Yesterday we had our Bedrosian Center book group discussion of the Last Days of Ptolemy Grey by Walter Mosley. I am a great fan of Mosley’s writing in general, and this book has become one of my favorites. It is a very difficult book because of its complexity and tone, which is sad.

I brought up what I considered to be the central policy issue in the book–there are many–and I was surprised to discover that I was the only reader who viewed the central decision in the book to be about physician-assisted suicide. In short: Mr. Grey is 91 years old at the start of the book, and he is confused. He has been suffering dementia for some time, and he is living in squalor, among things he inexplicably hoards. He can’t seem to understand much of what is going on around him, but he does understand that his grand-nephew Reggie, who looked after him, has been murdered. And he wants to know who did it, and he wants to right that wrong. He’s got several wrongs to right, but that one is most pressing.

He is recruited by a shady social worker into a drug trial for a dementia medicine that will give him his mind back, but is also almost to kill him within a few months, if he is fortunate. If he is unfortunate, he will die right away. Thus for all practical purposes, the drug trial is a form of physician-assisted suicide.

Bioethicists and health policy folks will readily recognize the issues in play, and they are apparent here, except for the whole “Death Panels” –a master stroke of framing that prematurely ended the national discussion about physician assisted suicide as part of national health legislation. I’ll cover a couple of things first, before I get there.

My colleagues were on Ptolemy’s side, and it would have been a short book if he hadn’t agreed to the drug; I was the only hold-out because I’m just not sure what I would do myself in that situation. It’s one thing to think about the issue in the abstract. It’s another when you are actually staring at the gun, as it were. In any case, we did cover some of the problems for Ptolemy and the decision to undertake physician-assisted suicide:

1. He’s not really in any shape to truly be giving consent. He’s confused, but he’s not fool, but it’s not clear what consent means when a patient is as confused as Mr. Grey is. Taking away the decision is awful and paternalistic. Pressing the decision is also awful and paternalistic.

2. He does not have relatives who are disinterested in his death, who might be there to support him through the decision, granted his confusion. Now that Reggie is gone, his relations pretty much see him as a pathetic old man they don’t really know what to do with, who isn’t doing anybody any good, including himself, and so why shouldn’t he just die and let them have what money he has? They don’t even know about his big cache; if they knew about that, his exit would be all the more appealing to them.

He does have Robyn, who is also not disinterested; but she does try to point out the consequences of the choice. He knows, and she knows, that she could stop him if she really wanted to, but she also doesn’t seem to want to override his own choice. One of Robyn’s best qualities is that she respects Ptolemy’s manhood–genuinely–at an age where much can emasculate. There is something decent and humane in the mutual understanding and other regard between them.

3. He also has, in his current condition, very little dignity or quality of life. These are two factors that I think have to be absolutely central to the public ethics of social policy, and they are not. They should be–I repeat.

So we have a bunch of conflicting principles there, and how you weight them will lead you in different directions. Mr. Grey’s family does not strike me as exceptional; I think lots of people are just waiting to clear out their parents’ or grandparents’ homes and sell them. It would be nice if people were better, but we do have a goodly bit of evidence that, sometimes, they are not.

Finally, and this is the part we don’t deal with in Ptolemy Grey, we have

4. Medical businesses and insurers also are not disinterested financially in ending lives. And that is one reason why the ‘death panels’ discussion turned south so quickly. For those of us who think about these issues, the “death panels” discussions were exasperating, like, “Geez, America, this is why we can’t have nice things.” But on reflection, I do understand it better: many HMOs treat people pretty badly. I’ve had one uncaring, indifferent, robot of a doctor after another act like I was a waste of his 7 minutes. There are great doctors out there, just like there are great professors, but there are also real jerks in both games, and thinking about the HMOs and the way medical services are delivered in this country, I can’t blame people for worrying about handing over ANY decisions about the end of life to that industry.

We still made a mistake not having a much more serious discussion about dignity and the end of life during the ACA debates, but still. I get it. I do.

The reason why I am a little on the fence in Ptolemy Grey’s case, and my own, comes back to the little core of Kantianism that tends to guide my intuitions about “the future.” With his tricky “lying to the murderer” scenario, he turns us inside out, on ourselves, and confronts us with the reality of the future rather than our perceptions of power and control surrounding it, and that is a bitter bill for Americans, particularly American progressives, who think you control your future. If you eat healthy, you’ll live longer. Sure, in some instances. In others you still get cancer or squished by a car or gunned down. If you save your money, you will retire in wealth and get to golf all day. If you are fortunate. Alternatively, you will get wiped out by one stock shock after another, or conned by somebody like Madoff, or you die before you use it.

The future is a problem for Kant, and it’s a problem that planners like me spend a good deal of time thinking they can influence, and they do, but not as much as we’d like, and that’s a problem, too. So some planning things to turn out really nice, and others do not. Because that mix may actually be, as Kant notes, in the nature of the future.

For ending our lives, how exactly do we decide when “there is no hope” for a person? I agree, there is little dignity in a long, awful, pain-filled death at the hospital when most people would rather die at home, with the chance to say goodbye to their families. It’s wrong to make medical professionals like nurses effectively torture patients with treatments that have virtually no chance of working, instead of letting the individual carry himself off gently while surrounded by his friends and family.

But in Ptolemy’s case, his body was pretty healthy save for the dementia. With Robyn in his life, he was being cared for. It is possible that given a year or two more, treatments for dementia could prove out. We’re not talking about intense suffering and short timeline when breakthroughs are pie in the sky. Mr. Grey might have had some years yet. And I hesitate to conclude that even in his confused state, those years could not have had value to him, even if he is confused. The young think that aging is terrible, and it is, but youth, too, has its terrors.