BY: REV. JOHN KAVANAUGH, SJ
Some Contemporary Thinkers Have Forgotten What "Healing" Really Means
Catholic health care today is engaged in a massive ideological struggle with an increasingly powerful school of thought. A leading theorist of this school is Peter Singer, who teaches ethics at Princeton University. In 1994 Singer announced—in his book Rethinking Life and Death (a text used in university ethics courses throughout the nation)—that the 2,000-year-old Western ethic governing decisions about life and death has collapsed. Hardly anyone believes any longer that all human life is sacred, Singer says.
This collapse applies, he argues, not just to the belief that it is wrong to intentionally end the life of an innocent human being, but even to our understanding of who counts—or does not count—as a member of the community of human persons. "The traditional ethic is defended by bishops and conservative bioethicists who speak in reverent tones about the intrinsic value of all human life, irrespective of its nature or quality," Singer writes. "[But] readers will already know that I do not speak in hushed tones when I refer to the traditional ethics of the sanctity of human life."1
We Catholics should note that if Singer is correct in his prognosis, and if his opinion wins out, everything we stand for, as articulated in every medical code—and especially in the mission statements of every Catholic Health Association (CHA) member—is, if not in shambles, at least quite near disintegration.
Singer is a leading member of a group of theorists who—although willing to give "personal" status to great apes and possibly also whales, dolphins, dogs, and pigs—suggest that unborn, profoundly handicapped, and brain-damaged humans do not qualify for it.2 His argument is similar to that offered by, for example, Evelyn Pluhar. Both believe that "persons" are only those who have "full personhood"—who possess, on one hand, the ability to act to fulfill conscious desires and, on the other, the self-knowledge and sense of responsibility that mark adult humans as moral agents. This of course excludes all people who, for one reason or another, cannot exercise their capacities.
As Pluhar puts it in Beyond Prejudice: The Moral Significance of Human and Nonhuman Animals, healthy animals perform as a rule much more effectively than marginal humans, and so should be given at least the same consideration, protection, and respect as is given to infants or brain-damaged humans, who—because of their limitations—are not "full-fledged persons."3 "Even primates considerably less well endowed mentally than [chimpanzees] have demonstrated capacities beyond the abilities of some humans," Pluhar writes. "Birds can carry out acts that appear to require considerable planning, cooperation . . . . Unfortunately there are many humans who could never equal any of these feats."4
This argument is interesting—and malicious. For indeed a spider can do much more than a human fetus. A rat performs more impressively than a three-day-old baby does—which is why some theorists do not want to give human babies personal status. They suggest that we wait a year or so before pronouncing babies members of the human community. Mary Ann Warren goes so far as to argue that infanticide is not the killing of a person. Infants are, in their lack of experience, more like fetuses than "full" persons, she writes.5
This depersonalizing tactic can be seen in the political world as well. At present, our courts and legislatures are debating a procedure called "partial-birth abortion."6 But it is indubitable that, even in the second trimester, a fetus is a living being; it has a beating heart, an active brain, and is responsive to its environment. Even if one will not admit that a fetus is human, one must at least agree that it is an animal. And yet contemporary society refuses to give a second trimester human animal the protection it gives to laboratory rats. Such is our insensitivity to the most vulnerable at the margins of personal existence.
In December 1999, Life magazine published a powerful rebuke to the court's denial of human status to an unborn human being. The article, "Born Twice," was accompanied by a splendid full-page photograph of a swollen womb—but one outside the body of the pregnant mother. Seen reaching through an incision in the uterus is a tiny human hand, grasping the giant-like finger of a physician who is trying to peer inside the womb.7
The evidence is inescapable. This, we see, is a human hand, not a mouse's paw or even the hand of a great ape. This is a human patient's hand—the hand of Sara Marie Switzer, who was born a few weeks after the photo was taken. Our judiciary is currently debating whether it is more appropriate to dismember fetuses like her inside or outside the womb. But they are human. To kill them is homicide, whether one thinks it justifiable or not.
I know that some readers will be discomfited by this discussion; I apologize for my lack of propriety. But nothing short of impropriety will do in a society that rips apart its young without constraint. If we can be tolerant of that, we can be tolerant of anything. And if we are tolerant of everything, we will find that we truly love nothing.
The End of Human Dignity
This debate is not new. In Twilight of the Gods (1889), Friedrich Nietzsche declared (in a chapter called "A Moral for Doctors"):
The sick man is a parasite of society. In certain cases, it is indecent to go on living. To continue to vegetate in a state of cowardly dependence . . . once the meaning of life, the right to life has been lost, ought to be regarded with the greatest contempt by society. Doctors, for their part, should be agents for imparting this contempt. They should no longer prepare prescription, but should every day administer a fresh dose of disgust to their patients. A new responsibility should be created, that of the doctor—the responsibility of ruthlessly suppressing and eliminating degenerate life.8
Will Nietzsche's ominous prophecy become a standard for health care in our new century? One certainly hears a Nietzschean echo in the 1996 decision, written for a federal appellate court majority by Judge Stephen Reinhardt, striking down the state of Washington's law against assisted suicide: "A competent, terminally ill adult, having lived nearly the full measure of life, has a strong liberty interest in choosing a dignified and humane death, rather than being reduced at the end of his existence, to a childlike state of helplessness, diapered, sedated, incontinent."9
Wherein lies the dignity or value of a human being? We increasingly answer such questions by referring either to a subjective state of mind ("I have dignity if I feel I have it") or to the results of some extrinsic standard of measurement ("I have value or dignity because I got a raise or because I am not incontinent"). But when human worth is reduced to mere subjective attitude or external performance, no one is valued any longer for his or her own sake. If Reinhardt is right, then none of us has intrinsic dignity.
This odd forgetfulness, this repression of our inherent, inalienable value as persons, is a complete break with the Judeo-Christian tradition (as well as with Islamic law)—and especially with the very vocation of Catholic health care. But then the Judeo-Christian tradition is precisely what Singer is talking about when he says it should be abandoned and replaced by the values of utility.
Consider end-of-life decisions, for example. To believe in the inherent dignity of a dying—and thus profoundly wounded—person is not to presume that all therapies must be undertaken in his or her behalf, or that none may be withdrawn. Ironically enough, it is the very fear of woundedness that often drives people to prolong their own or others' dying. What the dying need most is neither prolongation of their suffering nor even an end to it, but rather acceptance of themselves as persons, because this acceptance is healing.
What the dying do not need is "physician-assisted suicide." The deliberate killing of a patient—even with his or her consent—carries with it a deeper wound than that borne by the sufferer. It is a cutting into the heart of ethics itself, an assertion that human vulnerability, our very condition as embodied persons, is degrading and undignified. A community that truly values the intrinsic dignity of persons does not kill its sufferers. Instead, it alleviates the suffering and affirms the sufferer's goodness. As far as we in Catholic health care are concerned, no patient can have an illness so severe or so "degenerate" as to be robbed by it of his or her intrinsic value. And we reject the deliberate killing of damaged persons because it betrays that value.
The Meaning of Being Human
Underlying the debate about dignity, value, and performance is an old question: Who gets to define what a human person is? History is replete with the attempts of one group of people to bar others from "full" personhood. The poor, the uneducated, the racially different, the "enemy," the "unclean"—all at different times have qualified for noninclusion. Today human fetuses are described as "blobs of protoplasm" or "tissue"; criminals are "vermin"; profoundly damaged patients are "vegetables." The ancient habit of stripping certain people of their humanity continues.
But the truth is that any human person is an unfolding, developing, organic reality—a historical life, in which special endowments make possible the emergence of certain activities, among which are learning and loving. Many do not fulfill their potential, perhaps because of a lack of maturation or opportunity. Many others can no longer fulfill their potential because of trauma or simple aging. But they are still persons, even though unfulfilled or injured. Theorists like Singer fail to see this because they make a fundamental mistake. They identify personal reality with the performance of activities. Our actions, however, only reveal our personal nature. They do not constitute it.
Human beings are not their mental states, performances, achievements, or activities—not even their expressive behavior or communication with others. These do indeed fulfill us as persons, but they do not make us persons. Our performances are possible because we are embodied persons who can act in quite wonderful ways. We are beings who, possessing certain latent endowments that make us persons, are capable of informed consent and autonomous choice. It is only because there are persons in the world that there is autonomy, or ethics, at all.
We are personal lives, from the moment our lives begin. At that moment, we are not "potential" persons, but persons with potential. If we fail to perform well—because of lack of development, education, or opportunity—we are then unfulfilled persons, but persons nonetheless. If we happen to be afflicted with Alzheimer's disease, we are not for that reason "marginal persons" but wounded ones, unable to express our personhood, unable to perform as others might.
Chimpanzees, for example, can perform more impressively than can babies or adults who are comatose. Chimps are non-personal animals expressing their endowments, often on splendid array. Babies and comatose adults, however, have personal endowments, albeit unrealized and unexpressed. We humans are always much more than any particular stage of our development, than any achievement or any loss. We are living, developing beings, open always to more life, open always to death.
Four-year-old Helen Keller, both blind and deaf, "performed" more poorly than most pets. Presumably destined to spend her life in institutions, she was saved by the intervention of Annie Sullivan and the language of touch. But even before she met Sullivan, Keller was a human being with personal capacities, not a potential person. Sullivan's healing powers did not bestow on Keller the endowments of personhood. The therapist recognized and unlocked the inherent dignity that had, until then, gone unseen.
Human beings are indeed—as Singer, Pluhar, and others insist—animals. But we are animals with unique endowments. Singer and Pluhar, denying our special powers, equate us with animals. Other thinkers, denying our essential animality, find our dignity as persons incompatible with our fleshly and temporal frailty. I believe that disgust at our very animality is, oddly enough, at the root of our willingness to disassociate ourselves from our earliest stages of development, and also from the most diminished, dependent aspects of our dying.
The Wound of Humanity
People today have a great ambivalence about themselves as embodied persons. We tend to fear and reject our animality—our bodies, our developmental lives, our dependence on each other and the Earth—because that reminds us we are imperfect creatures who ultimately die. This tendency can be seen in a number of apparently disparate phenomena.
Undesirable Down Syndrome In 1990, Joycelyn Elders, then Arkansas's health director, told a congressional committee that the legalization of abortion was good because it had reduced the number of children born with severe defects. "The number of Down's Syndrome infants in Washington state in 1976 was 64 percent lower than it would have been without legal abortion," she said.10 A 1990 study of 22,000 Canadian women who had received a prenatal diagnosis revealed that 88 percent of those pregnant with a Down syndrome pregnancy aborted the fetus.11
The aborting of such pregnancies is clearly, no matter what the motives, the elimination of damaged or incomplete human beings—a choice that an increasing number of ethicists, scientists, and philosophers recommend, even after birth.
Down syndrome itself is a genetic anomaly that may some day be corrected before fetal life even begins. Most of us would celebrate such an advance. But are we sure that the world would be better without Down syndrome people? I am not.
Desirable DNA Earlier this year, an advertisement in Ivy League newspapers offered $50,000 for donor ova for "assisted reproduction." The donor, the ad said, must be blonde and 5 foot 9 inches tall and have an IQ of 140. Of course, men and women have for centuries tried interbreeding, in hope of producing children with certain positive traits. Today, however, with the availability of genetic testing, we are more likely to seek the elimination of negative ones: a proclivity for violence, for example, or alcohol addiction, color blindness, Down syndrome, or depression.
But how can we be sure that such traits are in fact negative? I happen to be color blind, for instance; I also have pretty good pitch. Could there be a connection between the two traits, one "positive" and one "negative"? And who, after all, is to define positive and negative? Might not some apparent disability turn out to be of use to the world?
Bothersome Bodies Medical science can now reconstruct the bodies we were born with. In fact, it is quite a lucrative enterprise. In a 1998 Frontline program on the Public Broadcasting System (PBS), a surgeon confessed that he had ceased performing reconstructive surgery on children with birth defects because he could make more money doing liposuctions, face-lifts, and breast augmentations on adults.12 Here again we are dealing with presumably embarrassing human traits. But what, ultimately, is the trait we would most love to alter. Is it not the body itself? Is it not our mortality?
We are entering a century during which we may change the very meaning of what we are as personal animals, as embodied spiritual beings. Bill Joy, the founder and guru of Sun Microsystems, predicted in the April issue of Wired magazine that advancements in genetics, molecular technology, and micro-robotics will make possible not only the refashioning but the casting off of our woundable bodies.13
Why not trade our flesh and bones for silicon, if that enables us to live for 200 years? Some philosophers imagine "downloading" the entire content of human experience into a computer that will never wound or scar. As machines we could avoid suffering the fate of our shameful animality. We would not have to endure the disfigurement of our bodies or bear the cross of our incarnate, fleshy spirit, which—though we be like gods in intellect—reminds us that we must die.
I am not a Luddite in these matters. I am grateful for the gains that genetic therapy, genetic diagnosis, and even molecular electronics offer us. Even so, I am forced to ask: What is behind it all?
The Fright of Our Fragility
It is, I suspect, our fear of death that both drives us irrationally and impersonally to prolong dying and, at the same time, to control it, so as to avoid experiencing our own dependency and need for others.
Christianity invites us to take our bodies seriously. We Christians celebrate conceptions, births, marriages, and, yes, our woundedness and our deaths as well. We are fully aware that once we were fetuses and will, on another day, be dying bodies. Our relationship to our bodies is problematic, and the difficulty lies in our animality. Both birth and death signal our ultimate lack of control over our existence, and so we seek to control or to deny both events. "I never was a dependent, needy fetus or an infant that needed to be fed or cleaned," we try to tell ourselves. "I never will be a dependent, needy old person, relying on others to nurture me, to clean me." This is our terrible fear, the fear of our mortality.
The protagonist of Tolstoy's The Death of Ivan Ilyich is the perfect exemplar of our fear of death. Ilyich can comprehend the death of other people, but not his own. In unguarded moments, however, death creeps unavoidably into his thoughts.
He could not understand it; and he endeavored to put away this thought as false, unjust, unwholesome, and to supplant it with other thoughts true and wholesome. But this thought, not merely as a thought, but, as it were, a reality, kept recurring and taking form before him . . . . And he summoned in place of this thought other thoughts, one after the other, in the hope of finding succor in them. He strove to return to his former course of reasoning, which hid him of old the thought of death.14
Fear of death drives what Daniel Callahan calls the "troubled dream of life," wherein we attempt to deny the reality of death, clinging instead to illusions of control and mastery.15 This fear drives the decisions so many of us make—encouraged to do so by the availability of ever more astonishing technology—to prolong our dying rather than accept it and enter it with care and hope. The fear drives our anxieties about helplessness and dependency.
We are haunted by our animality. We would prefer to be wholly identified with our brains, with the brain's "higher" state and its more elegant and controlled expressions. But we human persons are more than mind. We are incarnate, fleshly beings. Our brains themselves, so marvelous in operation, look like embarrassing mounds of meat.
Sooner or later, our animality forces us to embrace our creaturehood, our needs and neediness. The shock of our enfleshed condition jolts us, like Ilyich, into self-confrontation. Rather than induce panic or self-rejection, however, such moments of recognition beckon us to accept our truth, love ourselves as we really are, and finally be healed.
What, then, is it that needs healing? What is it that is sick, diseased, dying? Is it not the way we try to deal with our woundedness? Is it not our very disgust with our creatureliness that needs healing? And might it be only the wounded who—because their frailty cannot fit the American dream of control, performance, and success; because their frailty reminds us of our own—can heal us?
There is great resistance to this question. A 1993 PBS broadcast of The Health Quarterly concerned legal euthanasia in Holland. In one case, a man afflicted with AIDS has decided he wishes to die. The decision discomfits the treating physician, and the patient notes his reaction, asking, "Is this difficult for you?" "No," the doctor replies, "I've had three others." But when talking to colleagues, the physician admits that he does indeed have great difficulty controlling his anguish in performing euthanasia. In a second case, a retired professor apparently in the early stages of Alzheimer's is asked whether he wants to die. "No," he says, "but I see no reason to go on living."16
Watching such exchanges is excruciating. In the first instance, the doctor cannot admit even to himself that assisting in suicide is personally painful for him. In the second, a lonely old man is clearly seeking a bit of human warmth from his physician, whose "professionalism" will not allow him to respond in a warm way. The two patients are studies in depression. Both obviously hunger for someone who cares enough to urge them to go on living. Such is the harrowing reality of authentic relationship. Such is our fear of anything beyond our control, especially death.
In an essay called "Hospice: A Prophetic Moment," the physician Sheila Cassidy recounts with uncommon honesty her own transition from "professionalism" to the care and comforting of people whom Nietzsche would have described as "degenerate life":
It is difficult to explain the love-hate relationships we have with those specters at the feast of life, gaunt figures with their tissues and their vomit bowls, oblivious to the appalling stench from their foul necrotic tumors. We are not immune to the smell of decaying flesh, and, like anyone, we long to escape to where the air is pure. And yet, cohabiting peacefully with our distaste, is a real love for these broken people. People mutter: "How awful! If it were a dog, you'd have it put down." But then, [the patient] is not a dog, but a man with cancer in his mouth, who is living out his last precarious days, loved and cherished in a way that he has never known before. It is in this lavishing of love on patients that the hospice movement stands in a prophetic relationship to society at large, for it affirms the value of the brain-damaged, the mutilated and the old to a world which values the clever, the physically beautiful and the athletic.17
It is what Cassidy calls the "love-hate" quality of such relationships that makes them so poignant. The sight of a broken body reminds us of the shame we feel concerning our own bodies—because they are woundable, subject to infirmity, powerless before time. That reminder is capable of generating the most profound of hates and fears, such as Nietzsche's. But it is also capable of evoking our strongest courage and deepest love.
Authentic Healing of the Person
What needs to be healed—both in ourselves as individuals and in our national culture—is our terrible sense of shame over our vulnerability, our wounded sense of personal dignity. "Marginal" people, whom so many would like to eliminate (or at least forget), remind us of who and what we are. The physically, psychologically, and economically afflicted invade our comfort, and we want to flee from them. In refusing to attend to the wounded and marginal, however, we reject our own humanity.
This brings us, at last, to the prophetic role of the Catholic health ministry, which, as I understand it, has two, inextricably connected aspects:
- To act as a voice for the voiceless, the marginal, Nietzsche's "degenerate humanity"
- To provide true healing for all the wounded
Catholic health care providers sometimes feel themselves to be on the defensive, primarily because of their opposition to abortion and assisted suicide. The forces favoring both measures are increasingly strong in our culture—so strong that I can imagine a future in which Catholic facilities are known as "places where they don't kill you just because you are unwanted." That could well occur if the thinking represented by Peter Singer and his sympathizers becomes culturally dominant.
But health care of that sort could provide only false healing. It would, as Leon Kass, MD, suggests, amount to trying to eliminate the source of our wounds by eliminating the wounded among us.18 It would deprive the dying patient of the only experience that can heal even death itself, God's love as expressed through human contact, affection, and care.
True healing is the healing mission of Jesus, the word made flesh. Through it, God enters our humanity so as to transform our wounds. When we flee from the wounds of our brothers and sisters, from the fact of woundedness, we reject our very humanity. The Canadian philosopher Charles Taylor gently chides some contemporary philosophers (whom he calls "naturalist humanists") for their shortsightedness:
Is the naturalist affirmation conditional on a vision of human nature in the fullness of its health and strength? Does it move us to extend help to the irremediably broken, such as the mentally handicapped, those dying without dignity, fetuses with genetic defects? Perhaps one might judge that it doesn't and that this is a point in their favor; perhaps effort shouldn't be wasted on these unpromising cases. But the careers of Mother Teresa or Jean Vanier seem to point to a different pattern, emerging from a Christian spirituality. I am obviously not neutral in posing these questions . . . . I do think naturalist humanism defective in these respects.19
Taylor suggests that if we expose our hearts and intellects to "the damaged," "the handicapped," and "the defective," they may reveal to us the deepest truths of our being. For what is defective in them serves to remind us of the contingency that is one with our frail embodiment as persons. What we lose by ignoring them may be nothing less than the power of our humanity to call forth and bestow love.
In the Manner of Jesus
A discussion of this kind can seem abstract. But it certainly is not. Talk about healing always reminds me of my late friend, Sr. Ann Manganaro, SL, MD.
Sr. Ann, a physician, teacher, and the founder of several small health care organizations in Central America, died in St. Louis at age 47. Bereft of her great skill and her lovely appearance, she was reduced in her last days to receiving care from others.
"I finally understand the wounds," Sr. Ann told a friend at that time.
"Your wounds?" the friend asked, for Sr. Ann had undergone a mastectomy when she was first found to have cancer. "No," she replied.
"The wounds of El Salvador?" the friend persisted. Sr. Ann had often performed emergency surgery in that country during its civil war.
"No," she answered. "I mean the wounds of humanity, the wounds of us all."
Ann Manganaro was a woman of the Gospels. As we know from the resurrection narratives, St. Thomas was scandalized by the terrible reality of Jesus' wounds—they blocked his faith and his hope. It was for that reason that, when the risen Lord came to him, Jesus said only, "Enter the wounds."
Like St. Thomas, we are all called to acknowledge not only the wounds of the Lord but also the wounds of our own humanity. We must not repress the memory of what we truly are. We must love our wounds. If we love them, they will never disgrace or degrade us. They will be our glory.
As a teaching resident physician, Sr. Ann had spent a good deal of her time in the neonatal intensive care unit with Tamika, a tiny, family-less girl who had been born prematurely. When Tamika died, six weeks after she was born, only Sr. Ann, the funeral director, and I attended the wake. I was desolated and angry. "This poor baby," I complained. "She had no family, no real funeral; she never had a day unplugged from tubes and shunts, never a day of breathing on her own; her life was meaningless."
But Ann disagreed. "You are forgetting that Tamika had the power to evoke my love."
And so, when Ann herself came to die, just a few years later, she finally came to share with little Tamika only the power to evoke our love, nothing else. In her dying as in her living, she learned, as we all must, that the wound of our humanity is never repressed or denied. But it can be transformed and made into something of glory.20
Fr. Kavanaugh is professor of philosophy, Saint Louis University, St. Louis, and the author of Who Count as Persons? Human Identity and the Ethics of Killing, forthcoming from the Georgetown University Press.
NOTES
1. Peter Singer, Rethinking Life and Death: The Collapse of our Traditional Ethics, St. Martins, New York City, 1994, p. 4; italics added.
2. Singer, p. 182.
3. Evelyn Pluhar, Beyond Prejudice: The Moral Significance of Human and Nonhuman Animals, Duke University Press, Durham, NC, 1985, pp. 77-81.
4. Pluhar, p. 83.
5. Mary Ann Warren, "Postscript on Infanticide," in Louis Pojman, ed., Life and Death, Jones and Bartlett Publishers, Boston, 1993, pp. 311-312.
6. On June 28, 2000, the U.S. Supreme Court, by a 5-4 vote, struck down a Nebraska law forbidding the procedure. But the debate goes on.
7. Life, December 1999, p. 114.
8. Friedrich Nietzsche, The Philosophy of Nietzsche, Geoffrey Clive, ed., Mentor, New York City, 1965, p. 425.
9. Compassion in Dying v. State of Washington, 79 F. 3d 790, Ninth Circuit Court (1996).
10. Quoted in Tucker Carlson, "Eugenics, American Style," The Weekly Standard, December 2, 1996, p. 20.
11. Tucker Carlson.
12. "The High Price of Health," produced by Rachel Dretzin, Frontline, April 14, 1998.
13. Bill Joy, "Why the Future Doesn't Need Us," Wired, electronic edition (wired.com), April 2000.
14. Leo Tolstoy, The Death of Ivan Ilyitch and Other Stories, Almayer Maude, trans., New American Library, New York City, 1960, pp. 132-133.
15. Daniel Callahan, The Troubled Dream of Life, Simon & Schuster, New York City, 1993.
16. "Choosing Death," The Health Quarterly, March 23, 1993.
17. Sheila Cassidy, "Hospice: A Prophetic Moment," in Stanislaus Kennedy, ed., Spiritual Journeys, Veritas, Dublin, Ireland, 1997, p. 163.
18. An extended, if somewhat early, version of Kass's humane vision of medicine can be found in Toward a More Natural Science (Free Press, New York City, 1985). See especially chapter 8, "Thinking about the Body."
19. Charles Taylor, Sources of the Self, Harvard University Press, Cambridge, MA, 1989, p. 518.
20. The anecdotes about Sr. Ann, as well as some of the ideas, themes, and examples used in this article, have previously appeared in different form in the "Ethics Notebook" column of America magazine. Fuller discussions of "intrinsic human value" and acceptance of vulnerability will be found in two chapters of my book, Who Count as Persons? Human Identity and the Ethics of Killing, forthcoming from Georgetown University Press.
Copyright © 2000 by the Catholic Health Association of the United States
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