Abstract
Many bioethical arguments rely implicitly on the assumption that the concept of “human part” is one on which everyone must agree, because it is unambiguous. But various parties interpret this “unambiguous” term in incompatible ways, leading to contention. This article is an informal presentation of a topomereological system on whose preferred interpretation several distinct but related meanings of “human part” can be isolated: part of a human body, part of the completion of a human body, and part of a human being. A case is analyzed (the first total artificial heart (TAH) implantation), demonstrating in the process much of the apparatus of the system. By means of a casuistic methodology, the analysis is translated into recommendations for the ethical conduct of future TAH research. The more general conclusion, however, is that formal methods may provide useful tools for clarifying thought processes and organizing arguments in debates over bioethical issues.
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Notes
The acronym is standard in the literature. In fact, the “Jarvik-7” was a bi-ventricular prosthesis attached to vestigial atria [1, p. 849].
Dr. Clark’s post-implant suicidal ideation gets significant attention in a comprehensive discussion of the case by his psychiatrists, Berenson and Grosser [3, p. 913]. Notably absent, however, is any mention of a competency evaluation or any other indication that his requests to be killed were taken seriously. The oversight is all the more strange since, as Berenson and Grosser were aware, his desire to die was not itself a symptom of anything, but rather a rational reaction to his deficits and hence evidence of competence [3, p. 915; 4]. As patient/subject, then, Clark was deprived of both basic patient and basic subject protections. As subject, he was deprived of his right to give a “competent, voluntary, informed, and understanding” consent to the experiment [5, p. 202]; as patient, he was deprived of his right as a competent adult to have treatment withdrawn at his request [4; 5, p. 89]. For more on these points, see “Recommendations” and “Discussion”, infra.
The situation bears some comparison to that of “David G.” (Donald “Dax” Cowart), who also was suffering greatly from life-preserving medical treatment but unable to end his life without the cooperation of others [6]. A full discussion of Robert Burt’s very insightful critique of the received bioethical notion of autonomy is beyond the scope of this paper. For counter-critiques, see [7, 8].
The options currently available to the researcher now are few and unsatisfactory. The sorting of implanted devices into “parts” or “treatments” (with distinctive rights and duties attached to each) is well-nigh hopeless. In general, ethicists will be able to find good reasons for treating devices as both [10]. Indeed, there is no rigid ontological distinction between them (see footnote 12). Some alternatives have been suggested, including a “biofixture” analysis and an “integral device” analysis [11, 12]. These categories are murky; they provide no clear guidance on how or why we should behave in one way as opposed to another when faced with a novel situation involving parts.
With a few notational exceptions (⊆ instead of <, ⊂ instead of ≪, ⇒ and ⇔ for the material conditional and biconditional, respectively), this survey basically follows [20, chs. 1–2]. Although up-to-date only until 1987, this work remains a very valuable resource for anyone interested in mereology. Chapter 2, “Survey of Extensional Mereology,” presupposes a knowledge of set theory through order; chapters 7 and 8, “Essential Parts” and “Dependence,” presuppose an acquaintance with modal logic. A technically sound yet accessible general introduction to the field of “mereotopology” (see footnote 8) is [17]. For more recent developments in this field, see the current bibliographies of Maureen Donnelly, Barry Smith, and their various collaborators.
An alternative supplementation principle is “Weak Supplementation.” A mereology with Weak Supplementation does not afford the PPP as an inference when added to the axioms for the partial ordering.
Calling TM a “mereotopology” (as developers of formal models for spatial representation usually call their systems) would be misleading, for TM differs significantly from prior systems. For example, it rejects Casati and Varzi’s axiom C.1 [17, p. 52] and the inorganic axiom C.3’ [17, p. 54]. Furthermore, while the various mereotopologies all posit an apparatus of regions independent of objects, TM rejects such an apparatus for philosophical reasons. These distinctive features justify the deviation from the standard nomenclature.
The Oriental medical doctor (OMD) will partition the body as Western doctors do—up to a point—recognizing most of our major organ systems. But she will also observe channels (meridians) and their vessels, divergences, sinews, and points, which do not in general correspond to any material feature recognized by biomedicine [26].
See [14] for an effective axiomatic treatment of this approach.
In [28], Zemach distinguishes four basic ways entities can be situated with respect to spacetime. These include events, which are partitionable both in time and space; continuants, which are partitionable in space but “wholly present” in time; processes, which are partitionable in time but wholly present in space; and types, which are wholly present both spatially and temporally. Zemach contends that each of these ontologies is complete: each is alone capable of accounting for all the phenomena of the spacetime world. Hence, as noted, Quine (and others) take “continuants” to be “events,” etc. I will rely on Zemach’s insight later, when I consider the Jarvik-7 (nominally a machine, a “continuant”) as a process, viz., in its aspect as a sustaining mechanism or activity essential to life and, as such, wholly present wherever it is present at all. The usage is not without precedent; Hudson [29] effectively deploys the concept to solve the problem of vague boundaries for persons.
“A container is a fillable thing, and fillability is a complex dispositional property that cannot be explained in terms of simple part-whole structures” [17, p. 139].
See [34, p. 42]. One might wonder how a law can be a law if it is not a necessary truth (i.e., true in every possible world). The formulation is standard for Humeans, although it has been subjected to forceful critiques by scientific realists like Armstrong and Lowe, who hold that the proper form of scientific laws must posit relations among universals (see, e.g., [35]).
This is why I prefer this formulation of Niche to that of [36], according to which “Niche” excludes the encompassed part.
I will eschew the obvious choice of “identical to the body” for the simple reason that there is no reason preferentially to identify “person” with any one of the three types of human wholes; and identifying persons with all three would contradict the transitivity of identity sentences (since none of these wholes is identical to any of the others).
Since in all these cases we will have manifest behavior to explain, it will be simpler to posit that the principles reflect a desire that some state of affairs be instantiated than that they reflect a belief that actions intended to bring about a state of affairs more consistent with the principles is morally obligatory; for this would still require attention to the contentious question of whether or how “reason can be practical” (i.e., how moral beliefs motivate). Locke wrote, “The motive, for continuing in the same State or Action, is only the present satisfaction in it; the motive to change is always some uneasiness [desire]; nothing setting us upon any new Action, but some uneasiness” [42, p. 249].
Studies indicate that distrust of physicians may also play a role [5, p. 192].
That processes are “wholly present” wherever they are present at all is true by the definition of processes (see supra). But can a consistent mereology include axioms that assert the existence of such things? A viable solution can follow the lead of the Anti-Foundation Axiom of set theory, which posits a unique solution (Ω) to the equation X = {X} [45]. Briefly, I will define a class of Ω objects, objects which are proper parts of themselves. Given this definition and the definition of a process as any entity that is part of all its proper spatial parts, it is easy to show (1) that Ω objects obey the four basic axioms of extensional mereology; (2) all processes with any proper parts are Ω objects; (3) all parts of processes are identical to the whole and to each other. Further details (as of the whole system) will be presented elsewhere.
The idea that one is part of something greater that is also a part of oneself plays an important role in the teachings of Christianity, Hinduism, and Mahayana Buddhism.
Personal psychological factors, such as a generally compliant nature and difficulty saying “no” to requests, may also have contributed to his attitude towards the experiment [3, p. 911].
For more on casuistry, see [47].
Although Rady and Verheijde assert that dependent patients die within minutes of the deactivation of their LVAD, at least one case reports normal heart function for over 24 h in a presumptively dependent patient after LVAD failure [48, p. 2; 49, p. 1690]. We do not know who is “dependent” until the device is turned off.
This is not intended to be a blanket condemnation of paternalistic physician decision-making. There are cases where the physician can see a brighter future for the patient with great clarity, which may in some circumstances justify continuing treatment over a refusal (see [50] for a discussion of pertinent considerations). Novel interventions by their nature cannot invoke this exception.
The use of LVADs as destination therapy (i.e., not as a “bridge-to-transplant”) raises the question of whether portability is an adequate substitute for full implantability. The answer here is “no.” Portable, partially implanted devices are in effect “wholly external organs” and (in addition to turning a body cavity into a hollow) leave a troublesome ambiguity surrounding patients’ physical boundaries. See my response to an objection in the “Discussion” section infra; see also footnotes 24 and 27.
Although their deactivation is not an immediate cause of death, LVADs are not true assistive devices; their implantation degrades natural circulatory function [51].
The reader may safely infer from this that I think the regulations requiring the organs of such patients to be evaluated for transplant suitability are ill-advised (see, e.g., [54]).
A competent adult patient has both a constitutional [5, p. 89] and a common law [4, p. 272] right to refuse treatment. The sensational cases involving a “right to die” almost always involve decisions for incompetents or non-adults. (For an exception that nevertheless affirms the right, see ([5, ch. 3].) Dr. DeVries averred, “After implantation, the recipient reserves the right to discontinue participation in additional experimental procedures, in which case supportive care will be provided” [1, p. 850].
Cf. Dr. Kevorkian’s “killing machine” [5, ch. 16].
In an (unfortunately) very influential article, Rachels argues that “the bare difference between killing and letting die does not in itself make a moral difference” [59, p. 40]. This conclusion is based on analogy to a case of “passive malthanasia”: A man bent on murder for gain allows his prospective victim to die. There is no moral difference between having committed the murder and having “[stood] by, ready to push the child’s head back under if necessary, but it is not necessary” [59, p. 40]. A case of “passive euthanasia” should be analogous to that of passive malthanasia. Imagine that a physician has decided to euthanize a patient, and finds him (as the victim in the first case) drowning. He stands by, ready to give the patient a shot of potassium, but it is not necessary to do so. Grant arguendo that this physician is as morally culpable as the physician who actually gives a shot. But there is a morally significant difference between what this physician does and what a physician does when she “lets a patient die.” When a physician “lets die,” she does not stand by ready to kill if necessary. Indeed, if the patient should miraculously recover, she would be ecstatic. Put another way, termination of treatment does not apodictically entail termination of life. Therefore, it is not morally equivalent to it (on Rachels’s argument, at any rate; for a different argument to the same conclusion for neonates only, see [60]).
As to Recommendation (1a), all the ethicists I have read on the topic insist on the necessity of comprehensive, effective informational activities with patients prior to VAD implantation—unlike the presumption of permission appropriate to established medical intervention [4] and much more like that required of subjects in human subject research (see footnote 2). The extent to which these recommendations are currently being implemented in actual consent procedures is unknown.
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Acknowledgments
The author gratefully acknowledges many helpful suggestions from the Journal’s editorial staff, including Jeremy R. Simon and several anonymous reviewers. The assistance of Dorothy Walsh of the interlibrary loan staff of College of Staten Island, CUNY was invaluable. I am indebted to Angela Fried for preparing the diagrams. Very special thanks are due Douglas Lackey, who commented on an early draft and whose suggestion provided the original impetus for this project.
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Fried, E. Prolegomena to any future mereology of the body. Theor Med Bioeth 34, 359–384 (2013). https://doi.org/10.1007/s11017-013-9263-3
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DOI: https://doi.org/10.1007/s11017-013-9263-3