[Paleopsych] Hedgehog: Jonathan B. Imber: Twilight of the Prosthetic Gods: Medical Technology and Trust

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Jonathan B. Imber: Twilight of the Prosthetic Gods: Medical Technology and Trust
The Hedgehog Review - Institute for Advanced Studies in Culture

           Jonathan B. Imber is Class of code 1949 /code Professor in
     Ethics and Professor of Sociology at Wellesley College. Formerly
     editor of The American Sociologist, he has been editor-in-chief of
     Society since 1997. He is a former fellow of the Woodrow Wilson
     International Center for Scholars in Washington, D.C. His books
     include: Trusting Doctors: The Decline of Moral Authority in American
     Medicine (forthcoming); The Feeling Intellect: Selected Writings of
     Philip Rieff (1990); and Abortion and the Private Practice of Medicine

           It was Sigmund Freud's lamentation about happiness in
     Civilization and Its Discontents that introduced the idea of a
     prosthetic God:

       Man has, as it were, become a kind of prosthetic God. When he puts
       on all his auxiliary organs he is truly magnificent; but those
       organs have not grown on to him and they still give him much
       trouble at times. Nevertheless, he is entitled to console himself
       with the thought that this development will not come to an end
       precisely with the year code 1930 /code a.d. Future ages will bring
       with them new and probably unimaginably great advances in this
       field of civilization and will increase man's likeness to God still
       more. But in the interests of our investigations, we will not
       forget that present-day man does not feel happy in his Godlike
       character. [3]^1

           The unhappiness to which Freud refers may be about mortality
     itself, but it may also be about how extensively the "Godlike
     character" of human beings, and the technology that makes it possible,
     is associated with what is meant by happiness.

           For the past half century, the material progress of medicine has
     given rise to two types of debates about technology and the human
     person: one has to do with the limits of such progress, the other with
     the autonomy of those who are subject to it. In this essay I will
     argue that these two debates are, in reality, reflections of one
     enduring problem about the nature of trust in persons and, in
     particular, "corporate" persons, that is, professionals. The
     significance of technology in relation to this problem of trust arises
     not so much in the nature of technology itself but in its application
     to problems that arise as a result of confrontations with disease and

Autonomy and the End of Life

           Surely Friedrich Nietzsche's moral code for physicians
     establishes one basis for understanding the cultural meaning of
     autonomy as it has come to take its place in modern life:

       A Moral Code for Physicians.--The invalid is a parasite on society.
       In a certain state it is indecent to go on living. To vegetate on
       in cowardly dependence on physicians and medicaments after the
       meaning of life, the right to life has been lost ought to entail
       the profound contempt of society. Physicians, in their turn, ought
       to be the communicators of this contempt--not prescriptions, but
       everyday a fresh dose of disgust with their patient.... To create a
       new responsibility, that of the physician, in all cases in which
       the highest interest of life, of ascending of life, demands the
       most ruthless suppression and sequestration of degenerating
       life--for example in determining the right to reproduce, the right
       to be born, the right to live.... To die proudly when it is no
       longer possible to live proudly. Death of one's own free choice,
       death at the proper time, with a clear head and with joyfulness,
       consummated in the midst of children and witnesses: so that an
       actual leave taking is possible while he who is still living is
       still there, likewise an actual evaluation of what has been desired
       and what achieved in life, an adding-up of life--all of this is in
       contrast to the pitiable and horrible comedy Christianity has made
       of the hour of death. [4]^2

           Nietzsche did not advocate a private dying; on the contrary he
     regarded the deliberate choice to end one's life as something to be
     "consummated in the midst of children and witnesses." Why children? I
     suppose for the purpose of impressing upon them from an early age the
     contempt for decrepitude that Nietzsche championed. Children do not
     easily and readily pay attention to adults; they are more often served
     by adult attention, especially today. It is entirely better in
     Nietzsche's view that they learn early on to forget about needing to
     attend to those who cannot give them attention. What better way than
     to witness suicide, perhaps regularly, and, even better, that kind of
     suicide we now call "assisted" at the skilled hands of physicians? If
     I read such autonomy correctly, it requires a corporate assent that
     includes family, friends, and friendly physicians. It is a socially
     and culturally defined autonomy of a particular kind.

           Nietzsche's idea of autonomy found resonance, of course, among
     Nazi ideologists, but the idea of having some sort of control over
     one's departure from life is not destined to be murderous. William
     Edward Hartpole Lecky (1838-1903), the Irish historian whose two
     works, History of Rationalism (1865) and History of European Morals
     (1869) established him as one of the major mediators between natural
     theology and modern rationalism in the nineteenth century, stated the
     dilemma less polemically than Nietzsche did:

       But the time must come when all the alternatives of life are sad,
       and the least sad is a speedy and painless end. When the eye has
       ceased to see and the ear to hear, when the mind has failed and all
       the friends of youth are gone, and the old man's life becomes a
       burden not only to himself but to those about him, it is far better
       that he should quit the scene. If a natural clinging to life, or a
       natural shrinking from death, prevents him from clearly realizing
       this, it is at least fully seen by all others. [5]^3

           Two notions of autonomy compete for our acceptance. On one
     side--which is our Nietzschean inheritance--we define liberty not only
     as freedom from others but also as freedom from ourselves, from that
     aspect of our bodily and mental capacities we wish to change in some
     way or another. This would not be especially troubling except for the
     specific kinds of choices such freedom offers. On the other
     side--which is represented by the cultural inheritances from our major
     religious traditions--we define the limits of our liberty as a way of
     determining our responsibilities to others and ourselves.

           We understand the recognition of the divide between personal
     liberty and social responsibility to be one of the enduring features
     and tensions of modernity. The "right" to kill oneself, in the same
     way as the "right" to abortion, has always struck me as peculiar to
     and indicative of the modern sensibility about how personal liberty
     and social responsibility go together. All of modern public health is
     a testament to this sensibility, one in which the ancient motivations
     of shame and guilt have been recycled into the modern motivations of
     self-improvement and self-convenience.

A Shift in Moral Sensibilities

           In his chapter on "Saintliness" in The Varieties of Religious
     Experience, William James remarked:

       A strange moral transformation has within the past century swept
       over our Western world. We no longer think that we are called on to
       face physical pain with equanimity. It is not expected of a man
       that he should either endure it or inflict much of it, and to
       listen to the recital of cases of it makes our flesh creep morally
       as well as physically. The way in which our ancestors looked upon
       pain as an eternal ingredient of the world's order, and both caused
       and suffered it as a matter-of-course portion of their day's work,
       fills us with amazement. [6]^4

           The "strange moral transformation" that James described paved
     the way to our present circumstances in which the endurance of pain is
     unacceptable except as we may choose to endure it. The ever louder
     cultural protest has been, for at least a hundred years, against the
     blind acceptance of any inevitability about the human condition,
     including how we depart this life.

           What has happened in the course of truly great achievements in
     the history of public health and of modern medicine is that larger
     numbers of our fellow human beings are conscious that only one thing
     yet remains unavoidable, that final relieving of anxiety, which our
     more refined anxieties obviously anticipate. This is why James' remark
     about the strange moral transformation marks a cultural turning point
     in what the quest for health and well-being means in an era when only
     death, if not disease, seems defiant of rational apprehension. Genetic
     determinants of illness will be, I expect, for some time to come
     reflected in public opinion as something akin to bad luck. But even
     this will change, perhaps in some series of dramatic breakthroughs,
     leaving us with the following sense of fate: only the accident of
     consciousness (or what was once put philosophically and sociologically
     as the "accident of birth" [7]^5 ) and accidents themselves (now high
     on the list of causes of mortality in those under fifty years of age)
     will not yield to complete invention or prevention.

           What demographers have pointed out for some time is that with
     the decline in birthrates, helped by the decline in infant mortality,
     and with the steady increase in longevity, due to a steady improvement
     in public health measures and medicine over the same time, we have
     created a world in some places, certainly not all, where individual
     health and wellness are not only indirect benefits of centuries-long
     scientific and technological progress but have also become intense
     sources of investment, anxiety, and expense.

           In recent years, expenditures on healthcare in the United States
     have reached around 14% of the gross domestic product, or
     approximately $ code 4,390 /code per capita. When compared to the
     percentage of GDP spent on healthcare in the United Kingdom, the
     number is about half. The significant point of comparison, however, is
     that the United States and England have comparable figures with
     respect to morbidity and mortality rates, longevity, and other
     principal measures of health and well-being.

           For most analysts of public health, and in particular,
     economists, such a comparison is the equivalent of exposing not only
     inefficiency but immorality. Otherwise insistent about the imperatives
     of the rational actor, more than a few economists over much of the
     past century have never been entirely persuaded that the medical
     profession is anything other than, to use George Bernard Shaw's
     memorable remark, a conspiracy against the laity. Of course, Shaw was
     condemning the medical profession's concealment of malpractice, but he
     meant to convey that all professions, including the profession of
     economics, are "conspiracies against the laity." It would be better to
     look beyond this remark to his even more powerful summation of the
     situation: "Invited to contribute a series of articles in a Manchester
     paper in reply to the question, `Have We Lost Faith?' Mr George
     Bernard Shaw gives his answer in this single sentence: `Certainly not;
     but we have transferred it from God to the General Medical Council.'"

           Shaw's humor, the truth of which we recognize more clearly today
     perhaps than readers did a century ago, had more to say about doctors
     than about patients, who are, I think, equally deserving of being
     reminded that when physicians profitably acquiesce to requests for
     more examinations and tests, we see that the road to wellness has also
     been paved with better intentions than either astute economists or
     complaining patients are necessarily ready to acknowledge. The fact
     that the United States leads the world in the consumption of
     healthcare resources may have less to do with the nature of medical
     practice than with the remarkable convergence of science, technology,
     faith, and affluence that serve to inspire American complaints about
     everything to a finer degree than is possible anywhere else. To be
     exquisitely anxious is a kind of cultural resignation to the absence
     of more immediate and momentous problems that have beset so much of
     humanity for so long.

           There is something wonderful about this kind of progress and
     wonderfully empty, as Freud lamented in his observations about
     "prosthetic Gods" in Civilization and Its Discontents. [9]^7 The goal
     of complete prosthetic replacement parallels the obsessive avoidance
     of all that may imperil us. The logic of such developments,
     sociologists and anthropologists long ago recognized, defines the
     nature of institutions in which those aspects of individuality,
     including the individual himself, are necessarily dispensable. No
     individual is an institution, at least not for long. Freud recognized
     that discontents were not principally based on the organization of our
     environment--although the central dogma of public health would so
     contend--except for that vast internal environment within each of us
     that is inaccessible to others and often to ourselves as well.

           The unintended consequence of living longer has been that we
     expect, indeed demand, that less happen to us in terms of adversity
     along the way. Such yearning for clear sailing is nothing new, and I
     am hesitant to call this being selfish or spoiled in some new way,
     because I think it represents a problem that was just as familiar to
     Plato in his Dialogues as it was to John Wesley and Cardinal Newman in
     their respective sermons on "The Danger of Riches." This problem for
     our time is that health and well-being, although quite understandably
     conceived of as material things, are something we either have or do
     not have in terms of blessings rather than rights. Newman, for
     example, knew that having such riches and putting our trust in them
     were two different things entirely. The trust, as he and many others
     after him have observed, is misplaced, a sight lower, as it were than
     where such trust should be placed. But this is our fate after the
     backdrop of heaven and hell has fallen away and in its place we put
     our trust in physicians, in their science and their technologies. The
     intensity of distrust in doctors, I would contend, is in fact evidence
     of the demand for trust in things that we believe will keep us alive
     longer, if not forever.

William Osler and Public Trust in Doctors

           That public confidence in the motives and actions of doctors has
     never been thoroughly secure should not surprise us. What is
     interesting, quite apart from some expected frequency of deviance
     among those otherwise trusted in their medical vocation, is when
     ridicule is directed at the most distinguished rather than the least
     reputable. A spectacular, and thus revealing, instance occurred upon
     the occasion of William Osler's departure from the Johns Hopkins
     University in 1905. In my reading of such an incident, the
     illuminations of authority are most important to examine. It is the
     character of this authority in its personal and corporate
     manifestations that defines the nature of trust and directs our
     attention to those anxieties that such trust is intended to appease if
     not eliminate.

           Osler (1849-1919) is regarded as the doctor's doctor, and his
     name remains synonymous with humanistic medicine. He was in every
     sense an iconic figure, larger than life, and an embodiment of
     vocation and dedication. [10]^8 Osler's appointment at Hopkins as
     Professor of Medicine began in 1889, where he remained for sixteen
     years. He was instrumental in the founding and subsequent fame of the
     Medical School at Hopkins (which opened in 1893), and it was during
     this same time that his reputation and fame increased greatly. In
     1904, he accepted the Regius Professor of Medicine at Oxford and left
     Hopkins on May 15, 1905. [11]^9

           How and why was it, then, that for a brief period he was widely
     regarded as an advocate of forced retirement and euthanasia? Various
     analyses of the specific incident that led to the ridiculing of
     Osler's reputation have been written defensively. They blame
     journalists but take little notice of what the widespread upset may
     have revealed about the public's perception of doctors. The canonical
     account is given by Harvey Cushing in The Life of Sir William Osler.

           In preparing for his final address to his Hopkins' colleagues in
     February 1905, Osler selected the title "The Fixed Period," after
     Anthony Trollope's novel of the same name. The novel, published in
     code 1882 /code at the end of Trollope's life, is set in code 1980
     /code and recounts the imaginary country of Britannula where the
     citizens pass a law whose purpose is to rid themselves of the
     infirmities of old age by fixing an exact age when all people should
     be euthanized. The Fixed Period is narrated by the President of
     Britannula, John Neverbend, who writes his account while returning to
     England after his efforts to carry out the plans for a fixed period
     are prevented by British authorities. Neverbend's sincerity never
     wavers about the merit of fixing a time when a person, by virtue of
     age (in Britannula, 67), should give up his life, in effect, for the
     good of all. It would also be a death with dignity: "I had felt it to
     be essentially necessary so to maintain the dignity of the ceremony as
     to make it appear as unlike an execution as possible." [13]^11 The
     first candidate for "deposition" in a "college" where, after a year,
     he would be put to death is Neverbend's "almost dearest" friend,
     Gabriel Crasweller. The naming of the college, Necropolis, is a source
     of some debate, with Neverbend preferring "Aditus," while another
     proposes "Cremation Hall."

           Those around Neverbend, including his wife, are not convinced of
     the idea itself or that Crasweller's time has come in any case. Their
     resistance and reasons for it are thick with common sense and everyday
     experience, despite the euphemisms that abound about its being
     anything but an execution. Critics at the time described the novel as
     a jeu d'esprit. Robert Tracy concludes that it "is not a satire on
     Victorian England. It is instead--as the President's name suggests--a
     satire on the narrow-mindedness and the lack of human sympathy that
     characterize abstract reformers." [14]^12

           When Osler took Trollope's jeu d'esprit and tossed it merrily
     into American public notice in 1905, it did not occur to him that he
     was introducing a bit of British satire that Americans might take
     literally. Here is Osler:

       It is a very serious matter in our young universities to have all
       of the professors growing old at the same time. In some places,
       only an epidemic, a time limit, or an age limit can save the
       situation. I have two fixed ideas well known to my friends,
       harmless obsessions with which I sometimes bore them, but which
       have a direct bearing on this important problem. The first is the
       comparative uselessness above forty years of age. This may seem
       shocking, and yet read aright the world's history bears out the
       statement.... The effective, moving, vitalizing work of the world
       is done between the ages of twenty-five and forty--these fifteen
       golden years of plenty, the anabolic or constructive period, in
       which there is always a balance in the mental bank and the credit
       is still good.... To modify an old saying, a man is sane morally at
       thirty, rich mentally at forty, wise spiritually at fifty--or never
       My second fixed idea is the uselessness of men above sixty years of
       age, and the incalculable benefit it would be in commercial,
       political and in professional life if, as a matter of course, men
       stopped work at this age. In his Biathanatos Donne tells us that by
       the laws of certain wise states sexagenarri were precipitated from
       a bridge, and in Rome men of that age were not admitted to the
       suffrage and they were called Depontani because the way to the
       senate was per pontem, and they from age were not permitted to come
       thither. In that charming novel, The Fixed Period, Anthony Trollope
       discusses the practical advantages in modern life of a return to
       this ancient usage, and the plot hinges upon the admirable scheme
       of a college into which at sixty men retired for a year of
       contemplation before a peaceful departure by chloroform. [15]^13
       That incalculable benefits might follow such a scheme is apparent
       to any one who, like myself, is nearing the limit, and who has made
       a careful study of the calamities which may befall men during the
       seventh and eighth decades.... Whether Anthony Trollope's
       suggestion of a college and chloroform should be carried out or not
       I have become a little dubious, as my own time is getting so short.

           The reactions in newspapers to Osler's address were thunderous,
     leading him to speak out in his own defense on the front page of The
     New York Times. Five days after his address, following numerous news
     reports with headlines such as "Useless at 40" and "Professor Osler
     Recommends all at code 60 /code to be Chloroformed," Osler responded:

       I have been so misquoted in the papers that I should like to make
       the following statement: "First--I did not say that men at sixty
       should be chloroformed; that was the point in the novel to which I
       referred, and on which the plot hinged. Second--Nothing in the
       criticisms have shaken my conviction that the telling work of the
       world has been done and is done by men under forty years of age.
       The exceptions which have been given only illustrate the rule.
       Thirdly--It would be for the general good if men at sixty were
       relieved from active work. We should miss the energies of some
       young-old men, but on the whole it would be of the greatest service
       to the sexagenarii themselves." [17]^15

           Osler's insistence that he was primarily misunderstood, and that
     Trollope's ideas were Trollope's and not his, allowed him to distance
     himself from the more hyperbolic claim that he endorsed the idea of
     literally disposing of the old. In the third edition of his deservedly
     famous book of essays Aequanimitas, Osler wrote from England:

       To one who had all his life been devoted to old men, it was not a
       little distressing to be placarded in a world-wide way as their
       sworn enemy, and to every man over sixty whose spirit I may have
       thus unwittingly bruised, I tender my heartfelt regrets. Let me
       add, however, that the discussion which followed my remarks has not
       changed, but has rather strengthened my belief that the real work
       of life is done before the fortieth year and that after the
       sixtieth year it would be best for the world and best for
       themselves if men rested from their labors. [18]^16

           It is impossible, from such a distance in time, to estimate the
     effects of Osler's remarks on the public, however much they may have
     been taken out of context. He rationalized, for example, that
     newspapers might have been having their own fun at his expense. Twelve
     days before his departure from America, The New York Times published a
     cartoon depicting old men coming out from hiding as Osler walks off in
     the distance. His impression that the papers did have some fun at his
     expense was not unreasonable.

           However, a few reports appeared of people committing suicide,
     their bodies found with news clippings of Osler's address nearby.
     [19]^17 His apology to "every man over sixty" and his continued
     insistence about the rightfulness of his views about aging raise an
     interesting problem about the role of professional advice--individual
     and corporate--especially in light of the association of reports of
     suicides with his remarks. It is entirely possible that a few older
     people took his words to heart, that is, they recognized the
     diminution of their own powers along with their social standing. Of
     course, Osler's was a social prescription, a vague statement of public
     policy, rather than a form of individual counsel. He failed to
     recognize the powerful connection in some minds between his authority
     as a physician with patients in his care and the meaning of his words
     outside that context to those not in his immediate care but who
     accepted his wisdom as a physician. In so failing, he illustrates one
     of the profoundest dilemmas of where to draw the line between personal
     responsibility and public good.

           Another problem emerges from this cautionary tale, in terms of
     the meaning of anecdotes and statistics. Osler based his social
     pronouncements on a literary text, a flight from a social reality
     which itself was captured, distorted, and missed in Trollope's
     imaginary musings. The missing part was reiterated in the newspapers
     in the form of examples of old people still vital and productive.
     Osler dismissed these examples as being exceptions to the rule, thus
     proving it. He never gave up his conviction that institutional
     mechanisms must be used to make room for the young in the pursuit of
     knowledge. He favored incentives to retire. The arguments he provoked
     have continued to inspire debates about retirement and euthanasia, two
     things lately that seem to have been separated in the public mind. But
     that retired physician, now imprisoned, Jack Kevorkian, whether or not
     he knows of Osler or Trollope, has called attention once again to the
     question of whose authority it is, in principle, to give and take away
     life. Appeals to a mix of anecdotal testimony and relentlessly
     gathered statistical overviews have put the matter of principle out of
     focus. Osler proposed a philosophical way of seeing that, like
     Trollope's, was contradicted in two ways: by the voice of experience
     and common sense and by the accumulating social-epidemiological
     evidence of continued vitality into old age. Nevertheless, he reminded
     that the principle of authority rises above the demands of experience
     and the facts of social science, for the betterment of both.

Control and the Absence of Certainty

           The example of Osler, in his personal authority as a physician,
     seems familiar to us but evermore at a distance--today the stakes
     appear higher in many respects, especially given the fact that the
     individual actions of physicians are exposed more for malpractice than
     celebrated for greatness. What we allow to be done or not to be done
     is no longer so consistently mediated by personal authority, and so
     looking for answers by looking for people to provide them may
     misconstrue how serious the stakes have become. But what is the
     alternative? Part of the absence of certainty about what is not to be
     done in particular arises from the hope of progress itself. Max Weber,
     in such formulations as "the disenchantment of the world" and "the
     rationalization of the world," envisioned a cold, brisk wind blowing
     across Occidental ideas about the connection between hope and
     progress. Progress proceeds, as it were, with neither a sense of
     divine intervention nor implication.

           Among his most brilliant insights, C. S. Lewis observed that
     when the apostles preached to the pagans, the pagans had and feared
     their gods, even as we have so many who doubt even that one exists.
     The pagan fear was about a choice among divine powers, whereas ours is
     a fear that no power is decisive. The religious mission has become
     doubly difficult because the laity has to be persuaded that it
     actually possesses a spiritual condition before it can be offered a
     cure, whatever that cure may be. Such was the older meaning of hope in
     the hope of progress. Torn from any number of spiritual moorings, this
     hope is now a will to power, at which complaints for over a century
     have been directed. Unfortunately these complaints have not succeeded
     in changing the character of this progress. The Weberian imperative of
     a science and technology projecting onto the world a vision of control
     of that world gives no indication of any kind of mediating authority
     about who is in control other than who succeeds at being in control.

           Taking control of your life, as the therapeutic prescription now
     requires, means trusting in others only to the extent absolutely
     necessary, and no more. Perhaps this shallowness of trust is inversely
     related to the intensity of our disappointments. At the center of this
     control, from opposite ends of the continuum of life, abortion and
     physician-assisted suicide, both employing relatively simple
     technologies, are manifestations of the shallowness of trust and the
     bitter heart of disappointment. But they are the pre-conditions for
     much of the prosthetic technologies and subsequent hopes that have
     followed for the individual. In a collectivist sense, the era of
     social engineering gave tyrants a license to imagine themselves as
     prosthetic gods. Perhaps the next utopian idea after the repudiation
     of collectivism will come to be seen as the complete exercise of
     "private" control over human beings in their removal from the world.
     Both abortion and physician-assisted suicide are the private
     abandonment of hope for and beyond this life. They are constantly
     heralded as public rights against which any resistance, however
     construed, is called infringement. But an enormous cultural inversion
     has taken place, since what is now perceived of as an infringement, at
     least in moral terms, was once regarded as protection based on a
     general prohibition against the taking of life.

           Some years ago in one of the many iterations of debate over the
     "right" to die, I came across the following three sentences in a
     letter to The New York Times:

       I prefer to die without being able to ask for a doctor to help me
       kill myself. Come the time, I will not even want to think about
       that. I surely will not want the people around me thinking I should
       be thinking about that. [20]^18

           This observation made by Mr. Julius B. Poppinga in code 1994
     /code clearly stands in stark contrast to the pronouncements of
     secular elites who are central to envisioning and thus promoting a
     world in which the pain of living may be as much a pain to others as
     it is to the person in pain. Mr. Poppinga, an attorney and an elder of
     Grace Presbyterian Church in Montclair, New Jersey, suggested a
     plausible alternative to Nietzsche's proposed solution of 1889: the
     "that" in his plea ("I surely will not want the people around me
     thinking I should be thinking about that") is a form of double
     forgetting, a double not thinking about "that." Mr. Poppinga was
     asking not only that he not have to consider the subject of
     physician-assisted suicide "come the time" but also that he not have
     to think about such an "option" as something on the minds of others
     "around" him.

           The term "around," as in "I surely will not want the people
     around me thinking," defines the social context, that is, the role of
     the will of others, in this kind of double-forgetting. A cultural
     repression is a form of prohibition that exists prior to consciousness
     and its deliberations. In this case the idea of physician-assisted
     suicide would be repressed both as something that one would consider
     for oneself and as something that one would know others would expect
     one to consider. Individual "autonomy" is presently credited as the
     source and arbiter of thinking about physician-assisted suicide. Yet
     such a widely debated expectation should be seen as the failing of a
     cultural repression that was once sufficient in its capacity to judge
     the individual consideration of all suicide to be a kind of
     self-doubt, a failure on the part of the individual. The next step in
     a failing cultural repression is the replacement of that self-doubt
     with collective affirmation that such self-doubt is instead a species
     of self-control.

           In the case of assisted suicide, the failing cultural repression
     does not, by the fiction of autonomy or by the collective indifference
     to suffering, necessarily lead to a widespread practice of euthanasia.
     This would require a wholly different degree of public coercion.
     Instead, an uneasy balance exists between those who are intent on
     hastening their own deaths by active intervention and those who
     acknowledge that pain, as William James observed, does not have to be
     endured for its own sake. This must be seen as a vast improvement,
     leading to more attentive hospice care, for example. In democratic
     societies especially, the resistance to shifting this balance too far
     in the direction of support for assisted suicide is likely to remain
     fairly strong, thus avoiding a broad transformation in the social
     patterns of how we die.


           In contemporary debates about the corruptions of the medical
     profession, the harshest criticisms have been aimed at the
     entrepreneurs of managed care and for-profit medicine. They certainly
     have something to answer for, although it seems that patient
     satisfaction in general has not suffered as much as some critics would
     like to contend. Various social and intellectual movements, in and
     around medicine, however, have diminished the status and importance of
     the individual practitioner in ways that have yet to be fully
     accounted for. Such practitioners operate, literally, in the twilight
     of moral sensibilities about the meaning of human life. When he
     examined comparable problems of physician authority twenty-five years
     ago in Ethics at the Edges of Life, the theologian Paul Ramsey

       [O]ur children and our children's children will not even have been
       cognizant of the fact they have journeyed on into the setting sun
       of Western law and morality, not seeing the shadows. We may even
       now be living "between the evenings" (a beautiful--and, I believe,
       Jewish--expression for "twilight"). That's the sum of it. [21]^19

     [22]^1 Sigmund Freud, Civilization and Its Discontents, The Standard
     Edition of the Complete Psychological Works of Sigmund Freud, Vol. XXI
     (1927-1931) (London: Hogarth, 1961) 90-1. ] [23]^2 Friedrich
     Nietzsche, Twilight of the Idols or How to Philosophize with a Hammer
     (New York: Penguin, 1968) 88. ] [24]^3 William Edward Hartpole Lecky,
     The Map of Life: Conduct and Character (London: Longmans, Green, 1899)
     340-1. ] [25]^4 William James, The Varieties of Religious Experience
     (Cambridge, MA: Harvard University Press, 1985) 239-40. ] [26]^5 See
     Herbert Spiegelberg, "`Accident of Birth': A Non-Utilitarian Motif in
     Mill's Philosophy," Journal of the History of Ideas code 22 /code
     (1961): 135-46. ] [27]^6 Bernard Shaw, Doctors' Delusions, Crude
     Criminology, and Sham Education (London: Constable, 1932) 1. ] [28]^7
     Exemplifications of such emptiness abound, represented in science
     fiction in such stories as Brian Aldiss's "Supertoys Last All Summer
     Long," the basis for Stanley Kubrick's final film, A.I. In real life,
     the family quarrel over the disposition of the remains of the
     legendary Ted Williams, whether put into cryogenic perpetuity or
     cremated, exemplified a pathos in which remembrance and preservation
     became hopelessly entangled. Along with cloning and artificial
     intelligence, the material extension of consciousness leaves open the
     question of its authority over others in each succeeding generation.
     See Leon Kass, "Mortality," Powers that Make Us Human: The Foundations
     of Medical Ethics, ed. Kenneth Vaux (Urbana: University of Illinois
     Press, 1985) 7-27. ] [29]^8 Osler's canonization as a medical saint
     has been assured in recent years by the publication of the proceedings
     of the American Osler Society. See Jeremiah A. Barondess, John P.
     McGovern, Charles G. Roland, eds., The Persisting Osler: Selected
     Transactions of the First Ten Years of the American Osler Society
     (Baltimore: University Park, 1985); and Jeremiah A. Barondess and
     Charles G. Roland, eds., The Persisting Osler II: Selected
     Transactions of the American Osler Society, code 1981-1990 /code
     (Malabar: Krieger, 1994). ] [30]^9 See W. Bruce Fye, M.D., "William
     Osler's Departure from North America: The Price of Success" in
     Barondess and Roland 245-57. ] [31]^10 Harvey Cushing, The Life of Sir
     William Osler (two vols.) (Oxford: Clarendon, 1925) 664-74. ] [32]^11
     Anthony Trollope, The Fixed Period (New York: Penguin, 1993) 39. ]
     [33]^12 Robert Tracy, Trollope's Later Novels (Berkeley: University of
     California Press, 1978) 287. See Donald Smalley, ed., Trollope: The
     Critical Heritage (London: Routledge & Kegan Paul, 1969) 487-92. ]
     [34]^13 In fact, Trollope's proposed means of departure in the novel
     was not chloroform: "As to the actual mode of transition, there had
     been many discussions held by the executive in President Square, and
     it had at last been decided that certain veins should be opened while
     the departing one should, under the influence of morphine, be gently
     entranced with a warm bath. I, as president of the empire, had agreed
     to use the lancet in the first two or three cases, thereby intending
     to increase the honors conferred" (39-40). ] [35]^14 William Osler,
     "The Fixed Period," Aequanimitas, With other Addresses to Medical
     Students, Nurses and Practitioners of Medicine, 3^rd ed.
     (Philadelphia: Blakiston's Sons, 1932) 381-3. ] [36]^15 The New York
     Times ( code 27 /code February 1905): 1. For accounts of this episode,
     see Henry R. Viets, "William Osler and `The Fixed Period,'" Bulletin
     of the History of Medicine code 36 /code (1962): 368-70; Steven L.
     Berk, MD, "Sir William Osler, Ageism, and `The Fixed Period': A Secret
     Revealed," in Barondess and Roland 297-301; Michael Bliss, William
     Osler: A Life in Medicine (New York: Oxford University Press, 1999)
     321-8. ] [37]^16 William Osler, preface, Aequanimitas, viii. An early
     biographer of Osler noted that his convictions about such matters were
     deeply self-referential, attributing their strength to his own early
     maturity. See Edith Gittings Reid, The Great Physician: A Short Life
     of Sir William Osler (London: Oxford University Press, 1931) 174-7. ]
     [38]^17 See David B. Hogan, "Sir William Osler: Fixed Terms, Fixed
     Ideas, and `Fixed Period,'" Annals of the Royal College of Physicians
     and Surgeons of Canada code 28.1 /code (February 1995): 25-9. ]
     [39]^18 Julius B. Poppinga, letter to the Editor, The New York Times (
     code 13 /code June 1994): A14. ] [40]^19 Paul Ramsey, Ethics at the
     Edges of Life: Medical and Legal Intersections (New Haven: Yale
     University Press, 1978) 42. ]

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