Bioethics is Love of Life: An Alternative texbook

Darryl R. J. Macer, Ph.D.
Eubios Ethics Institute

Copyright 1998, Darryl R. J. Macer. All commercial rights reserved. This publication may be reproduced for limited educational or academic use, however please enquire with the author.

4. Love of our own life

It is not a coincidence that the popular paraphrase of ethics, "love others as you love yourself", uses love of ourselves as a reference point for comparing love to others. It claims that we have the ability to love others as we do love ourselves. Creatures that did not love themselves would not be expected to be alive, nor would they be expected to live long enough to have children to perpetuate the next generation. All creatures need to have a love of their own life in order to live at all. We could even describe it as a natural law of life, that self-preservation is necessary, at least until reproduction is obtained for the genes.

One view of self-love is that it is to be positively valued as revering one's individual liberty and particular life, a life that is unique. There is broad religious and moral support to have concern about our own flourishing and development, and in this view the moral evil may be inactivity or sloth rather than pride (Outka, 1992). Laziness will mean that whatever potential we have is lost, and the potential to love the life we have been given, and to love others or God has been lost. The view is that self-love is just normal and neither good or bad, but this can be close to apathy - though very few beings on this planet are not born with the instinct for self-preservation. The other view, that self-love is pride, will be discussed in section 4.2.

People teach to their children that they must take care of themselves, and strive to do the best in what they are doing. We are taught from an early age to work hard, study hard, because it will be better for us. Education at school and competition for places in higher education, and better employment, reinforces the idea that we should love ourselves. Respect for people's love of themselves or of their family has been called autonomy.

4.1. Autonomy and self-loveself-love

Autonomy comes from the Greek words autos (self) and nomos (rule). It means a person decides using their own values. At one level, it is easy to see that people are different, if we look at our faces, sizes and the clothes that we wear. This is also true of the personal choices that we make. Some people may decide to play soccer, read a book, or watch television. We may be put under some pressure by the people around us to engage ourselves in a particular activity, or to behave in a certain way, but ultimately it is our choice.

Autonomy is also expressed in the language of rights, by recognizing the right of individuals to make choices. Respect for the autonomy of individuals is a fundamental principle of ethics, and is found in early times in those religions which recognized freedom of belief. If we respect autonomy of human beings we should respect their right to have at least some property, or territory, and control over their own body. We are animals, and most animals (social insects excepted) have individual control over their bodies.

Part of recognition of autonomy is respect for individuality, which also relates to confidentiality. The keeping of confidences is also necessary to retain people's trust, and has been a common feature of business and medical ethics. Privacy includes the right to refuse questions. For example, if medical insurance companies try to take only low risk clients by prescreening the applicants, there should be the right to refuse such questions. The only way to ensure proper and just health care is to enforce this on insurance companies, or what is a better solution, a national health care system allowing all access to free medical treatment. The problem of respect for personal autonomy is related to justice, that develops situations and circumstances where everyone may pursue their autonomy to a similar degree.

One can ask if the unit of autonomy is an isolated individual? Interestingly, originally in ancient Greece, autonomy applied to self-governance of Hellenic city states. Therefore there are precedents to apply the principle to not only individuals but also families, societies and states. Many rejections of autonomy as a principle are based on misunderstanding autonomy as a concept only applying to individuals. In family-orientated societies like Japan the concept may often be better applied to families. In the previous chapter the concept of individual liberty was discussed which is the one which overlaps most with the modern Western idea of autonomy.

M.C. D'Arcy (1947) in The Mind and Heart of Love distinguishes between two loves, self-love which seeks power and is self-assertive, and sacrificial, self-giving love. The first type is like eros, and the second agape, but he regards them as companions. However D'Arcy then considers reason to be self-seeking and opposing agape, but reason can also seek the benefit of others. Conflicts between moral duties to others and self-interest produce many dilemmas, however, many philosophers, like Beauchamp and Childress (1994) say that those dilemmas are not moral dilemmas. I would disagree, and argue that self-interest or self-love, or selfishness, are inseparable from the principle of autonomy.

Within medical ethics, autonomy is often discussed with rights and the concept of informed consent. The theory of medical ethics of Thomas Percival (1803) focused on beneficence and non-maleficence and did not include autonomy or justice. Beneficence is doing what is best, and could be followed under autonomy or heteronomy (rule by another). Authority of an external kind may not always be counter to autonomy. There is also a difference between long term goals, for example intensive study needed for an education to quality one for a desired occupation, and the short term feeling of wanting to play with friends.

One of the basic applications of the Western principle of autonomy to bioethics is the idea of informed consent. There is debate over the definition of informed consent and its origin. Faden and Beauchamp (1986) define three conditions necessary for informed consent:

1) a patient or subject must agree to an intervention based on an understanding of (usually disclosed) relevant information.

2) consent must not be controlled by influences that would engineer the outcome

3) the consent must involve the intentional giving of permission for an intervention.

In addition to their study of informed consent there are two competing historical considerations of the emergence of the idea of informed consent. Martin Pernick (1982) concluded for the nineteenth century USA that "truth-telling and consent-seeking have long been part of an indigenous medical tradition, based on medical theories that taught that knowledge and autonomy had demonstrably beneficial effects on most patient's health". Legally many trace the concept back to the early twentieth century, to a 1914 court case with "informed choice" and consent. John Fletcher (1983) quoted court cases from 1941 but said the moral obligation of informed consent was clear before 1939. However, Jay Katz (1984) in a legal sense disagreed saying that judges have only briefly considered informed consent since 1957. Faden and Beauchamp (1986) consider the problem in historical interpretation is one of interpretation, but agree that the 1957 Salgo court case is the beginning of the strict legal concept. They found a paper including consent in the title was Purdy (1935), and one on truth-telling in 1930. They noted they did find more papers on consent in European medical journals in the 1930s and 1940s with 27 articles specifically on consent. Following the Nazi wartime atrocities the Nuremberg Code was formulated with clear protection to individual subjects of medical research.

While medical ethics was developed in ancient times, as seen in the survival of the Hippocratic Oath of the 3-5th century BC, it did not mention consent. However the Hippocratic Corpus does mention issues of truth-telling, with a dismissal of the concept, advising physicians it is best to "conceal most things from the patient, while you are attending to him ... turning his attention away from what is being done to him; ... revealing nothing of the patient's future or present condition" (Jones 1931). However one could argue that this may refer to the difficulty of predicting the outcome, and the fear of doctors who were competing for the custom of patients of being seen by the patient to not be able to properly predict the future. Many of the writings in the Corpus were on etiquette rather than medical ethics. Given that doctors were competing for patients those doctors who gave desired choices would have prospered if the social background sought that as a quality. At least some individuals may have done so.

In the 1767 English court case Slater v. Baker and Stapleton a patient who protested against unorthodox medical practice took doctors to court, and several witness doctors said that not only they disagreed with the method used, but that they would have sought the patient's consent (Faden and Beauchamp, 1986). The first case identified in the United States was 1889 (Pernick, 1982). There are cases of patient's refusing operations in 19th century USA, so we can ask what the situation was in other countries. Analysis of medical records of the Japanese 19th century doctor Hanaoka Seisyu, show informed consent given to women who faced masectomy for breast cancer.

Another expression of love of our own life that is dominant in medical ethics is the sanctity of life. This sanctity of life is also often imposed upon others on the behalf of the person who has their life threatened. The argument is also used by opponents of abortion, claiming the fetus also has a sanctity of life. Jewish Law gives overriding value and sanctity to human life, rejecting any Hippocratic, Christian or modern compromises (Jakobovits, 1975). The duty to preserve life is the dominant obligation, and this is reflected in their medical ethics, however preservation of fetal life was not reflected in the International Bioethics Survey results from Israel (Macer, 1994).

The Christian's role model is Christ, not Hippocrates. There are five basic principles of Catholic medical ethics, those of stewardship of the body, inviolability (sanctity) of human life, the principle of totality, of sexuality and procreation, and the principle of double effect. There are many Catholic Hospitals and Medical Institutions which are instructed to follow the Catholic ethical codes, which differ principally from the standard Western codes with regard to reproductive questions and abortion, as we can see in the results of my surveys from the Philippines. Modern Protestant medical ethics is based more on viewing the relations between the patient and the physician as a covenant (Ramsey, 1990), than the sharply formulated principles of Catholic moral theology. Christian codes regard beneficence, such as striving to do the best for the patient and avoiding harm in the Hippocratic ideal, as a command which does not just apply to the patient but an active duty to all people. Situation ethics of Fletcher (1966) was discussed in chapter 3, as were alternative theories on bioethics based in a Christian tradition.

In Islamic medical ethics, the desirable characters and etiquette of a physician included being sensible, learned, pious and act without haste, and have faith in God (Levey, 1977). It also includes the concept of sanctity of life, and that we should not harm. Hindu medical ethics includes some oaths, including the Oath of the Caraka Samhita from the first century which is structurally similar to the Hippocratic Oath. There is also an instruction to pray for all creatures. The directive to leave dying patients without medical help is not found in the Hippocratic Oath (Etziony, 1973), but is seen in some Hippocratic writings. The code is linked to the idea that ill health is because of bad behaviour in this or past lives. Since the thirteenth century there has been influence from Buddhism and Greco-Arab influence which led to Yunani medicine, which has a code similar to the Hippocratic one.

The Indian philosophy also includes the idea of do no harm, ahimsa, as one guiding principle. Indian medical ethics today includes Hindu and Western influences, plus many folk traditions and other religious groups. India includes followers of many religions, and the long tradition of living together, and has a holistic environmental ethic (Azariah, 1994). In Jainism patience is regarded as a good and pleasure is a source of sin, so that true freedom is independence to outside things. Depending how removed we attempt to be from the material world, we might accept our fate without medicine. However, there is a long tradition of Indian medicine, suggesting that like elsewhere, people seek to cure sickness.

Modern secular philosophy is different from that of either Hippocrates or religious ethics, and within the last decade has led to the emergence of the concept of patient rights (Veatch, 1981; Beauchamp and Childress, 1994). This was discussed in chapter 3. Patient rights came together with general civil rights, which became dominant after the 1960s, also involving environmental concerns. The American Hospital Association 1972 formulated a "Patient's Bill of Rights" in 1972, and within several years this was adopted into law by US Government agencies. The Parliamentary Assembly of the Council of Europe adopted a recommendation "On the Rights of the Sick and Dying" which also states that the patient has the right to refuse medical treatment in 1976. The responsibility for bioethical decisions in the West has shifted to the individual public during the last few decades, though this has gone to the extreme in the United States.

Ratanakul (1986) wrote a book written on the subject of the similarity of traditional Thai Buddhist concepts and Western medical ethics. Buddhism includes the idea that medical knowledge alone is insufficient for medical treatment, a caring relationship must also be present. Although the concept of karma (like fate) is recognized, similar to other religious traditions, human effort is also a means to lengthen human life. The sanctity of life concept is extended to animals in some types of Buddhism, as in Hinduism, as is discussed in chapter 6.

Autonomy is also applied to many life choices that are bioethical dilemmas, for example personal transport of an automobile is associated with high environmental load. People are free to pursue sports that consume large amounts of energy, or to buy large cars or large homes that are beyond what is necessary for a comfortable life. Personal or cultural freedom in continuing to eat whale meat in Norway, Iceland or Japan is considered more important that concerns that whales might have greater intrinsic moral status than previously thought.

There are precedents for limiting autonomy in behaviour towards the environment, as will be discussed in chapter 7. Personal taste in tropical timber products is one choice that has began to be limited by restrictions on tropical forest logging. Another limit is personal choice of use of ivory in statutes and personal name stamps in many countries due to the endangered status of elephants. In chapter 7 I will discuss the idea of environmental quotas and their consistency with love.

4.2. Love of our own life and selfishselfishness

The above section has explored the idea of autonomy and how we may pursue love of our own life (Figure 6). What can we say about the person who loves their children very deeply, doing everything for their future? This is a common social norm of parenting, yet it may not be pure altruism as discussed above. Each parent has half their genes in the child, which embodies the survival of the genes, and from the selfish gene or evolutionary point of view, means the parent must fight for the survival of the child.

Parental love for children is usually unconditional, however some extremely handicapped children are rejected by parents. There may be different reasons for this beyond the difficulty of looking after a child with handicaps or that suffers. Biologically the desire to look after children that cannot reproduce and continue the germ-line would work against parental love for children with handicaps, however, a number of parents dedicate their life to looking after children with intractable diseases who cannot be expected to reproduce. The reason for this may be that parental love is deeper than mere biological urge.

However it could be companionship for the present, that motivates parents to continue to love children beyond being biological survival machines. Human beings are social animals, seen in the number of persons who also live together with pets and other species, rather than living alone. Modern isolated families have meant that the companionship that the extended family offered may have been lost and replaced with other forms of comradery. It makes us wonder whether parental love has been extended from mere biological survival. A question that can asked of guide dogs and pets, but of few animals isolated from human society.

Many human activities are performed with a long term perspective in mind, for example parenting of children in some societies develops in a different way to the reproduction of grandchildren. In some societies parents may even dispense with the constant seeking of partners for their children and try to dominate the life of a child so that the child dedicates their whole life to look after the parents without having children. The biological urge for gene survival is replaced by the individual desire for personal survival, at the expense of gene survival. This is another sign that in human beings mere evolutionary forces have become less than love of our own life.

One factor that is often discussed that may lead to even greater selfishness is the reduction in family size, so that the proportion of only children increases in society and children get used to receiving what they desire. Their objects of love may become material goods, toys, as well as affection and devotion from family who can focus upon the one child. Many children in the world are now deprived of nothing except perhaps the chance to be unselfish, and the joy of giving. The one child per family policy in China has been criticized for various reasons, although it has decreased population pressure on the planet. One of the reasons is that families are focusing all their parental love onto one child, with many claims that selfish children are the result.

Another consequence of modern society is the love of materials. However, this could be explained more readily as the pursuit of power and property, a feature found across most species, that is indirectly related to later gene survival by the accumulation of power that will support more mates. Love of money is not always that same as love of oneself, as it depends what the money will be used for. It may be to give to the extended family, though as will be discussed, where selfishness for one person and one family or community ends and love for others begins is not clear. However, money is often used as a goal to inspire children to work harder, or for people to aspire to. A good career in the image of parents is seldom one which does not pay well. The alternative is one which will make one happy, which is also centred on selfish goals.

Usually the goal of service to others is given as a rationalization for a life choice which is unusual, for example, "She went for volunteer service to Africa but it might help them there", the comment from a parent of a child who chose to take time off from career development to give to others. Even among those who give time for volunteer service, often the goal is self-development by broadening their experience and a chance to see the world. However, self-involvement is not the same as selfishness or self-love.

Self-love in the sense of respect for oneself and confidence about one's talents and powers is not unethical. However, desire for greater self-respect is self-interested, and trying to get others to love oneself so that one feels more respect for oneself is also self-interested. Aristotle considered self-love can be commended if it is committed to virtue when someone "assigns to himself the things that are noblest and best, and gratifies the most authoritative element in himself and in all things obeys this" (Nicomachean Ethics IX, 8). He criticized however those people who have the other kind of self-love, for assigning themselves "the greater share of wealth, honours and bodily pleasures".

A central question for human relationships is what friendship is, and what friendship means to a person. Aristotle elaborates the concept of philia, in Books VIII and IX of Nicomachean Ethics. When two people have attained a reciprocal friendship this is to be valued, "Those who thus wish good we ascribe only goodwill, if the wish is not reciprocated; goodwill when it is reciprocal being friendship" (VIII, 2). Three kinds of friendship corresponding to lovable objects, the good, the pleasant and the useful are included, with the first one the highest, the perfect friendship (see section 2.2). While friendship should go beyond goodwill, goodwill itself has moral value and Aristotle called goodwill a kind of inactive friendship (IX, 5). He insists that loving is more essential to friendship than being loved, giving the example of maternal love (VIII, 8). Aristotle has an ethical conception of the self and the life that constitutes it in action, being rooted in but not exhausted by the identity of the living physical substance that is a human. There is an implicit distinction between the self as a subject of choice and desire (a person and a substance), and a persona constructed by forming desires and making choices. The practical persona is realized in sequences of desires, choices, actions and results (Price, 1989).

Plato in Lysis has a dialogue concerning friendship (philia), and the conclusion of Socrates is "I do not even know how one person becomes a friend of another" (212a5-6). He concludes "We have not yet been able to discover what a friend is" (223b7-8). Three usage's of philos are made: reciprocal equivalent to the word friend; passive meaning dear, and active, meaning fond, but all three are mixed by Socrates. Aristotle took Lysis as a starting point for Nicomachean and Eudemian Ethics (Price, 1989). Aristotle conjoins the three meanings, saying "A man becomes a friend whenever being loved he loves in return" (Eudemian Ethics '.2.123a14-15).

Even the perfect friendship defined by Aristotle as loving individuals for their own sake and doing good for them without any expectation or thought of getting something from them, has been criticized by Naknikian as egocentric because one person wishes for the others good because of appreciation of the other as a person, that the person loves the other because they have characteristics that make them beneficent to the one who loves them (Soble, 1990).

In Western philosophy, the Greek word philautia was used in a negative sense in the post-Christian era, for example, Philo of Alexandria regarded self-love as the central impiety from which other vices flow. However in Plato's Laws there is a traditional saying "every man is naturally his own friend", from which Aristotle developed friendship. Saint Augustine was the first major writer to explore the theme of self-love in Western thought, and he said "There is no one who does not love himself; but one must search for the right love and avoid the warped" (O'Donovan, 1980).

It is another universal belief that it is better for one's soul to be nice than nasty, to be loving rather than unkind. As the Dalai Lama (1995) wrote "There are various positive side-effects of enhancing one's feeling of compassion. One of them is that the greater the force of your compassion, the greater your resilience in confronting hardships and your ability to transform them into more positive conditions". Hare (1981) wrote "Those who do not love their fellow men are less successful in living happily among them." There is a popular saying that it is better to give than to receive, reflecting the positive affect on ourselves of giving. However, few would call giving selfishness, if the motive is love of others.

The exceptions to the idea that it is better to be nice than nasty stem from the times of war, though at this time the love for one's country or an ideal is put above the demand of love that says do not kill. People may say "I am not enjoying to do this but there is no other way". In Descartes work Les Passions de l'ame (1649), a self is created which is constantly on guard against emotion that is not understood or directed by the system of will, but when touched by love is involved in a process of self-perfection that becomes a goal unto itself, love serving then only as a means (Horowitz, 1977). Love is a way towards self-perfection, though he also points out the dangers of ill conceived love.

Love can make us blind, and the love of God is the same as other loves. Are we blind to our own inability to be God, to understand only part of the complete truth? We can understand only what God allows us too! We can hope at best to learn from our mistakes and improve our actions for the next time. Each time improving our soul, to become more wise - yet never wise enough. Yet we have to do what we can, doing good, while trying to minimize the harm of our mistakes.

If we analyze all our decisions so deeply it will be difficult to have any pure virtue. This is one of the reasons people gave up to try to use love as a standard for practical ethics. However, just because it is difficult to separate the motives does not mean we should give up on the standard. Love can become the dominant force or passion for our life. Where is the line between love as a desire to do something good for others as well as yourself or to have something (possession), and the instinct of selfishness? We can ask is there a line? If we say to give makes us happy as well as showing love to others, is there a line between the two? Is love of music something to soothe the soul, true love, or survival of the troubled mind? Does God inspire music?

There are many questions we can ask, but I come back to selfishness with the theory of egoism, meaning pursuit of self-ego. Thomas Hobbes (1588-1679) identified two elements out of which all voluntary action developed, desires and aversions (movement away from objects). He said every human aims at satisfaction of desire, and avoiding the things they dislike, calling the former good and the later bad. The restriction of desire is due to conflicts with others which may result in limitations to later long-term satisfaction, and is necessary to stabilize society.

Scaglione (1963) looked at the relationship of love to nature, while focusing on social laws such as marriage and family, conventions such as artificial nobility, uneasiness about positive moral rules, and the area of life which cannot be assigned to reason. It focuses on Boccaccio's Decameron, looking at Italian and French literature. Decameron is a systematic collection of novellas, or short stories which are parables with a moral, and many had origins in Indian literature.

In Moderated Love, Campbell (1984b) includes an analysis of this conflict between self-love and gratification from love of others. He reviews Erich Fromm (1962), The Art of Loving that emphasizes the importance of both self-love and love of others (see section 2.2). Fromm argued that love is not merely an emotion but an attitude or orientation of character which determines the relatedness of the person to the world as a whole, and it is a universal craving for union.

Tillich (1954) described love as power to bring about union of the separated, and love is seen as the most fundamental experience of human life. He wrote: "Life is being in actuality and love is the moving power of life. In these two sentences the ontological nature of love is expressed. They say that being is not actual without the love which drives everything that is towards everything else that is. In man's experience of love the nature of life becomes manifest. Love is the drive towards the unity of the separated. Reunion presupposes separation of that which belongs essentially together. It would, however, be wrong to give to separation the same ontological ultimacy as to reunion. For separation presupposes an original unity. Unity embraces itself and separation, just as being comprises itself and non-being. It is impossible to unite that which is essentially separated". Verene (1972) wrote "Love is a power to bring together that which is apart and diverse, and it is thus a force that is close to the process of life itself." We can think of the ideas of contact between persons, and the following interaction, which breaks down the separation (Dilman, 1987).

We could conclude that people are happier and more self-contented when they are loving to others than selfish, and it makes us feel better. In the Gradual Sayings of Buddha (A.iv.150) there are eight benefits that an individual can gain from the liberation of mind which is love when it is sustained, cultivated, practiced frequently, made into a habit, made strong, undertaken, increased and made into a commitment, which are: The individual sleeps well. He wakes well. He does not see horrible dreams. He is dear to humans. He is dear to non-humans. The deities protect him. He is not affected by fire, poison or weapons. If he has no higher realization, then he ascends to the world of Brahma [after death]." The benefits may not occur, but we could reason that the development of love goes hand and hand with these benefits, for if we are dear to others, others will reciprocate.

4.3. ErosEros and sexual love

There have been numerous books written on love and sexual desire. Given that bioethics considers questions of life, and sex is the means to generate new human life as well as a basic way to strengthen relationships between partners who may be making decisions together, it is basic to bioethics. In English language and modern Western culture sexual intercourse has been called "making love", and it has had moral overtones (Verene, 1972). In Japan, the term for love, Ai, is used somewhat more exclusively for romantic love, but still has a wide range of meanings (as also noted by Fletcher, (1966)).

Whatever language we use, it is true that often the strongest emotions of elation and grief are associated with the affairs of erotic love. Bayley (1960) wrote that "for everyone recognizes that - whatever you call it - sexual love is for most people the most interesting and memorable aspect of life. It is this kind of love, eros rather than agape, with which literature is most concerned..." George Moore the Irish author wrote "One of the glories of society is to have created woman where Nature made a female, to have created a continuity of desire where Nature only thought of perpetuating the species; in fine, to have invented love". His view could be considered very reductionist, but he still rejoices in the creation of love. The ancient Greeks regarded sex as a natural human activity, seen by the absence of major moral discussion of sex by Plato and Aristotle (Verene, 1972). Homosexual and heterosexual activity were considered natural activity and not raising moral issues, a situation changed by the Christian writings of the New Testament in the Jewish tradition. Anthropologically the situation is not so different from global bioethics, only about 5% of human societies regard sex outside of marriage as a taboo (Haviland, 1997), although the dominant ones do.

Plato in the Symposium has a succession of eight speakers at a drinking party writing on the nature of love. Phaedrus argues that love is sexual desire stimulated by an experience of beauty. Pausanias argues that good and bad love can be distinguished by the degree to which love promotes or inhibits the realization of human happiness. At the end, Socrates, the mouthpiece of Plato, says love is neither mortal or immortal, neither pure alteration or unbroken continuity, but a combination of the two. Socrates says "Love is for possessing the good oneself for ever" (206a11-12). Love is a mediator between divine and human realms. Love (eros) is the passionate struggle to maximize the realization of the potentialities of human life, being a quest for the maintenance of bodily existence, physical health, worldly goods, aesthetic pleasure, and immortality through personal knowledge of good.

Plato declares that eros is "the thirst for a knowledge of the good and the beautiful". Eros was considered by Plato to be a force which leads the soul in the direction of the ideal world. Aristotle expanded Platonic theory to describe eros as a force in all things, a force that represents the longing of all things to reach out and become higher. The Neoplatonists developed eros into a universal force, the primary energy of existence, the power of cohesion in the universe (Siegel, 1978).

Price (1989) regarded that there are two ways in which the beautiful (kalos) is integral to love: the lover desires to possess beauty (which is love's goal); and within specific eros the lover is inspired by someone else who already possesses beauty (and is love's occasion). This later generation of beauty might mean begetting upon a beauty, or else bringing to birth in the presence of beauty. The goals of love, good (agathos) and beautiful (kalos) are used interchangeably, and in the end the goal is happiness (eudaimonia). Dover (1980) expands the goals, "Anything which is kalon, i.e. which looks or sounds good (or is good to contemplate), is also agathon, i.e. it serves a desirable purpose or performs a desirable function, and the vice versa". The kalon is what presents itself appealingly while the agathon is good for someone in some way; the kalon draws us and the agathon helps us; but they are equivalent; whatever attracts us also benefits us, as long as our judgment is good (Price, 1989). Thus the goal of love is beautiful.

Sexual love is more than just benevolence as "it can occur between any two individuals however casual or sexless their acquaintance may be" (Singer, 1987). It cannot be reduced to genital instinct which may occur without love. Singer suggests that sexual love reveals at least an inclination to benefit the person one sexually desires, to care about that person's welfare. Osborne (1994) had a different view of the ancient use of eros, in which she claims that love was considered inexplicable, and we cannot find the reason why someone loves another. She regarded desire or admiration of the fine qualities of another, as something which occurs as the result of love, but not love itself. She then suggests love is an attitude that is acquired with no motive or purpose, but an attitude that changes our whole outlook and response to the objects we love.

The Christian tradition generally avoided the term eros, preferring agape or philia, probably because of the sexual connotations of eros. In addition agape was available to all people everywhere, coming from God. Augustine tried to synthesize the eros of the Neoplatonic tradition and the agape of the Christian tradition. Of the different forms of love, eros, sexual love or romantic love, has most often been associated with pursuit of ego satisfaction (Soble, 1990). Eros recognizes value in the object of love, agape creates value in it. Anders Nygren (1969) argued that eros and agape were not related at all, the former being profane love and the later sacred. He argued that even the heavenly eros which is the most spiritualised form is egocentric, in contrast to agape which is theocentric.

Freud (1921) claimed that the nucleus of love is sexual love with sexual union. The eros of Freud was associated univocally with self-love, as well as love for parents, children, siblings, and humanity as a whole, like the Greek eros and Indian kama. Freud said the eros of Plato in the Symposium coincided with the love force, libido of psychoanalysis (Santas, 1988). Platonic eros was for the good to be ones' forever, the goal is everlasting possession of the good. Plato implied that the value of love depends entirely on the value of the object, because as I said above he puts the forms beauty and goodness above all. However, Freud wrote that the goal of libido is pleasure or satisfaction. Freud's love is based in the unconscious sexuality, it is a love instinct with the value of love depending on more immediate satisfaction.

Deep romantic relationships, both doing loving and being loved, challenge the autonomy of the lover and the beloved (Lamb, 1997). In this way, the unit of self may expand to become two or in some situations more, working together for common interest. This has consequences for bioethics, including whether to share sensitive information with others inside the relationship of friendship or family, and obtaining consent for medical procedures. The combination of individual moral agents into units may occur for other forms of love, commonly within a family, but couples bound by eros may be the strongest.

At the same time the power of erotic love has meant that it has been considered a disease if it is erotic mania, as Plato attributed to Venus and Eros. In Medieval medicine, as in the writing of Halyabbas and Avicenna, sex was considered normal but passion was considered an illness (Scaglione, 1963). This is interesting for sex was animal instinct and normal, but passion and imagination was considered a disease. Shakespeare wrote in Hamlet that "Love that is not madness is not love". There continues today to be a major profession of counselors who try to help people with broken hearts from failed romantic love (Pope, 1980). This may be because marriage that institutionalizes romantic and sexual love is the core of most family and community structures in the world (Lerner, 1979).

There are a variety of forms of marriage found in the world. Marriage can be defined as "a transaction and resulting contract in which a woman and a man are recognized by society as having a continuing claim to the right of sexual access to one another, and in which the woman involved is eligible to bear children" (Haviland, 1997). Marriage gives the social, legal and economic backing to a sexual relationship, although mating may occur outside of marriage. In not all societies are new families formed by marriage. The love relationships in monogamous marriages may be less complex than in polygamous marriages, but modern Western society now also has a common system called "serial monogamy" of repeated marriages and divorces, which has made the relationship of marriage less secure than it was. In many societies today marriages are based on an ideal of romantic love, perhaps India is the largest country that still adopts the alternative system, of love following marriage than preceding it. However, in Europe in the Middle Ages virtually no one married for love, and there was a medieval saying "to love one's wife with one's emotions is adultery".

Sexual love has often been used as an example for discussion of morality in general, with most major philosophers writing something on the subject (Verene, 1972). Numerous writers in literature have considered agape and eros, for example Shelley in Adonais (Allsup, 1976). The Indian god of romantic love is Kama, the divine personification of sensuous attachment, desire and erotic pleasure, which is like eros, also identified with the basal energy that drives the life force through every living being. Images of sexual love are also used to model divine love, as seen in the Christian image of man and women in marriage, like church and God. A study of Queen Henrietta's Masques's written for the royal court in 1630-40 in England, developed the ideal conception of love beyond the person themselves, as procreative and sexual love, to a belief in the connection of love with divine Providence. In these plays women seek to extend the concept of love beyond its sexual connotations to the whole range of virtuous human actions and relationships, honnetes femmes, who defend beauty and virtue (Veevers, 1989).

Sex is intrinsically related to the romantic love that is essential for stability of the family in evolution (Wright, 1994). Sex can also be used as a method for reconciliation between human couples who have had an argument. In bonobos, both homosexual and heterosexual behaviour is used to reconcile two opponents after a conflict, serving the cohesion of the group (de Waal, 1988). Homosexual behaviour is also seen in rhesus macaques and baboons, and it has been suggested as a method for bonding in humans (Wilson, 1987), therefore biologically linking eros and philia. Lewis (1962) considered eros to mean "being in love", and thought affection was the form of love which comes closest to that of animals, rather than eros. He considered eros to be a human variation of sexuality. Love however outlasts sexual activity and affects our personality much more than sex (Brown, 1987).

Eros is certainly not limited to sexual love, rather eros is a drive to know. Intellect has its own eros, a drive to learn things. Pure eros or drive may be closest to autonomy seeking and selfishness, if it is not controlled by agape. Before we consider the conscience, let us also consider quality of life.

4.4. Self love and the quality of lifequality of life

In times of sickness, the quality of life is more important for most people than the length of life. There is little value in being alive if the quality of life is terrible. Rather than spending much effort to fight genetics and disease to increase the length of human life beyond the eighty to one hundred years of lifespan many in industrialized countries can enjoy, we need to spend greater effort to improve the biological, social and spiritual quality of life. This question is relevant to euthanasia, and genetic selection before birth.

Human procreation is associated with a high degree of error, because when genetic elements rearrange there are often mistakes. The number of fertilized embryos with genetic abnormalities may be about 70%, a very high figure compared to simpler animals. Most of the genetically abnormal individuals are spontaneously aborted in early stages of pregnancy. But some are born and will die later, some have a painful life others do not. If a fetus has a serious genetic impairment, with a consequence of serious mental deficiency, some people might say that the fetus does not, and will not in the future, have a "life" as "normal" humans have a life, it's potentiality is different.

How can love help us in such dilemmas? In Fundamental Principles of the Metaphysics of Morals, Kant (1785) argued that the prohibition against suicide is a universal maxim, and part of moral law. The principle of self-love is a feeling to improve one's life so Kant argued that it would be wrong to destroy life by self-love, even if longer life is likely to bring more evil than satisfaction, because it would be a contradiction. Nietzsche supports that view in Die Frohliche Wissenschaft writing "Life - that means continually expelling from ourselves something that desires death". However, the principle of self-determination and autonomy suggests that human beings have been given the freedom to make decisions about their own life and the pursuit of the goals. At least they can decide to refuse any offer of help from outside, including what may be routine medicine like blood transfusions.

Using love as a basis for ethics finds that self-love is present in animals that may not be considered conscious of others, or persons. Love of life is a strong desire. In my mind one image that I will always retain is the crawling of an injured dog in the streets of Cairo. The dog had just been run over by a car, so it could only use its front legs to walk, yet it struggled with the front legs to get off the road. Such is the love of life, beyond concerns of pain and suffering. Whether on reflection we may reassess this desire to love because of quality, at least in emergencies we can assume that individual organisms do want to survive.

We can consider the case of severely handicapped human newborns. Do we deny the potential for spiritual relationship between God and the most diseased forms of human life? Severely retarded individuals may never be spiritually aware - but can we judge? Many religions would argue there are no "worthless" lives. In Christianity this is because in God's eyes each human person is precious and the property of God. In Buddhism each life has its own "karma". However, most traditions support limits to interventions to save life.

No individual is an island of themselves, and policy must consider social justice, as discussed in the next chapter. The allocation of society's resources has to consider equity rather than social merit, social productivity, quality of life, or ability to pay. Considering justice we may consider quality of life as one factor in distributing limited resources, and in fact if we don't, we are ignoring other people's lives. We do not need to maintain life at all costs, as this may not be in the patient's best interests or in God's will. One of the early statements on the distinction between extraordinary and ordinary treatment came from the Pope Pius XII (1957); "We are normally held to use only ordinary means, according to the circumstances of the situation, but are not obliged to any grave burden for oneself or another to life... Life, death, and all temporal activities are subordinate to spiritual ends."

The quality of life relates to the individual person, and conceptions of it change with time and situation. The personal goals of self-love may be many, as each explores their potential. People have different hopes and ambitions, and the capacity for personal growth from a given state is important. Recently advance directives, or living wills, have been introduced which allow people to make choices before they reach a situation where their quality of life will become very bad and hopeless.

The distinction between acts and omissions is often not consistent, as in cases of letting severely handicapped newborns die. However, it may be a useful legal barrier as there is the existence of a potential slippery slope to widespread euthanasia. The law in the Netherlands allows some active euthanasia. An objection used by many to this is that it is interference with providence, but in a modern hospital one could argue that many medical treatments interfere with nature. If we regard life as sacred, then we may not agree with the modern concept of the right to decide our own life, or autonomy. If we intervene to prolong life with experimental therapy this can be just as much playing God as shortening may be.

A disease that might seem to make someone less "human", in fact may make others around them more human in the love and care that they give. There is a strong idea that ideal ethical behaviour is keeping with our true humanity, we need to be able to love to be fully human. Often much of the suffering we see in others is what we would imagine they feel if they had our sense of what is suffering (Hauerwas, 1988). The suffering that is being avoided may be more that of the family than the actual individual. Yet, everyone would agree there are some lives too full of suffering to ever understand.

The issue of the value of life (Harris, 1985) is fundamental in many issues in bioethics. This question is important when considering the financial investment into new technology including new genetic technology, offset against the cost of life if using genetic screening and such negative means. Despite the ideal of treating every disease, there are limits. These limits include both technical and financial ones.

While there should be no limit to our love, and we should not limit opportunities to show love, we should not just impose technological solutions to delay death. It is the same as taking our reasoning away from a situation to say this is "out of my hands" and it is up to God or fate. To ignore quality of life concerns is like putting our head in the sand like an Ostrich. Both to act or not to act, are ethical decisions, and we must now consider our conscience as a judge for making such decisions.

4.5. Love and conscienceconscience

While we cannot treat individuals as isolated persons, we do believe that moral agents are morally accountable for their actions. We expect children to develop moral judgment, with guidance from family, close friends, school and the community in general. Often religious instruction is also given the task of teaching ethics, both within a school system and separately in religious institutions outside of school time, like church Sunday schools, mosque schools, and various religious initiation ceremonies. The conscience can be used both as a noun and as a verb. Fletcher (1966) argued that 'conscience' is merely a word for our attempts to make decisions creatively, constructively, fittingly. Situation ethics considered more its concern with prospective decision-making rather than with retrospective judgment-passing. He argued that prudence is the same as love, in the terms of doing good for others. Prudence gives love the carefulness that it needs, so that love becomes justice.

The development of conscience in personal moral development has been studied in psychology and education. Freud used an explanation using the concept of Superego which has both feelings of obligation and guilt to regulate behaviour. The ego ideal gives positive values for the individual to aspire to while the conscience prohibits and controls the instinctual drives of the personality. As a child grows, parental control is gradually replaced at an age around 5 years by internal control of feelings and actions, where the parental authority is no longer seen as external but rather internalizes the moral authority of the parent as part of their self, the conscience.

Given the importance of conscience in regulation of behaviour and pursuit of self satisfaction, and the early development of conscience, it would be naive to expect moral reasoning taught at a later stage based in academic principles to be a general substitute for the role of conscience in decision-making. Our choices may result from early experiences which we are not aware of now, and may not be very objective. If we are promoting love as a principle of bioethics, we have to ask whether it can be taught? How do we learn to love? Can we teach others? Plato writing with the dialogue of Socrates in the Meno denied that virtues could be taught, while Protagonas said it could be. Protagonas said that virtues are taught by parents, friends, spouses, early childhood stories and colleagues. If I did not believe in the power of the intellect to convince us of the need for love, and better inform our consciences, I would not need to write this book or waste my time trying to teach bioethics.

If we are trying to better ourselves and reach our full potential, as demanded by self-love, this also means trying to improve the way we live and decrease the number of mistakes that we make, whether we call them sins of action or omission, we should still try to do better. Many have said that the power of love (or power of God) is the only force that can transform a human soul to act in love, but whatever our background, almost no person likes to do wrong or make mistakes. Inside our societies, as discussed in the next chapter, we can see tougher forms of judgment used upon individuals who ignore their conscience in actions.

In Christian scripture, the fourth Gospel starts with the Greek term Logos, translated Word in English, which is the truth which the mind seeks when it tries to understand the principles which govern the life of the world (Williams, 1967). This is consistent with the scientific and logical understanding of the world that is becoming popular in industrialized countries, and with the approach of developing prescriptive bioethics that has been reviewed in the previous chapter. Saint Augustine understood that intellect seeks the same object as love, God's being and his truth, but the intellect can do its proper work only when it is orientated within the life of love. As Gilson (1961) wrote "Loving another with one's whole soul does not mean disowning or sacrificing oneself; it means loving one another as oneself, on a basis of perfect equality." Augustine agreed with the Platonists that knowledge of the truth requires a re-orientation of the intellect through discipline of the self. However, he was also aware of the limits of intellect alone to understand love. He regarded perfect self-love as love for God.

In the Gradual Sayings (A.iii.443) of Buddha, at the end of the description of six praiseworthy results that inspire a monk to develop the perception of suffering with regard to all conditioned phenomena given in section 2.2, finally the monk will have served the teacher with acts of love. The acts of love refers to the insights that forever liberate a person from mental defilement. Gotama in the Gradual Sayings also informs monks that he sees no other phenomenon to compare with the "liberation of the mind which is love" (metta cetovimutti) (Aronson, 1980). The liberation of the mind means liberation from being possessed with anger, and other hindrances. The monks are also told that they should cultivate loving minds, and they should universalize the love they have for any individual.

Universal love includes the sublime attitudes of compassion, love and sympathetic joy (Gradual Sayings A.iii.224-5). This style of thinking, with love as a means to expand the self continues in some religious thought that follows Vedic philosophy (Aron, 1986). Part of this may be absorbing aspects of other persons into ourselves, as a form of self-expansion. We can ask several questions of our conscience, as shown in Figure 7. Our conscience should be pricked into action by the call for love from others.

An unnamed girl in Sri Lanka joins a protest against child labour and sexual abuse, with the simple words "We need love". We all do.

While, Shakespeare wrote about romantic love, "Love is too young to know what conscience is", and love may cloud rational judgment, a complete love comes together with the work of conscience. In addition, the love of self and love of others cannot be separated, a healthy person needs some of both to find happiness. The intellect needs love and love needs intellectual understanding, this is a reasoned emotional power that can help us solve practical dilemmas. In the same way that there are both individual and cultural trends in the conscience and common sense, there are also differences in the application of intellect to decision-making, and in the intellect itself. While we can ask the question whether there is a limit to giving love (Figure 8), giving love does renew the heart and we can get power for our own life from giving. Let us now consider how this has been, and can be, effected in human society.

Figure 5: Autonomy to chose when and where to go up or down

Dusky DolphinsDolphins, New Zealand

WhalesWhales are global citizens of the seas

Figure 6: Expressions of love of self

Love of FoodFood

A beer tanker in New ZealandNew Zealand as a symbol of the love of drinking

BuddhaBuddha taking a bath, Ajanta Cave, 7th century, India

- The ladies are preparing Sandal Wood Paste and Scents for his bath. Jesus Christ also said there was a time for luxury and a time for fasting.

Adelie Penguins, AntarcticaAntarctica

- Courtship rituals are seen as preparation for sexual love in most species

Figure 7: The call of the needy

Figure 8: Can love be sucked dry?

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