Review

Art

Attention

Culture

29 November 2023

5 min read

The very image of kindness

Photography risks cruelty in search of sensation. Andrew Davison contrasts such works with Dorothea Lange’s compassionate gaze.

Andrew Davison

Andrew works at the intersection of theology, science and philosophy. He is Canon and Regius Professor of Divinity at Christ Church, Oxford.

A black and white close up of a mothers cradling her jaw in worry as children cuddle into her.

'Migrant Mother', Lange's best known image.

Public Domain, The J. Paul Getty Museum, Los Angeles.

A black and white picture shows a farm worker wearing a headscarf and holding her arm over her head for shade.

, "Young girl looks up from her work. She picks and sacks potatoes on large-scale ranch, Edison, Kern County, California, April 11, 1940."

A young man wipes his face with an open hand showing his palm.

"Migratory cotton picker, Eloy, Arizona 1940."

A young woman wearing a sun hat leans against a wall seeking shade.

"Young migratory cotton picker, Arizona, 1941."

A farmer stands and leans against an implement he hold with one hand.

“Black sharecropper with twenty acres, 1938”

Migratory field worker picking cotton in San Joaquin Valley, California, November 1938."

Do you like your photography cruel or kind? I’m generally an enthusiast for kindness – an unsung virtue – but I was mesmerised by a 2019 show of photography by Diane Arbus (1923–71) at the Heyward Gallery, London, and she’s the cruellest of the lot. Her photographs are a study in the awkward, the disturbing, and the unusual: a pair of brothers with extraordinarily large ears, a child with a grimace and a toy hand grenade, a boy from a pro-war parade, wearing with straw boater and “Bomb Hanoi” badge.

Arbus’s photographs have an undeniable charge. They hold your view. I’m glad, however, that I stand in front of her prints, not in front of her lens. She was not out to show you at your best. Here is Germaine Greer, describing a photoshoot with Arbus in the Chelsea Hotel in Manhattan.

'Clutching the camera she climbed on to the bed and straddled me, moving up until she was kneeling with a knee on both sides of my chest. She held the Rolleiflex at waist height with the lens right in my face. She bent her head to look through the viewfinder on top of the camera, and waited… as soon as I exhibited any signs of distress, she would have her picture… Nothing would happen for minutes on end, until I sighed, or frowned, and then the flash would pop. After an eternity she climbed off me, put the camera back in her bag and buggered off. A few weeks later she took an overdose of barbiturates and slit her wrists.'

Reviewing the Aperture monograph that would secure Arbus’s fame, Susan Sontag described her work as ‘a hymn to the isolation and atomization of the individual’. I am not sure that’s entirely fair. There was undeniable cruelty to Arbus. “You see someone on the street,” she wrote, “and essentially what you notice about them is the flaw.” Perhaps all photography risks cruelty, depicting us warts and all (at least before the advent of the Instagram filter, although I’m inclined to call Instagram filters the worst indignity of all). Yet, even in Arbus, just in portraying the human as human, compassion lurks at least just round the corner.

But sometimes compassion is nearer at hand, even centre stage. For that, I turn to Dorothea Lange (1895–1965), and to a recently-opened show of her work at the National Gallery of Art in Washington, DC, entitled Seeing People. It holds Lange before us as the archetype of compassionate photography.

Lange could not have produced the photographs she did, however compassionate she might have been, without time, care, and attention.

Lange trained as a portrait photographer, establishing a successful studio in San Francisco in the 1920s. Her approach to photography as a humane act developed during her work documenting rural poverty in the decade that followed. With it, she drew public attention to the effects of the Great Depression and the dust bowl, and helped to shift the public mood. From 1935, she did that under the auspices of what would soon become the Farm Security Administration. A photograph taken in March 1936 – “Human Erosion in California” (eventually known as “Migrant Mother”) – proved to be her career-defining shot. It shows Florence Owens, mother of ten children, photographed in the pea pickers’ camp in Nipomo, California. She and her family were in a dire situation, constantly moving to find new, transitory work.

In the 1940s, Lange documented the suffering of Japanese Americans during the Second World War (“Japanese American-Owned Grocery Store, March 1942”), not least once Japanese Americans began to be moved into internment camps (“Grandfather and Grandson of Japanese Ancestry at a War Relocation Authority Center, July 1942”). For the rest of her career, Lange would travel to places in the United States that rarely, if ever, feature in genteel conversation, to photograph people scraping through on very little, never failing to capture a sense of their dignity.

So, Lange was a compassionate photographer. I knew that before this show opened, and kindness is there in print after print. I was expecting that. What struck me for the first time is that Lange’s compassion was no light, easily achieved affair. She was careful, prepared, painstaking. She spent extended periods in deprived parts of her country, sometimes travelling for months at a time. She immersed herself in the life of a community, not least in its religious life, rather as an anthropologist would. She took detailed notes, and laboured over how to describe her subjects in captions and accompanying prose.

It is too easy to say that Lange was compassionate in way in which Arbus was not: too easy, if that implies that the fruits of her compassion were easily achieved. Lange could not have produced the photographs she did, however compassionate she might have been, without time, care, and attention.

She ‘saw people’, as the name of this exhibition reminds us. She saw people is because she took time to look. Before she clicked her shutter, she looked, she saw, she listened.

In contrast to Lange’s deliberate intent, Arbus was a wanderer. She had a remarkable eye, and she took what she wanted. She is among the greatest of opportunist photographers. Sontag got to the heart of that, remarking that Arbus treated human beings like the “found objects” that Surrealists elevated to the status of art:

What may seem journalistic (read “sensational”) in Arbus’s photographs places them, rather, in the main tradition of Surrealist art—with their taste for the grotesque, the proclaimed innocence with respect to their subjects, their claim that all subjects are merely objets trouvés.

Therein lies the difference from Lange.

The world could do with more compassion. Who would deny that? The message of the Washington exhibition, and of Lange’s work as a whole, is that compassion is not the work of a moment. Posting outrage to social media, or posting solidarity for that matter, is not going to change very much at all. It may make things worse. Lange’s lesson for this hour is that compassion requires us to take time. Her message is in her anthropological attention to people, communities, stories. She ‘saw people’, as the name of this exhibition reminds us. She saw people is because she took time to look. Before she clicked her shutter, she looked, she saw, she listened.

Dorothea Lange: Seeing People runs from 5 November 2023 to 31 March 2024 in the West Building of the National Gallery of Art, Washington, DC. Entry is free.

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.