Review

Books

Culture

Friendship

9 May 2023

6 min read

Why do we ignore the power of friendship

Elizabeth Day’s Friendaholic: Confessions of a Friendship Addict.

Belle Tindall

Belle is the staff writer at Seen & Unseen.

A large group of friends sit at a crowded table and share a meal together.

Photo by Priscilla Du Preez on Unsplash.

Elizabeth Day is a journalist, a novelist, a podcast host, a broadcaster, and a friendaholic. This isn’t a term that she uses lightly, she’s not merely delighting in some quaint wordplay here. Rather, Elizabeth has identified within herself a chronic compulsion, a psychological need, a habitual seeking out, and an emotional reliance on friendship (or, at least, what she perceived friendship to be – more on that later…)

Therefore, when she labels herself a friendship addict, she does so with every ounce of seriousness. She also describes the symptoms of her addiction with impressive levels of introspection.

‘I would get a buzz from a moment of exchange; a hit of pure friendship adrenaline. In that moment, I would feel worthwhile and liked and accepted. I wanted more of it. Then I needed more of it. Then it became something that I relied on for my own self-worth. I must be OK, the reasoning went, I’ve got so many friends.’

These intimate confessions lead Elizabeth to begin the epilogue of her book with a familiar, albeit reconfigured, turn of phrase: ‘My name is Elizabeth Day’ she writes, ‘and I’m a recovering friendaholic.’

The quality of our social life, whether it be too large or too small, has a significant impact on our mental, emotional and physical health.

Elizabeth pre-empts any criticism of what could be perceived as a ‘woe-is-me’ memoir by meeting those who may be reaching for their ‘metaphorical tiny violins’ head on. This book unashamedly takes the impact of friendship, or a lack thereof, very seriously. And so should we. Afterall, social injuries are proven to be very real and loneliness a serious determinant of health. On the opposite end of the same scale, ‘social burnouts’, which often lead to social anxiety, are becoming an epidemic, while an increasing number of mental health issues are being accredited to the profound impact of ‘toxic’ friendships. In short, it is becoming common knowledge among researchers that the quality of our social life, whether it be too large or too small, has a significant impact on our mental, emotional and physical health.

And yet, despite this - we have barely any language with which to adequately address or inspect the topic of a ‘social life’. It seems that generation after generation, we have failed to take the art of friendship seriously.

‘Friendship is unnecessary, like philosophy, like art.... It has no survival value.’

C.S. Lewis

Considering the psychology, this seems non-sensical. Why would this be?

It could be a symptom of individualism; the emphasis that our Western society places on individual success, personal goal setting and the virtue of independence. Maybe it has more to do with our inclination toward all things productive, and, to (partly) quote C.S Lewis, ‘friendship is unnecessary, like philosophy, like art.... It has no survival value’. The other explanation could be our pre-occupation with romantic relationships, and the habit we have of idolising them over and above all other social attachments. In her book, Notes on Love, Lauren Windle powerfully reflects on this, she writes

‘maybe it’s time to stop looking for a partner who is also my ‘best friend’ and start appreciating my best friends. Maybe it’s time to stop feeling bereft of true love and realise that I already experience it. Every day.’

Whatever the reason(s) may be, we have neglected to take seriously the science of the social life, and the results of such an oversight are encapsulated in Elizabeth Day’s self-diagnosed ‘friendship addiction’, and the book that has documented it.

Elizabeth places her personal life on the altar in this book, she sacrifices the privacy of her emotional life.

Elizabeth talks us through her most formative of friendships - the long-standing and the fleeting, the nourishing and the draining, the durable and the fragile – this book is an ode to them all. She introduces us to her ghosts of friendship past and present (although, once they read of their appearance in this strikingly honest book, I do worry that a couple of her friends may slip from the latter into the former category), and does so in a way that makes you, as the reader, instinctively close the book for a moment and indulge the continual urge to reflect on the mosaic of people who have entered and exited your own life.

Elizabeth places her personal life on the altar in this book, she sacrifices the privacy of her emotional life for the purpose of speaking with powerful candour. She tells the intimate stories of how her addiction came to be, and how she has sought to feed her need for a thriving social life at her own expense. Elizabeth has offered herself up as a case-study of what inevitably happens when we don’t have the tools, the maps, or even the language with which to engage with the subject of friendship. As it turns out, friendship – the real kind – was not what she was addicted to, nor was it what she was accumulating. Rather, it was approval. It was the self-worth that she drew from the affirmation of others. If we, as a society, ensured that we were more socially-literate, perhaps Elizabeth could have identified the difference much sooner. Perhaps we all could.

As well as telling her own stories, Elizabeth weaves together insights from psychology, philosophy, history, and the experiences of others in differing contexts. This ensures that as many people as possible are able to find themselves in the pages of this book. And, as a result, I found Friendaholic to be the book that I didn’t know I had been missing.

It’s funny. It’s emotive. It’s generous. It’s honest. And it’s refreshingly serious about friendship. I recommend it heartily.

Nobody is totally immune to cultural individualism, the idol of productivity, nor the heroizing of romantic love.

There’s just one thing that felt missing, one insight that I instinctively began to fill any gaps with. I found myself willing Elizabeth to take a biblical route (totally unfairly, I should add, as she doesn’t identify as a Christian, nor does she claim this to be a book of any religious inclination).

I wanted her to explore the Bible, because in it, she would find an abundance of evidence for almost every point she felt compelled to make. Friendship soaks the pages of the Christian Bible.

Friendaholic quotes Jesus in its very first chapter, making reference to his declaration that ‘greater love has no one than this, that someone lay his life down for his friends’, but then never picks this astonishing claim, nor the history-altering man that it came from, up again (once again- this is no criticism, if it were, it would be a mightily unfair one). The platonic love that Elizabeth takes so seriously, and that our culture doesn’t take nearly seriously enough, is claimed to be the ‘greater’ love by Jesus, who subsequently kick-started a movement which was defined by this kind of love. Friendship was weaved into the earliest expressions of what we now call Christianity/the church. Jesus’ words were, and still are, lived out with astonishing impact.

This is not to say that Christians always perceive or do friendship perfectly. On the contrary, nobody is totally immune to cultural individualism, the idol of productivity, nor the heroizing of romantic love. Indeed, the afore mentioned quote by Lauren Windle has been taken from a book where she tells the story of ‘being single in a marriage obsessed church’.

It’s for this reason that I so enjoyed Elizabeth’s offering. Friendaholic felt like a literary dusting brush, brushing aside generations worth of dirt from a long-neglected jewel; the jewel being real, true, and deep friendship. The kind of friendship that is as integral to our health as food and shelter, the kind that was included in the original blueprint for human flourishing, the kind that is both dramatically underrated, and yet greater than all other human loves.

You can take it from an ancient book, or Elizabeth Day’s brand new one – as it turns out, they will tell you the exact same thing.

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.