In Whose Image Shall We Die?

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Given the close connection between bioethics and biomedical technology, it is hardly surprising that bioethicists often think about the future. There is a certain prophetic pleasure that comes with predicting the problems ahead, and a strong inclination to believe that our ethical thinking needs to “keep pace” with our technology, constantly updating its moral vision of man in light of the material possibilities of the age. In some sense, of course, this is true: our ethics does need to keep pace with our changing technological condition. New problems arise for which old thinking is inadequate. Yet to see the future clearly, it might also help to recover what is first in bioethics — first in the sense of the discipline’s origins and first in the sense of man’s perennial problems and possibilities.

In one sense, bioethics — at least American bioethics — began in the 1960s and 1970s, with a group of philosophers, theologians, and physicians interested in the future of human life in the budding age of biotechnology and advanced medicine. They held meetings. They wrote articles. They advised government bodies and influenced judicial decisions. They debated issues ranging from end-of-life care to organ transplantation to research with human subjects to the initiation of human life in the laboratory. Through their labors, a new discipline and myriad new institutions were born: think tanks, journals, degrees, commissions, committees, consultants, and media stars.

Yet many of the questions these first bioethicists were asking are in fact very old, and so were many of the conflicting answers. New technological possibilities — such as in vitro fertilization, genetic testing of the unborn, the biochemical manipulation of psychic experience, the extended preservation of bodies between life and death, the transfer of body parts from the newly dead to the still living — were altering some of the fundamental experiences of being human. But these technical possibilities made us anxious because the image of man himself seemed to be at stake, with all the old conflicts and perennial problems about the good life and good death taking on a new, dramatic shape. Recovering this clash of images is the first step toward understanding the origins and thus the future of bioethics.

Why Death is the First Question

Metaphysics, the philosopher Hans Jonas once wrote, “arises from graves.” So, in a crucial sense, does bioethics. Of course, death is not the only human problem of bioethical significance. Natality, not mortality, is arguably the source of today’s gravest and most novel quandaries — from the prospect of human cloning to the genetic screening of embryos to the return of eugenics in the form of amniocentesis-and-abortion.

Yet it is also the case, interestingly, that the very technological civilization that has developed these marvelous new methods of making babies — children for the infertile, children without disorders, children for older women — is also the least interested in procreation, at least by the numbers. Modern, advanced democracies have the lowest birthrates in human history; they are not producing enough children to replace themselves. And it may be that our anti-natalism has much to do with our understanding (or misunderstanding) of our mortal condition. We readily ignore death, making procreation seem less urgent to men and women who think there will always be more time; and we desperately evade death, making procreation seem less important than sustaining the healthy self into the indefinite future. A death-denying civilization is also, it seems, a child-denying civilization.

Moreover, if one considers the most passionate bioethical debates of recent times — embryo research and Terri Schiavo — the central question seems to be how to live well with death, or how to care well for those who live on the precipice between life and death. With embryo research, we are forced to ask: Is it better to accept death than to destroy human embryos in an effort to oppose it? Is it better to submit to suffering and surrender to mortality than to use the seeds of the next generation as raw materials in the search for cures? With Terri Schiavo, we are left to ask: Is it love or is it torture to keep her alive indefinitely in such a diminished state? Is it mercy or is it betrayal to let her die of dehydration by removing her feeding tube? On both fronts, we need to ask: What is the good death, or what is the best death possible for moral beings who must die and who know it?

Of course, these are hardly the only issues in public bioethics that place death at the center. Modern medicine’s capacity to defeat earlier, acute causes of death may also lead, for many of us, to an extended decline into debility and dementia. The heart attack one averts at age sixty-five might lead to a decade of Alzheimer’s disease — a gradual erosion of the self much different than the young Terri Schiavo’s overnight debilitation. More generally, our heightened capacity to fend off death, for now, means that most of us will die in hospitals, hooked up to machines, with the end only coming when our tortured loved ones say “enough.” Meanwhile, those inventions — like dialysis — that were once seen as life-saving miracles are now seen as torturous burdens. Instead of appreciating the thousands of individuals saved each year by transplanting human organs — individuals once destined to die of organ failure — we see the organ waiting list as a “crisis” in need of solution or as an unconscionable failure of public policy. We tend to think that things are getting worse rather than imperfectly better. And we wonder: Might it be better to buy organs from the poor or conscript organs from the nearly dead than to accept a death that might be averted? Should we lift our moral limits and set aside our ethical qualms to save more lives?

Whatever one thinks about any particular bioethical issue, the problem of living well with death is integral to them all, even those that seem to center more on natality than mortality. And how one thinks about each particular bioethical issue depends, whether explicitly or unknowingly, on the image of death that we see as best. To face our most modern dilemmas, we need to recover some very ancient wisdom. Our culture offers at least five paradigmatic images of the good death: the remembered death of Jacob; the tranquil death of Socrates; the redeemed death of Christ; the technological opposition to death of Benjamin Franklin; and the crisis of death described in Albert Camus’s myth of Sisyphus. These images are the best prism for seeing our past, present, and future bioethical dilemmas for what they truly are. In the age of ventilators and nursing homes and regenerative medicine, we must always ask: In whose image should we die, and in whose image should we live on the way to death? The Bible, as usual, is a good place to start.

The Remembered Death

Jacob is the last of the three great biblical patriarchs, who dies surrounded by his many children. He dies naturally, from illness. He is not killed by an enemy, or lost in a tragic accident, or sentenced to death by a just or unjust court. His death is foreseeable, but there is little reason to believe that he suffered an extended decline. He dies knowing that he is dying, not after years of dementia, when self-awareness of one’s impending oblivion is existentially impossible. He faces death frontally, manfully, without illusions. In his final moments, he performs the parting act of instructing his sons in their obligations and prospects. How he does this, and why, is the key to understanding Jacob’s image of the good death. (The account that follows relies heavily on the work of my friend and teacher Leon Kass.)

The biblical text begins its account of Jacob’s death as follows: “When Jacob was told, ‘Your son Joseph has come to see you,’ Israel summoned his strength and sat up in bed.” Jacob is sick, but he will not address his sons in a sickly posture. He sits up before them; his physical presence embodies both his mortal fragility (in bed) and his paternal majesty (sitting up). Even sitting, he remains the upright master, worthy of reverence, still in command even as his body shuts down. Even as his last speech is a recognition of his own mortal limits, he is never an object of pity in his children’s eyes.

But Jacob’s death, in the end, is not ultimately about him, but about the way of life that may persist after he is gone. He recounts how God promised to make him “fertile and numerous, making of [him] a community of peoples.” He beholds his grandchildren with special amazement, as the fleshy embodiment of the promise of perpetuation. Then he addresses each one of his children — some with great hope, some with stinging disappointment — for he knows that the fate of his divine purpose rests on their shoulders, a prospect that leaves him to die without the certainty of success, but also without the certainty of failure. He asks his children to remember him, awakening their ancestral piety as the ground for continuing life beyond themselves, in “teeming multitudes upon the earth.” He links reverence for the past with hope for the future. He dies, in other words, as the dying father and the dying son. This fidelity in death centers symbolically and ritually on burial — the return of Jacob to the land of his fathers. More importantly, it depends upon the willingness of his children to raise up children of their own, before whom they will one day stand in death, children who will in turn have children of their own, to perpetuate God’s holy and hopeful way into the future.

One episode in particular captures this way of dying well. Just before his last speech to all of his sons, when he knows he is dying but before they do, Jacob orders Joseph to put Joseph’s hand under his thigh and pledge to bury him in the land of his fathers. The point of the pledge is not simply to satisfy Jacob’s self-regarding wishes — to fulfill his advance directive, so to speak. It is also a reminder to Joseph of where he comes from, who he is, and what he must teach his own children. In demanding this oath, Jacob instructs his son never to forget. By demanding that Joseph place his hand under the thigh — in that physical place where the next generation finds its origins — Jacob instructs Joseph of what fidelity really means. One remembers the dead by giving birth to the living; one dies well by giving one’s children their final instructions.

Now imagine, instead, if Jacob had put his hand on Joseph’s back, on the body of his son, and requested a kidney in the desperate hope to stay alive. Or imagine if he had produced an embryonic clone of himself, nascent flesh of his own flesh, in the hope of manufacturing a life-saving cure. This is strange to imagine, and not merely because of the historical distance between our mythical ancestors and our modern medical practices. Such desperate requests or actions — violating the body of his son, destroying the seeds of the next generation — would pervert Jacob’s way of dying well, in which he stands before his sons commanding their fidelity, majestic even in dying. Jacob needs his sons to continue life after he is gone much more than he needs their bodies to extend his life here and now. Yet Jacob’s need for his sons — for he is impotent in death without them — never seems needy. Jacob’s death makes sense because he stands aside for his children, yet stands above them even in the moment when he needs them most — to remember him, to bury him, and to carry on his sacred purpose. This is the Jewish way of dying well, of living well with death.

It is also why, throughout the story of the patriarchs — indeed, throughout the whole Hebrew Bible — barrenness, not sickness, is the real threat to the good life and the good death; opening the womb is the truest evidence of God’s beneficence. Sarah’s misery, Rebekah’s misery, Rachel’s misery, Hannah’s misery — all finally answered when God remembers them with a child — is the misery of infertility. Even earlier, in his address to Noah after the flood, God tells man to “be fruitful and multiply” — first as a divine blessing, then as a divine commandment. God seems to realize that the human revolt against children — willful sterility, not un-chosen barrenness — is a permanent human possibility, as men get lost in the ecstasies or the miseries of present life. God seems to know that only man among the animals can choose against the next generation — seeing children as a burden, or seeing life as too burdensome to inflict on another generation.

Yet in our time, in the most death-defying civilizations in history, procreation is becoming an afterthought, as noted above. Modern technological societies, infatuated with embryo research and organ transplantation and life-saving cures, are having the fewest children of any societies in human history. Today’s potential parents are much less likely to die surrounded by their offspring, or remembered by their children, or sustained by their children’s children. From Jacob’s perspective, we are dying badly by dying alone, with no sons and daughters to instruct in our final days.

But Jacob’s way of dying is also threatened from a different angle in modern societies, also noted above. Today, we are much more likely to die only after an extended demise, after long years of physical and mental decline into dependency and dementia, unable to sit upright before our children in our final days. The very medical triumphs that make long life and prolonged vigor possible for so many can also (if unintentionally) make dying an extended misery. Our medical machinery makes Jacob’s version of the good human death ever more unlikely. Even in the eyes of the most devoted children, we risk becoming an object of pity. Or, in our childlessness, we risk becoming a burden on the state. Such circumstances threaten to usher in a new age of euthanasia, both as a way of restoring the social balance between the old and the young and as a way of recovering the tranquil, timely death that most people still want but few people now get.

The Tranquil Death

The death of Socrates, as remembered by his student Xenophon, is a very different kind of human death — a noble euthanasia. The philosopher has been convicted by the city for worshipping false gods, or no gods at all, and for corrupting the youth of Athens. Unlike Jacob and his fathers, Socrates does not see his life as the fulfillment of a divine commandment, or his wisdom as dependent on God’s revelation. When the oracle of Apollo declares that Socrates is the wisest man alive, he sets out (as Leo Strauss noted) to prove the oracle wrong, only to discover that the oracle is right. Everyone who claims to be wise is actually foolish, believing he knows the truth of ultimate things when in fact he knows nothing. Socrates at least knows that he knows nothing. He also knows when it is time to die, or at least how to die well. He has little interest in admitting guilt, or apologizing, or escaping into exile in order to avoid death. As Xenophon says, Socrates “had come to regard death as for himself preferable to life,” and so he accepts his death sentence with a certain tranquility.

Still a great giver of speeches, Socrates also knows that his bodily decline is looming. He seems to abhor the prospect of losing his mental powers, of being alive without the capacity for wisdom, of being an object of pity or contempt to all those who presently admire or fear him. He knows that he cannot be a thriving philosopher forever, and he sees his death, under these circumstances, as a kind of good fortune — one he attributes to a God, but which comes about by his own forced, if willing, human hand. As Socrates says:

It may be … that God out of his great kindness is intervening in my behalf to suffer me to close my life in the ripeness of age, and by the gentlest of deaths. For if at this time sentence of death be passed upon me, it is plain I shall be allowed to meet an end which … is not only the easiest in itself, but one which will cause the least trouble to one’s friends, while engendering the deepest longing for the departed. For of necessity he will only be thought of with regret and longing who leaves nothing behind unseemly or discomfortable to haunt the imagination of those beside him, but, sound of body, and his soul still capable of friendly repose, fades tranquilly away.

Interestingly, the President’s Council on Bioethics cites this passage in its 2005 report Taking Care: Ethical Caregiving in Our Aging Society as an image of what the good death might look like, in contrast to an extended modern decline into dementia or the awful prospect of dying too soon. But the Council’s sympathy for this Socratic death is not without caveats and questions, which it raises in a lengthy footnote:

If we are still sound of body and mind, can we ever really accept death with tranquility? And if we are still a source of happiness to our friends, would they let us “fade away” if they had the power to keep us going? Do human beings deserve the most tranquil death? Or is death, in some ways, the very opposite of tranquility — a nasty robbery of life, to which we can surrender gracefully but never happily? And what is the meaning of the fact that the peaceful death here described (the death of Socrates) is brought about by deliberate — or deliberately imposed — human action (that is, by the drinking of hemlock)? Nevertheless, Xenophon is clearly on to something: a peaceful death, in the right season, is for most of us the best we can humanly hope for.

Unlike Jacob, Socrates dies among students and friends, not among his children. It is his friends’ trouble he seeks to avoid; their fond memories (“longing for the departed”) he seeks to sustain. That Socrates dies a noble death — a death with dignity — is hard to deny. He stands unflinchingly, almost playfully, before his supposedly pious accusers. And he asks them questions they cannot answer, confronts them with contradictions they cannot ignore, and demonstrates for eternity that independent spirit that belongs to the philosopher alone. Where Jacob accepts a natural death he cannot escape, Socrates accepts an imposed death he might have averted, but averted only by betraying who and what he was. Death thus becomes the vindication of philosophy, of truth opposed to opinion, wise questioning opposed to ignorant certainty, without the wisdom-wrecking decay of the mortal body. It is an upright death, a death that preserves the immortal dignity of the man who died at the summit of his powers and on the eve of his decline. It is also a pleasant death — swift, painless, “easiest in itself.”

Yet, for all its renown, the death of Socrates seems less fully human than the death of Jacob, which unites the private drama of father and sons with the public drama of Israel’s beginnings as a nation. Jacob’s speech, if less grand than the apology of Socrates, seems truer to what it means to live in time, called to a purpose, remembered through the fidelity and perpetuation of one’s offspring. And ultimately, the Socratic death embodies a certain ambiguity as both the brave death and the tranquil death. Socrates dies well by accepting death rather than betraying his commitment to truth; yet he also needs death to come sooner rather than later, so that nature does not destroy his nobility as a philosopher by destroying his embodied mind, turning the wisest man into a post-philosophical body. For Socrates, the most pleasant death is, necessarily, the least natural death — the controlled exit, without nature’s “unseemly or discomfortable” afflictions “to haunt the imagination of those beside him.” But the dignity of this pleasant, unnatural death also seems to require that such a death be un-chosen. The death sentence of Socrates replaces the deathbed of Jacob. The heroic and the tranquil are united in one final sip of hemlock, a poison that the poisoned man sees simultaneously as both an injustice and a gift.

The Redeemed Death

The death of Jesus is also heroic, but hardly tranquil. Like Socrates, Jesus dies at a time decreed by the civil authorities, not by the entropy of nature. He spends his final hours among his disciples, not his children. Yet unlike Socrates, Jesus dies the most painful death imaginable, an extended public torture, horrifying to those who love him. Like Socrates, his death is imposed upon him by others. But whereas Socrates, at least according to Xenophon, seems to prefer death to life, Jesus dies as an act of submission. And while Jesus is destined in the story to rise again, there is also a way in which, unlike Socrates, Jesus dies before his time; he dies not in the proper season; he dies watched by his mother, not remembered (like Jacob) by children who follow in his footsteps.

Jesus’ death is not finally about him, of course, but about the divine purpose he is called to fulfill. Childless, he looks to his disciples to perpetuate his holy way, to preach the gospel, to spread the good news. He dies the paradoxical death — mocked, but dying to redeem the mockers; innocent, but dying to conquer sin; submitting to death, but only so he might conquer death through love. For Jesus, unlike Jacob or Socrates, death has to be a misery, “discomfortable” to those who love him. Even in his innocence, he embodies the fact that death is the wage of sin, a just sentence upon humanity, lifted only by God’s grace; death is not the injustice it so often seems. Jesus’ death is both in need of redemption (the human Jesus) and the redemptive act itself (the divine Jesus). His death is meant to change death forever, allowing even mere mortals to die wretchedly with the faith that death is not final. As Caitrin Nicol writes: “Jesus’ death is a physical display of sin, sister to death since Genesis, and it is sin itself that is most importantly being conquered — not faced, not escaped, not accepted, but actually conquered. As mortality was the consequence of the Fall, the literal undoing of death in the Resurrection of Jesus is there to show that the Fall has really been reversed.”

Although he begs in Gethsemane that the cup might pass from his lips, he does not resist it when it comes. When one of his disciples tries to defend him by force, he charges him to put away his sword. Cursed by his enemies, betrayed by his friends, abandoned even for a moment by his Father — “my God, my God, why has thou forsaken me?” — Jesus confronts death and the “power of darkness” with no force save one: the love that triumphs over all.

In Jesus, we see what it means to love in the face of misery, to believe in the face of physical horror, to conquer death by submitting to it. Jacob does not conquer death; he steps aside for the children who will remember him and perpetuate his holy mission. Socrates does not conquer death, but simply removes its sting, by treating it as a great unknown and therefore not a known evil, and by accepting the pleasant exit that is so unnaturally offered to him. But for Jesus, death is understood as a problem; it needs to be conquered, not simply accepted. It stings, yet with God’s help, man can love and be loved even in the face of its sting.

One wonders what Socrates would have done if his punishment had been crucifixion, not hemlock: Would he have had Jesus’ strength, or might he have sought some escape? And one wonders what Jacob’s sons would have done if their father, through nature’s malignancies rather than man’s, had suffered before them as Jesus did? Could they have stood to witness their father so tortured and still believed in their father’s God, and would his desperate state have elicited their pity, or rage, or despair? Unlike Socrates and Jacob, Jesus confronts us with the horror of death endured in all its horribleness: not sought as an exit, yet not escaped at the cost of betraying one’s given purpose. In Jesus, we learn what it means to forgo all control and retain all control simultaneously — what it means, passively and actively, to die as an act of surrender.

The Opposed Death

Modern man, by contrast, faces death with a different credo: never surrender. For modern man, as for Jesus, death is a problem; mortality is an affront; it needs to be conquered. But the route to conquering death — or trying nobly — is not submission, but cleverness; not faith, but science. The aim is regeneration of the body (a self-made act), not resurrection of the body (a God-dependent act). We have taken a page from old King Asa, who in his illness “sought not to the Lord, but to the physicians.” In a wonderful letter to Rev. John Lathrop in 1788, Benjamin Franklin gives voice to this modern sensibility — the thirst to extend life with “useful utensils and instruments.” As Franklin writes:

I have sometimes almost wished it had been my destiny to be born two or three centuries hence. For invention and improvement are prolific, and beget more of their kind. The present progress is rapid. Many of great importance, now unthought of, will before that period be produced; and then I might not only enjoy their advantages, but have my curiosity gratified in knowing what they are to be. I see a little absurdity in what I have just written, but it is to a friend, who will wink and let it pass, while I mention one reason more for such a wish, which is, that, if the art of physic shall be improved in proportion with other arts, we may then be able to avoid diseases, and live as long as the patriarchs in Genesis; to which I suppose we should make little objection.

Franklin, like Socrates, seems to have an equanimity about life and death. He admits that his yearning for an ageless body is a kind of “absurdity,” and requests from his friend an understanding “wink.” He also acknowledges that such blessings will not arrive in time for him. But his optimism is not simply ironic. He believes that progress will fend off death’s many causes, if not defeat death itself, and that science will (almost) restore the lost age of man’s timeless innocence, or at least secure a life long enough to satisfy man’s many curiosities. He believes that technology is a partial — and perhaps the best available — human answer to death.

Of course, we now live “two or three centuries hence,” and we might wonder what Franklin would think about our achievements. The marvels of modern medicine surely outstrip the blunt instruments of his own day. The art of biology holds death at bay; it immunizes us from disease, rescues us from disease, and replaces diseased parts with new (or healthy used) ones. But at 84 years of age when he died, Franklin’s life would still be long by modern standards, though his once uncommon longevity is increasingly routine. Science answers many deadly threats, making the body’s longevity less a matter of genetic chance or good fortune, and more a matter of human control. But science has not — cannot — answer death itself. Surely one would be a fool not to see modern medical science as a godlike, perhaps even a God-given, blessing. But one also cannot ignore what Franklin’s contemporary Rousseau observed about the effect of technological progress on human desire and human happiness:

[S]ince men enjoyed very great leisure, they used it to procure many kinds of commodities unknown to their fathers; and that was the first yoke they imposed upon themselves without thinking about it, and the first source of the evils they prepared for their descendants. For, besides their continuing thus to soften body and mind, as these commodities had lost almost all their pleasantness through habit, and as they had at the same time degenerated into true needs, being deprived of them became much more cruel than possessing them was sweet; and people were unhappy to lose them without being happy to possess them.

Of course, the sick still see their cures as blessings; they are still filled with gratitude toward their doctors when they leave the hospital to return again to normal life. But Rousseau is clearly on to something. His insight is borne out, for example, by the contemporary outcry over the “shortage” of organs for transplant. Once regarded as a miraculous gift for the fortunate few who were able to find a suitable organ, transplantation has, by its own successes, come to be regarded as a necessity. Waiting for an organ has become a novel kind of misery. The miracle of a new organ has become, for those in need, an expectation, such that “being deprived of them [is] much more cruel than possessing them [is] sweet.” Organ transplantation is just one example of a more widespread phenomenon. All too often, our modern medical technologies are transformed in our eyes from achievements to failures, precisely because they cannot fend off death itself or reverse the ravages of natural time that they temporarily hold at bay. The blessing of dialysis becomes a curse in just a few decades. The diseases of old age come to be seen as epidemics, turning life itself into a war against disease — a permanent, restless march for a cure.

The Crisis of Death

Perhaps this is why Albert Camus’s modern hero is the embattled doctor in plague-time, with the distance between plague-time and normal-time blurred by the omnipresence and omnipotence of death. In Camus’s myth of Sisyphus, Franklin’s yearning for indefinite life becomes a rage against death. Death becomes a crisis, not just a problem. Perhaps the difference is that Sisyphus knows death firsthand, in all its wretched blankness. He dies and then returns; his passion for life comes from knowing the alternative of nothingness.

But when he had seen again the face of this world, enjoyed water and sun, warm stones and the sea, he no longer wanted to go back to the infernal darkness. Recalls, signs of anger, warnings were of no avail. Many years more he lived facing the curve of the gulf, the sparkling sea, and the smiles of earth. A decree of the gods was necessary. Mercury came and seized the impudent man by the collar and, snatching him from his joys, led him forcibly back to the underworld, where his rock was ready for him.

Whereas Socrates sees his tranquil death as a divine gift, Sisyphus sees death as a divine theft, to be opposed (futilely) with all his mortal might.

In Camus, Franklin’s desire for life is taken to passionate extremes. The passion of Sisyphus is more like the passion of Christ, but without the redemptive victory. Instead of the long hours of crucifixion followed by the eternity of resurrection, Sisyphus faces the permanent recurrence of pushing a rock up a hill, never reaching the top, always rolling back down to the underworld, never fully rising again. For Sisyphus, opposition to death is everything, but success is impossible. There is, at most, a brief moment of existential satisfaction, when the rock lies still near the top, before beginning again its eternal slide to nothingness.

In Sisyphus, Camus believes he has found an answer to the modern crisis of death: heroic revolt, ending in knowing acceptance of futility, a knowledge that makes man superior to the absurdity of his fate. “The lucidity that was to constitute his torture at the same time crowns his victory. There is no fate that cannot be surmounted by scorn.” To some, perhaps, such scornful stoicism is satisfying, but for most people it is not. They prefer to look away from death until it stares them in the face; and when it does, they seek Franklin’s help, hoping the cleverness of science can triumph one more time over the oblivion that terrifies them.

Modern science thus takes up the mantle of death-as-crisis; the ethic of triage makes ordinary morality seem absurd in the face of death’s permanent absurdity. This point has been described beautifully by Yuval Levin in these pages, reflecting upon the deeper meaning of our current debates over embryo research:

[I]f the fight against disease writ large — indeed the fight against natural death — is an emergency, and if … it is a struggle we can never expect fully to win, then we must always live in a state of emergency. We should be always in a crisis mode, always pulling out all stops, always suspending the rules for the sake of a critical goal. And that means, in effect, that there should be no stops and no rules; only crisis management and triage…. But if life is always at risk and we are always in crisis, then we must always do things that moral contemplation would suggest are wrong. If we are always in a mode of triage, then we must always choose the strong over the weak because they have a better chance at benefiting from our help.

The trouble is that in this war against disease and death, we risk undermining the ideals we profess to hold most dear, beginning with the ideal of human equality. We are tempted to treat the most vulnerable as tools to sustain us in the struggle against death. And when this fight must end inevitably in the defeat we cannot avert, we are tempted to violate equality yet again, by treating the old and debilitated (including the future self) as “lives unworthy of life,” as unsightly evidence of our failure. Without Jacob’s remembering children, without Jesus’ saving faith, without Franklin’s triumphant method, we are left in the condition of Sisyphus: faced with the crisis of death we cannot conquer, trapped in a mortal condition we seem ill-equipped to endure. In modern times, the hemlock of Socrates seems ever more appealing, requested in desperation rather than accepted in nobility. In an aging society, in which the elderly come to seem and come to feel like paralyzing burdens, the seduction of euthanasia may be too strong to resist.

The Crisis of Equality

If we are to resist those answers to death that might dehumanize us, we need to reinvigorate the ideal that every enlightened man and woman still professes to hold dear: the ideal of human equality. Death, in one sense, is the great equalizer: rich and poor, weak and strong, young and old, all return equally to the dust from which they came. But the unequal circumstances of death — especially the natural death of a child, which seems particularly unnatural — confront us with the problem of death most poignantly. As it turns out, one promising route to opposing the inequities of death — embryonic stem cell research — may require violating the principle that all human beings are equally worthy of protection, or at least equally possessed of the right not to be used simply as a means to others’ ends. To find a cure for the ailing child, we would destroy the developing embryo. To solve the problem of death, we introduce the crisis of equality. We are tempted to treat the not-yet-abled (i.e., human embryos) as tools to help the sick who might be abled again; and when such cure-seeking fails us, we are tempted to treat the no-longer-abled (e.g., the octogenarian with dementia) as better off dead, giving them a swift, comfortable exit from life, and in the process freeing ourselves from the excessive (unequal) burdens of their care.

In America, the ideal of human equality is grounded first and foremost in the Declaration of Independence, a political document with metaphysical significance. The Declaration’s claim that “all men are created equal” should immediately strike us as strange. For in so many ways, human beings are not created equal: Some are born with remarkable natural gifts, others with debilitating natural liabilities. Every newborn is vulnerable and needy; none can survive on his or her own. But newborns are not equally vulnerable, as a brief trip to the neo-natal intensive care unit quickly reminds us, and these native differences often become more pronounced over time. While an ample share of nature’s unequal gifts hardly ensures the realization of human excellence or human happiness, a disproportionate share of nature’s unequal liabilities, especially malignant disease, often ensures that the pursuit of happiness will be gravely impeded or even impossible. No one who has cared for and mourned a child with a lethal cancer can easily stomach the claim that “all men are created equal.” And yet those same caregivers, in their many heroic acts of devotion, are clearly moved by the belief that even a doomed child is worthy of the greatest sacrifice. Created unequal, the child’s claim on them — and us — is arguably greater, not smaller.

From this existential truth about the natural fact of inequality, we might draw different ethical and social conclusions about what being “created equal” really means. In the Declaration, the teaching about equality seems designed to be limited: We are equal in rights, not necessarily in dignity or happiness. We are equally entitled not to be harmed by others, not to be treated as property, not to be used as mere things or enslaved by those who are stronger. We are equal in negative rights, which governments exist to protect; whether those rights have any positive meaning — whether we have life, or can use our liberty, or can pursue happiness with any promise of its realization — often depends on the contingencies of fate.

But for most of us, this limited teaching about political equality is existentially and morally unsatisfying. We are not content to leave the sick, or the young, or the old, to fend for themselves. We seek to make men equal by ameliorating the inequities of disease through regenerative medicine and by correcting the inequities of birth through redistributive politics. This belief that the afflicted deserve to be made more equal is grounded in a belief that they are already equal — that is to say, equally worthy of the care that might make an equal pursuit of happiness possible.

The trouble arises when making men equal is beyond our power, or when the means of doing so are morally illegitimate. At times, our two understandings of equality — equality as a moral aspiration and equality as a morally binding fact about our nature — come into direct tension. This tension is seen most clearly in the spirit and methods of modern eugenics, which aim to give every child the genetic equipment to pursue happiness as equals, without biological disadvantages. In our democratic society, the supposed quest for biological perfection is really a quest for perfect equality. So we abort the imperfect in the name of equality. We discriminate against the disabled, using prenatal genetic screening as our litmus test, in the name of producing a society where no one is disabled. We abandon the vulnerable in the name of egalitarianism. We destroy the morally binding ground of equality in our excessive hunger to make nature perfectly just.

The moral alternative to eugenics — seeing the genetically unequal as equally worthy of care, seeing the not-yet-abled and the no-longer-abled as equally worthy of protection — requires a different kind of moral imagination. It, too, is rooted in a radical egalitarianism, the proposition that all men are equal in the eyes of those who behold them, including those who are created unequal at birth. To see our fellow human beings in this way requires an acknowledgement of our common vulnerability: We were all once dependent on others to nurture us to self-reliance, and we may all, one day, lose our powers of self-reliance. Even more importantly, this moral disposition to treat all men equally also requires an uncommon human excellence — the resolve to stand with the no-longer-abled, not-yet-abled, or never-to-be-abled, especially when standing by them requires giving up our own hopes and plans. Living equality requires a kind of moral elevation. It is the elevation of the child who stands by a parent with Alzheimer’s; the elevation of a parent who stands by a handicapped child; the elevation of a patient who accepts death rather than seeking an embryo-destructive remedy.

In the end, the most radical teaching about human equality is also a teaching about human excellence — the excellence of love, of seeing immeasurable human worth even in those who might seem worthless, of using one’s superiority to elevate the weak who cannot elevate themselves. For those who believe in a redeeming God, this kind of excellence is an act of imperfect imitation. For those who believe there is no redeeming God, it is the redemptive human alternative — the activity of acting like the God that would exist, or should exist, if the world were created with love rather than set in motion with indifference.

For some, of course, even nature’s most generous portion is not enough. The right to life becomes the right not to die; the right to liberty means the right to be free from all misery; the right to pursue happiness becomes the right to be happy. For those with such an insatiable hunger, the teaching that all men are created equal is a much-needed check on their ambitions. We should not extend our lives by shortening the lives of others; we should not exercise our liberty by infringing on the rights of others; we should not pursue happiness by using others as a mere means.

Yet affirming the equal worth of every human being — the equal right not to be used — does not necessarily mean that everyone possesses equal human dignity in every sense of that complicated term. The truth is far more puzzling. In a limited sense, human dignity resides in the physical being of the human person — especially at its most perfected or most graceful, but even in its most deformed or still forming. In this sense, non-human animals possess a dignity of their own, as living creatures with their own distinct forms and flourishing, yearning to exist but destined to die. Yet there seems to be another dimension of human dignity for which mere physical being is not sufficient; this higher dignity depends on the lived human capacity for excellence and for shame — capacities that are uniquely human but not possessed by all humans. Only human beings can look indignantly upon themselves when they fall short of their own aspirations to dignity. Only human beings can be ashamed at standing before others in all their physical, or moral, or existential nakedness. And only human beings can aspire, through willful exertion, to perfect their given natures.

From this angle of vision, it seems misguided to say that a human embryo or a person with late-stage dementia possesses “equal dignity” in every sense, except in potential for the future or in memory of the past, as the being that might be or the being that once was. For the very young, the capacity for excellence and for shame does not yet exist; for the very old, it may be gone forever; for the rare, unfortunate few, it never truly arrives. Yet the fact that some human beings have lost, still await, or never achieve this higher human dignity does not make them simply sub-human things. For it would be beneath our dignity to dehumanize our fellow humans, whether in the name of cures, or mercy, or self-elevation.

When it comes to human embryos, our responsibility should be obvious. After all, these nascent lives might grow up to be our moral and intellectual superiors; to destroy them now is to violate the promise they uniquely embody. When it comes to those with dementia or debility, our responsibility may be less clear. Our belief in equality bids us to treat the person with Alzheimer’s as a life equally worthy of living; yet something human in us also revolts against the prospect of living indefinitely and ultimately dying in such a state, against seeing our identity robbed from us, against coming to behave without dignity because we lack all control. Faced with this dire prospect, as more and more of us will be, we might wish for a death more like that of Jacob, and we can understand those aging parents who flirt with the Socratic method of dying — the unnatural exit — in order to stand before their children one last time as more than objects of pity. Perhaps the hardest life to regard as equally worthy of living is that of the future self who lacks the vigor and self-control of the person I am now.

In the end, however, a true commitment to human equality rightly tempers the belief that death is a crisis, or that only the flourishing human life is worth living. It invites us to recognize that in the face of mortality’s inevitable triumph, the best we can do is care always for those in need, even for the most debilitated and least developed human beings, and even when the aspiration to “cure now” is met with nature’s recalcitrance. It also invites us to submit to the care of others when the time comes, tempering the pride that tempts us to suicide. To believe in human equality ultimately requires the heroic acceptance of death, seeing it as neither a friend to be pursued in the name of mercy or nobility, nor an enemy to be opposed at all costs. We are born toward death, and all those activities that elevate us above the stark fact of our mortality require living well with our unavoidable and usually un-chosen demise.

Death and Bioethics

In the late 1960s and early 1970s, Paul Ramsey (one of the founders of modern American bioethics) wrote extensively about the ethics of end-of-life care. Ramsey’s central worry was the technological dehumanization of death. He feared the transformation of dying persons into objects, with a humane exit made impossible by the unyielding machinations of the modern hospital, with its modern ethic of “never surrender.” A decade or so later, however, Ramsey was far more worried about the opposite problem: terminating life-sustaining treatment too early; treating the debilitated as “better off dead”; defining as “futile” those who could never be restored to normal but whose lives were hardly over. Ramsey did not, in that period, undergo a philosophical transformation; rather, the facts on the ground changed, and so did his bioethical concerns and priorities.

The development of Ramsey’s work reminds us that we are all creatures of time and place, and that the bioethical concerns of the present and future require seeing man’s permanent problems in light of changing technological and social conditions, and in light of those philosophical orthodoxies that reign supreme in both our bioethics institutions and the culture as a whole. Yet the deepest problems of the age are always connected to the deepest problems of every age; to face the perils of the moment we need, or should want, to draw upon the wisdom of those ancient giants in whose image our lives are rightly judged.

In modern America, Franklin’s technological spirit — the will to oppose death through science — hardly needs additional support. The National Institutes of Health budget has risen dramatically in the past decade, no matter how large the federal deficit or how perilous the condition of our entitlement programs for the elderly. Likewise, in our society, the spirit of liberation hardly needs additional moral support. We are liberated from unwanted conceptions; liberated from unwanted births; liberated from the responsibility of rearing disabled children; liberated from the responsibility of providing economically for our elders in old age; liberated to nip and tuck our given bodies in the name of pursuing happiness. Too little autonomy, like too little enthusiasm for scientific progress, hardly seems like our most pressing bioethical problem.

The real challenge upon which the future of American bioethics will turn is learning how to live and die without trampling on the principle of human equality in the name of medical research, and learning how to step aside for the next generation without treating the debilitated elderly with a fiscally responsible inhumanity. We need to recover, as best we can, Jacob’s way of dying well: naturally, without endless machines or swift poisons; surrounded by his children, all assembled at the bedside and prepared to honor the dying patriarch by having children of their own; frail but upright, with neither the delusion of endless life nor the burdens of an extended decline into dementia.

This image of human excellence in life and in death hardly translates into a ready-made recipe for dealing with every current or foreseeable bioethical dilemma. But it might shape our moral intuitions and cultural aspirations, from which our law and our policies ultimately derive. That is, we might become more willing to let loved ones die, within an ethical and legal framework that prohibits euthanasia and assisted suicide; more open to the responsibility to have and raise multiple children, rather than seeking the freedom that childlessness uniquely offers; more welcoming of children unconditionally, rather than subjecting them to the inegalitarian litmus tests of modern genetic screening; and more devoted to the unique human excellence required to be loving caregivers and noble patients, who forgo their plans and accept their mortality rather than mistreat the vulnerable or betray their fellow men.

Looking around, it is easy to be disheartened about bioethics and the human future: birthrates are falling, the incidence of dementia is rising, genetic screening and abortion and embryo destruction are becoming more commonplace. But so long as we remain open to persuasion, open to the recovery of forgotten images of man, our present errors will always be amenable to future reformations. And as we look around and ahead, we should never forget that every age is twisted in its own unique way, stained by errors, getting worse even as it gets better. The only ineradicable error is believing that all the problems of human life can be solved once and for all. Short of that, we will muddle through in bioethics as we do in every realm of human life where the meaning of our humanity is on trial — with examples of excellence and depravity, but most of us stuck in that imperfect in-between, neither beasts nor gods but men with birthmarks.

Adapted from "Mortality, Equality, and Bioethics" by Eric Cohen in 7 Yale Journal of Health Policy, Law, and Ethics (forthcoming 2007). Eric Cohen, "In Whose Image Shall We Die?," The New Atlantis, Number 15, Winter 2007, pp. 21-39.

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