Relieving one’s relatives from the burdens of care

The discussion about such a duty, as it has been proposed by John Hardwig in particular,³ has been somewhat confused because it has been unclear what is meant by a ‘duty’ in this context. Could it be a strict or perfect duty that you may owe to your relatives? If so, they would have a corresponding claim-right to the fulfilment of the duty, a right that they could also waive, if they wished. Hardwig has denied that he meant such a perfect duty, he prefers to speak of a ‘personal responsibility’. But how can this be, critics have asked.⁴ The reason why you are supposed to have this responsibility is that you are causing harm to your relatives, more than you can reasonably expect them to bear. Doesn’t this imply that, if it is wrong to expect them to take that burden, it is wrong to them? If so, your duty to relieve them of that burden can only be a duty you owe to them.

But such a duty cannot exist. Either your relatives owe you a duty of care, then they cannot require you to relieve them from the burdens involved. Or they have no such duty. Then it makes no sense for them to claim that you relieve them from the burdens of care by ending your life. When the burdens of care are getting too heavy, they can, instead, stop caring and leave the consequences to you. It would be perverse for them to require you to save them the emotional costs of stopping to care by stopping being there as a possible object of care. How could we make sense of those ‘emotional costs’, if they are not rooted in a concern for your welfare?

Outside such weird institutional environments there cannot be any proper duty to die, because it is inconsistent to attribute to anyone at the same time an unlimited duty of care, and a claim-right to be freed from its burden by the elimination of its recipient. At the very least, in stead of choosing to kill oneself, one could always waive one’s supposed right to the care of others. But it is more proper to say that, if there is such a right, it has some inherent limits. It may be true that, if you have no claim to the care of others, and they in fact do not intend to do more than their duty, the inevitable consequence for you will be death, but that still doesn’t mean that you have a duty to die.⁵

How do we determine the inherent limits of the relatives’ duty of care? One could suggest that the duty ends when its burdens to the care-giver outweigh its benefits to the recipient. In general this requirement is much too strong, but family members are usually supposed to have more extensive obligations to each other than others. On most accounts, however, the limits of your relatives’ duty of care are not only determined by your needs and their own capacities. A plausible view is that the extent of any duty of family members to each other depends on the way they have mutually defined their relation through the history of their interaction. Only parents have duties of care to the people they have put into existence that do not fully depend on the actual development of their relation.⁶ It is true that, even if the obligations of relatives to each other are historically contingent in this way, at any particular moment they are a moral fact that is not open to instant renegotiation. But, whatever their history, they are never unlimited.

Of course your relatives are free to go on caring for you beyond those limits. And precisely because these limits are not only dependent on their capacities but on many other factors as well, the fact that they have reached the upper limits of their duty doesn’t necessarily imply that they will be overburdened by continuing to care. That doesn’t mean, however, that you need not be concerned at all about the burdens involved in that care. Either at this or at some later time you may have to conclude that these burdens are growing excessive and that, out of concern for their welfare, you shouldn’t allow them to go on.⁷

Doesn’t this mean that you really have a ‘duty to die’ of sorts after all, even if it isn’t a perfect duty that you owe to your relatives? It is common and not improper to say of someone who has decisive moral reasons to act in a certain way that she has the ‘duty’ to act in that way, but I prefer to avoid that language.⁸ Such a ‘duty’ is not a perfect duty owed to someone who has a correlating claim-right. The substantial question, however, is whether, even if you cannot have a strict duty to end your life, you can have decisive moral reasons to do so in the interest of others.

In order to answer that question, we should distinguish between several possible scenario’s. Suppose first that if your relatives stop providing you the care they used to give, your condition though significantly worse than before, will still be such that you prefer to go on living. In that case you need only to agree to the cessation of the existing arrangement, or, if necessary, to refuse its continuation. You may for example insist on being transferred to a nursing home.

It is only when, thirdly, your very refusal of your relatives’ care means by itself that you inevitably die on the short term, and no second decision is needed, or only a decision concerning the exact timing and manner of your death, that your refusal can plausibly itself be seen as an altruistically motivated choice for death. Consider the well-known case of Captain Oates. It had been permissible for Oates’ comrades to leave him behind and let him die. They had no duty to endanger their own lives by taking him with them. Hence Oates did not have a strict duty to end his own life either, corresponding to a claim-right of his comrades that he did.⁹ He did have, however, decisive moral reasons not to allow them to endanger their own lives. To refuse to be taken along further was therefore the right thing for him to do, even though he would have violated no-one’s rights if he had allowed his comrades to go on taking him with them. Because the decision to stay where he was implied certain death, it was a decision to die.¹⁰ In this sense Oates acted on a moral requirmenet which can be properly described as a requirement to die.

Decisions in this third category are probably very rare, perhaps virtually non-existent in the Western world, at least in the context of care. In emergency cases you will not be left to your fate. If this is correct, the really interesting case is the second scenario, in which acting in a responsible way requires you to refuse your relatives’ efforts, knowing that this will lead to a situation in which refusing treatment or suicide will, for self-regarding reasons, be your best next choice.¹¹

How should we then understand the relevant notion of right and wrong decisions, if not in terms of proper duties? We could explain it in virtue-ethical terms: if you don’t refuse your intimates’ care when it threatens to destroy their lives, you are lacking in the relevant virtues of parents, partners, friends, etc. That is not incorrect, but the problem with it is that, by itself, it doesn’t capture the reasons of the virtuous person herself. The focus of her concern isn’t her own virtue, but the welfare of her children, partner, friend. Her motivating reason is not ‘I would be lacking in proper concern if I didn’t stop my daughter to be overburdened’, but ‘my daughter is overburdened’. The best explanation therefore is that if you don’t refuse your relatives’ care, there is a relevant other-regarding consideration that you don’t give its proper decisive weight. The point is that there are such considerations that aren’t considerations of (strict) duty.¹² It is not improper, although less precise, to say that it would be wrong for you not to refuse your relatives’ care. It would be wrong, even if you would not be wronging them.

That it is only your personal responsibility to give this consideration its proper weight, not a duty you owe to anyone, doesn’t imply that others cannot criticize you for failing to do the right thing. That is not already ‘exercising a claim right’. But that you are criticizable for a moral failing at some point doesn’t mean that everyone is in an equally good position to reprimand you. In particular, if your relatives of their own free will make excessive sacrifices in caring for you, it would be improper for them, not only to claim it as a duty you owe to them to renounce those sacrifices, but also to criticize you for accepting them.

Hardwig’s own present view is that your responsibility (on his view the responsibility to end your life when the burdens of care for your relatives are getting too large) is implied by your personal commitment to take their interests into account.¹³ That, however, doesn’t seem quite right either, for it seems to assume that this commitment is optional. In that case you would, depending on your choice to accept or to reject this basic commitment, at best only have a conditional responsibility. We should rather say that you may have a categorical responsibility, but it should be left to you to recognize it and act on it. In a similar way you may have a debt of gratitude to someone, that on the one hand does not depend on your recognition of such a debt, but on the other hand cannot be claimed by your benefactor. For nothing you would pay in response to such a claim would express gratitude.¹⁴

Shouldn’t we rather say that it would be praiseworthy for you to refuse your relatives’ caring efforts, with all the consequences it has in the different scenario’s, but not blameworthy not to do so?¹⁵ Consider how your family would respond to such a ‘supererogatory’ act. Most likely they would reproach you for not permitting them to express their love to its full extent. Perhaps they would pity you for your neuroticism. They would have a point: if they are prepared to go a long way, it would be a kind of personal rejection not to allow them to go it.

That doesn’t mean that you have to go as far as they are prepared to go: at some point it would be wrong for you to accept further sacrifices. But below that point it might be equally wrong for you not to accept them. As Eva Feder Kittay puts it, “we have a moral responsibility to receive with grace care that is offered in good will and with the requisite competence.”¹⁶ Hence there is not much room for heroism in this area. Perhaps, if you are the kind of person for whom it is extremely hard to be dependent on the care of others, you should even be prepared to make some sacrifices in order to permit your relatives to make theirs.¹⁷

That point also applies to the second scenario. If you decide that, having refused your relatives’ contributions to the fulfilment of your needs, you can only welcome death as your best remaining choice, you may also welcome the fact that you thereby will take an emotional load off their shoulders, at least in the long run. But your self-regarding reasons should in principle be sufficient for justifying that choice. Otherwise you are in danger of creating a new, perhaps even greater load.

Hardwig doesn’t accept this division of moral labour because he believes that such decisions ought to be collective ones, decisions for which all family members take equal responsibillity. That is a paradoxical position for him to take, because it overlooks the extent to which sharing this responsibility can be burdensome itself. The consequence could be that in order to relieve your relatives from the burden of care you saddle them with the even greater burden of being co-responsible for your death. It is not an ‘individualistic fantasy’ to suppose that in such conditions people should consult their relatives to the extent that this is possible without causing them undue additional distress, but should insist on taking full responsibility for their own decisions.

I have argued that, under conditions that may actually occur, you can be required to forgo the offer of your intimates to give you the care you need, even though this leads to a situation in which your best prudential choice will be to refuse treatment or to end your own life. Although that second decision itself is self-regarding, it belongs to a package of decisions that is primarily other-regarding. Hence the package is still close enough to Hardwig’s ‘duty to die’ to invoke the same criticisms.

Let me consider those criticisms. A first objection is that we should be very reluctant to allow that people can be too much of a burden to each other, because people who are vulnerable to depressive disorders can catch on to the idea and start developing suicidal thoughts. Feeling oneself a burden to others is one of the most common and forceful motives for suicidal thoughts and acts,¹⁸ and often they reflect mistaken estimations of either the actual burdens or of the caregiver’s love and commitment, estimations that may be caused by a sense of one’s own unworthiness.¹⁹ On the other hand, however, these estimations may sometimes be correct or reasonable, hence they should not be considered to be a pathological symptom as such. To outlaw a public consideration of the possibility of a correct assessment altogether may not help people to calibrate their actual assessments, and therefore increase, rather than decrease the risk of their acting on mistaken ones. The bottom line, however, is that there is a truth of the matter, even though it may be advisable not to be too outspoken about it, at least not in all contexts.

A second objection is that actually there is no ‘truth of the matter’, or at least no authoritative or objective way to establish it. In considering whether the burdens of care are becoming too heavy, people will disagree about that, in particular the provider and the recipient of that care, and there will be no way to solve their disagreement.²⁰ But the claim that ‘we have no way to solve our disagreement’ is ambiguous. It can mean that we have run out of arguments, because there is no determinate answer to the question in dispute. If this is the meaning of the claim, we need only to observe that there may be a zone of indeterminacy around the borderline we are trying to identify, but that doesn’t mean that there are no clear points at either side of the border outside that zone. If the answer to the question was fully indeterminate, there would, indeed, be not upper limit to the duty of care, but no lower limit either. A claim that the burdens are too heavy would then make no sense, but the claim that they are acceptable or proportional would make no sense either.

The second possible meaning of the phrase ‘we have no way to solve our disagreement’ is that, if one of us is mistaken, there is nothing the other can do about it, because there is no procedure to arbitrate our conflict. If this is the objection, the answer is that no arbitration is needed, because we are not talking about enforceable duties. The people involved all have to make up their own minds about their own responsibilities. But they cannot determine their responsibilities. For if they have to make up their minds, rather than throw a dice, that presupposes that the decisions to be made on both sides can either be correct or mistaken, or at least reasonable or unreasonable, though there may be a grey area where they are not clearly either.

A third objection is that in setting up the problem as a conflict of interest between care-giver and care-taker, one discriminates against the elderly, because their lives are supposed to be of lesser value. Note, to begin with, that we are not talking about the value of their lives for others, but for themselves, a point often overlooked in such discussions. The main point to be made is then again that the problem of weighing the value of survival against the costs of care it requires others to pay, does not go away by denying its existence. By maintaining that the life of the elderly ‘has no price’, one necessarily leaves it to someone to pay the actual price. This is generally true of this rhetoric. Actually the problem arises for every case in which the burdens of care have to be distributed, not only when the care concerns elderly people. But a second point is that, other things being equal, both age and life-expectancy really are relevant. It is true that even very old people can still have genuine interests in survival. But not everyone has, and those who have can both consider that they have already had their ‘fair innings’,²¹ and that they only have a short time left to acquire more. Remember that we are not talking about the right to life which everybody has equally, let alone about social policies, but about responsible personal decision-making.

The most important objection is, finally, that within the family there should be no talk about duties of care and their upper limits, or about burdens that are ‘too heavy’, and that are attached to one family member’s valued existence. People’s interests are so interwoven with each other that even the burdens of care cannot be distributed, both the benefits and the costs will be internalized equally by all. However huge the burden of care, the burden of failing to provide it will be greater.²²

Suppose that you are the person who needs to be cared for. The objection assumes that, if a moral requirement to refuse your relatives’ care at some point is recognized, it will be your care-giving partner, son or daughter who will complain that the burdens are becoming too heavy, and that your response to that claim should be that you unburden them, however grudgingly. Surely that is not a picture of a loving family. But if the burdens really are disproportionately high, you should be the first to recognize the fact. It could even be that your partner, son or daughter is quite willing to go to any length in order to give you the care you need. In that case surely you should at first be quite happy to be at the receiving end of that care and not be too scrupulous about ‘being a burden’. It is a normal condition of human beings, in particular at the beginning and the end of life, to be dependent on the care of others, and you should be particularly grateful if you have loving family members willing to take that task upon them.²³ But it is quite another thing to be willing to let that task destroy their lives. Even if they don’t count the cost, you should. And even when they protest that they are fully prepared to go on paying that cost, they should understand that they cannot expect you to be equally willing to let them pay. Perhaps in a truly loving family people do not shrink from shouldering the burdens of care, however huge. Family may in that sense be a “haven in a heartless world”.²⁴ But it is inconsistent to imagine these same people not to shrink from the same sacrifices to be made for them. The safe haven for the recipient might then become a heartless world for the provider.

Actually I do not agree that it is always praiseworthy to be prepared to give the care that is needed, irrespective of the costs. At some point it will be quite proper, in particular for caring children or friends, to remember that they have a life of their own to live. It may even be a duty they owe to themselves, if not to other family members, for example their own partner and children.

In most actual cases, you will only need a level of care that could overtax your intimates because of a physical and/or mental condition that will also corrode your capacities to contribute to the fulfilment of your own or other people’s basic interests and, partly for that very reason, cause you severe suffering.²⁵ Hence in making up your mind about the discontinuation of your reliance on their endeavours when ending your life will be the corollary of that decision, you need not decide whether you would make the second decision without the first one, and even if you doubt whether you would, you need not explain this to them. In some cases an open conversation may be possible in which all parties are only sincerely trying to establish the facts as they are, eventually arriving at a decision that all can endorse. Though your relatives will start remonstrate with you by claiming that no amount of care will be ‘too much’ for them, they may allow themselves to be convinced by you when you say that there is much more at stake for them than for you, that they cannot expect you to stand aside and watch them sacrificing the ‘more’, and that this would even spoil the benefit they intended to create for you. But in many cases only by being less than fully transparent can we sufficiently respect each others’ feelings. That is not by itself a moral defect. From the fact that we cannot responsibly reveal some motive, it does not follow that we cannot responsibly be led by it. Even within fairly harmonious families there may be limits to the extent that the members can share their reasons.

I certainly do not wish to deny that your very thought of being a burden to your loved ones can itself be burdensome to them, even if your thought is fully true to the facts. One could even imagine a case in which you face the choice of devastating their life, either by the burdens of the care you need, or by their awareness that your refusal of that care has led you to end your life at the next step. Sometimes you could solve the dilemma by deciding to go to that nursing home after all, whatever your personal feelings, but if your relatives realize that this is really for you a fate worse than death, it is no solution. But the very fact that such an extreme case may present you with an unsolvable dilemma shows that the relevance for your decision of the fact of being a burden cannot simply be put aside by appealing to the nature of family life.