Kindness and the Ethics of Physician-Assisted Suicide

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Abstract

In this paper I explain four features of kindness by examining how four artworks depict them: Giotto di Bondone’s painting of St. Francis of Assisi giving his robe to a beggar, the character Bishop Charles-Francois Myriel in Victor Hugo’s Les Misérables, the person Adam in William Shakespeare’s As You Like It, and the role of Sonya Semyonovna Marmeladov in Fyodor Dostoevsky’s Crime and Punishment. These four examples describe kindness as supererogatory, altruistic, a belief about how the world ought to be, and the possibility of unction. With this understanding of kindness, I examine the most likely moral motives of the physician in physician-assisted suicide and find that the practice does not display the four characteristics of kindness but rather displays the emotion (though it may be sincere) of condescending pity towards the unfortunate people who deem their lives are devoid of the value to live.

Introduction

On November 1, 2014 Brittany Maynard took her life with the assistance of a physician. She was diagnosed with a terminal brain tumor and decided she did not want to live long enough for the tumor to kill her. Since physician-assisted suicide was not legal in California at the time, she moved to Oregon to receive the procedure. The right-to-die organization, Compassion and Choices took up her case and made her a popular and national figure for their cause. Their main argument was if she has the right to end her life and, thus, not to suffer unnecessarily, then it is an act of compassion from others and society to allow her to do so.

I do not doubt the compassion people showed Brittany during the ordeal, but I want to analyze what kind of compassion is implied in physician-assisted suicide and what the ethical ramifications of it are.[1] My main point is that the particular compassion often associated with physician-assisted suicide is more an act of pity than kindness, and, consequently, does not exhibit the profound ethical features of kindness. Overall, I want to analyze the ethics of physician-assisted suicide from the perspective of the importance we give to kindness as a special and important aspect of our efforts to experience meaningfully and rightly the world.

To make this case, I first discuss the nature of kindness and then ethically analyze physician-assisted suicide. I aim to show, first, that kindness expresses the excellence of a person altruistically committed to affirming the value of others in ways that reveal the way the world ought to be, and, in some instances, provide an unction upon others. Furthermore, I then show with this description of kindness that physician-assisted suicide does not exhibit these features of kindness.

Artistic Examples of Kindness

I believe art has the unique capacity to inform us about the nature of reality. It does not merely describe events, objects, or impressions. It exposes a universal dimension of the human experience implied or embedded in the events, objects, and impressions. Aristotle correctly expresses this capacity of art by contrasting the cognitive productions of art with history:

From what has been said it will be seen that the poet’s [artist’s] function is to describe,     not the thing that has happened, but a kind of thing that might happen, i.e. what is           possible as being probable or necessary. The distinction between historian and poet is       not in the one writing prose and the other verse—you might put the work of Herodotus            into verse, and it would still be a species of history; it consists really in this, that the one       describes the thing that has been, and the other a kind of thing that might be. Hence poetry is something more philosophic and of graver import than history, since its   statements are of the nature rather of universals, whereas those of history are singulars.[2]

Art presents universal features of the human experience of the world, and in the aesthetic experience of an artwork, the artwork provokes us to consider the proper ways to view and act in the world. An experience with art exposes us to a powerful but undefined meaning of the human experience in the world. Even though we can identify kindness when we experience it, we cannot account for its unique reality with a strictly historical (or natural-scientific) description of it. We need to see how it is lived, how it shapes people’s lives in various morally demanding situations, and art can help us understand the features of kindness by arresting us to acknowledge and react to the aesthetic experience generated by the artwork. With this understanding of art, I use four art works to learn four essential characteristics about kindness.[3]

First, there is the incident rendered in the painting by Giotto di Bondone of St. Francis of Assisi giving his robe to a beggar. Most biographies of St. Francis describe this event, and thus it becomes emblematic of St. Francis’ character.[4] In 1297 Giotto paints 28 scenes of St. Francis’ life, and the giving of the robe is the second: “Scene 2: St. Francis Giving his Mantle to a Poor Man.” The painting focuses on St. Francis’ eyes. The blue sky and valley in the background form a “v” pointing directly at his right eye, which looks intently into the beggar’s eyes. The real gift is not the robe but the overflowing of St. Francis’ personhood in the act of affirming the beggar. G. K. Chesterton says of St. Francis, “It is perhaps the chief suggestion of this book that St. Francis walked the world like the Pardon of God. I mean that his appearance marked the moment when [people] could be reconciled not only to God but to nature and, most difficult of all, to themselves.”[5] St. Francis’ impact on the poor, ill, and outcast enables a reconciliation and connection to nature, others, and God, creating a sense of belonging and wholeness to their lives.

Second, Bishop Charles-Francois Myriel plays one of the most significant events in Victor Hugo’s monumental story of Les Misérables. Instead of having Jean Valjean arrested for stealing his silver candlestick holders, he unexpectedly gives them to him after the police catch him. Myriel senses that what Jean Valjean needs at that moment is not punishment but grace, not condemnation but a nudging towards his true destiny, that he in fact is not a thief but a desperate person in search of his true human self-worth. This act contributes to Jean Valjean’s transformation from a bitter and hateful person into one of deep faith and love.

Third, in Shakespeare’s As You Like It, the old servant Adam plays somewhat an insignificant role. He is caught between the conflicting brothers, Orlando and Oliver, and finally sides with Orlando, sensing the true fatherly blessing of Sir Rowland de Boys belongs with the younger son. As Orlando is about to leave the home for the forest of Arden, Adam offers Orlando his service and life’s savings of 500 crowns, knowing that his sacrifice is justified. “Take that, and He that doth the ravens feed, yea, providently caters for the sparrow, be comfort to my age!” (II, 3, 43-45). As they depart, Adam muses to himself, “Yet Fortune cannot recompense me better than to die well and not my master’s debtor” (II, 3, 75-76). Adam realizes providence has led him to act generously towards Orlando, that his bonding with Orlando is the way life ought to be. On the way to the forest of Arden, Orlando stumbles onto the Duke Senior and others eating. The Duke invites him to join them, but Orlando delays, saying he must feed Adam first, because “Who after me hath many a weary step limp’d in pure love: (II, 7. 130-131). Unlike so many in the play who hide their identities and their plans, Adam is transparent in his commitment to Orlando.

Fourth, perhaps one of the most unforgettable and unlikely kind figures in all literature is Sonya Semyonovna Marmeladov of Fyodor Dostoevsky’s Crime and Punishment. She is vulnerable, poor, uncomely, and driven to prostitution to care for her parents and siblings. Yet, she has a quality of ease and generosity to people that make her attractive and infectious towards others. After Rodion Romanovich Raskolnikov confesses his insidious murders (of an old woman, a money-lender, and Sonya’s friend Lizaveta) to her, she is not horrified by him but in fact cares for him. She tells him publicly to confess his murder and assault against the earth by kissing the ground of the Haymaker Square of St. Petersburg, and, after he is eventually arrested and sentenced to prison, she follows him to Siberia (where they marry). At the prison town the villagers are drawn to her special quality of wholeness and tenderness. She embodies an affection of acceptance, which transcends the normal rules that govern human relationships.

Each of these figures exemplifies kindness and stands out for their unique character and actions.

Kind Acts and Kind People

One of the reasons we praise kind people is because their actions reflect their character. If we were to realize a supposedly kind act was done for selfish or mercenary reasons, we might be thankful, but we would not call the person a kind person. Ludwig Wittgenstein, the Cambridge philosopher, once said of G.E. Moore (another Cambridge philosopher) that he was kindly but not kind and, consequently, did not have warm feelings towards Moore.[6] Moore was known for his gentle and graceful ways, but, according to Wittgenstein, he lacked something. What was it?

Supererogatory

We would think St. Francis disingenuous if, after giving his mantle to the beggar, he asked for payment or said he was only following a duty to help people. His act was kind because it was beyond what we would think would be ordinary obligations owed to people. Immanuel Kant’s famous definition of duty as that which is universally obligatory upon us without exceptions would say that the beggar is in fact no different than anyone else, that St. Francis owed the same kind of respect to everyone. A true dutiful act does not acknowledge the peculiarities or circumstances of the situation but does conform to a universal maxim that veils us (so to speak) to the particular time and place, lest our actions be motived by prejudice or selfishness.[7] The Kantian sense of duty recognizes why we should respect the dignity of all persons, but it does not clarify why we do acts of kindness. That is because they are supererogatory.

Kind acts are “above” the universalizable maxims of Kant’s categorical imperative. Yet, they have a sense of duty to them. Sensing in the encounter a forceful obligation, St. Francis feels compelled to give his mantle. It is not that St. Francis senses the dignity of all humanity in the beggar, but that he has the capacity to recognize that the appropriate response in the situation is to act in a way that he could not universalize (that is, the giving of his mantle) but that he must do. He has the capacity because he cares for the beggar. It is a form of duty but not one defined by a universalizable maxim. It is defined by care for the other.

Care is not merely sympathizing for others. We can be emotionally influenced by others and their situations and not necessarily act towards them in a beneficial way. However, if we care, we understand and commiserate with the other’s situation. We realize they are experiencing something that ought not be, that there is a disunity of body and spirit, a fracturing of their health, important relationships, and connection to others and reality. In caring for them, we experience a similar state, not necessarily in an identical way but in an analogous way. We envision what life would be if we also were “walking in their shoes.” Because we know that “there but by the grace of God go I,” we are drawn to help, heal, and affirm their worth as a healthy being united in body and soul. This natural attraction of a caring person towards people who need care obligates us to act. Instead of a universalizable duty, it is a caring duty, which is relative, situational, and idiosyncratic. Just as Kant explains the compulsion of the universalizable maxims based on our intellectual state as rational agents (that is, we can universalize a maxim), kindness acknowledges the deep compulsion of being a caring person. We would not think a person who lacks the emotional ability or volitional desire to sympathize with another’s state to be acting kindly, even if their actions benefit another.

Because kindness is a duty-of-caring, its motives aim to bring affirmation and wholeness to the person.[8] Consequently, they are not trite. We would not call St. Francis’ action truly kind if he tells the beggar that he was merely trying to assuage his guilt for not helping a beggar the day before or that he had many mantles to give away. Assuaging our guilt and giving out of our abundance are not unethical actions and, in fact, may be ordinary and common place explanations for why we act benevolently towards the underprivileged, but they are not kind actions. Kind actions are “above” the ordinary and common place motivations for moral acts. They arise from the care of others and are what is needed relative to the situation so as to bring affirmation and, when relevant, healing to the other person. Because kindness is supererogatory, the ethics of kindness is truly situational ethics.

Conclusion—kindness is motivated by a duty-of-caring to bring wholeness to a particular situation.

Altruistic

We not only admire Bishop Myriel, but he also inspires us. We admire people for what they accomplish and represent, but it is the conjunction of their right motives and aims towards what is good that inspire. Victor Hugo uses Myriel’s actions toward Jean Valjean as a necessary part of the narrative about a transformed man in the midst of the French revolution. For us to explain Jean Valjean’s character and sacrificial actions, we need to recognize the pivotal role Myriel plays in his earlier life. His act not only excuses Jean Valjean from his crime, but also inspires him to change from hate and bitterness to the love of others and faith in God. Myriel’s act is more than a benefit to him. A judge in a court of law could have pardoned Jean Valjean of his crime and, thus, could have altered his life from a life in prison to a free life. The judge’s decision would have had beneficial consequences, but it would not have converted him away from hate and fear to love and faith. Because Jean Valjean realizes Myriel’s act is truly altruistic, that he has no ulterior motive and no intention of gaining in stature or reputation, Myriel thus inspires him to change.

Myriel nickname is “Monseigneur Bienvenu,” a name revealing his nature. He welcomes people into his own life (his future, emotions, and hopes). The narrator summarizes the Bishop’s approach to life: “There are men who toil at extracting gold; he toiled at the extraction of pity. Universal misery was his mine. The sadness which reigned everywhere was but an excuse for unfailing kindness. Love each other; he declared this to be complete, desired nothing further, and that was the whole of his doctrine.”[9] Myriel’s kindness to Jean Valjean springs from his altruistic approach to others.

Altruism has two possible meanings—pure and teleological. Pure altruism implies that we can act with total harmonic intentions, that we do not experience any conflicts of motives, and that the decision is not between different and competing motivations but only one motive. Although we might imagine some trivial instances of pure altruism (for example, saying hello to a stranger), serious ethical decisions are complex and deal with competing motives because of our own memories of successes and failures of past ethical decisions, and because of our own need to be affirmed and acknowledged as the ethical persons we try to be. We would not think Myriel to be less kind in his decision toward Jean Valjean, if we were told that he desired more than anything for his life to be pleasing to God, to be a Good Samaritan, to preach liberty to the captives. We can still be kind and have conflicting motives (for example, the need to be loved and the need to give love) in our actions. In fact, as long as we know Myriel’s ultimate purpose is to save Jean Valjean, we would still think Myriel to be kind, even if we learned his action springs from a repressed feeling of guilt due to past failures to help a similar desperate person. It is possible to align our motives, even those in conflict with acts of kindness, to an overriding purpose. This would be teleological altruism.[10]

Teleological altruism is not merely a benevolent or beneficent act. We can wish well of others and not feel the need to act selflessly or exceedingly generous towards them. Also, we can aim to do good towards another and not necessarily disregard any positive benefits the act may confer on us. Although Myriel is both benevolent and beneficent towards Jean Valjean, his action indicates another characteristic. His gracious forgiveness starts a course of life that changes Jean Valjean. In this way, kindness is a blessing to another in that it creates a moment of acceptance, appreciation, and affirmation that has germinative power to change the person. Although kindness may be small acts or go unnoticed by others (even the recipient), part of kindness’ uniqueness is that its impact transcends the immediate needs. A kind act inspires us to believe that there is a purpose greater than the moment and circumstances, that the act starts a process in people, and onto the others they influence, that shows love is better than hate, that hope is better than cynicism, and that forgiveness is better than vengeance.

Because kindness is not a universalizable duty (in the Kantian sense) nor a calculated maneuver to reach another goal, it reveals the dedication of the doer to introduce an affirmation, acknowledgement, or aid toward someone else. A kind person embodies the goal of the kind act, and thus altruistically serves the purpose of the action. The person and act conjoin in the manifestation of kindness and creates effects that last longer than the deed and continue to generate the affirmation, acknowledgement, and sense of importance. People like Myriel inspire us about the possible goodness even of thieves like Jean Valjean because they have made tangible the goodness of life, people, and the world by giving of themselves to that mission.

Kind acts and kind people reveal a certain kind of goodness. It is not a utilitarian goodness in which the maximization of people’s preferences and desires are materialized. That makes goodness a percentage of preferential units and also is more reflective of what people at certain times and places prefer or desire. The satisfaction people experience in receiving a kind act is not reducible to an increasing of tangible and measurable preferential units. We are not appreciative of kind acts because they have increased our desires or pleasures. Rather, kindness does something else—it displays an affirmation about life’s purpose more pervasive and permanent than our immediate desires and pleasures.

Kant’s notion of goodness helps us understand this aspect of kindness. Kant believes we all sense the moral law within us; that is, we acknowledge, though cannot prove by pure reason, a summon bonum, a state in which people are free and moral ends in themselves and in which all people are motivated to act in ways for everyone’s goodness because they too are moral agents.[11] Kindness affirms the desire of life itself and worth of human existence in the moment of kindness. In receiving it, we recognize that the kind person believes in human goodness and aims to materialize it in the situation. Kind acts create the experience of the summon bonum in the specific situation by materializing what ought to be in terms of affirming the possibility of goodness for the recipient, whether the deed is small or large.

Although Myriel does not play a specifiable role in the novel’s plot after Jean Valjean’s journey away from the Bishop, his act of kindness endures and continues to create through Jean Valjean’s own acts of kindness moments of affirmation, acknowledgement, and care. It is because kind people act selflessly, committed toward an aim of affirming the goodness of the person or the moment that the action does not continually refer back to the giver nor must it always bear their names. It has a life of its own and thus propagates the goodness it creates into future events.[12]

Conclusion—kindness is a teleologically altruistic action that materializes goodness in a particular situation.

The Way the World Ought to Be

Even though Adam is a secondary character in Shakespeare’s As You Like It, his role is provocative and indicates an important aspect of kindness. After II, 7, Adam is not seen or mentioned again. He does not enter the forest of Arden, where what is good in people is intensified (sort of a salvaged, pastoral Garden of Eden). What Adam is good at (that is, kindness), he is already manifesting. Because he does not need the mysterious powers of Arden to display the way the world ought to be, Adam is the most Edenic figure of the play.[13] In 2.3.58, Orlando says of Adam that he is “the constant service of the antique world,” the antique world of the Garden of Eden that occasionally appears in the midst of hurtful plots, sibling hatred, and family dissolution, revealing what should be the case in a fallen world.

Adam’s generosity to Orlando is helpful but not essential for Orlando to travel to the forest of Arden and eventually to marry Rosalind. In fact, although we can see that Adam acts benevolently towards Orlando, his actions are not needed and are not a required beneficence. They are not a utilitarian necessity. His love is pure not because Orlando needs his service or life’s savings, but because Adam’s motive reveals what should be the case between them. Orlando is now a total orphan, without father, mother, and cast out by his elder brother Oliver, but Adam seeks to ground Orlando in a reality that will not evaporate nor disappear once they leave the home of Sir Rowland. His kindness endeavors to create a situation according to the way Orlando’s destiny ought to be.

Shakespeare never tells us why he chooses the name Adam, but the allusion to the First Adam suggests Shakespeare might have a point in mind. Adam’s behavior to Orlando indicates how people ought to act. Obviously, the allusion is not to the Adam who eats the forbidden fruit and is cursed and exiled for doing so. It is to Adam’s pre-lapsarian state, the “antique world” of what ought to be. His actions represent a sense of the primal order between people, of how people ought to act towards each other, and, thus, his actions are part of a providential plan to bring kindness into the family of Sir Rowland.

If Orlando had acted in a similar way towards Adam (perhaps only half of his life-savings instead), we would not call it kindness. Orlando is the son of power and privilege; Adam is a life-long servant. Orlando’s generosity would definitely have been beneficial to Adam, but it would be the benevolence of a more powerful person to a lesser person, of a socially superior person to an inferior one. That would be pity, not kindness. Orlando’s nobise oblige would be helpful to Adam but would not raise his social status, because Orlando would still be the son of the house. However, in acts of kindness, people who may be different in many ways are equal in their worth as persons. It creates an occasion where social status is secondary to the bonding of two people in the state of affairs.[14]

The way in which Halley Faust differentiates kindness from compassion helps us understand how kindness creates equality between and among people. Faust argues that though a compassionate person emotionally identifies with another, compassion by itself tends to pity the other and thus creates inequality between the people. However, in that kindness does not require emotional identification, it does not paternalistically condescend towards the other in need. “By not requiring an emotional attachment, [it] frees us from the concern about judging a patient even when judgment might be a natural inclination.”[15] Because kindness cultivates an environment indicative of the way the world ought to be, Faust is right to describe how kindness cultivates equality among people, whereas compassionate pity perpetuates a patronizing disposition.

However, I think Faust overstates his point by insisting that kindness does not involve emotional identification. Not all emotions are the same. In pity we feel sympathy for others, not because we see them as equals in social status or virtue but because we see them as pitiful, an estimation definitely not consistent with kindness. Yet, in experiencing people and even the world as it ought to be, we experience the profound emotions of wonder and gratefulness that such a world is possible amidst the “whips and scorns of time.”  Thus, these emotions would be concomitant with kind actions. Hence, we can imagine Adam’s inner state to be filled with wonder and gratitude, when he realizes that “Fortune [could not have] recompense[d] [him] better than to die well and not [his] master’s debtor.” (II.3.75)

Because kindness creates equality between and among people, we should think of it as an attribute of a new state of affairs and not merely a feature adorned to the state. In all likelihood, we would not experience at that moment the new state without the act of kindness. The act materializes the new occasion. Kindness is a necessary attribute of what ought to be, rather than an appendix that is unessential to the situation. We thus should think of the word kind in the phrase a “kind act” as an attributive adjective and not a predicative one. That is, kindness is not like the color of a car which does not reveal the essential function of the car. Rather, kindness is like the adjective good in the phrase a “good car.” Kindness expresses the purpose of the event, and in its action, reveals the reality of what it is: an attribute.[16]

Since kindness manifests our belief in what ought to be, it serves as a regulative ideal for our moral actions and goals. Even though Orlando is in a state of affairs which ought not to have been (that is, orphaned from home), Adam knows that it is wrong and that the true state of what ought to be is needed. Thus, he acts with this ideal in mind. Adam does not need to know fully what providence ordains for Orlando or himself, nor the exact details of the summum bonum so to act out of pure love, out of kindness. Yet, he needs to know that the ideal can be practically realized in his act of kindness. Even though we may not be able to prove metaphysically the existence of a kind world, kindness acts as though there is one, and, thus, kindness becomes normative for actions that aim for the ideal life.[17]

For instance, we would not say that the world is the way it ought to be on the whole, if we were apathetic or indifferent towards others. Disenchanted people who believe they live in a disenchanted world are not motivated to act as though they could create the world into what it ought to be. They can act kindly on occasions to others but not with the conviction they reveal the moral purpose of the world, not as “the constant service of the antique world.”

Also, we would not say the same if we acted primarily out of pity towards others. Of course, acts of pity may bring benefit to others, but they do not overcome the divisions among people. They reinforce them. However, we are more likely to think the world is the way it ought to be when people act kindly towards each other. In this sense, William S. Hamrick calls kindness a “regulative ideal.” Kindness indicates the possibility of morality achieving its ideal expression. “Therefore, even if we are not always capable of achieving it, we should not stop trying to bring into existence a world in which it is always realizable.”[18] Because kindness is the experience of what ought to be, kind people do not lose hope when situations are not the way they ought to be.

Kindness presupposes this ontology, and without this conviction, we would not be motivated to act kindly, though we might be moved to show pity to the suffering. If we believe the world were totally “nasty, brutish and short,” without purpose, inherent beauty, or the possibility of providence, we could not account for kind actions. If we were nihilist, believing the world to be devoid of moral norms and the possibility of an objective meaningful moral life, then we would not feel the obligation to act from kindness. Without the belief that the world morally ought to be a certain way, we would not act kindly, but with the belief, we persist in trying to materialize it through kind acts.[19] In that kindness indicates the way the world ought to be, it thus suggests that a divine order of kindness underlies our experiences of creation and that kind acts accentuate that order.

Conclusion—kindness testifies in a specific circumstance to the way the world ought to be.

A Kind Soul

Sonya is a kind soul. “A sort of insatiable compassion, if one may so express it, was reflected in every feature of her face.”[20] Dostoevsky presents her not necessarily as a religiously or morally pure person. She is a prostitute. However, she plays an important role—the presence of unction that leads to the transformation of Raskolnikov. It is not her actions or her social status that contribute. It is her presence.

Sonya embodies the beauty of human existence that brings moral conviction and hope for the possibility of human goodness to people, to the villagers in Siberia as well as to Raskolnikov. She is beautiful not because her body is symmetrically and proportionally perfect or because she intellectually expresses timeless truths about God and the world, but because of the congruence of her love for others and her actions. This congruence displays her uniqueness, her soul, and why she gives healing and hope to people. Her deeds are blessings, an overlaying of her own wholeness of purpose and action upon others. Hamrick calls this the “aesthetic humanism” of kind people. “There is a nimbus of kindness around the kind person that equally radiates a world of kindness, and we have already looked at several example of how kindness can aestheticize the environment.”[21] Analogous to the influence of art, a kind soul creates an aesthetic experience of the beauty of being a good person, a nimbus of kindness, and hence manifests a blessing to others.[22]

The kind soul is not made by one act of kindness, nor by two or three, etc. The kind soul is similar to Aristotle’s great-souled person, who expects much, seeks much, and deserves much. That is, a great-souled person’s nature drives them to experience the best aspects of life and society.[23] They are unique among people, not because they may be more just, temperate, or courageous, but because they acknowledge that life offers the chance of great pleasures and beauty, even amidst the squalor and depravity of life (as Sonya does in St. Petersburg and Siberia). The presence of great-souled people in a community indicates that there are not only such people of great expectations and potential for a life fully lived, but also that it is possible in society for the great-souled people to experience the fulfillment of their virtue.

In an analogous way the presence of kind-souled people indicates that we not only live among people who have the disposition and commitment to be kind, but that moments of unction and blessing are possible. They are the kind of people who seek goodness in human life, who want to experience it in their relationships, and who thrive in creating moments of human wholeness with others (that is, an integration into their self-understanding the value of themselves, others, their future, the world as a whole, and God). The moments they create reveal a life better lived than a life without kindness. Because we seek human fulfillment rather than its diminishment, the fact that kind souls live among us assures us that the best of human life, the affirmation of our worth and rightful place in the world, is possible.[24]

Of course, cruel and apathetic people also live among us, and we do not conscientiously argue that they live the way life ought to be lived. Even though kind souls may be unusual and few, because they make tangible the possibility of a blessed life, of a life influenced by the goodness of humanity and the possibility of the love of God in the world, they are an ideal of human behavior. They may come across as naïve and anomalous individuals in comparison to the worldly savvy and jaded population, but in terms of affirming the goodness of life and others, they live life as we know it ought to be lived.

Obviously, a cruel or apathetic person would not and probably could not become a kind soul. They either pervert or reject the possibility of blessing others, of manifesting in their lives the goodness of human life. Even if they did a kind act, we would not call them kind souls.[25] We would clearly misuse the phrase “kind soul” to call the disenchanted Meursault of Albert Camus’ The Stranger a kind soul, just because in the end he calmly accepts the absurdity of his life or to call the cruel and impulsive Lear of Shakespeare’s King Lear a kind soul just because in the end he shows love to Cordelia. If we were asked to choose an ideal person to model how we ought to live, we would not choose Meursault or King Lear, for they do not bless people, provide unction, or make the world better. However, Sonya does.

Of course, not many people are kind souls and ideal models for us. However, in that our habits of life shape our desires, if we habitually show acts of kindness, we may grow into kind souls. Sonya has the emotional and volitional desire to affirm others, and by her habit of life she becomes a kind soul, a blessing to Raskolnikov and the villagers of Siberia.

Conclusion—the kindness of a kind soul manifests in the person a blessing and unction upon others.

Summary

We know kindness is not the following:

1. benevolence without action; only to wish well towards others does not change their reality.
2. beneficence without sincerity; good deeds alone do not reveal a person’s character.
3. duty without compassion; mechanistically performing perfunctory acts does not move the other person’s affective center.
4. pity; condescending beneficial actions towards others empowers the actor, not the recipient.

We know kindness is the following:

1. an exceeding affirmation of others; kindness spotlights the unique and valuable personhood of others.
2. oriented towards the other’s well-being; kind acts aim to materialize in others their best natures.
3. a materialization of goodness; kind acts reveal the way the world “ought to be”.
4. and, when a kind soul, an unction to others; the presence of certain kind people manifests to others the possibilities of personal wholeness and future salvation.

Kindness and Physician-Assisted Suicide

I now want to apply the above analysis of kindness to the ethical issue of physician-assisted suicide. In particular, I focus on whether the physicians’ acts are kind ones. It may be that physicians feel a duty to respect the rights of patients to determine when they should die, and it may be that physicians sympathize with the patients and thus want to assist them to die. Nonetheless, as I will try to show below, the physicians’ acts are not kind ones.

Of the prominent and influential arguments for the ethical permissibility of physician-assisted suicide, scant attention is given to the primary moral motive of the physicians. Tom L. Beauchamp and James F. Childress argue that physicians can assist patients who wants to die as “a way of showing respect for the person’s autonomous choices,” and because of this respect, the physicians’ assistance is just as much an act of caring for the patient who suffers in life and wishes for death as would curing a disease or healing an injury.[26]

Gregory Pence contrasts two fundamental roles of physicians—as healers or patients’ advocates—and argues that the latter is more ethically compelling because it acknowledges the autonomous right of patients to determine the quality and length of their lives. Medicine is not primarily for healing but for the caring of patients. Pence adds, “The job of physicians is to help patients, and that therefore, physicians should help terminally ill patients die as they wish.”[27]

Timothy E. Quill justifies his assistance (indirect) in the ending of Diane’s life as a way of helping her courageous and inspiring dying process. He concludes as, “Diane taught me about the range of help I can provide if I know people well and if I allow them to say what they really want. She taught me about life.”[28]

Dan W. Brock rejects the ethical distinction between killing and allowing to die, because patients’ right of autonomy over their own lives should determine when to die. Patients know better what constitutes their well-being, and physicians should honor that. Brock states, “If self-determination is a fundamental value, then the great variability among people on this question makes it especially important that individuals control the manner, circumstances, and timing of their dying and death.”[29]

The famous “The Philosopher’s Brief” given before the United States Supreme Court in 1997 also bases its endorsement of physician-assisted suicide on the patients’ autonomous decision to decide their time to die. It claims that “Each individual has a right to make the ‘most intimate and personal choices central to personal dignity and autonomy.’ That right encompasses the right to exercise some control over the time and manner of one’s death.”[30] Like Brock above, the authors of the brief reject the ethical difference between allowing to die and killing. Since the right of dying is left to the patient to determine, the distinction is moot.

In each case the physician’s moral position is determined by the morally trumping autonomy of the patient. Even though they do not explain nor defend the presupposed ethical principle “for every right, there must be corresponding duty,” they rely on it and assert that because patients have a right to die, the physicians must have a duty to assist them. If even the physician’s assistance is called an act of care, it is not a care for the patient’s health but for the patient’s autonomous decision. When the decision is no longer to act as a healer but as a patient’s advocate, patients determine the kind of care reflective of their own most fundamental value and how physicians should comply to it.

However, as is the case, physicians do not always defer to patients’ autonomous requests. Physicians would probably not show the same kind of deference as given in physician-assisted suicide if the patient demanded an untested and questionable medical practice. It would be contrary to their professional role as healthcare providers.[31] Yet, patients would be choosing for their health, certainly a fundamental consideration for them. People think of the value of their lives in terms of their health and well-being. Thus, in requesting assistance to die and the untested, questionable treatments, the patients make autonomous decisions and expect their physicians to be their advocates. Is there a significant difference between patients asking doctors to assist them in dying and asking them to perform questionable medical procedures?

On one hand, the physicians would think the patient’s request for questionable medical procedures would be inappropriate and wrong, but, on the other hand, the physicians would think the request to assist in the patient’s death to be appropriate and right. Clearly then the difference is not determined by the patients’ autonomous decision about what is most important to them, because in both scenarios, the patients are choosing fundamental rights—health and the right to die. Yet, if physicians reject performing a questionable procedure, they in fact would not be deferring to the patients’ fundamental right of self-determination; they would be refusing to comply with the patients’ autonomous choice. However, with physician-assisted suicide, physicians feel a duty to comply with the patients’ autonomous choice.

The difference between the two reactions is that in refusing to do a questionable procedure the physician is affirming the patients’ health and in acquiescing to assist in the patients’ death the physician affirms the patients’ conclusion that they have more dignity in dying than living in their undignified state. In the first, physicians affirm the value of the patients’ life enough that they would refuse to do what the patients request, and, in the second, the physicians acknowledge that because the patients want to die, the patients’ life is not worth sustaining. If their death is an act of dignity, then their continual living must be undignified. In complying to the patients’ request, physicians affirm the indignity of the patients’ life so as to endorse the dignity of their death, and in assisting patients to die, physicians would be saying that in the cases when death would be dignified, life must then be undignified, not worth keeping and, in fact, pitiful.[32]

Thus, the real issue for the physician is not the self-determination of the patients but rather their dignity or indignity. To justify physician-assisted suicide, physician would have to be able to determine when a life is not worth living, and in assisting the patients’ dignified dying, the physician declares the patients’ lack of valuable life. Physicians may feel sympathy for people who believe they lack the dignity to continue to live, and the same physicians may also feel sympathy for the well-being of the patients who request questionable procedures.

Yet, the motives for the sympathies are different. Physicians would not reject doing questionable procedures because they pity their patients. Rather, they value the patients’ lives and health and thus reject the procedures. However, in physician-assisted suicide physicians pity the lives of their patients and thus perform the procedure to assist their dying. They would have to be able to determine that the patients’ lives lack enough value of living so that they would have more value in dying with dignity, that the patients’ lives are indeed undignified. Pity would then be the primary motivation in assisting patients to die.

At this point an advocate for physicians’ role in assisted suicide could say that in some cases patients’ lives are indeed not worth living, and that they are not only terminable (an ambiguous term) but in abject pain and cannot function with any deliberation and responsiveness to others. It would not only be an act of pity to assist them to die but an act of merciful compassion. Even though none of the above advocates for physician-assisted suicide make insufferable and interminable pain a necessary condition to justify physicians’ contribution to the death of the patients, it is plausible that physicians could give such a justification, and thus might say that the patients should die because of their intolerable pain and suffering.

However, the justification for physician-assisted suicide does not logically depend on the patients being in an intolerable state of pain and suffering. Rather, it depends on whether the patients’ determination to die reveals that their lives are no longer valuable enough to keep alive. If I am correct in the above analysis that the patients’ lack of a valuable life is the primary determination (that is, the sufficient condition) for justifying physician-assisted suicide, the patients’ experience of insufferable and interminable pain is not a necessary condition for the ethical permissibility of physician-assisted suicide. It is not that they should die because they suffer greatly, but that, in their minds, they should die because they lack the value of life to continue to live. Their undignified life is the necessary condition for wanting to die, and that condition is the same whether the patients horribly suffer or not. Certainly, if they suffer greatly, it is expected that all people involved would naturally feel more compassion towards them, but the ethical justification for physician-assisted suicide does not depend on their compassionate motive to alleviate the patients’ pain and suffering; it depends on whether the patients and physicians determine that the patients’ death is more valuable to them than their lives in the current state.

To demonstrate this point, consider the probable responses from the patients and physicians if the procedure used in the assistance fails. For example, suppose the dosage of secobarbital tablets dissolved in water was not potent enough to cause death or that the antiemetic premedication did not stop the patients from vomiting up the drug. Those involved would not believe that another chance had been given to them so that they could restore value to their lives with dignity but, most likely, would feel the horrible regret of a failed action and the misery of having to decide to cause their deaths again. Because they believe that death is more valuable to them than their lives, and that their remaining dignity requires them to acknowledge their lives are not worth sustaining, the failed attempt would cause more anguish to their self-understanding as people who should die rather than live.

To make this point more precise, consider the different reactions between, on one hand, a failed attempt at physician-assisted suicide and, on the other hand, the unsuccessful efforts through extreme measures to abet or eliminate the causes of insufferable and seemingly interminable pain. In the latter case, the physicians may go to such extreme means to treat a disease or lessen the pain and suffering that they become aware the patients may die from their efforts.[33] However, they believe that the patients’ lives are worth trying to save and that it is their vocational duty, even if death is the possible outcome of their actions, to do what it takes to use medicine or surgery to treat the illness or to ease the intolerable suffering and possibly restore the patients’ health. If in their care, the patients die, the physicians do not presume they failed in their efforts to treat the patients with dignity by treating the sickness or by alleviating the horrible pain. Rather, they presume they did all they could do to preserve the value of the patients’ lives. Moreover, if their efforts do indeed succeed and the excoriating pain and suffering subside and the patients can eventually return to some degree of health, the physicians and patients consider their efforts successful. Whether the patients live or die, the physicians actively try to affirm the lives of the patients, and by their efforts, they indicate that the patients still have dignity as persons to remain alive.[34]

In the above case, even though the patients’ death may result after the physicians’ efforts to treat the disease and end the intolerable suffering (for example, with extensive chemotherapy), the patients and physicians acknowledge that the patients’ value as living persons was worth the risk. If the physicians’ efforts in extreme care fail to save the patients’ lives, they may regret the failure, but they do not deem the patients’ lives not worth their best efforts to keep alive, and in fact could reason that by their efforts of extreme care, at least their patients’ lives were no longer in the intolerable state of suffering.

However, in the case of physician-assisted suicide, if the procedure fails, the patients do not gain a newfound value of life and thus rediscover a dignity in continuing to live, but rather they are forced to acknowledge that the justification for trying the procedure in the first place still exists. The failure is not that the patients are still in suffering but that they are still alive. The motive and aim of physician-assisted suicide remains in place after a failed attempt at it—that is, the desire to end a life that no longer has enough value to continue to live.

After the experience, the physicians may feel great sympathy for the patients desiring assistance-to-die (as they may have felt before the experience), but the sympathy is more an act of pity than kindness. Even though pity may compel the physicians to show sympathy and care, pity is a dubious moral motivation. An examination of what two philosophers—Baruch Spinoza and Immanuel Kant—say about pity shows why it is a dubious moral motivation.

The 17^th century Dutch philosopher Spinoza thought that “pity in itself is useless and bad.”[35] It is useless and bad because pity disorders our lives, it frustrates our rational efforts to experience in our understanding a “harmony with the order of nature as a whole”[36] (a balance in life by knowing the comprehensive nexus of all things). We experience this harmony when we contribute to the balance of all our emotions, aims, and relationships. Pity arises when upon seeing other peoples’ pain and suffering we feel discombobulated and believe the proper balance of life is disturbed. So, we look upon others who suffer with a disdain for causing our discombobulation. It is because they have put us in such a situation that we have to do something for them that they cannot do for themselves that we try to alleviate their suffering. Consequently, we try quickly to end the imbalance in the person’s situation so that we can regain our sense of equanimity and control. A piteous emotion thus reveals a disordering in our souls, because it reflects a disordering in reality, in the way all things should be. Thus, the emotion of pity is really a detrimental basis for moral action because it actually prevents all those involved to relate rightly to reality, to find a way to be in “harmony with the order of nature as a whole.”

Immanuel Kant also disvalues the effects of pity on us. At the center of Kant’s philosophy is the claim that we can know what is the moral law by ascertaining and acting according to what is universally a duty for all occasions. The moral law thus, according to Kant, demands that we treat all people with dignity, with the respect owed a rational person trying to know and live up to the moral law. But piteous feelings and actions towards others stem from a sense of superiority over others because of their deficiencies and inabilities. Hence, because pity does not acknowledge the inherent dignity of those in a pitiful state, the reality of the moral law would never compel us to act from pity towards others, and, consequently, a morally-right thinking person would “desire to be free from [pity].”[37] Even though pity may arouse strong sympathetic feeling, they do not spring from an ethical respect of the other but, rather, from a derogative attitude towards the other. Pity is always a condescending action of one who assumes to be superior to an inferior.

Spinoza and Kant’s explanations explain why pity usually has a negative connotation. We say things like “don’t pity me,” “I don’t want your pity,” and “keep your pity to yourself.” Because pity subserviates a person to another, it suggests a hierarchy of importance in which the superior person patronizes to the other and wants to show sympathy to the other, not because the other has inherent dignity as a living moral agent but because the superior person feels sorry for the other. Even though in the eyes of others an act of pity looks compassionate and caring (and indeed the person may feel sincere sympathy), the motivation to act from pity arises from a sense of patronizing care in which a superior person stoops to help an inferior person.

Pity more than kindness accurately defines the moral motivation in physician-assisted suicide. In the situations that lead to the act of physician-assisted suicide, patients are considered undignified in their lives and can only restore dignity in choosing the manner of death. In this sense, assisting their dying would be an act of noblesse oblige, an act of condescending to the pitiful state of the patient. By assuming a responsibility to assist the patients to die, physicians demonstrate their position of authority and influence, and in exercising their power as physicians, they may display and be sincerely motivated by a heartfelt pity for the patients. Even so, they also display to society that they have the professional position and power to determine when people’s lives lack enough dignity to remain alive and, thus, that these people should exercise their right of self-determination to end their undignified lives. Although the physicians may believe they are acting as advocates for the patients’ autonomous decisions to die, they are also communicating to society that some lives are so lacking in dignity that it would be better for them to die and possibly to gain some sense of dignity in the act of killing themselves.

This justification would encourage society to distinguish between lives worth valuing and those devoid of a future worth keeping, of lives deserving of the best of healthcare and those no longer worth the physicians’ commitment to care for the goodness of their beings. It may be that the physicians believe they are affirming the dignity of their patients in assisting them to die, but in fact they make more widespread in society the belief that some people’s lives lose dignity and lose a value worth affirming and maintaining. Ironically, by becoming primarily the patients’ advocate in agreeing with their own assessment of their indignity, physicians increase the despair and depression that follows when people lose their sense of dignity and think suicide is their best and last autonomous action.

Hence, such actions by the physicians cannot be called acts of kindness. It fails the four aspects of kindness (explained above). First, assisting people to die who are pitiful in their lives is not a supererogatory act that demonstrates a duty to care for the patients’ wholeness. In fact, the patients’ wholeness (that is, the link between their present state with their future) is denied so that their death can be welcomed and justified. Subsequently, the physicians acknowledge a limit to their care for the patient, that the patients’ determinations that their lives are not worth preserving qualifies the physicians’ responsibility to render healthcare to the patients. When physicians understand their role in the situations that lead to consideration of physician-assisted suicide to be primarily an advocate for the patients rather than the patients’ healer, they do not display the extra quality to a moral act that kindness conveys—the exceeding affirmation of the others’ inherent worth as the persons they are. An advocate may be considerate and sympathetic, but parameters of advocacy are shaped by the contractual expectations of the relationship; that is, patients want and need something and the physicians provide it. However, physicians as kind healers would convey to patients that regardless of their situations and their expectations, the physicians act by motivations greater than just the professional role of being the patients’ doctor; they endeavor to affirm the dignity of the patients, whether they are fighting to live or accepting their dying.

Second, the action is not an altruistic act that aims to increase the goodness of the patients. The patients’ lives are devoid of enough goodness that would require the physicians to attempt to heal and maintain the patients’ lives. In fact, in physician-assisted suicide, the physicians stop trying to heal or care for the patients’ lives and, consequently, mold their professional actions according to the patients’ autonomous decisions. By complying to the patients’ wishes in such cases, physicians bend their professional role as healers and healthcare providers to the prevailing preeminence of the autonomous agent in current society. Instead of sacrificing their time and emotional state to show extraordinary care for dying patients, the physicians would be submitting to the societal hegemony of the right of the individual to determine not only their own lives but how the medical profession should treat them.[38]

Third, when physicians determine that patients’ lives can be so miserable that the only dignity they can have is to cause their own deaths, they would not be showing in their action that this is the way the world ought to be. Rather, they would communicate that the patients’ lives are the way the world ought not to be and it would thus be better for them to die. Although the physicians may be contributing to the desires of all involved and may help bring physical and emotional relief from an unwelcomed situation, they fail to communicate to the patients, families, friends, and society a more profound sense of the way the world ought to be.

For instance, consider the implications in deciding one of the two options—physicians can render care to allow patients to die or they can assist patients to kill themselves. In each case, death is the end. Death is obviously part of the way the world is, and, consequently, when we think of the way the world ought to be, we must recognize that death is a permanent state of our experience of living in the world. Thus, the issue is which of the two is more indicative of the way the world ought to be. The second option says the patients’ lives are so devoid of the value of life that it would be better for them to end their lives before their natural death. The first option maintains that the patients’ value of living remains with them until their natural death. The second option communicates that the value of living can be minimal enough to want to die and the first option communicates that the value of living is convincing enough that it is worth maintaining up to the patients’ natural death. That is, it is more consistent with the way the world ought to be to affirm a view of the world that says life is valuable up to the natural end than a view that says the value of life is tenuous enough that it would be better in certain occasions to take one’s life because it lacks the value of life. It is more indicative of the way the world ought to be for physicians to affirm the value of living in spite of unwelcomed situations than to say those situations can erase from a person the value of living. Thus, the first option (that is, treating while allowing to die) would be more of an act of kindness than the second option would be.

Fourth, by displaying a noblesse oblige towards the pitiful, the physicians would not be a blessing for all involved. Their presence and action would not be an unctuous action that would affirm the wholeness of the patients and reveal the nimbus of kindness. They would primarily play a functional role with the imprimatur of the medical profession to validate the patients’ assessment of their own lack of the value of life and their right to choose the manner of their dying. In such a role, physicians would not be kind souls. It may be that physicians believe it is not their role to be kind-souls, that their role is to provide a professional service and be the advocate for the patients’ autonomous decisions about the importance and destiny of their lives. However, because such a belief primarily defines the physicians’ role as providing a contractual service defined by transactional goals, the belief would argue against physicians seeing their roles as having the rare opportunities in people’s lives to provide occasions to experience the powerful moments of being blessed to be alive.

References

[1] The phrase physician-assisted dying has become the more recent name given for the procedure. For instance, in Beauchamp and Childress’s 5^th edition, 2001, of Principles of Biomedical Ethics, they call the procedure physician-assisted suicide. By the 2013 7^th edition, they call it physician-assisted suicide, physician-assisted death, and physician-assisted hastening of death, and then in the 8^th edition of 2019 they drop the phrase physician-assisted suicide all together and use physician-assisted hastening of death. They justify the change by saying “here [the Oregon law] the terms letting die and killing do not illuminate or help evaluate what happens when a physician helps a person escape the ravages of a fatal illness;” Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics, 8^th ed. (New York: Oxford University Press, 2019), 185. However, the phrase “hastening death” could also explain a patient removing a life support device like a respirator or feeding tubes, whereas people utilizing a device or drinking a drug that kills themselves is more an act of suicide than a hastening to death. Their actions directly cause their deaths, rather than merely hastening their natural process of dying. Even though the recent names may try to avoid the difficulty of having to justify an act of suicide, the reality of the act is still an act of suicide.

[2] Aristotle, Poetics 1450, 9:34–1451:8; in The Basic Works of Aristotle, ed. Richard McKeon (New York: Random House, 1941), 1463–1464.

[3] Even though I look at our experiences to explicate kindness, I start by appealing to our aesthetic imagination by examining four aesthetic expressions, one painting, two novels, and one play. Whereas science utilizes the rigors of logical understanding to clarify the empirical and causal aspects of our experiences, art utilizes the imagination to suggest the moral possibilities of being human in the world. Both the understanding and imagination give us knowledge, and for this reason I agree with Albert William Levi, that aesthetic imagination informs us about the humanistic values, and I use the aesthetic imagination to inform us about kindness. See Albert William Levi, Literature, Philosophy and the Imagination (Bloomington: Indiana University Press, 1962), 2–3.

[4] Ewert Collins, ed., Bonaventure: The Soul’s Journey into God; The Tree of Life; The Life of St. Francis (New York: Paulist Press, 1978), 190. Bonaventure wrote his biography in 1263, but the incident is also in the earlier biographies by Thomas of Celano (1229), Julian of Speyer (1232), and Henri d’Avranches (1232).

[5] G. K. Chesterton, Saint Thomas Aquinas and St. Francis of Assisi, (San Francisco: Ignatius Press, 1986), 314.

[6] William Hamrick mentions this assessment of Moore by Wittgenstein; see William Hamrick, “Kindness,” in Phenomenology in Practice and Theory, ed. William Hamrick (Boston: Springer, 1985), 211.

[7] Immanuel Kant, Groundwork of the Metaphysics of Morals in Practical Philosophy: The Cambridge Edition of the Works of Immanuel Kant, translated and edited by Mary J. Gregor and general introduction by Allen Wood (Cambridge, England: Cambridge University Press, 1996), 69–73.

[8] William Hamrick in his seminal book on kindness states this point in a similar way—“When I eventually come to perceive a previously undetermined act or omission as kind, I see the act or omission invested with a motivated freedom, purpose, and sensitivity to my welfare,” William Hamrick, Kindness and the Good Society (New York: The State University of New York Press, 2002), 21; also “Kindness thus actualizes what is most proper to human beings as such” (249). Hamrick perhaps has written the most and the best on kindness, and it would be tempting to reiterate his work. Suffice it to say that I endorse fully his work but seek to add my own contributions to the study of kindness (especially as it pertains to medical ethics).

[9] Victor Hugo, Les Misérables (New York: Crowell & Co., 1887; Project Gutenberg, 1994), vol. 1, bk. 1, chap. 14, https://www.gutenberg.org/files/135/135-h/135-h.htm#link2HCH0014.   

[10] Because kindness suggests an ontological claim about the way the world ought to be, I differ with Marvin Kohl’s definition of kindness as not a natural or rational act—“Helpfulness towards someone in need, not in return for anything, nor for the advantage of the helper himself;” Marvin Kohl, “Kindliness: Some Classic Views,” Journal of Medical Ethics 5, no. 1 (1979): 35. Kohl’s definition is not complete enough. In trying to emphasize that kindness is not a natural survival response, he fails to recognize the ontological suggestions experienced in acts of kindness.

[11] The role of the summum bonum permeates Kant’s ethical teaching; that is, the profound conviction generated by the experience of the moral law must believe that the moral life has a real goal and reward. My use of Kant’s idea of the summum bonum stems from the way he talks about it in The Groundwork of the Metaphysics of Moral. “For, all rational beings stand under the law that each of them is to treat himself and all others never merely as means but always at the same time as ends in themselves. . . . A rational being belongs as a member to the kingdom of ends when he gives universal law as in it but is also himself subject to these laws.” Kant, Practical Philosophy: The Cambridge Edition of the Works of Immanuel Kant, 83.

[12] George Eliot poignantly expresses in Middlemarch a similar point about the future ripple effects of good and kind deeds. “For the growing good of the world is partly dependent on unhistoric acts; and that things are not so ill with you and me as they might have been, is half owing to the number who lived faithfully a hidden life, and rest in unvisited tombs” (in Hamrick, Kindness and the Good Society, 160). In the biblical wisdom writings, Ecclesiastes poignantly expresses this sense of our actions creating conditions that lead to unknown and unforeseeable fulfillment as “Cast thy bread upon the waters: for thou shalt find it after many days” (Ecclesiastes 11:1 KJV).

[13] See Marjorie Garber, Shakespeare After All (New York: Pantheon Books, 2004), 440–441.

[14] Orlando does show kindness to Adam when he genuinely cares for him by carrying him on his back when Adam is too weak to continue. At that moment, it is easy to see they share a common destiny and bond as humans to each other, regardless of their social status.

[15] Holley S. Faust, “Kindness, Not Compassion, in Healthcare,” Cambridge Quarterly of Healthcare Ethics 18, no. 3 (2009): 298, https://doi.org/10.1017/s0963180109090458.

[16] This distinction between predicative and attributive adjectives comes from Peter Geach. See P.T. Geach, “Good and Evil,” Analysis 17, no. 2 (1956): 33–42.

[17] Kenneth Strike is right to argue that liberalism (the view that all people are the same) and communitarianism (the view that only our community shapes our values) cannot account for the special impact of kindness upon us. “What I have claimed in the argument of this paper is that when we engage the stranger there is a voice we can hear which is neither the partisan voice of our own Gemeinshaft community [communitarianism] nor the voice from nowhere [liberalism],” Kenneth Strike, “Liberalism, Communitarianism and the Space Between: in Praise Kindness,” Journal of Medical Education 29, no. 2 (2000): 140, https://doi.org/10.1080/713679340.  Kindness has an ontological reference to the way the world ought to be.

[18] Hamrick, Kindness and the Good Society, 242.

[19] Joseph B. Soloveitchik makes a theological point that definitely undergirds this aspect of kindness—“The great ideal is hesed [which he defines as ethical kindness]. Hesed is the origin of the ethical norm. God’s hesed refers to His over-abundant, all-inclusive existence, His all-inclusiveness that lets others share and be included in His existence,” Joseph B. Soloveitchik, Maimonides: Between Philosophy and Halakhah, edited with an introduction by Lawrence J. Kaplan, foreword by Dov Schwartz (Jerusalem: Urim Publications, 2016), 196. Soloveitchik interprets Maimonides’ Guide for the Perplexed as not only promulgating a scientific knowledge of the world, ordained by divinely instituted natural laws, but as also stressing the religious-ethical principle of hesed as the cornerstone and purpose of creation. Thus, an act of hesed is also a fulfillment of creation.

[20] Fyodor Dostoevsky, Crime and Punishment, translated by Constance Garnett (2016, Project Gutenberg), https://www.gutenberg.org/files/2554/2554-h/2554-h.htm#link2HCH0024.

[21] Hamrick, Kindness and the Good Society, 246.

[22] There is clinical research attesting to the health benefits of kindness not only to those who receive kind acts but also who give them. See B.L. Fredrickson et al., “Open Hearts Build Lives: Positive Emotions, Induced through Loving-Kindness Meditation, Build Consequential Personal Resources,” Journal of Personality and Social Psychology 95, no. 5 (2008): 1045–1062, https://dx.doi.org/10.1037%2Fa0013262; and Khoa D. Le Nguyen et al., “Corrigendum to ‘Loving-Kindness Meditation Slows Biological Aging Innovices: Evidence from a 12-week Randomized Controlled Trial,’” Psychoneuroendocrinology 108 (October 2019): 20–27, https://doi.org/10.1016/j.psyneuen.2019.104440.

[23] “Since the magnanimous person [that is, a great-souled person] is worthy of the greatest things, he is the best person. For in every case the better person is worthy of something greater, and the best person is worthy of the greatest things; and hence the truly magnanimous person must be good.” Aristotle, Nicomachean Ethics, IV, 3, 14, translated with introduction, notes, and glossary by Terence Irwin (Indianapolis: Hackett, 1990), 57.

[24] John Cottingham also argues that kindness is an ontological indicator, that it has a cosmic significance. He maintains the theistic view of divine love as the basis for creation gives confidence to our experiences of kindness. He admits we cannot metaphysically prove the reality that kindness indicates, but kindness is a compelling form of life, and hence, we are right “to be able to trust that the vision is valid;” John Cottingham, “Loving Kindness and Mercy: Their Human and Cosmic Significance,” Philosophy 94, no. 1 (2019): 42, https://doi.org/10.1017/S0031819118000487.

[25] “As McTaggert once observed somewhere, providing refreshments in the intervals between tortures does nothing to prove the humanity of the torturer;” Hamrick, Kindness and the Good Society, 216.

[26] Beauchamp and Childress, Principles of Biomedical Ethics, 8^th ed., 189 and 192.

[27] Gregory E. Pence, Classic Cases in Medical Ethics: Accounts of Cases That Have Shaped Medical Ethics, with Philosophical, Legal, and Historical Backgrounds, 3^rd ed. (New York: The McGraw Hill, 2000), 112.

[28] Timothy E. Quill, “Death and Dignity: A Case of Individualized Decision Making,” in Bioethics: Principles, Issues, and Cases, 4^th ed., edited by Lewis Vaughn (New York: Oxford University Press, 2020), 669.

[29] Dan W. Brock, “Voluntary Active Euthanasia, in Bioethics: Principles, Issues, and Cases, 4^th ed., edited by Lewis Vaughn (New York: Oxford University Press, 2020), 670.

[30] Ronald Dworkin, Thomas Nagel, Robert Nozick, John Rawls, Thomas Scanlon, and Judith Jarvis Thomson, “The Philosophers’ Brief,” in Bioethics: Principles, Issues, and Cases, 4^th ed., edited by Lewis Vaughn (New York: Oxford University Press, 2020), 724.

[31] Physicians must balance the demands of the patients’ autonomy and what is the proper care. The rejection of the questionable procedure is not a denial of the patients’ autonomy. In choosing the standard of care over the patients’ demands, physicians are making what Beauchamp and Childress call a prima facie choice. “It is no objection to moral norms that, in some circumstances, they can be justifiably overridden by other norms with which they conflict,” Beauchamp and Childress, Principles of Biomedical Ethics, 15.

[32] Because the issue is often defined as the choice between living with indignity and dying with dignity, physicians’ promotion of physician-assisted suicide probably exerts undue influence on vulnerable people to think of themselves as devoid of dignity and pitiful and hence would be better dead, I agree with Alan J. Wiesbard and Mark Siegler who argue that physicians and our society are too quickly justifying physician-assisted suicide. We may be encouraging some people to die who might have benefits in continuing to live; Alan J. Wiesbard and Mark Siegler, “Killing Patients with Kindness: An Appeal for Caution,” in By No Extraordinary Means: The Choice to Forgo Life-Sustaining Food and Water, ed. Joanne Lynne (Bloomington: Indiana University Press, 1986), 108.

[33] Even though I am not using the phrase double effect to label what I am describing, my hypothetical case is close to such a designation. Typical to explanations of the doctrine of double effect, we must meet four conditions to qualify as double effect: 1) the act must be good and not bad, 2) the agent must not will the bad effect, 3) the bad effect must not be the cause of the good effect, and 4) the good effect must be proportionally desirable to compensate for allowing the bad effect. These conditions presume a moral difference between good intentions and unwelcomed foreseeable consequences, and also between the ethical permissibility between being the direct or indirect agency of a harmful and unwelcomed effect. Even though the doctrine is subject to the criticism that these distinctions are ambiguous, the doctrine is ethically significant because it recognizes the essential and important role of intentions to account for the morality of our actions. For a succinct but thorough explanation of the doctrine, see Allison McIntyre, “Doctrine of Double Effect,” in The Stanford Encyclopedia of Philosophy (Spring 2019 edition), ed. Edward N. Zalta, December 24, 2018, https://plato.standford.edu/archives/spr2019/entries/double-effect/.

[34]In describing these medical procedures, I refrain from citing the often-used illustration of double effect in which the physician, intending to alleviate the pain, uses an amount of morphine that causes the lungs to cease functioning. This illustration is often given as a clear case for double effect. For instance, Gilbert Meilander uses the illustration in Bioethics: A Primer for Christians (Grand Rapids: Eerdmans, 1996), 70. In 2001 Beauchamp and Childress give it in the 5^th ed. of Principles of Biomedical Ethics (129); also, T. A. Cavanaugh uses it in Double-Effect Reasoning: Doing Good and Avoiding Evil (Oxford: Clarendon Press 2006),  xii; Lewis Vaughn uses it in Bioethics: Principles, Issues, and Cases, 4^th ed. (Oxford University Press, 2010), 42; and in 2019 McIntyre mentions it as one of the four classic cases of double effect in “The Doctrine of Double Effect,” The Stanford Encyclopedia of Philosophy. However, research has shown that physicians do not use morphine or opioid medication in this way and that morphine does not necessarily lead to the cessation of lung function. Thus, the illustration is unfounded on actual medical practice. See Tatsuya Morita et al. “Effects of High Dose Opioids and Sedatives on Survival in Terminally Ill Cancer Patients,” Journal of Pain and Symptom Management 21, no. 4 (2001): 282–289, https://doi.org/10.1016/s0885-3924(01)00258-5; and Russell Portenoy et al., “Opioid Use and Survival at the End of Life: A Survey of Hospice Population,” Journal of Pain and Symptom Management 32, no. 6 (2006): 532–540, https://doi.org/10.1016/j.jpainsymman.2006.08.003. “In conclusion, opioids and sedatives used for symptom control in the last days are not associated with patient survival. They are safe and useful medications to palliate severe distress in the terminal stage of cancer when administered with a low initial dosage and adequate titration” (Morita et al., 282). “This analysis revealed that opioid dosing was associated with time till death, but this factor would explain very little of the variation in survival. In a hospice population, survival is influenced by complex factors, many of which may not be measurable. Based on these findings, concern about hastening death does not justify withholding opioid therapy” (Portenoy et al., 532).

However, there is the problematical practice called “terminal sedation” that can be used in which patients receive barbiturates, which also suppress their respiration and may cause asphyxiation.

[35] Quote is from The Ethics, Benedict de Spinoza, On the Improvement of the Understand, The Ethics, Correspondence, trans. by R.H.M. Elwes (New York: Dover Publications, 1955), 221.

[36] Spinoza, The Ethics, 243.

[37] Immanuel Kant, The Critique of Practical Reason, trans. by Lewis White Beck (New York: Dover Publications, 1956), 123.

[38] For a thorough and convincing demonstration of how the principle of the individual autonomous agent dominates current ethical and legal reasoning in the United States, see O. Carter Snead, What It Means to Be Human: The Case for the Body in Public Bioethics (Cambridge: Harvard University Press, 2021).

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