What is man, that thou art mindful of him
And the son of man, that thou visitest him?Psalm 8
It was John Henry Newman, as eminent as English stylist as a churchman, who put it best: ‘When I show a man that he is inconsistent,’ he said, ‘I make him decide which he loves the better: the portion of truth he already holds, or the portion of error.’ And though the point he was making was of more general character, he thereby set up an agenda for our troubled discourse as we would live and speak in this age of ambiguous conviction. For just as faith continues to recede, we are a century on from Mathew Arnold’s Dover Beach and the long-forecast post-Christian centuries have yet to begin. By the same token, the deep ambiguities of a culture still half-convinced of the old verities while half-convinced also of the new should leave us little source of comfort. What it does mean is that it is in the inconsistencies of our day that we shall best find its clues; just as the apologist’s task is to press Newman’s resistless logic, if we would read the times and be enabled to speak to them we shall need to get better at understanding what it is to live with a foot in the old world and one in the new: to be as unconscious of inconsistency as one is untroubled.
It is in that context that I raise what I call the ‘prior questions.’ We are familiar with the fact that when discussion becomes particularly dense, when logic seems unrewarded and disagreement intractable, it is generally the case that we are discussing the wrong thing. That is to say, those on opposing sides are in fact disagreeing primarily about something that is not part of the conversation, and yet which influences it profoundly. We know this experience in many areas of our culture. It is nowhere more true than in bioethics. And, within bioethics, it is supremely at the end of life that the deep-seated differences become most plain, and most interfere with our attempts at conversation on questions such as so-called ‘physician-assisted suicide.’ The discussion is not a simple one of whether Oregon is right or wrong; it ranges over the question of the meaning of death, what it is to be human, and how we construe the identity and task of the physician. Simply to put that in those terms is to illustrate how hard it has become to engage in public conversation today, for the voters of Oregon generally made up their minds (in whatever direction) in ignorance of all such issues. Which is another way of noting that at times of great cultural shift and crisis, everything gets more complex to discuss, for what appear to be straightforward questions involve us in analyzing fundamental issues that are in flux.
In this brief presentation I would like to open up three of these questions by way of illustration. The point is to help set these enormous discussions within a series of contexts that are typically unaddressed when what we call end-of-life issues are on the agenda. We could add others. And we could focus more acutely on the human dimension, the existential context of those who are sick and in pain and who contemplate their future with perplexity and it may be with fear. I shall not say much about that, and I know that others will. If we believe, however, that logic should sway the argument we need to consider, alongside the culture crisis in which we live and which divides the mind of our day, we need also to ponder the experience of the sick and the dying and the ways in which their own minds work. Some here are sick, and it may be some are dying, or know it to be soon, when the rest of us trust it will not be. Let me quote Emily Dickinson who as usual makes the point with her supernatural economy of words:
The heart asks pleasure first,
And then, excuse from pain;
And then, those little anodynes
That deaden suffering;
And then, to go to sleep;
And then, if it should be
The will of its Inquisitor,
The liberty to die.
1. The question of human being
It seems the most obvious question to ask, does it not? What does it mean to be human—and what clue does it give us as to how we should treat those who are, including ourselves? And yet the difficulty we have answering the question has kept it firmly from public view. In the major arena of human life conflict of the past generation, this question has been curiously confused, for the abortion debate, at least when it surfaced a generation ago as a major issue of public policy, was focused not on what it means to be human but on how we may know that a human life has begun. The fact that we may impute a degree of disingenuousness to those who raised the issue in this way does not detract from the character that the debate has taken, as is evident in the fact that almost every attempt to counter the pro-abortion position has been grounded in an assertion that in utero life has indeed begun. The question So what? was never expected in reply, but the move of the debate into the realm of infanticide, as evidenced most sharply by Peter Singer’s candid embrace of child killing, shows how far we have come. Yet we have moved in the direction of logic: Newman’s question has begun to be answered.
The fate of the Judeo-Christian understanding of human being as bearing the imago Dei lies at the heart of this debate.
2. The question of death
If we do not know who we are, then it is hardly surprising that we are confused as to how we should die. One of the most interesting themes of contemporary medical-bioethical discussion is the manner in which veterinary medicine vies with Hippocratic in setting our norms. Of course, many of the ‘new technologies’ in medicine are imports from the veterinary field, all the way from artificial insemination (AI) through in vitro fertilization (IVF) to cloning, initially of stem cells for purposes of vivisection but ultimately as yet another contribution to the armamentarium of the industry of ‘reproductive’ ‘medicine.’ At the same time, the popular euthanasia discussion is laced with such reflections as ‘I would not want my dog to suffer like that’, which is in fact a most interesting statement. We do not indeed believe that we should subject our beloved pets to the kind of suffering which we as humans are called on to experience, although (Newman again) we need to clarify just what is at stake: it is debatable in many cases whether pets should have broken limbs set, and few would argue for extensive surgical or other procedures that in humans we take for granted. The point is this: in general we all of us understand that people are not the same as dogs, but we have less and less grasp on the extent and reason that is so. And the matter is focused most sharply at the point of death: why can it be good to show ‘more compassion’ to an injured dog than to a child? The death of a dog is one thing; the death of one of us is another.
3. The question of medicine
The focus on ‘physician assistance’ in ‘suicide’ draws our attention forcibly to the changing role of medicine. The conscience of the profession remains sensitive and not entirely disconnected from its origins at this point. As we know, there have been extensive debates as to whether physicians should be involved in any way in the operation of the capital sentence (even in certifying death). The calling of the physician is to be something other than a technician of the body, a plumber who will do the patient’s (or someone else’s) bidding; the professional vision is not quite lost. Yet the Hippocratic legacy is crumbling.
4. The question of bioethics
It is important also to orient ourselves in the wider world of bioethics, and for two particular reasons. First, because bioethics as an enterprise has set itself the practical task of the reconstruction of the western view of human nature. That is the simplest and best way to understand this strange enterprise, which flourishes on the fringes of medicine and is ever seeking to shape its future and that of all of us under the impress of technological possibility and in a firm divorce from the Judeo-Christian-Hippocratic vision. Secondly, bioethics has set in place as its central organizing principle the notion of autonomy. This is of course a plastic term with many shades of definition, but in bioethics hands it essentially performs the function of transferring to the patient the moral accounting for medicine, breaking candidly with notions of physician paternalism (which are typically overdrawn) but implicitly also with the professional idea and indeed the principle of the public policy framework which gives validity to the practice of medicine in the community. If it is only the patient’s exercise of moral will that has any standing in patient care, all else is called into question. ‘Informed consent’ procedures, which are to a significant degree simply exercises in legal fiction, become the operating principles of medical decision-making. And however imperfectly the system and its practitioners may adapt (most patients still want their physicians to play a major role in decision-making, and the evidence is that that still largely happens), in principle it has radically shifted; the symbolism of the so-called Patient Self-Determination Act of 1991, which gave a huge fillip to the so-called ‘living will’ for the alleged purpose of enhancing self-determinative opportunity, is striking. And, needless to say, the autonomy justification and the living will precedent are the bed in which the case for voluntary euthanasia in its various guises is laid.
This article first appeared in Theology Matters, Vol. 7, No. 1 (Jan/Feb 2001).
