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by Robert A. Burt
University of California Press, 2002
Review by Edrie Sobstyl, Ph.D. on Jul 31st 2003

Death Is That Man Taking Names

            We don't talk much about death. As a result, we deprive ourselves of a deep understanding of why it is regarded as unpleasant, even taboo. In Death is That Man Taking Names, Robert Burt steps into this social silence and bids us to notice, not our own finitude, but the means by which we conceal death from view.

            Burt does not approach death in broad terms. His emphasis in this elegant and accessible book is on three "death-dealing" contexts: end-of-life decisions, abortion, and capital punishment. He also includes an examination of death in combat as a source of changing beliefs about justifiable death. With such politically charged issues at its center, one expects the book to be controversial. But the source of controversy is not these specific topics. Rather, Burt's provocation is aimed at a fundamental ambivalence about death at the heart of the American psyche. On the one hand, we are heirs to the liberal democratic notion of the autonomous Self. Death is an affront to this ideal, and because it underpins so many of our moral concepts, death has implicitly come to be regarded as a moral affront. There is something wrong about death that goes beyond fear. It poses a threat to the very individualism on which our values are based. Death cannot be made meaningful when seen in this light.

            On the other hand, the last century has seen a trend toward rational management strategies in most aspects of life, and death is no exception. Starting in the mid-nineteenth century, Burt examines medical and judicial efforts to bring death under the control of professional expertise and sound public policy. This trend appears in the 1859 campaign by the American Medical Association to medically regulate abortion. While this was a watershed event, Burt points out that there have been many such turning points. He explores history, from the Civil War through Nuremberg to Roe v. Wade, the Quinlan case, legislation on the death penalty and physician-assisted suicide, and the Patient Self-Determination Act. None of this is new territory, but Burt's approach is novel in seeking conflict underlying the continuity. For him, what ties these threads together is the mounting tension between our moral ideals of selfhood and the medical, judicial, and legislative management of death.

            Burt insists that this tension is ultimately irresolvable. With each layer of social history, he shows that ambivalence about death is repressed rather than confronted. The specter of Freud occasionally intrudes into the discussion, which may put some readers off, but the argument stands up without Freud. Burt argues that managing death, however well intentioned, has two undesirable consequences. First, believing that we can compel death to answer to the canons of reason violates the central ethic of medicine. Instead of alleviating suffering, this belief has created more suffering. Unnecessary procedures are performed, pain goes unrelieved, advance directives are ignored, and patients and their families are abandoned when death is imminent and their need for compassion is greatest. These are harsh judgments, and physicians may find them offensive. But Burt is careful to avoid attributing malicious motives to doctors who mismanage death. On the contrary, he finds the consciously intended goodness of physicians to be part of the problem because, when it comes to death, we as a culture are simply no longer sure what goodness amounts to. Empathetic care is wanted, but so is patient autonomy, and in death the two cannot comfortably coexist.

            The other negative consequence is the gradual erosion of the features of the autonomous Self that made it worth enshrining in the first place. By using self-determination as a protective barrier, we rob ourselves of the kinds of knowledge that we need to make reasonable decisions about death -- our own and those of our family members, but also the deaths of soldiers, convicted criminals, and fetuses. The creation of legal checks and balances in all of these cases only exacerbates the problem by continuing to promote the illusion of rationality. This conflict cannot be sustained. Burt recommends, first, that intentional, unambiguous infliction of death should be avoided. He contrasts capital punishment and abortion here, and his defense of reproductive choice is not altogether persuasive. Secondly, he exhorts us to acknowledge our ambivalence about death, and to make our unease publicly visible in our discussions and practices surrounding death. It is not clear what impact this more tentative attitude might have in practice, for example, in medical education. It is clear, however, that such a discussion is needed.

 

 

© 2003 Edrie Sobstyl

 

 

Edrie Sobstyl was educated in Edmonton, Canada, and teaches philosophy in the History of Ideas program at the University of Texas, Dallas. She is the author of several articles on feminism and science, and has been a research fellow for the Rockefeller Foundation for the Humanities. Her current work is on ethics and regulations for protection of human subjects in research, which she is developing as a Visiting Assistant at the University of California, San Diego.