1 Martin Kemp, Christ to Coke: How Image becomes Icon, OUP, 2011.
2 Sahih Buhari, vol. 4, Book 54, Number 447.
10
– Dying in Time –
The old Hippocratic Oath, which enjoins the doctor to aim only to preserve life, belonged to a time when people died young, when infection and injury were the principal causes of death, and when the slow, irreversible decline to which many of us now have to look forward was a rare event, and one that could be accommodated precisely because it was rare. Increasingly, however, doctors and nurses are under pressure to act in ways that will shorten the life of their patients, and this pressure comes both from the patients and from those who love them (not to speak of those who stand to profit by their deaths).
It could be true (and I think it is true) that our moral understanding is rooted in conditions that do not easily make room for such dilemmas. Many of the most pressing ‘end of life’ issues result from medical advances that have reshaped the human condition, while appealing to moral considerations is appealing to the human condition as it was, and not as it is. This does not mean that we have no moral guidance, however. The conscience is ever vigilant, and refuses to go blindly into novel situations. Always it wants an answer, and it wants to reconcile that answer with the intuitions about life and death from which our morality begins. The question is how far, and by what means, those intuitions must be revised in the process.
For example, we have intuitions about justice, and about the relation between justice, which is a right, and charity, which is a privilege, and these intuitions are constantly being challenged, not only by modern medicine but also by the near universal takeover of medical provisions by the state. Maybe it was once the case that doctors and hospitals sold their services to those who could pay for them and gave them free, when they were able, to those who could not. Doctors were then bound by duties of justice to those whom they had contracted to help, and by duties of charity to those who could not afford the contract but who nevertheless had no one else to whom they could turn. The situation was prodigal of dilemmas and irresoluble conflicts; but there is no doubt that the dilemmas and conflicts were radically changed by the appearance of the welfare state, which grants health-care as a civil right to everyone, and makes no distinction between those who can pay for it and those who can’t. At once issues of charity and discretion are changed to issues of justice and right. Since resources are scarce there will inevitably be questions of their just allocation. Old people may find themselves then in a weak position, not least because their survival into old age is itself the normal result of universal health-care. The question inevitably arises, whether the state should devote its scarce resources to maintaining a frail old geezer precariously in being, or to treating the ailments and injuries that impair the lives of the young. That is one of many issues in which changes in medical practice and the availability and effectiveness of healthcare have begun to present us with new dilemmas that they do not themselves resolve.
Rather than reflect on the new questions of justice, I wish to consider the changes that have been wrought by modern medicine in our attitude to death. Modern medicine has prolonged the average life-span beyond anything that would have been anticipated a century ago – and naturally there arises the thought that maybe it could, in principle, prolong it forever, offering each of us a medical victory over death itself. About this latter possibility, I have only this to say: that life prolonged by the elixir of immortality would be a life from which the things that we most value – love, adventure, novelty, courage, benevolence, compassion – would inexorably leach away. If you don’t believe this, then you should read The Makropulos Case, of Karel Čapek, or (better still) listen to the opera that Janáček made from this play.1
And besides, by what right do we clutter the planet with our permanent presence, so leaving no room for future generations? If this is where medicine is heading then we have a moral obligation to stop it now.
In contraposition to the fantasy of eternal life on earth I suggest that we have important and useful intuitions concerning the right time to die. Nietzsche made the idea of timely death fundamental to his morality. His own death was preceded by ten years of mental vacancy: about as untimely a death as one could imagine. But his intention was to remind us that what we value in life may be damaged by longevity, and that the achievements and affections that give purpose to our being may be retrospectively eroded by our future decline. This will perhaps seem strange when we consider the matter only from our own point of view. An extra bit of life, even if troubled by aches and regrets, is still a bonus. Hanging on is surely better than falling off, when falling off means ceasing. Thus it is normal to think that
The weariest, and most loathed earthly life
That age, ache, penury and imprisonment
Can lay on nature, is a Paradise
To what we fear of death.
Measure for Measure
The point is that there is no retrospective view of my death that is available to me: my death can be known and thought about only in the future tense.2 Hence there is no way that I can so arrange things in my thinking as to see my death as timely. It occurs for me always in the future, the horizon of my decision-taking. But the judgement of timeliness can be made only from a point beyond that horizon – a point that I cannot reach.
But we don’t and can’t see things only from our own point of view. I believe that we can make some progress if we put our point of view to one side and adopt the third person perspective. In this perspective we see human life in terms of values and projects that are independent of our own urge to survive. And when we consider things seriously, we are presented with another concept of human life than the one that is familiar to the biologist. We encounter the moral concept of human life. Human life, from the moral point of view, is not a special case of the biological category that we know as life in other organisms. We do not understand human life simply as the process whereby a human being endures from birth to death. We understand it as a continuous and developing drama, with a meaning that resides in the whole, and which is not reducible to the felt significance of its parts.
A life is an object of judgment, like a work of art; and judgment means viewing it from outside, as the life of another. That, to my mind, is the real definition of the moral point of view. It is the point of view of the other, which sees the self as another too. And the life-concept has its home in the moral point of view. That is why the Greek sages told us to judge no man happy until he is dead. They meant that the worthwhileness of a life is a property of the whole life, and that death and dying are as much part of that life as the experiences that precede them. Anybody who has lived through some great affliction, loss or humiliation knows that nothing of our past is really secure. The greatest love, the greatest achievement, the greatest renown can be poisoned by some sudden reversal – as when a woman learns of her husband’s infidelity and sees her own love, in which she had deposited her trust and happiness, as wasted, or as when some famous politician, whose corruption has been exposed, reads contempt in all the faces that previously had glowed with admiration.
Thus states of being that seemed at the time to be unquestionably worthwhile, can be retrospectively poisoned, lose their smiling aspect, and come to seem like proofs of weakness. To live to the point where that happens is surely to live too long – for it is to enter a time of regret, like the man who loses a fortune overnight, having not used a penny for his own enjoyment. It is important, therefore, to know what features of the human condition can bring about that sudden change. Ancient wisdom tells us that the reversal of our happiness comes with shame or humiliation – adverse judgement in the eyes of others. To put the point in a more modern idiom: reversal occurs when our life loses its objective support in the ‘I-thou’ relations that hitherto defined us. Just as ‘having a life’ is a moral idea, so is ‘losing a life’. And the secret of happiness is to die before that loss occurs.
It was therefore perfectl
y coherent of the ancient Greeks, of the Japanese, of the Romans, of the Anglo-Saxons and of other such warrior people to believe that death is to be preferred to a shameful survival – so that, for example, battle can present you with a situation in which it is right to die. Plutarch, Livy and others abound in moral stories that turn upon the decision, taken by some ancient hero or heroine, to put an end to a life that would be better, overall, if ended now than if continued into the future. And even when the subject himself is not the agent of his death, and is taken away by some accident or against his will, it is perfectly coherent to think that he might, in this or that circumstance, have died at the right time (before some shame or misfortune that otherwise threatened to engulf him, for instance).
Those ancient ways of thinking reflect circumstances that have to a great extent disappeared – lives that were more precarious, more exposed to external threat, and more lived in the eyes of judgement, than our lives today. But they bring home to us that there is nothing incoherent in believing that a life can be comfortable, healthy and even buoyed by affection, yet have gone on too long – beyond the point at which it would have been right to die. (Cf. the words of Brutus and of Cleopatra’s servant Charmion, on taking their own lives, as reported by Plutarch.) If we ever entertain similar thoughts today, it is seldom for the reasons rehearsed by Plutarch and others – seldom because we judge continued life to be shameful, or unworthy of the person we took ourselves to be. Nevertheless, we share with Plutarch’s heroes the view that death is not the worst thing that can happen to us.
And our way of thinking, like that of Plutarch’s heroes, is imbued with moral ideas. A person lives too long when his or her survival has become a moral offence. This may happen because of something he or she has done: even those who don’t believe in the death penalty will admit that a person can so forfeit the privilege of living that his survival is an insult to his victims. Whatever he thinks, the rest of us believe that he is living beyond his time. It is perfectly coherent too for people to believe that it is wrong to live to the point where one’s life has become a burden, when one has the benefit neither of projects of one’s own nor the love of others. This thought arises from another moral perspective than that which propelled Brutus or Cleopatra. It is not the fear of shame and humiliation that is in question, but rather the sense that the value of a life lies to a great extent in the love of those who cherish it. To lose the possibility of that love is to lose what makes life worth living. For the Christian, of course, we can never lose the possibility of another’s love. God’s love flows perpetually over all of us, and we need only open our hearts to receive it. But it is partly the decline of the Christian vision that has made the question of longevity so urgent for us today.
There is another and more self-centred idea of timely death that feeds into our modern sensibility. This idea is self-directed rather than other-directed. It has both a positive and a negative aspect. In the positive aspect it is the idea of a perfect satiation in the moment, beyond which further life would be a life downhill. The thought is expressed by Keats in his Ode to a Nightingale:
Now more than ever seems it rich to die,
To cease upon the midnight with no pain …
Those lines, written by a doomed poet, speak to all of us. We see life not only as a whole, to be understood as a complete statement, with a beginning and an end. We see it as a succession of moments, and in some precious few of those moments we encounter a concentration of the whole of things, like the sky contained in a drop of dew. Because the moment vanishes, we regret surviving it, since in that instant, we are granted a vision that we can only lose or pollute by swamping it with future experiences.
But this positive aspect of the sensuous idea is counter-balanced by a more frightening negative aspect, which is the suffering that precedes death and which makes death welcome in another way, as the only exit from intolerable pain. Those who commit suicide in order to avoid pain act from a very different motive from those who commit suicide in order to avoid shame. Those who kill themselves from shame are trying to rescue their life, by removing the annihilating gaze of the other. Those who are seeking a way out of pain are not trying to rescue their life, but merely to end it. They are not attempting to triumph in the face of defeat; they are not completing a drama that requires just this as its ending. They are avoiding pain, no less, no more.
Shame and pain are both invitations to put an end to one’s life. But there is another way of out-living life, which is the way of debility and decline. The person whose mind has gone, who can make no decisions for himself, or who has in some way fallen out of human relations is someone whose life is, so to speak, over before its end. The death of a person is not, like the death of an animal, a mere terminus to life. It is the envelope in which a life is contained, and a light that shines along the path that leads to it. At least, that is what we would like it to be, and what it was for Brutus and Cleopatra. But when a person loses his personality before dying, it is as though the envelope of his life is torn. His life seeps messily out of its container, and what might have been complete and worthy becomes instead increasingly disorderly and scattered as the years wear on.
Of course, there are many cases here. But the case I am imagining is one in which the victim loses his capacity to relate to others, and is an object of love only because he is remembered as such, and not because he has the ability to give or receive love now. He has become a burden to his relatives, and also to himself. Yet he is not in such pain that death would be a mercy. Nor is he suffering from some shame or humiliation that would turn his thoughts in that direction – indeed, nothing turns his thoughts in any direction at all.
The worthwhile life is not something that we understand or realise alone. Life becomes worthwhile through relations with others, in which mutual affection and esteem lift our actions from the realm of appetite and endow them with significance – significance for the others who observe them and acknowledge them as worthy, and significance for that very reason for ourselves. The wholeness and fullness of our lives is not revealed to us alone, and is not to be achieved without help: it is a wholeness and fullness that has its origins in the judgement and affection of those whom we encounter. To live beyond the point in which their approval and love can be called upon is to live into a moral wilderness, a place of shadows and negations, compared with which even the Hades of the ancients, as the ghost of Achilles describes it in the Odyssey, is a place to be desired. And this wilderness lies before us all, if we live beyond the point where understanding, will and inter-personal relations still govern our conduct.
Now many people will look after a relative who has reached such a state, loving his memory and loving him too on account of it. But others will find it impossible to make the necessary sacrifices, since they will find love turning to toleration, toleration to irritation and irritation to anger or despair. Hence, increasingly, the response to this kind of irreversible decline is to put the victim into a home, where he will be cared for by professionals whose care will be reliable, just and cold. This use of precious resources and precious human capital is hard to justify in utilitarian terms – which I take to be a criticism of utilitarianism, rather than a criticism of institutional care. And it raises in an acute form the question whether we should not do more than we do, collectively and individually, to work for a timely death. Maybe we should be more prepared than we are to take death into our own hands, and not to leave it to an unfathomable fate to settle the question.
Now, modern medicine and healthcare have made it normal to survive into a time of life when our mental capacities and physical competence are in steep decline. We fear this, but we go on taking the medicine and visiting the doctor. The fear is rational, but the medication less so. We are presented with a continuous choice – to wear out the body while we still inhabit it, and then make the best exit we can, or to go on postponing the moment of truth to the point when we are no longer able to do anything to help ourselves. The person who
has done so much to stave off death, that he has staved it off to the point where he is unable to make any clear decisions in the face of it, is not someone to whom we owe any help, when it comes to deciding what to do.
The question that concerns me, then, is just how we can aim at a timely death, and what would be right or wrong to do in pursuit of it. I find nothing to disapprove of in the suicides of Brutus or Cleopatra, as Plutarch and (following him) Shakespeare describe them. It would be impertinent, it seems to me, to say that those great human beings had no right to do what they did. But they made it their own responsibility, and in doing so made the act beautiful and generous, an acknowledgement of the wider world and of their duty towards it. What, though, of you and me, creatures who have been maintained in the amniotic bath of the welfare system, who have spent a life avoiding danger and are looking forward to spinning out our pleasures for as long as we can? When should we make such a decision, how and why? And what should others do to help us?
I think we should make a clear distinction here between death conceived as an escape from pain, and death conceived as a protection against mental decline. The first can be understood and acted upon on another’s behalf; the second can only be understood and acted upon on behalf of oneself. Thus all who care for the terminally ill, whether professionally or out of love and attachment, wish to alleviate suffering. And if the means of doing so also shortens the patient’s life that will be only a secondary concern. I envisage successor drugs to morphine and codeine that will painlessly weaken vital systems, so granting the ‘easeful death’ that Keats invoked. Of course there will be those furious characters like Dylan Thomas, who will implore their dying dependents not to ‘go gentle into that good night’, and to ‘rage against the dying of the light’. But those who forget their own drama, and attend in love to the one who really matters, will surely agree that the discovery of such drugs, and their use by professionals under proper supervision and control, will do something to justify all those other and more questionable medical advances that have brought us face to face with the horrible diseases of old age. If such drugs exist, then it would surely not be homicide either to ask for them or to administer them – provided only that the diagnosis of terminal illness is secure.
Confessions of a Heretic Page 11
