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Giving and Receiving: An Alternative Framework for Discerning the Good. Revisiting the Question of Physician-Assisted Suicide

John Kleinsman
Issue 24, April 2008

... a person does anything and everything he or she does only because that thing at least 'appears' to be good. Even when I choose something that I know is bad for myself, I nevertheless choose it under some aspect of good, i.e. as some kind of good. (McGee, 1999, http://www.aquinasonline.com/Topics/natlaw.html)

Introduction

We know only too well that people disagree over what is good. McGee's quote highlights the challenges that we as a society face when we start to debate the various ethical issues that confront us. When, for example, some argue in favour of physician-assisted suicide (PAS), and others argue against it, the proponents of both positions are articulating what they believe is good for people. Differences in opinions reflect differing perceptions of what is good and consequently lead to differing desires: differing world views are in competition with each other. Believing that they are each right, people want the freedom to choose to act on their convictions. But a society that allows personal conviction to become the acceptable standard of judgement undermines the notion of a common morality, leaving us with only an arbitrary or relative morality (moral relativism). The 'good' seems to be totally negotiable.

The Catholic moral tradition holds that a more critical approach is needed to determine the truth about what is good, one that questions the assumptions underlying different perceptions and desires. This will require deeper reflection on the nature of the human person to determine desires which are genuinely human in so far as they are consistent with our authentic human nature.

In his famous work Ethics, the German Lutheran pastor and theologian Dietrich Bonhoeffer offers the following insight about our search for what is good: "It is as creatures and not as creators that we enquire about the good" (1995, p. 211). How might his insight inform an alternative framework which could provide us with a fresh and illuminating perspective on the complex ethical issues associated with PAS?

Bonhoeffer continues: "We are not asking what is good in itself; but we are asking what, on the assumption that life is given, is good for us as living men. We are enquiring about good, not at all by abstracting from life, but by looking deeply into life" (emphasis added). It would seem, then, that a critical element in understanding what Bonhoeffer means by the term "creatures" is our recognition of the givenness of human life. Bonhoeffer's insight points towards a philosophy and theology of gift that takes proper account of the particular context and culture we find ourselves in.

The idea that life is a divine gift features prominently in the religious writings of the Judaeo-Christian tradition. In the opening verses of Genesis God is identified as creator of all that exists – heaven and earth, light and darkness and all living creatures including humankind.

The givenness of human life is also the concept underlying the case made by Brian Johnstone for an "ultimate framework within which we can understand human living" (2008, p. 81). Johnstone's framework is 'traditional' in that it acknowledges the proper starting point for Christian morality is a sense of thanksgiving for what God has done. It is 'novel' in offering a very different paradigm for describing the norms of right reason. In the next section I will outline Johnstone's approach before, in a final section, applying it to the question of physician-assisted suicide.

Developing a Philosophy and Theology of Gift – A Synthesis

In an article titled Moral Conscience and Christian Innovation: Elements for a Theological Reading Brian Johnstone describes the divine act of creation as the first and fundamental 'innovation' of God: an act that is totally gratuitous in that it originated in a choice God did not have to make. That is to say, our very existence is pure gift, based on an act of divine goodness. What does this tell us? "Reason thus understands being as given being and thus grasps the basic norms of reason as the norms of giving and receiving" (p. 73). In Johnstone's words, not only does God's gift of life make human existence and the human tradition of reason possible, it also shapes our reasoning. It is the 'givenness' of our life that forms the horizon of all human reasoning and becomes the fundamental guiding point for defining the nature of human life and what is good.

Belief in God as creator allows us to deduce, continues Johnstone, that if God gives being then God's nature is essentially defined by giving. This suggests that we should conceive of the divinity "not as thought thinking itself, but as giver giving the gift" (p. 74). What is more, God's nature as 'giver' has been further revealed in the historical giving of God's self in the Incarnation, an event that culminated in the self-giving of Jesus on the Cross and his subsequent Resurrection. Johnstone understands this as God's second fundamental 'innovation', "the testimony to which gives rise to the Christian tradition" (p.77). The absolutely gratuitous gift of God's self in Jesus and the absolutely gratuitous gift of the Spirit become the norm of truth (pp. 78-79).

Further, humankind, by virtue of having received the gift of life from God, comes to participate in the actuality of God's being, and thus "we become capable of giving to others" (p. 73). Because divine reason is characterised by giving, then human reason can grasp that the basic norms of human reason are likewise characterised by receiving and giving. Therefore, it follows that "[t]he criteria of right reason are developed within the framework of receiving and giving, this being the ultimate framework within which we can understand human living" (p. 81): "the way to truth is by following the norms of giving and receiving" (p. 78). In other words, we discover the meaning of 'truth' in the framework of gift and giving (p. 79). The original gift, and the other gifts by which human life is sustained and promoted, constitute what we call human tradition, "and the giving and receiving of these gifts through time constitute our 'historicity' ... historicity only makes sense in reference to the continuous giving and receiving that is tradition" (p. 74).

The relevance of this for our enquiry about the good now becomes clearer. Johnstone argues:

The norms of practical reason come to light in the acts of free, gratuitous giving and receiving of gifts that constitute tradition. The ideal moral act is the free gratuitous gift of oneself to the other, a gift that makes the other capable of free gratuitous gifts to others again, thus forming a 'chain reaction' of giving and receiving that forms human community in a process through time aimed at the goal of the ideal community of giving and receiving ... A process of practical reasoning is 'right reason' when it accords with the strictures of gift, that is, when it rightly discerns the genuine gift and allows its reception by the receiver, when it guides the receiver in integrating the gift and when it directs the giving on of the free gift to others (p. 75).

From this it becomes clear that the goals of human tradition must be directed towards the giving of gifts. This understanding of practical reasoning, in turn, defines the role of theoretical reasoning.

Theoretical reasoning then emerges to give meaning to this process [of practical reasoning]. A basic role of theoretical reason is to discern the nature of the human person and the genuine desires of the human person so as to be able to discover what would be a true gift for that person. (pp. 75-76, emphasis added).

Johnstone then concludes: "Thus we have a reasoned basis for judgements that some gifts are true gifts and that some acts of giving and receiving are right acts. They are so because they are acts of giving true gifts. It is in the context of the tradition and giving and receiving that the notion of truth appears" (p. 76). What is a true gift? It is "a gift that enables that other to become a giver of gifts to others and thus find fulfilment" (p. 76).

Drawing on philosophers of gift such as Derrida and Marion, Johnstone acknowledges that the ideal of a free gratuitous act is impossible given the fragility of human nature. This means that "our 'human' traditions ... can never be the expressions of a truly gratuitous giving, and will always include elements of self-seeking with the urge to dominate and control others for one's own sake" (p. 76). Therefore, "a genuine tradition must promote and sustain conversion in the form of personal conversion from the self-centred desire to dominate and in the tradition's being open to change so as to better promote its goals" (p.76). In particular the Christian and Catholic traditions must "reject any form of tradition that has been distorted so as to become an instrument of domination" (p. 76), domination and control being the antithesis of free and gratuitous giving. The Christian tradition:

... must be such as to stimulate and sustain continual conversion [moral growth]. Here conversion entails not only a break with all forms of self-serving and domination of others, but an abandonment of the self-sufficiency that would oppose the reception of God's gifts and that form of domination that would follow from an attempt to take over from God the role of giver of gifts (p. 78).

How might this framework be applied in practice? Johnstone (p. 79) offers six questions that should be asked when addressing a particular innovation or moral issue:

  1. Is the proposed innovation offered as a free gift that can be freely received?
  2. Can it be received in such a way as to enable the receiver to integrate that gift so as to become more fully a giver of gifts to others?
  3. Can it be received in such a way as to promote human community as a community of receiving and giving?
  4. Is it a genuine gift, and not a form of domination and control?
  5. Does it promote conversion and genuine transformation of the person and of the tradition by promoting more possibilities of giving and receiving and moving it closer to the ideal community, thus making it a more adequate symbol of the ideal community of the reign of God?
  6. Does it constitute a further step in the overcoming of evil, both physical evil and the spiritual evil of sin?

An Analysis of Physician-Assisted Suicide Drawing on the Framework of Receiving and Giving

The Catholic tradition is very clear in its rejection of all forms of assisted suicide. So why is there any need to analyse this issue from a different perspective? To quote again from Benedict XVI: "... every generation must also make its own contribution to establishing convincing structures of freedom and of good which can help the following generation as a guideline for the proper use of human freedom" (Spe Salvi, n. 25). Insofar as Johnstone argues that a philosophy and theology of gift can help explain the relationship between faith and reason (p. 81), and to the extent that reason itself is capable of discerning the fundamental norms of giving and receiving, it is hoped that the framework of giving and receiving will result in new common ground for meaningful dialogue between Christians and others on this and other key issues.

I believe that Johnstone's approach enables us to look at the issue of PAS in a fresh way. Accordingly, in this third section of this article, I will apply his framework to the question of physician-assisted suicide, here defined as the voluntary termination of one's own life by administering a lethal substance with the direct or indirect assistance of a physician. The question is how the framework outlined by Johnstone might help us to judge whether physician-assisted suicide is a genuine act of faith and a good moral act.

At a recent gathering a friend openly shared with me his feelings about his elderly and increasingly frail and dependant mother. He has slowly watched her 'quality of life' deteriorate as she becomes less and less able to do the things that have sustained her and given her life meaning. The experience of seeing her frustration and suffering has left him feeling powerless and frustrated, both for his mother and for himself. He openly expressed his regret to me that PAS was not legal in New Zealand. "A person should be able to choose when they end their life – if there is no longer any point to being around then why should they not be able to go when they choose? Why wait until all dignity is gone?" Interestingly, my friend was adamant that neither he nor his brother would want to administer the lethal substance. How do we as individuals and as a community respond to such genuine and heartfelt cries of pain and help? How can we dialogue in a compassionate way in the face of such deeply-held convictions?

In the first instance it is apparent that reflection on PAS in the light of Johnstone's framework and his six questions moves the assisted suicide debate away from questions about personal autonomy and the protection of free choice. The immediate question becomes: To what extent is it possible to describe PAS as a gratuitous and freely given gift that can be freely received?

For my friend, and for many others, PAS appears as a gift – a gift that is often described as a relief from the pain of suffering and meaninglessness experienced by the elderly/dying person as well as loved ones who must stand 'helplessly' by. Their wish to see PAS legalised is grounded in a concern to alleviate such suffering, as well as a concern to 'do something'. Such anecdotes illustrate Bonhoeffer's claim that two kinds of motive lie behind the issue of PAS; "consideration for the sick and consideration for the healthy" (1995, p. 159).

Given that PAS involves a number of actors each with a part to play, there are a number of perspectives from which to analyse this practice. Looking at it from the perspective of family and society, I believe that the often-expressed reluctance of family members to personally assist in a loved one's suicide, and their desire to leave it to a health professional who is less emotionally attached, are highly instructive. Such reluctance does not sit well with a description of PAS as a gift freely given.

One might also consider PAS from the perspective of the dying person. In a society which legalises it, to what extent will PAS be perceived as a gift freely given and received? Rather than resulting in greater freedom for individuals approaching the end of their life, it is arguable that the legalisation of PAS will place greater pressure on the frail and terminally ill to end their lives so as not to be a burden. This, in turn, creates a sense of obligation likely to be at odds with what, deep down, a person genuinely desires. In other words, PAS presents itself in a coercive way – hardly compatible with an act freely taken or a gift freely received. From this perspective it is not inaccurate, then, to describe PAS as a person's refusal to receive the care that is due to them by virtue of their inherent dignity. Bonhoeffer notes insightfully that "this idea springs from the false assumption that life consists only in its own usefulness to society. It is not perceived that life, created and preserved by God, possesses an inherent right which is wholly independent of its social utility" (1995, p. 162). From a societal perspective, the notion that the value of a life is a function of its social usefulness is more reflective of an attitude of 'taking' (using) than giving and receiving. Thus a framework of giving and receiving exposes the (usually hidden) utilitarian assumptions that lie behind many arguments in favour of PAS.

Furthermore, I contend that PAS cuts short the opportunities to build a close communion between the dying person and those closest to them. I suggest that it will also fail to promote a culture of caring concern for the vulnerable and those facing old age and death. PAS will arguably incline us to see death more as an enemy to be defeated rather than as gift or opportunity. It may also make us less tolerant and caring in the face of suffering and death. The focus will shift to managing death rather than creating a loving and nurturing community characterised by giving and receiving.

Conversely, I would argue that the prospect of serious decline and death provides our giving and receiving with a heightened sense of freedom and authenticity. Caring for those who are severely incapacitated and close to death involves a greater opportunity for gratuitous giving because of the potential at that time for our acts to transcend any sense of self-interest or reciprocity. In their absolute helplessness the dying person is, ironically, able to gift caregivers and loved ones (and society) with the opportunity to make genuinely free acts of care. This gift of the dying person is, according to Johnstone's definition, the true gift because of its inherent potential to enable others to become givers. In this sense, accepting one's powerlessness in the face of death enables the 'chain reaction' of genuine giving and receiving that is capable of building up our communities. Here we encounter, yet again, the paradox of suffering and death; it becomes possible to describe death as a gift even while acknowledging the loss and pain that accompanies the death of a loved one, and it becomes possible to describe the dying person as a giver of the genuine gift.

On the other hand, it is hard to see how the use of PAS can achieve this. PAS appears more as an act of domination, the expression of a gift rejected rather than one 'freely received'. If we accept that all human gifts contain elements of self-serving and domination of others (in Christian language often described in terms of sin), nowhere is this likely to be more poignantly evident than when we experience the finality of our own or another's death. New Zealand moral theologian Vincent Hunt has noted in an unpublished essay that "we live in a time when there is an enormous expenditure of expertise and effort to establish and extend human control of both nature and human beings". Given that death represents the ultimate frontier beyond which we have no control, PAS might well be described as a current and typical example of this effort. The desire to avoid and or control death presents as an important area for individual and communal conversion.

To see death as a 'gift' necessarily involves embracing uncertainty and relinquishing control. But it is this uncertainty which also fertilises the very ground in which hope can grow and flourish.

Witnessing to the hope of faith in the midst of the uncertainty and suffering posed by death is arguably one of the gifts of the dying person to the community. My own rich, and painful, experience of accompanying my mother in the last months of her life is a testimony to that, as is the experience of many others.

A framework of giving and receiving directs attention to the elements of human self-seeking and self-serving in a way that other approaches fail to. Acceptance of the dying process as well as our own helplessness in the face of death provides a unique occasion for us to recognise and transcend the elements of self-seeking and control that characterise human nature in its fragility; our own death or the death of a loved one presents as a unique opportunity for moral growth, a chance to promote the conversion and genuine transformation that Johnstone alludes to.

The framework of giving and receiving offered by Johnstone also represents a direct challenge to the anthropological assumption, often voiced but rarely questioned, that our bodies are our possessions, to be used as we see fit as long as we don't harm anyone else. This argument has been and continues to be especially prominent in the assisted suicide debate. The notion that our bodies and our lives have been gifted to us creates a richer moral imperative, one characterised by gratitude for what has been joyously received; one which includes, but builds extensively on, the narrower notion of ownership that we attach to possessions we have bought or earned for ourselves.

Conclusion

It is immediately apparent that the framework proposed by Johnstone raises very different questions from those that normally surface in debates about the moral acceptability of physician-assisted suicide. In turn these questions open up a richer and, I believe, more robust discussion of the issue than when debate is constrained by theoretical models that (over-)emphasise autonomy and free choice to the detriment of other values, and draw on an anthropology which sees the body more in terms of something that is possessed than something we have been gifted with..

A person's interpretation of life is rooted in a particular worldview. A philosophy and theology of gift is grounded in the fundamental Judaeo-Christian belief that all life is a gift created by God. This belief is further reinforced by our experience, in faith, of the gift of God's self in Jesus Christ. Therefore, for Christians, our ethical norms are first of all rooted in giving on God's part and the receiving of God's gift on our part. In particular, the framework of giving and receiving articulated by Johnstone ensures that exploration of particular ethical issues will be considered from a broader community perspective and not just from an individual utilitarian perspective centred on the importance of autonomy and choice.

Returning again to the pastoral question that is the focus of this article: Can physician-assisted suicide be accurately described as an appropriate personal or communal response to a terminal illness or to declining capacity? In light of a framework of giving and receiving PAS is, I have argued, more appropriately described as an act of human control; as an act that, in seeking to pre-empt our helplessness in the face of the uncertainty of death, fails to recognise the nature of Christian hope; as an act that ultimately rejects the gifts associated with the caring accompaniment of a person who is dying; as an act that largely fails to recognise decline and death as an opportunity for moral and spiritual growth and conversion.

It is in the nature of a gift to be waited for because a gift is, by definition, not owed. In the same way, the death of each of us, seen through the eyes of faith as a passage into God's gift of eternal life, is something that needs to be waited for and gratefully received. When all is said and done, a philosophy and theology of gift shows up physician-assisted suicide as an act of human domination that takes over from God the role of giver of gifts and simultaneously rejects a gift freely given.

To paraphrase Dietrich Bonhoeffer: It is as creatures and not as creators that we must boldly face the reality of death.

References:

Bonhoeffer, D. (1995). Ethics (First Touchstone ed.). New York: Simon & Schuster.

Johnstone, B. (2008). Moral conscience and Christian innovation: elements for a theological reading. In Sgreccia, E. & Laffitte, J. (Eds.), Christian conscience in support of the right to life: Proceedings for the thirteenth assembly of the Pontifical Academy of Life (pp. 71-81). Vatican City: Libreria Editrice Vaticana.

John Kleinsman is a Doctoral Student on the staff of The Nathaniel Centre