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Bioethics and Medical Ethics

Meanings of Death

Patricia S. Mann

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ABSTRACT: I examine the ways in which our cultural expectations with respect to death may be transformed by the legalization of assisted suicide. I suggest the inadequacy of the philosophical framework currently taken as the basis for discussing the advantages as well as the dangers of legalizing assisted suicide. I do not believe that individual autonomy is any sort of possibility for dying patients, regardless of the social policies that surround death in a society, insofar as our individual agency in this situation is necessarily intertwined with that of various relevant others. By means of a theory of agency relations, I attempt to show the dynamic ways in which we may all adjust to the option of assisted suicide as a preferred end-of-life option. My theory of agency relations does not deny individual choice; rather it explains the qualitative complexity of individual choice, as well as its dynamic social process of evolving.

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"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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(1) Emmanuel Levinas, Time and The Other, trans. Richard Cohen (Pittsburgh: Duquesne University Press, 1987), p.79.

(2) Simon Critchley, Very Little...Almost Nothing: Death, Philosophy, Literature (New York: Routledge, 1997), p.25.

(3) See Margaret Pabst Battin, The Least Worst Death (New York: Oxford Univ. Press, 1994), p.190.

(4) Jacques Derrida, Aporias, trans. Thomas Dutoit (Stanford: Stanford Univ. Press, 1993), p.11-12, 16.

(5) See "Assisted Suicide: The Philosopher's Brief," authored by Ronald Dworkin, Thomas Nagel, Robert Nozick, John Rawls, Thomas Scanlon, and Judith Jarvis Thomson, in New York Review of Books, March 27, 1997, p.44.

(6) Ronald Dworkin, Life's Dominion (New York: Random House, 1994), pp.179-80.

(7) Dworkin, Life's Dominion p.211.

(8) Patricia S. Mann, Micro-Politics: Agency in a Postfeminist Era (Minneapolis: University of Minnesota Press, 1994).

(9) Margaret Battin remarks upon recent critiques of autonomy in cultural studies and literary theory, and acknowledges that they have "real bite," despite their failure to make much headway in bioethics so far. See her The Least Worst Death, p.25. In fact, the Hobbesian/Freudian account of our desiring agency is so naturalized, so taken for granted within our tradition at this point that it is the rare philosopher, such as Battin, who retains the capacity to even speculate upon other possibilities.

(10) It is also important to state that a denial of autonomy does not require a denial of individual agency. I believe that it is the quality of individual agency that is the issue at this point.

(11) See my analysis of how Freud complicates while extending the Hobbesian tradition of desiring agency in Micro-Politics, Chapter Two.

(12) See Arlie Hochschild's The Time Bind (New York: Henry Holt & Co., 1997) for a penetrating sociological analysis of what Hochschild judges a general shift in social priorities in American society today. Women and men alike are spending increasing time in the workplace. Women are finding various ways to decrease absolutely or to "outsource" all the traditional domestic duties they once performed, including childcare, as well as care of the sick and elderly.

(13) See also Arthur and Joan Kleinman, "Cultural Appropriations of Suffering in Our Times," Daedalus, vol.125, no.1 (Winter, 1996), pp.14-15. As anthropologists, the Kleinmans find shifts in the American cultural rhetoric of illness which correspond with Hochschild's findings as to the devaluation of traditional domestic duties of women. Our cultural rhetoric, the Kleinmans remark, "is changing from the language of caring to the language of efficiency and cost; it is not surprising to hear patients themselves use this rhetoric to describe their problems. Thereby, the illness experience, for some, may be transformed from a consequential moral experience into a merely technical inexpediency."

(14) See Robert Kastenbaum, "Suicide as the Preferred Way of Death," in Edwin S. Shneidman, ed., Suicidology: Contemporary Developments (New York: Grune & Stratton, 1976), pp.425-441, for a much earlier analysis predicting that our society would readily embrace suicide as a desirable way of dying.

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