"What is the tie between two instants that have between them the whole interval,
the whole abyss, that separates the present and death, this margin at once both
insignificant and infinite, where there is always room enough for hope?" (1)
"Is death possible? Can I die? Can I say 'I can' with respect to death?
Can I?" (2)
I. Comprehending Death: The Limits of Philosophy
We philosophers are always trying to get a grip on death, and always failing.
Anthropologists and social historians are likely to do better than philosophers in their
efforts to characterize death, insofar as they can investigate the many faces of death in
different cultural contexts: death in battle may be heroic; death in youth may be tragic;
death in old age benign. In different times and different cultures death means very
different things, as well, as is clear when we read of suttee, the Hindu widow's
immolation of herself on her husband's funeral pyre, or of seppuku, the suicidal
disembowelling done by Japanese for infractions of honor. (3)
Yet all these so-called meanings of death are more precisely identified as different
social practices and associations surrounding death. Death itself is an event that exceeds
our human capacity to wrest meaning from occurrences in the world. Strangely in our world
and of it, death is also elusively yet absolutely not of our world. As when we speak of
God, we speak of death in self-consciously metaphoric ways. We speak of a loved one's
dying in terms of their "leaving us," "passing" or "passing
away." But when we say they have left us, we mean only that they are no longer
capable of interacting with us in daily physical interactions. We didn't really see them
leave, and we have no real idea of where they have gone, even if we are believers in
heaven and the immortality of the soul. And they do not fully leave us, remaining present
in our memories, or in books or letters they have written or in sweaters they have knitted
or in projects they have begun for us to finish.
Similarly, when we say someone has passed away, we experience their physical absence,
but we don't experience their actual passing to another place, whether to nothingness or
some spiritual realm. The event of death is one that we only understand from the side of
the living. A person who dies passes out of our culture, but its not clear how they go, or
where. We have no physical, temporal or conceptual grasp upon where they are going, and so
there is also no obvious border between our world and death. As Jacques Derrida remarks,
"The crossing of a border always announces itself according to the movement of a
certain step — and of the step that crosses a line... Consequently, where the figure
of the step is refused to intuition, where the identity or indivisibility of a line is
compromised...the crossing of the line — becomes a problem. (4)
For this reason, Derrida designates the boundary that is death as an "aporia," a
site of interminable confusion. So long as we live, we see only life and living, and so we
speak necessarily with metaphors and elliptical partiality of our experience of another
person's death and passage from life.
II. The Case for Assisted Suicide: Ronald Dworkin and The
Philosopher's Brief
The much debated issue of assisted suicide corresponds with a rather paradoxical social
situation in our late twentieth century. On the one hand, a combination of social and
technological forces have combined to give individuals an unprecedented sense of control
over their physical narratives. When we are hungry we may nonchalantly satisfy our hunger
with fruits from Peru or condiments from India. When it becomes very hot, we move from one
air conditioned environment to another. When we experience allergies, we take medications
that eliminate our symptoms. We utilize contraception of various sorts so that sexual
interactions cease to be organically related to reproduction. When a hip, knee or shoulder
joint fails, we replace it. We even replace such basic organs as kidneys and hearts. It
seems consistent with this extraordinary level of control over our physical options that
we would also exercise greater control over the time and place of our death. It is in this
spirit that six contemporary moral philosophers have referred to an individual's death as
"the final act of life's drama," in a recent amici curiae brief submitted to the
Supreme Court in support of a constitutional right to assisted suicide. (5)
On the other hand, many people are discovering that it can be difficult to retain any
sense at all of personal control over the end of one's life within a high-powered medical
context. Medical technology has developed amazing resources for dealing with the failure
of various bodily functions and organs; and the institutional commitment to life-saving
treatment of the medically ill tends to move into high gear as patients become sicker and
nearer death. The medical technology for curing bodily ills is on a continuum with the
technology for extending life through deferring systemic bodily failures. A high-minded
medical commitment to preserving individual lives can sometimes today lead to a tortuous
standoff between powerful medical technologies capable of deferring immediate death and a
bodily self whose physical resources have dwindled to the point where the continuation of
life seems futile. Yet the dying individual may experience herself as caught up in a force
field of medical technology, and she may be frustrated in efforts to extricate herself.
Indeed, she may experience intolerable pain and seek help in dying more quickly, to no
avail. As legal philosopher Ronald Dworkin declares, these are situations we all dread
today, and he believes that individuals require the right to assisted suicide in order to
properly exercise self determination in the face of a medical establishment which often
seems implacably and impersonally committed to the extension of life. (6)
As one of the foremost public intellectuals addressing this issue today, Ronald Dworkin
brings the philosophical resources of our liberal democratic tradition to bear on this
problem in a clear, incisive manner in his book, Life's Dominion. Assisted
suicide involves an effort to restore to individuals a conscious relationship to their own
process of dying and death. Assisted suicide is defended as an extension of the individual
autonomy or self determination we seek to enact throughout our lives. As Dworkin explains
it, we act in the course of our lives in response to various convictions about what makes
life worth living, and these convictions about how to live tend to color our views about
when and how we should die. (7) An aggressive medical
establishment may treat our bodily ills while disregarding these personal views about how
and when we should die. Our sense of personal autonomy may be compromised in such
instances, and assisted suicide is proposed as a means of restoring a sense of control to
individuals nearing the end of their life. It is thus envisioned as a logical extension of
our individual freedom to pursue our lives as we please, so long as we do not harm others.
Poignantly, if also a little oddly, assisted suicide is viewed as a way of making our
individual death a meaningful concluding act in our own individual life.
III. Rethinking the Philosophical Framework of Agency at the End
of Life
The discussion of assisted suicide has centered on notions of individual autonomy and
self determination, as the values ideally characterizing an individual's decision to seek
an end of his or her life. And criticisms of assisted suicide have focussed on social and
political reasons why various groups of people — the poor, the disabled, minorities
— are not likely to be allowed to exercise an autonomous choice. I want to suggest
that the whole notion of an autonomous choice at the end of one's life is problematic and
misleading. I believe that we need a richer framework for understanding the agency of
dying individuals. In fact, as I first argued in my book, Micro-Politics, we
require a multi-dimensional and social framework for adequately understanding individual
agency in most circumstances. (8) Because we are so
accustomed to a one dimensional conception of desiring agency as a basic perspective of
liberal individualism, we rarely notice problems with our theory of agency. But I think
end of life situations provide a particularly powerful demonstration of my earlier
critique of our typically one-dimensional, self-referential notions of individual agency.
Our modern tradition of individualism is founded on a rationalist Cartesian theory of
knowing selfhood and a materialist Hobbesian theory of desiring individual action. For a
Cartesian self, knowledge of the world is premised upon a foundational consciousness of
oneself; and all social acts of a Hobbesian self can be finally traced back to
self-interested desires. A politics of liberal individualism highlights the value of
autonomy, or lack of interference from others, insofar as our self-interested desires are
presumed to conflict with those of others. While a number of contemporary philosophers
have criticized Cartesian notions of unitary selfhood and rationality, the
Hobbesian/Freudian tradition of desiring individual agency, as well as the liberal
framework of autonomy have as yet escaped serious critique. (9)
I first began to have doubts about the adequacy of the one dimensional Hobbesian theory
of desiring agency when I sought to analyze gender relations and the agency of women
within familial settings over the last several centuries. Women's actions as wives and
mothers did not fit the paradigm of desiring individual agency, and this puzzled
behavioral theorists such as Freud, who famously declared women "a dark
continent" insofar as it was not clear what they desired. While some feminists
equated the oppression of women under patriarchy with a suppression of their agency, women
in traditional roles frequently manifest a sense of personal efficacy. In order to take
such women seriously I had to broaden my vision of agency in several respects. A major
portion of these women's actions originated in a sense of responsibility or obligation to
others, and so I posited that feelings of responsibility could be as basic to a sense of
individual agency as self-referential desires. Indeed, this dimension of agency
illuminated actions of men in relation to their families, as well. In addition, I found a
third dimension of agency necessary to fully comprehend individual actions; individuals
act out of expectations of recognition and reward, often quite apart from their immediate
desires. Moreover, actions not properly recognized and rewarded never attain full status
as acts of agency, as women found when they began moving outside their traditionally
designated roles. And this is surely the case today with respect to unacknowledged acts of
assisting and assisted suicide.
I argued in Micro-Politics that agency in the richest sense is a three
dimensional concept, comprised of dimensions of desire, responsibility, and recognition
and reward. One is empowered when one has agency involving all three dimensions. But quite
typically these dimensions are distributed among different individuals within a situation,
often in accord with prevailing power relations. We care about the desires of the dominant
person, and we offer them recognition and rewards. The subordinate person's agency, by
contrast, involves primarily the dimension of responsibility. Servants, slaves, minimum
wage workers, women in traditional roles may have important duties and responsibilities,
but they receive relatively little recognition and reward for them, and people rarely
inquire after their desires.
An important consequence of this distribution of the dimensions of agency is that we
can only understand the agency of any particular individual insofar as we understand their
relationships with other individuals. The binary opposition of self and other, encouraged
by the Hobbesian schema of competing desires no longer makes sense; each of the dimensions
of agency are about self-other relations in constitutive but different ways. Whether we
act out of desires, or out of a sense of responsibility, or with an expectation of
recognition and reward, we are acting in relation to relevant others. Autonomy, understood
as freedom from interference of others, ceases to be a meaningful value, insofar as it
ignores the fabric of relationships, good and bad, within which our actions necessarily
occur. (We could, of course, still use a notion of autonomy to refer to situations in
which we were free from overt forms of physical or mental coercion. But we would have to
be very careful not to let this slip back into a vision of being free from the influence
of others.)
IV. Agency Relations as We Live and Die
My three dimensional social theory of agency relations allows us to discuss the
situation of sick or dying individuals in terms of the various relationships that affect
their sense of living and dying. And it enables us to consider how these relationships
will be affected by legalizing assisted suicide.
We may begin by reassessing the end of life situation that, as Ronald Dworkin points
out, many people most dread. Suppose we become very ill, perhaps unto death, and we are in
the care of a highly respected doctor at a major medical institution. The agency of this
doctor is quite clear. Everything in her medical training and practice promote in her a
strong desire, compounded by a sense of medical duty via the Hippocratic oath, to find a
method of returning us to health. Moreover, her recognition and rewards in the world of
medicine are based upon her reputation for overcoming the forces of disease and physical
decline. The hospital stands behind her in this. The agency of this doctor is well-defined
in terms of her commitment to the care and maintenance of life.
As a patient, we are often less certain of our goals, and almost always less certain as
to how to go about achieving them. As we experience bodily decline, it is common to be
ambivalent and confused about our own desires. And even if we have a firm commitment
either to fighting for life to the very end, or alternatively, a commitment to die with
dignity while we still have all of our faculties about us, we are likely to require a
great deal of help in accomplishing either goal. We also may possess a strong sense of
responsibility, quite apart from our desires, to either continue living, or to die as
rapidly as possible. But here too, we may be conflicted, and we will require aid in
accomplishing our goals. Expectations of recognition and reward may add to our sense of
anxiety and ambivalence. We may be horrified at the thought of losing our mental and
physical capacities and being remembered in that way. We may thus desire to die as quickly
as possible, but at the same time we may not want to be remembered as one who would choose
the cowardly path of killing themselves. There is no end to our possible conflicts about
living and dying at this stage of our life.
Our physical situation makes us extremely dependent upon others, in a society in which
dependency is not recognized as a basic and constant human reality. Only children are
acknowledged as legitimately dependent, and so we may feel like children when we are ill.
Our society also emphasizes the value of having clearly articulated goals, on a daily as
well as longer-range basis. But with death approaching, we must establish a very different
sort of relationship with our future. As Levinas observed, our relationship to death is a
relationship with mystery. And as Derrida said, death is fundamentally confusing and
paradoxical. Our sense of being out of control at the end of our life has as much to do
with our extreme dependency and with our sense of uncertainty in relation to the approach
of our death as it does with an aggressive medical establishment denying our wishes.
The potential appeal of assisted suicide to dying individuals in our society is almost
too clear. As a dying person, we are, as Levinas pointed out, experiencing a final form of
passivity. Our agency is waning, objectively, and painfully. We confront mystery,
uncertainty, aporia. Yet our culture teaches us that mature adults are supposed to
struggle against all forms of uncertainty and dependency. Accordingly, in choosing
suicide, we marshall our waning powers aggressively in order to put an end to uncertainty
and dependency in the only way possible. We may congratulate ourselves upon seizing back,
not just from an overwhelming medical establishment, but from God him or herself, the
power of death. We refuse finally the fundamental and continuing fact of human
potentiality and hope in order to control the moment and the site of our final breaths of
life. As Heidegger would point out, however, we seek to create a final act which we can
never experience as a final act, insofar as our human subjectivity ends when its
potentiality ends.
Let's examine the other agency relations surrounding such a death. In the first place,
since we are asking assistance in this suicide, there is at least one medical doctor
involved. If assisted suicide becomes legal, some doctors will no doubt assert their
continuing commitment to the Hippocratic oath and refuse to participate in it. But many
doctors will adjust their practices, and gradually their values, as well. Initially, some
will simply desire to help patients in this final act, and some will feel it part of their
medical responsibility to do so, regardless of their personal desires. Insofar as assisted
suicide is a cost efficient means of death, doctors are also likely to be rewarded by
healthcare companies for participating in assisted suicide. As institutional expectations
and rewards increasingly favor assisted suicide, expectations and rewards within the
medical profession itself will gradually shift to reflect this. Medical students will
learn about assisted suicide as an important patient option from the beginning of their
training. We may expect that a growing proportion of doctors will find themselves
sympathetic to this practice, and will find themselves comfortable with recommending it to
their patients.
Families will also be affected by the legalization of assisted suicide. Familial agency
in the context of a dying loved one is likely to be as confused and conflicted as that of
the patient. Family members may want a loved one to remain alive as long as possible,
while also harboring secret desires to be done with this painful process. Many people
today are ashamed of such secret desires, regarding the very thought of hastening a loved
one's death as wrongful and blameworthy. But if assisted suicide becomes legal, such
desires will cease to be wrongful in such an obvious way. If patients themselves may
decide to put an end to this painful process of dying, then it is not blameworthy for a
relative to inquire whether they might be thinking along these lines, and to offer
sympathetic support for the idea.
As dying individuals begin to articulate their desires to be done with this painful
process of suffering and decline, relatives will participate in this dialogue, adding
their own perspectives on the option of assisted suicide. They may quite reasonably desire
to get on with their lives, and in this new context of considering assisted suicide, they
may experience these desires more strongly. Where they once felt great responsibility to
put up with the pains and inconveniences of an extended process of dying, they may no
longer feel it necessary to hide their impatience with this process. And they may even
find themselves emphasizing their competing responsibilities to healthy children and
spouses. Where they would once have felt ashamed to feel these things, and may even now be
surprised to hear themselves saying them, they now feel free to have them recognized. Once
assisted suicide ceases to be illegal, its many advantages to busy relatives will become
readily apparent. More than merely an acceptable form of ending, relatives and friends may
come to see it as a preferred or praiseworthy form of death. They will become comfortable
with considering the merits of assisted suicide in relation to their loved ones because it
will be designated a socially good end.
Healthcare organizations will also be involved. If dying sooner is more cost efficient,
their profit-based concerns will make them desire for patients to choose assisted suicide.
Their sense of responsibility to shareholders will reinforce this. As with families, they
will no longer feel ashamed to have these interests and competing obligations recognized.
Assisted suicide will now be an established, approved ending. Insofar as it is an accepted
patient alternative, everyone is allowed to have and to express their own interests in
relation to it. Economic interests may still seem crass in relation to dying patients, and
yet we are already accustomed to recognizing them in the context of treatment, as well as
in all other contexts of daily life. When we legalize assisted suicide, it too becomes a
part of daily life.
The appeal of assisted suicide to relatives and friends and to healthcare organizations
is very easy to comprehend. In legalizing assisted suicide, we will be legalizing a method
of death which will be very much more convenient as well as more cost-effective than
current methods of dying. In our society, where almost everyone is pressed for time, and
many are pressed for money, individual notions of agency and the fabric social agency
relations may evolve very quickly to reflect its conveniences and cost efficiency. (10)
The agency of medical doctors is likely to remain more conflicted, insofar as their
primary role remains one of healing. Many doctors may find it difficult to change hats and
aid people in dying. But as doctors come to be employed primarily by healthcare
organizations, they will inevitably come to reflect the efficiency concerns of their
employers.
Assisted suicide will offer all patients a way to escape overwhelming and unpleasant
feelings of dependency and uncertainty as they experience serious bodily and perhaps
mental decline. And the undeniable convenience of avoiding a lingering, painful,
indeterminate period of dying will have great advantages for the friends and relatives of
almost everyone. In a society where an ever larger portion of our population is becoming
elderly, the cost efficiency of cutting short a potentially extended process of dying is
readily apparent and desirable in general social policy terms. A lingering death may come
to seem an extravagance, a frivolous indulgence. If you doubt that our views on death
could change so rapidly, remember, or try to remember how strong the expectations were for
even highly educated women to become full-time homemakers during the 50s and 60s. And
consider how rapidly we have come to consider it somewhat indulgent and eccentric for such
a woman to decide today to give up work and remain at home full time caring for her
children and house. We can be relatively certain that our views of dying will change quite
radically if and when assisted suicide is legalized. (11)
My analysis does not indicate whether assisted suicide is an appropriate social option
at this time within our culture. As the elderly make up a growing proportion of our
populace, the costs and inconveniences of the dying process are already growing
astronomically. Assisted suicide is a very efficient way of dying. Perhaps, the Supreme
Court will find it a constitutionally sanctioned liberty interest within the next few
years. If so, assisted suicide may become a ubiquitous form of death within the next
quarter of a century. That may be a good thing, or it may not. Insofar as it is clear that
our agency relations with relatives, friends, medical caregivers and institutional
providers will be transformed, it will be important to evaluate the quality of the new
relationships, something I cannot do here. What I hope to have done, however, is shift the
grounds of evaluation; away from an illusory goal of autonomy, and towards the new social
relations that will develop.
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