The really annoying thing about dying

In his first Notes from Solitude, the death of his dad causes Roger Bretherton to reflect on the relationship and the strange emergence of 'father’.

Roger Bretherton

Roger Bretherton is Associate Professor of Psychology, at the University of Lincoln. He is a UK accredited Clinical Psychologist.

A pocket watch rests next to a black and white photograph of a father lying beside a new born baby.

Photo by Anne Nygård on Unsplash.

The death of my dad was sudden and unexpected. I don’t know why it is that, from the moment he died, I have had to fight the almost irresistible urge to refer to him as father- a term of address I never used about him or to him during his life.

Perhaps in some psychotherapy session at some point my therapist referred to my ‘father’, and I may have followed suit. And maybe occasionally when socialising with those who seemed a cut above my largely lower-middle class background, I called him father so as to avoid the flat northern vowel sounds that would expose me as an interloper. But that was just to fit in- on all other occasions he was decidedly not father and definitely just good old plain, dad.

At death he became a classic, a museum piece, a part of history, not the dad who taught me how to ride a bike.

But for some reason the moment he died, it felt like dad wasn’t enough. I now had to call him father - those were the rules. At death he became a classic, a museum piece, a part of history, not the dad who taught me how to ride a bike by panting and sweating my five-year old self round the block, but the father who taught me to be… a man, or something like that.

The F-word has gravitas, presence, authority. Dads are human, often bewildered, occasionally pissed off, eminently huggable, easily taken for granted - just there. Admittedly, Freud would have lost significant gravitas if oedipal theory had considered common-all-garden dads and not cigar-smoking brandy-swilling fathers. And no doubt the climactic scene of The Empire Strikes Back would have lacked considerable pathos had Darth Vader casually quipped, ‘No Luke, I’m your’re Dad’.

The curse of the martyr, write Albert Camus, was to have other people tell their story. The principle doesn’t just apply to martyrs, it’s true of all those who die. To be dead is to become a character in other people’s anecdotes. That’s the really annoying thing about dying, we become a topic of gossip, people get to talk about us without the courtesy of ever having to talk to us. We become object, no longer subject. I think that’s why I resist calling my late Dad, Father. It objectifies him, makes of him something that he wasn’t. It, most definitely fails to do justice to all that he meant to me.

She simply said, ‘It’s your Dad’, and held me tight in a hug that lasted longer than usually permitted in polite company.

I say he died suddenly. It was a Sunday morning. I was in church at the time. Actually, worse than that, I was on stage speaking to a church. As a psychologist working in academia, I teach and train all kinds of people in every kind of organisation imaginable, but every now and then I get to speak in churches.

On this occasion I was talking about character, the positive qualities of being – like love, gratitude, hope, wisdom and so on – that make life worth living. When I stepped off the stage my wife was waving to me from the back of the room, which was weird given that we don’t go to that church and she hadn’t come with me. When I wandered to the back of the auditorium wearing my ‘what are you doing here?’ face, she simply said, ‘It’s your Dad’, and held me tight in a hug that lasted longer than usually permitted in polite company. For someone who prides himself on social insight, it shames me to say that it took a while for the penny to drop. We were in the car with the engine running before it finally dawned on me what she meant.

I try not to make too much of divine timings or fate, but there was something odd in the timing of getting that news. In that month I had addressed church congregations three Sundays in a row- which, as someone who is generally lazy and prefers not to work weekends, is an unusually intense frequency. But over three successive Sundays I had reflected aloud with those congregations that there were prayers that had accompanied the various stages of my life. Prayers that I found myself praying, almost as if they were prayed through me, as if they had chosen me rather than I they.

In my twenties I had found myself praying as regularly as a heartbeat, ‘God do whatever you need to do with me, to make me into the person you would like me to be.’ It was a radical invitation for God to put me through whatever was needed to become who I was meant to be. But then the prayer faded. Its visit was over, it had done its work and it moved on. But as I addressed the congregations on those three Sundays I mused aloud that while the prayer of my twenties had departed decades before, I found a new prayer stirring in my forties. Now as the father of teenage boys, my new prayer was, ‘God do whatever you need to do with me to make me the father you would like me to be.’

In the weeks that followed, people asked me whether I had had a good relationship with my dad. The most accurately answer was: we had the best relationship of which we were both capable. We both tried in our own ways to deepen our connection, but we were like the lovers in a romantic comedy; we always managed to miss each other. When he tried with me, I didn’t want to know. For several years, he left a book lying around at home that he wanted me to read. I never saw anyone touch it, but it moved around the house under its own steam. It was by my bedside, in the toilet, on the dining room table… Macavity the Mystery Cat would have been proud. It was called, Things We Wish We Had Said. We may have wished, but we didn’t say. I never read it. Years later, when I tried with him, he was too flustered to respond. Both of us in our own ways lacked the courage to connect any deeper. But I was never in any doubt that he loved me, and I him.

When he was alive I was most aware of how different we were. I defined myself in opposition to whatever he was. If he was gentle, I was assertive. If he was indecisive, I was ambitious.

He died of a heart attack on a Sunday morning asleep in bed, while my Mum was at church. Almost immediately his absence prompted a profound change of consciousness in me. When he was alive I was most aware of how different we were. I defined myself in opposition to whatever he was. If he was gentle, I was assertive. If he was indecisive, I was ambitious. If he was inexpressive, I was articulate. If he was like that, I was like this. And yet, almost at the very moment of his death, a reversal of awareness occurred. I started to see just how very much like him I was. His gentleness, his uncertainty, his scepticism, his care, his humour, were all mine.

There is a rule in family therapy, that adult children relating to their parents should set their expectations to zero. We never truly see our parents until we stop viewing them through the lens of our own desires; what we wanted from them but never got. Until we do that our lives don’t really work, we sit around waiting for an impossible transformation, a payday that never comes, the moment our parents become exactly how we would like them to be, not as they are. For me, that moment of acceptance for dad only came when he was gone, I accepted him as he was when there was nothing left to accept. I don’t write this with any great sense of guilt or regret at opportunities lost, more with a sense of gratitude for what was given but often taken for granted.

Oddly though, in the shadow of that seismic shift in my interior furniture, I detected the stirrings of an answer to my own prayer to be a better father. No longer compelled to define myself in contrast to what he was, I was freed to be what I was- both like and unlike him, and to be fair, more like him than I cared to admit. At some visceral level I came to appreciate how much of myself originated with him. I came to accept myself as a dad and my dad as a father.

Article

Assisted dying

Care

Culture

Death & life

13 November 2024

8 min read

The deceptive appeal of assisted dying changes medical practice

In Canada the moral ethos of medicine has shifted dramatically.

Ewan Goligher

Ewan is a physician practising in Toronto, Canada.

a doctor consults a tablet against the backdrop of a Canadian flag.

Once again, the UK parliament is set to debate the question of legalizing euthanasia (a traditional term for physician-assisted death). Political conditions appear to be conducive to the legalization of this technological approach to managing death. The case for assisted death appears deceptively simple—it’s about compassion, respect, empowerment, freedom from suffering. Who can oppose such positive goals? Yet, writing from Canada, I can only warn of the ways in which the embrace of physician-assisted death will fundamentally change the practice of medicine. Reflecting on the last 10 years of our experience, two themes stick out to me—pressure, and self-deception.

I still remember quite distinctly the day that it dawned on me that the moral ethos of medicine in Canada was shifting dramatically. Traditionally, respect for the sacredness of the patient’s life and a corresponding absolute prohibition on deliberately causing the death of a patient were widely seen as essential hallmarks of a virtuous physician. Suddenly, in a 180 degree ethical turn, a willingness to intentionally cause the death of a patient was now seen as the hallmark of patient-centered doctor. A willingness to cause the patient’s death was a sign of compassion and even purported self-sacrifice in that one would put the patient’s desires and values ahead of their own. Those of us who continued to insist on the wrongness of deliberately causing death would now be seen as moral outliers, barriers to the well-being and dignity of our patients. We were tolerated to some extent, and mainly out of a sense of collegiality. But we were also a source of slight embarrassment. Nobody really wanted to debate the question with us; the question was settled without debate.

Yet there was no denying the way that pressure was brought to bear, in ways subtle and overt, to participate in the new assisted death regime. We humans are unavoidably moral creatures, and when we come to believe that something is good, we see ourselves and others as having an obligation to support it. We have a hard time accepting those who refuse to join us. Such was the case with assisted death. With the loudest and most strident voices in the Canadian medical profession embracing assisted death as a high and unquestioned moral good, refusal to participate in assisted death could not be fully tolerated.

We deceive ourselves if we think that doctors have fully accepted that euthanasia is ethical when only very few are actually willing to administer it.

Regulators in Ontario and Nova Scotia (two Canadian provinces) stipulated that physicians who were unwilling to perform the death procedure must make an effective referral to a willing “provider”. Although the Supreme Court decision made it clear in their decision to strike down the criminal prohibition against physician-assisted death that no particular physician was under any obligation to provide the procedure, the regulators chose to enforce participation by way of this effective referral requirement. After all, this was the only way to normalize this new practice. Doctors don't ordinarily refuse to refer their patients for medically necessary procedures; if assisted death was understood to be a medically necessary good, then an unwillingness to make such referral could not be tolerated.

And this form of pressure brings us to the pattern of deception. First, it is deceptive to suggest that an effective referral to a willing provider confers no moral culpability on the referring physician for the death of the patient. Those of us who objected to referring the patient were told that like Pilate, we could wash our hands of the patient’s death by passing them along to someone else who had the courage to do the deed. Yet the same regulators clearly prohibited referral for female genital mutilation. They therefore seemed to understand the moral responsibility attached to an effective referral. Such glaring inconsistencies about the moral significance of a referral suggests that when they claimed that a referral avoided culpability for death by euthanasia, they were deceiving themselves and us.

The very need for a referral system signifies another self-deception. Doctors normally make referrals only when an assessment or procedure lies outside their technical expertise. In the case of assisted death, every physician has the requisite technical expertise to cause death. There is nothing at all complicated or difficult or specialized about assessing euthanasia eligibility criteria or the sequential administration of toxic doses of midazolam, propofol, rocuronium, and lidocaine. The fact that the vast majority of physicians are unwilling to perform this procedure entails that moral objection to participation in assisted death remains widespread in the medical profession. The referral mechanism is for physicians who are “uncomfortable” in performing the procedure; they can send the patient to someone else more comfortable. But to be comfortable in this case is to be “morally comfortable”, not “technically comfortable”. We deceive ourselves if we think that doctors have fully accepted that euthanasia is ethical when only very few are actually willing to administer it.

We deceived ourselves into thinking that assisted death is a medical therapy for a medical problem, when in fact it is an existential therapy for a spiritual problem.

There is also self-deception with respect to the cause of death. In Canada, when a patient dies by doctor-assisted death, the person completing the death certificate is required to record the cause of death as the reason that the patient requested euthanasia, not the act of euthanasia per se. This must lead to all sorts of moments of absurdity for physicians completing death certificates—do patients really die from advanced osteoarthritis? (one of the many reasons patients have sought and obtained euthanasia). I suspect that this practice is intended to shield those who perform euthanasia from any long-term legal liability should the law be reversed. But if medicine, medical progress, and medical safety are predicated on an honest acknowledgment about causes of death, then this form of self-deception should not be countenanced. We need to be honest with ourselves about why our patients die.

There has also been self-deception about whether physician-assisted death is a form of suicide. Some proponents of assisted death contend that assisted death is not an act of deliberate self-killing, but rather merely a choice over the manner and timing of one's death. It's not clear why one would try to distort language this way and deny that “physician-assisted suicide” is suicide, except perhaps to assuage conscience and minimize stigma. Perhaps we all know that suicide is never really a form of self-respect. To sustain our moral and social affirmation of physician-assisted death, we have to deny what this practice actually represents.

There has been self-deception about the possibility of putting limits around the practice of assisted death. Early on, advocates insisted that euthanasia would be available only to those for whom death was reasonably foreseeable (to use the Canadian legal parlance). But once death comes to be viewed as a therapeutic option, the therapeutic possibilities become nearly limitless. Death was soon viewed as a therapy for severe disability or for health-related consequences of poverty and loneliness (though often poverty and loneliness are the consequence of the health issues). Soon we were talking about death as a therapy for mental illness. If beauty is in the eye of the beholder, then so is grievous and irremediable suffering. Death inevitably becomes therapeutic option for any form of suffering. Efforts to limit the practice to certain populations (e.g. those with disabilities) are inevitably seen as paternalistic and discriminatory.

There has been self-deception about the reasons justifying legalization of assisted death. Before legalization, advocates decry the uncontrolled physical suffering associated with the dying process and claim that prohibiting assisted death dehumanizes patients and leaves them in agony. Once legalized, it rapidly becomes clear that this therapy is not for physical suffering but rather for existential suffering: the loss of autonomy, the sense of being a burden, the despair of seeing any point in going on with life. The desire for death reflects a crisis of meaning. We deceived ourselves into thinking that assisted death is a medical therapy for a medical problem, when in fact it is an existential therapy for a spiritual problem.

We have also deceived ourselves by claiming to know whether some patients are better off dead, when in fact we have no idea what it's like to be dead. The utilitarian calculus underpinning the logic of assisted death relies on the presumption that we know what it is like before we die in comparison to what it is like after we die. In general, the unstated assumption is that there is nothing after death. This is perhaps why the practice is generally promoted by atheists and opposed by theists. But in my experience, it is very rare for people to address this question explicitly. They prefer to let the question of existence beyond death lie dormant, untouched. To think that physicians qua physicians have any expertise on or authority on the question of what it’s like to be dead, or that such medicine can at all comport with a scientific evidence-based approach to medical decision-making, is a profound self-deception.

Finally, we deceive ourselves when we pretend that ending people’s lives at their voluntary request is all about respecting personal autonomy. People seek death when they can see no other way forward with life—they are subject to the constraints of their circumstances, finances, support networks, and even internal spiritual resources. We are not nearly so autonomous as we wish to think. And in the end, the patient does not choose whether to die; the doctor chooses whether the patient should die. The patient requests, the doctor decides. Recent new stories have made clear the challenges for practitioners of euthanasia to pick and choose who should die among their patients. In Canada, you can have death, but only if your doctor agrees that your life is not worth living. However much these doctors might purport to act from compassion, one cannot help see a connection to Nazi physicians labelling the unwanted as “Lebensunwortes leben”—life unworthy of life. In adopting assisted death, we cannot avoid dehumanizing ourselves. Death with dignity is a deception.

These many acts of self-deception in relation to physician-assisted death should not surprise us, for the practice is intrinsically self-deceptive. It claims to be motivated by the value of the patient; it claims to promote the dignity of the patient; it claims to respect the autonomy of the patient. In fact, it directly contravenes all three of those goods.

It degrades the value of the patient by accepting that it doesn't matter whether or not the patient exists.

It denies the dignity of the patient by treating the patient as a mere means to an end—the sufferer is ended in order to end the suffering.

It destroys the autonomy of the patient because it takes away autonomy. The patient might autonomously express a desire for death, but the act of rendering someone dead does not enhance their autonomy; it obliterates it.

Yet the need for self-deception represents the fatal weakness of this practice. In time, truth will win over falsehood, light over darkness, wisdom over folly. So let us ever cling to the truth, and faithfully continue to speak the truth in love to the dying and the living. Truth overcomes pressure. The truth will set us free.