover its coordinated manner by which it sustains its life. To procure organs from these individuals is not a violation of the dead donor rule; they're dead.

They raise a second example in which they believe the dead donor rule is violated, yet they fail to point out that the decision has been made to not resuscitate these individuals, just like anyone else with a "do not attempt resuscitation" order in their chart. Obviously it's philosophically inconsistent if a patient goes through vital organ donation but has an advanced directive still in place to attempt resuscitation. Irreversibility isn't included in the legal definition of death because plenty of people who die could be resuscitated but are not because of their advanced directive, yet we still declare them dead when they enter into that state because we will not prevent them from naturally progressing to the point at which their body loses the capacity to maintain cohesion amongst its sub-systems.

Interestingly, Dr. Miller co-authored a paper in the New England Journal of Medicine on the topic of the dead donor rule, and a point was made that seems to stand contrary to the central argument of the article in question (Truog and Miller. The Dead Donor Rule and Organ Transplantation. 2008. NEJM):

"At the dawn of organ transplantation, the dead donor rule was accepted as an ethical premise that did not require reflection or justification, presumably because it appeared to be necessary as a safeguard against the unethical removal of vital organs from vulnerable patients. In retrospect, however, it appears that reliance on the dead donor rule has greater potential to undermine trust in the transplantation enterprise than to preserve it. At worst, this ongoing reliance suggests that the medical profession has been gerrymandering the definition of death to carefully conform with conditions that are most favorable for transplantation. At best, the rule has provided misleading ethical cover that cannot withstand careful scrutiny. A better approach to procuring vital organs while protecting vulnerable patients against abuse would be to emphasize the importance of obtaining valid informed consent for organ donation from patients or surrogates before the withdrawal of life- sustaining treatment in situations of devastating and irreversible neurologic injury."

The question, it seems, is irrelevant as long as strict adherence to informed consent and the advanced directive of the patient (if present) is upheld. Those are our guiding principles in choosing to withdraw aggressive care, whether it be from the patient with multi-organ failure in the intensive care unit or the patient with metastatic cancer in the outpatient setting who just wants to live his last two weeks free from the burden of chemotherapy and other aggressive interventions. The valid concern is that organs would begin to be harvested from people who have reasonable chances of survival or are not even in imminent danger of death. Yet we seem to navigate this labyrinth fairly well when patients or their families request a cessation of aggressive care apart from concerns of organ transplantation; the additional piece that must be added to it in matters of transplantation is the avoidance of euthanasia and physician- assisted suicide, the ethics of which will not be discussed here, but for the sake of this discussion I take for granted as wrong. I suspect it would be very difficult to determine a general rule that could apply to all cases, but that each patient must be approached individually.

Interestingly, Dr. Truog and Dr. Miller identify that, at worst, "this ongoing reliance [on the dead donor rule] suggests that the medical profession has been gerrymandering the definition of death to carefully conform with conditions that are most favorable for transplantation." It seems that is exactly what is being done in this paper Dr. Sinnott- Armstrong and Dr. Miller have submitted to the Journal of Medical Ethics and the applications reach beyond the field of transplantation. The authors are trying to figure a way to broaden the population that would be available to donate their organs. With the precedent set, each following step becomes easier to take and before long we really are harvesting organs from people who are in no imminent danger of death. Indeed, the reductio ad absurdum would be the harvesting of organs from individuals who are disabled in some capacity and do not even want their organs harvested. The authors attempt to stave off this objection by stating, "We can hold the line for vital organ donation by continuing to restrict it to those in a state of total (universal and irreversible) disability. It is only these donors who would not be harmed or wronged by vital organ donation, since all other donors have abilities to lose." Yet they are not holding the current line (i.e., the dead donor rule). So the line is moved this time and, perhaps even after the authors themselves are dead, still others will desire to move the line and will make arguments in favor of it. And another argument will be made to move the line further. This is the power of precedent setting. Why should we trust those who move the line to hold the line?

"What makes killing wrong" is a transparent attempt to do what Dr. Miller denounces in his paper in the New England Journal of Medicine: "gerrymander the definition of death," or in this case, gerrymander those circumstances about which one might be declared suitable for transplantation. The scope of this argument extends beyond organ transplantation, however, and into the broader world of medicine. If adopted, this view would color for the worse how we perceive the weak, the sick, the aged and the unborn.

Conflict of Interest:

None declared