Abstract
Over the past half century, death and dying courses have evolved in scope and grown tremendously in popularity on college campuses. The core debates within thanatological sociology—and the frontline issues of America’s current culture wars—are the hot button topics of abortion, physician assisted dying, euthanasia, and capital punishment. To these topics Ekland-Olson brings a different approach, one featuring an historical narrative that integrates these and other issues through crystallizing the ethical issues underlying court rulings, medical ethics proceedings, and legislation. The work is unlike any other within the discipline, developing the ongoing evolution of a moral system whose precepts are continuously challenged by new scientific insights, technological developments, and unanticipated “crystallizing events.” It is an important book, one deserving of required reading status for undergraduate and graduate students alike in not only death and dying but social movements courses as well.
Framing Ekland-Olson’s interrelated case studies is William Ogburn’s notion of “culture lag.” When, for instance, so many embryos result from novel fertility treatments that all may die unless some are aborted, the author repeatedly and richly illustrates how “existing moral principles, judicial decisions, and legislated statutes are frequently not well fashioned to address the implications of new scientific findings and technologies” (p. 374). The ethical limbos produced by these lags invariably spawn opposing social movements, which reassess the legitimacy of existing understandings and practices. “Metaphors are built, analogies are drawn, empathy-generating images are fashioned, and stories are told” by each side (p. 374). Unfortunately, as will be developed, on matters involving the boundaries between life and death, the moral calculus of “competing conceptions of a meaningful life, tolerable suffering, and social worth” (p. 112) yields no culturally acceptable solution.
A certain serendipity occurred upon receipt of this work. The reviewer was engaging his students in explaining why Americans believing in Darwin’s thesis of natural selection were, according to Pew’s 2006 Religion and Public Life survey, three times more likely to support abortion rights than those not believing in evolution. Their being more “liberal” or “secular” does not explain the ethical underpinnings of the correlation. Enter Who Lives, Who Dies, Who Decides? The book’s first section, “A Moral System Evolves,” begins with the inception and growth of the Darwinian-inspired eugenics movement, which was premised on the assumption that all human life and all moments of life are not equal in worthiness. We follow the post-Civil War career of Francis Galton, whose “science of improving stock” was “equally applicable to men, brutes, and plants” (p. 19). Attracted to the thesis that some human traits are detrimental to the health of the collective were such notables as Alexander Graham Bell, Justice Oliver Wendell Holmes, Helen Keller, and Stanford University president David Starr Jordan. While in Germany the movement led to the Final Solution, in the United States—where its peak coincided with Jim Crow miscegenation laws, dramatic increases in lynching and immigration, and publication of Madison Grant’s The Passing of the Great Race (1916)—it led to 60 years of state laws mandating the sterilizations of those labeled “defective, feeble-minded parasites” (p. 31). It also left an exclusionary moral logic that was to influence a host of seemingly unrelated death-related controversies that emerged over the remainder of the century.
The following two chapters develop the ethical fallout of Nazi medical research, producing no shortage of soul-searching in the postwar United States. The euthanasia movement, for instance, had infected the medical arts with the assumption that there exist lives not worthy to be lived. One of the drafters of the Universal Declaration of Human Rights, Dr. Leo Alexander, noted the tendency of physicians, challenged by incurable patients, to view themselves as failures and the sufferers as “unwanted ballast.” Further, there were revelations of the use of Americans deemed of less social worth—lower class cancer victims, syphilitic African Americans, retarded children, and recently aborted fetuses with beating hearts—as unwitting guinea pigs for horrific experiments, all in the name of science. The rationale for giving these individuals full-body radiation exposures, feeding them live hepatitis viruses from victims’ feces, and misleading syphilis sufferers into believing that they were being treated when instead they were given placebos echoed the defenses of Nazi physicians during the Nuremburg trials: “If patients of less social worth are going to die anyway, why not use them for the greater good?” (p. 98). Trust in physicians, behind closed doors, being the sole arbiters in deciding who lives and who dies, evaporated.
In reaction against medicine’s war against death and its technological torture of the dying emerged Cicely Saunders and the hospice movement, which gave equal moral footing to the alleviation of suffering with life prolongation. There arose questions about the limits of state power and how to protect individuals’ autonomy, privacy, and dignity. When the Seattle Artificial Kidney Center first opened in 1962 only five patients could be served. According to what ethical criteria were they to be selected and by whom? Similar questions arose with successes in organ transplants. Who should be the recipient of a scarce heart for transplant: a chain-smoking 60-year-old Nobel Prize winner on the brink of a cancer cure or a 30-year-old divorced receptionist and mother of three young children? New boundaries emerged, as limited supplies of suitable donors prompted redefinitions of death to include individuals sustaining irreversible coma as a result of permanent brain damage. The nascent bioethics movement was well underway and over the next half century would encounter undreamt of cases of moral ambiguity where any medical decision, no matter what its life-affirming intentions, led to its own slippery slope of unwanted moral outcomes (the Doctrine of Double Effect). Nevertheless, like the proverbial lifeboat sinking because of too many passengers, the intent must always be on preserving life and not on who must die.
Not only murky are the boundaries when “life” ends but when it begins, leading to a 90-page excursus into the issues of abortion and neonatal care. “When does abortion become infanticide?” (p. 115). The narrative begins with Anthony Comstock’s success in suppressing materials deemed obscene, including contraceptive devices, and the countermovement it produced. The latter, led by Margaret Sanger and her colleagues, viewed statutes of the Comstock Law allowing “inappropriate governmental intrusion into the private lives of citizens” (p. 118). Again, external events were to affect the course of arguments and legislation. The Great Depression, for instance, increased the persuasiveness of Sanger’s position as neither families nor the state could afford any proliferation of unwanted and unplanned for children. There was, with the civil rights movement and the resurgence of the women’s movement, broad senses of the illegitimacy of established institutions. With the human mutations produced by Thalidomide and a rubella pandemic, the long-simmering abortion debate was to resurface in public consciousness as between “alleviation of the potential suffering of the yet-to-be-born . . . and the imperative to protect protected life” (p. 123).
Though the real focus of early criminal abortion laws was to protect the life of pregnant women, not the unborn (p. 138), mounting opposition to Roe v. Wade was soon to shift on the latter. Fetal images produced by new ultrasound technology and appearing in “The Silent Scream” generated empathy for the unborn and a host of pro-life organizations, whose actions became increasingly aggressive, destructive, and deadly. Pro-choice forces attempted to frame legally the clinic blockades of Operation Rescue in terms of the Ku Klux Act of 1871; radical pro-life forces saw parallels between their behaviors and those violent antislavery actions of John Brown. Just when the boundary between abortion and infanticide was thought to be defined with the Partial-Birth Abortion Ban Act of 2003, there appeared highly publicized stories of late-term discoveries of developing babies with hydrocephalus and spina bifida, whose births were doomed to be proceeded by either death or endless noncurative surgeries. “If saved, would the life be worth living? When [are] we prolonging death and the infant’s suffering rather than protecting life?” (p. 192).
From the death-related issues of the unborn and newly born, the narrative proceeds into the issues of euthanasia, assisted suicide, and the right-to-die/death-with-dignity movements. New boundary notions and slippery slopes emerge when considering individuals’ rights to refuse medical treatment or demand accelerated deaths, the limits to tolerable suffering, and when new medical technologies create new categories of existence, like “persistent vegetative state.” New distinctions arose, such as between assisted suicide and assisted dying (p. 265).
The book concludes with the subject of capital punishment, where “[t]ransforming a fully protected citizen into a convicted, dehumanized felon whose life can be taken is an uncertain business” (p. 305). The chapter “Removing the Protective Boundaries of Life” begins with the post-Civil War lynching epidemics during an era of communal instability, two disastrous depressions, and when society became exclusionary. It was a time when “empathy faded; ostracism and animosity built; demonization, anger, and lethal violence became more likely; and a paradox of community in which the ties that bind us together become the ties that keep us apart was manifest” (p. 308). Once again, those on the margins of life were most vulnerable as the reader is reminded in vivid recounting of the race riots and lynching during the Red Summer of 1919, in Waco, Texas, in 1922, after which “local hangings were to be replaced by electrocutions in the state’s main prison” (p. 316), and in Sherman, Texas, in 1930. Of the travesty of justice in the infamous case of the Scottsboro Boys, where nine blacks were accused of gang raping two white women, Olson observes how “there was precious little difference between a trial and a lynch mob” (p. 321). And then, of course, there was the torture and murder of 14-year-old Emmett Till in 1955, whose legally cleared assassins later bragged of their deeds to a Look magazine writer. “Just as supply responds to demand, legitimacy rises and falls with a sense of injustice” (p. 331). The racial biases of state-mandated death became too obvious—and too great a source of embarrassment and moral vulnerability during this country’s Cold War campaigns against the legitimacy of Communism because of its human rights record.
Less than three decades have passed since Pope John Paul II condemned the “culture of death” he saw taking root in the secularizing West, evidenced by state-sanctioned abortion, euthanasia, capital punishment, and militarism. How such an ethos can evolve, even in a culture that holds life to be sacred and deserving of all protection, will find no better accounting than in Who Lives, Who Dies, Who Decides?