Ewan Goligher, How Then Shall We Die? (Bellingham: Lexham Press). 160 pp. $18.99 paperback.
As a current fellow training in palliative care medicine, one of the great gifts of my work is the ability to daily bear witness to those who face impending death. While this “gift” may strike some as morbid or masochistic, I presume this view to be held by those who have not themselves spent time around the dying. Being able to come alongside and learn from those who are facing imminent death affords a sobering but deeply important opportunity for those of us who remain ostensibly healthy to reckon with our own finitude in a way that is otherwise culturally discouraged. And this work is not merely voyeuristic; when done well, communing with the dying affords the patient the opportunity to maintain relationship and exercise virtue in her role as teacher to those who would come after her.
Yet this privilege—to interact with and learn from the terminally ill—is one that is largely proscribed in our contemporary Western culture. Rather than grapple with our own embodiment and contingency, our teenagers dabble in prophylactic botox. Rather than lionize and render what is due to our elderly forebears, we favor institutionalization. Rather than foreground the experiences of our sick and dying, we largely sequester them. While there has been an encouraging movement toward improving the dying experience of patients through the establishment of palliative care as a medical specialty, even this term “palliate,” which derives from the Latin “palliam”—to cloak—betrays our discomfort with the transparency of death.
As the conversation surrounding the moral permissibility of physician-assisted suicide/medical aid in dying (PAS-MAID) steadily amplifies, this societal distancing from death influences the views of those on both sides of the argument, but ultimately places the burden of proof on those of us who oppose the practice. Insofar as the act of death remains a largely hidden, privatized experience, arguments for the priority of personal autonomy will be progressively strengthened rather than questioned. To the degree that the idea of death remains taboo and uncomfortable to consider, society will generally accept the supposed preservation of dignity and mitigation of suffering purported by those who advocate for MAID. Thoughtful arguments in opposition will, meanwhile, atrophy over time.
In his recently published book How Should We Then Die? Canadian critical care physician Ewan Goligher seeks to bring the issue of death, and the attendant question of the moral permissibility of PAS-MAID, to the fore in a form that is succinct, accessible, and internally consistent. Goligher is clear and persistent in his argument that PAS-MAID constitutes a grave transgression of the intrinsic goodness of human life and ought never be considered licit. As he states from the outset, his goal is to provide an argument consisting of a series of ten distinct “theses” addressing various facets of this overall claim, intended for Christian audiences grappling with the urgency of the PAS-MAID question.
Goligher’s work serves the important purpose of putting forth a basic rhetorical grammar surrounding the PAS-MAID conversation for Christians who have yet to consider some of the fundamental moral assumptions at play. In this sense, he largely succeeds in providing a primer to those readers who might otherwise fall prey to the cultural avoidance of death which afflicts secular society and the Church alike. By advocating for the intrinsic value of people and the consequent inherent goodness of their existence, the failure of personal autonomy as a sufficiently robust principle upon which to base decisions of life and death, and the quasi-religious reasoning endemic to most secular arguments in favor of PAS-MAID, Goligher equips his reader with crucial (if simple) foundations upon which to ground opposition. Nevertheless, even within his intentionally limited and circumscribed argument, there are key areas that would benefit from deeper consideration.
As Goligher explicates near the book’s introduction, his argument proceeds in a deductive fashion, as he intends to first delineate universally agreed upon principles surrounding the intrinsic goodness and value of human life, then to consider their implications for the moral permissibility of PAS/MAID, specifically. He subsequently seeks to buttress these arguments by providing a Christian ethic grounded primarily on Scriptural references to creation, suffering, and the life of Christ that strengthen this vision of human worth that precludes intentional killing under any circumstances.
While Goligher’s move to proceed from “basic moral starting points that nearly everyone accepts and shares,” is laudable and in some ways rhetorically crucial to arriving at a non-particularist ethic against the moral permissibility of PAS/MAID, it is worth asking whether such a starting point in fact exists in our current cultural milieu. Arguments for epistemological accessibility to a universal moral law have been taken up by such diverse thinkers as Plato, Aquinas, Kant, and C. S. Lewis and do indeed serve for many as the fulcrum upon which considerations of weighty questions like the permissibility of PAS/MAID rest. Yet does such a universalist ethic recognizing the intrinsic and unconditional worth of human life truly hold water among those in a society such as our own today? The hegemony of autonomy calls this assumption into question.
While respect for autonomy as a guiding principle within bioethics (and culturally writ large) serves as a popular focus of criticism among conservative ethicists, it may nevertheless seem strange to consider autonomy as potentially subverting an argument for the intrinsic goodness of people. But when a healthy recognition of the importance of self-sovereignty mutates into what has been termed “radical autonomy,” in which the ability to self-determine one’s truth and goodness replaces the true and good as the highest good, then calculations of worth (particularly those of self-worth) are rendered contingent and subjective rather than absolute and objective. Goligher himself argues as much, when he later notes that an over-emphasis upon the centrality of autonomy affords the individual the ability to self-denigrate and (falsely) appraise his or her own life as not worth living.
The cultural grip that radical autonomy holds calls into question Goligher’s starting premise, that human life is indeed viewed by all as not only good, but unconditionally valuable. Insofar as individuals can misunderstand or even reject their own intrinsic goodness and worth, a shared ethic of the foundational goodness of human life cannot be assumed.
If the radical autonomy of the individual cannot serve as this reliable basis for unconditional worth, where are we to find such a foundation? Historically the answer has been found in religious and cultural traditions that espouse truths external to (and to an important degree), independent of the thoughts and experiences of individual participants in such traditions. Goligher conveys this point by propounding the Christian account of human worth and dignity as a rejoinder to the radical-autonomy account he deems as ultimately insufficient.
Yet one cannot help but feel that a robust Christian account ought to come sooner than it does in Goligher’s argument. For him, they seem to proceed by deduction from the “basic moral starting points” that are, in fact, subverted by the cultural ubiquity of radical autonomy. Goligher is not wrong to attempt to harness non-religious reasoning in his argument against PAS-MAID; as an academic critical care physician he is no doubt accustomed to this practice. However the unfortunate reality is that we as Christians may not be able to assume shared moral starting points we were at one time able to in these discussions, which should serve as an invitation for us to more deeply understand the Christian grounding for considerations like human worth and the goodness of life as increasingly countercultural.
While Goligher’s work largely focuses on reason-based arguments surrounding the internal logic of the permissibility of PAS-MAID, he would do well to make explicit the morally prior question upon which this debate hinges: what is a person?
Every ethics presumes an anthropology, and the task of delineating presumed views of personhood takes on a new urgency when dealing with questions of volitional and societally sanctioned killing. This important work for Goligher and those who would likewise oppose PAS-MAID is twofold: first, to accurately name the animating view of personhood and value espoused by those who would argue in favor of PAS-MAID, and second to consider how a more fitting anthropology might lead to the opposite conclusion.
While Goligher describes the overriding focus on personal autonomy as central to most arguments in favor of PAS-MAID, he doesn’t delve deeply enough into how this focus on autonomy shapes Western cultural imagination about what personhood actually is. In his book What it Means to be Human legal scholar and bioethicist O. Carter Snead provides an in-depth analysis of this default anthropological understanding and its implications for the legal infrastructure surrounding central bioethical issues today ranging from abortion to assisted reproductive technologies to PAS-MAID. Snead’s central thesis is that an anthropology of “expressive individualism” is baked into the legal understanding of these issues. Drawing on the philosopher Charles Taylor and sociologist Robert Bellah, Snead describes this vision of human identity as one in which “persons are conceived merely as atomized individual wills whose highest flourishing consists in interrogating the interior depths of the self in order to express and freely follow the original truths discovered therein toward one’s self-invented destiny,” which thus “equates being fully human with finding the unique truth within ourselves and freely constructing our individual lives to reflect it.”
There are three important implications of such a view of being human. First, this view prioritizes the cognitive ability to determine and communicate one’s self-determined will, a move that calls into question the full personhood of those unable to engage in such acts. Second, a priority on independence and “atomization” renders relationships voluntary and dependency aberrant and even pathological. Third, the act of autonomous choice is viewed as self-ratifying; the act of choosing for oneself is rendered the de-facto telos of such a moral vision, rather than the goodness of the choice itself.
Snead’s (by way of Taylor and Bellah) argument about how this anthropology of expressive individualism factors into questions surrounding PAS-MAID is incisive and reflects the empirical realities of the practice. As Goligher notes, demographic studies of those who choose to access PAS-MAID both in the United States and Canada are overwhelmingly white, college-educated, and affluent—those in our society most ostensibly able to make self-determined and non-coerced choices. Moreover, in contrast to frequent arguments in favor of PAS-MAID which attest to the cruelty of extending the suffering of the dying, the vast majority of those who choose to access PAS-MAID do not do so because of refractory physical or existential pain; rather the importance of maintaining autonomy and perceived dignity with an associated fear of frank dependence on others is highlighted.
In the same way that a deeper exploration of the problematic anthropology underlying typical arguments in favor of PAS-MAID would lend clarity to his critique, Goligher likewise misses an opportunity to provide a robust rejoinder to this faulty view of being human. While he does engage with Scripture to accurately highlight our fundamental nature as children of God—“we are too weak, too frail, too vulnerable to circumstance to be a firm foundation for our own value and significance,”—a more detailed constructive view of human nature and flourishing would strengthen his case. That is to say, an anthropology that normalizes our dependency, that views embodiment and not mere cognition as valuable, that recognizes our vulnerability to illness and senescence as inherent rather than aberrant, would render pursuit of PAS-MAID inconsistent with our end as humans.
Arguably the preeminent anthropological account based on these premises is Alasdiar MacIntyre’s Dependent Rational Animals where MacIntyre critiques the hegemonic view of personhood as consisting in presumed unfettered independence and pristine cognitive capacity. MacIntyre’s complex and far-ranging argument ultimately concludes that for human beings to flourish, it is imperative that they develop what he terms “virtues of acknowledged dependence,” which manifest both in acts of “uncalculated giving” and “graceful receiving.” Such virtues, to name a few, include just generosity, hospitality, and “misericordia”—which is the virtue of “taking on the suffering of another as your own,” as well as gratitude, humility, and friendship.
To be sure, MacIntyre’s is not the only account critical of dominant Western views of personhood and worth to provide an alternative view of human purpose and flourishing; indeed a robust anthropology attesting to the very virtues he mentions can be traced through the Psalms, the Gospels, and Pauline letters. However, it is crucial to make this vision of human nature concrete in order to provide a compelling account of what humans are for, and to make clear why such an account that recognizes our vulnerability, dependence, and embodied goodness is inconsistent with pursuit of PAS-MAID.
While Goligher explicitly names that his intent is not to consider questions of the ethics of the medical profession, it is ultimately impossible to neglect questions of the nature and purpose of medicine in these conversations. Even for those outside the guild, conversations about the moral permissibility of PAS-MAID become incoherent when separated from considerations of what it is that a doctor does, and what a patient can reasonably expect of her clinician.
Goligher’s description of those clinicians who would provide PAS-MAID as “priests of modern, secularized religion… [who] offer death as the means of salvation from suffering,” does suggest a transgressing of professional limits, and even a potential hubris present in such practitioners. However, such a critique does merit the question of where such limits exist, and what can be reasonably characterized as falling within a physician’s professional purview. In the same way that the question of anthropology circumscribes what it is reasonable and good for a patient to pursue, the question of professional identity defines and clarifies the physician’s responsibilities.
The question of medicine’s purpose, and the nature of the physician’s professional responsibilities that flow from this, is (perhaps surprisingly to some) an increasingly muddled one in contemporary Western culture. As Jeffrey Bishop has trenchantly argued in his work The Anticipatory Corpse the animating metaphysics of contemporary medicine (predicated on the logic of anatomical dissection) is that of efficient causation—a study of mere proximate cause and effect—to the total exclusion of teleological considerations of overarching purpose. Such a vision at its most bare reduces patients to mere “matter in motion,” rather than consideration of what maintenance of bare physiology is in service toward. Farr Curlin and Christopher Tollefsen echo this critique in their book The Way of Medicine arguing that in the absence of any objective telos of medicine or the physician’s role, the patient’s autonomous desires function as the de facto purpose of the practice.
Curlin and Tollefsen argue for a re-grounding of medicine as a practice oriented toward the objective end of the patient’s health, which they draw on bioethicist Leon Kass to define as “the well-working of the organism as a whole.” Their teleological understanding of the body and its constituent functions serves as the lens through which to determine whether certain interventions are appropriate for patients, rather than mere patient preference which may run counter to one’s health. It is this understanding that animated the Hippocratic vision to avoid harming the patient and prohibited PAS-MAID and abortifacients, the same oath that has been largely bowdlerized today and even replaced by the practice of medical students constructing their own “oaths.”
While Curlin and Tollefsen’s is not the only reasonable account for the purpose of medicine and the physician’s attendant responsibilities born of that purpose, it is crucial to provide such an account of the practice for arguments against PAS-MAID like Goligher’s to cohere.
While the above mentioned criticisms would serve to strengthen Goligher’s case, ultimately he does succeed in his (important) task of providing a condensed, coherent argument against PAS-MAID for those seemingly new to this issue. While questions surrounding basic moral starting points, anthropological underpinnings, and the nature of medical practice remain, Goligher’s work nevertheless starts the conversation, one that has for too long lingered in the shadows.