While Goligher describes the overriding focus on personal autonomy as central to most arguments in favor of PAS-MAID, he doesn’t delve deeply enough into how this focus on autonomy shapes Western cultural imagination about what personhood actually is.  In his book ‘What it Means to be Human’ legal scholar and bioethicist O. Carter Snead provides an in-depth analysis of this default anthropological understanding and its implications for the legal infrastructure surrounding central bioethical issues today ranging from abortion to assisted reproductive technologies to PAS-MAID.  Snead’s central thesis is that an anthropology of “expressive individualism” is baked into the legal understanding of these issues.

Making the Hidden Plain

As a current fellow training in palliative care medicine, one of the great gifts of my work is the ability to daily bear witness to those who face impending death.  While this “gift” may strike some as morbid or masochistic, I presume this view to be held by those who have not themselves spent time around the dying.  Being able to come alongside and learn from those who are facing imminent death affords a sobering but deeply important opportunity for those of us who remain ostensibly healthy to reckon with our own finitude in a way that is otherwise culturally discouraged.  And this work is not merely voyeuristic; when done well, communing with the dying affords the patient the opportunity to maintain relationship and exercise virtue in her role as teacher to those who would come after her.  

Yet this privilege—to interact with and learn from the terminally ill—is one that is largely proscribed in our contemporary Western culture.  Rather than grapple with our own embodiment and contingency, our teenagers dabble in prophylactic botox.  Rather than lionize and render what is due to our elderly forebears, we favor institutionalization.  Rather than foreground the experiences of our sick and dying, we largely sequester them.  While there has been an encouraging movement toward improving the dying experience of patients through the establishment of palliative care as a medical specialty, even this term “palliate,” which derives from the Latin “palliam”—to cloak—betrays our discomfort with the transparency of death.

As the conversation surrounding the moral permissibility of physician-assisted suicide/medical aid in dying (PAS-MAID) steadily amplifies, this societal distancing from death influences the views of those on both sides of the argument, but ultimately places the burden of proof on those of us who oppose the practice.  Insofar as the act of death remains a largely hidden, privatized experience, arguments for the priority of personal autonomy will be progressively strengthened rather than questioned. To the degree that the idea of death remains taboo and uncomfortable to consider, society will generally accept the supposed preservation of dignity and mitigation of suffering purported by those who advocate for MAID. Thoughtful arguments in opposition will, meanwhile, atrophy over time.

In his recently published book How Should We Then Die? Canadian critical care physician Ewan Goligher seeks to bring the issue of death, and the attendant question of the moral permissibility of PAS-MAID, to the fore in a form that is succinct, accessible, and internally consistent.  Goligher is clear and persistent in his argument that PAS-MAID constitutes a grave transgression of the intrinsic goodness of human life and ought never be considered licit.  As he states from the outset, his goal is to provide an argument consisting of a series of ten distinct “theses” addressing various facets of this overall claim, intended for Christian audiences grappling with the urgency of the PAS-MAID question.

Goligher’s work serves the important purpose of putting forth a basic rhetorical grammar surrounding the PAS-MAID conversation for Christians who have yet to consider some of the fundamental moral assumptions at play.  In this sense, he largely succeeds in providing a primer to those readers who might otherwise fall prey to the cultural avoidance of death which afflicts secular society and the Church alike.  By advocating for the intrinsic value of people and the consequent inherent goodness of their existence, the failure of personal autonomy as a sufficiently robust principle upon which to base decisions of life and death, and the quasi-religious reasoning endemic to most secular arguments in favor of PAS-MAID, Goligher equips his reader with crucial (if simple) foundations upon which to ground opposition. Nevertheless, even within his intentionally limited and circumscribed argument, there are key areas that would benefit from deeper consideration.

Radical Autonomy and the Challenge to the Moral Accessibility of a Universal Ethic

As Goligher explicates near the book’s introduction, his argument proceeds in a deductive fashion, as he intends to first delineate universally agreed upon principles surrounding the intrinsic goodness and value of human life, then to consider their implications for the moral permissibility of PAS/MAID, specifically.  He subsequently seeks to buttress these arguments by providing a Christian ethic grounded primarily on Scriptural references to creation, suffering, and the life of Christ that strengthen this vision of human worth that precludes intentional killing under any circumstances.

While Goligher’s move to proceed from “basic moral starting points that nearly everyone accepts and shares,” is laudable and in some ways rhetorically crucial to arriving at a non-particularist ethic against the moral permissibility of PAS/MAID, it is worth asking whether such a starting point in fact exists in our current cultural milieu. Arguments for epistemological accessibility to a universal moral law have been taken up by such diverse thinkers as Plato, Aquinas, Kant, and C. S. Lewis and do indeed serve for many as the fulcrum upon which considerations of weighty questions like the permissibility of PAS/MAID rest.  Yet does such a universalist ethic recognizing the intrinsic and unconditional worth of human life truly hold water among those in a society such as our own today? The hegemony of autonomy calls this assumption into question.

While respect for autonomy as a guiding principle within bioethics (and culturally writ large) serves as a popular focus of criticism among conservative ethicists, it may nevertheless seem strange to consider autonomy as potentially subverting an argument for the intrinsic goodness of people. But when a healthy recognition of the importance of self-sovereignty mutates into what has been termed “radical autonomy,” in which the ability to self-determine one’s truth and goodness replaces the true and good as the highest good, then calculations of worth (particularly those of self-worth) are rendered contingent and subjective rather than absolute and objective. Goligher himself argues as much, when he later notes that an over-emphasis upon the centrality of autonomy affords the individual the ability to self-denigrate and (falsely) appraise his or her own life as not worth living.

The cultural grip that radical autonomy holds calls into question Goligher’s starting premise, that human life is indeed viewed by all as not only good, but unconditionally valuable. Insofar as individuals can misunderstand or even reject their own intrinsic goodness and worth, a shared ethic of the foundational goodness of human life cannot be assumed.

If the radical autonomy of the individual cannot serve as this reliable basis for unconditional worth, where are we to find such a foundation?

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