Perchance to Dream What Dreams May Come: Day-Dreaming About Physician Assisted Suicide at the 2016 AAHPM Annual Assembly

What dreams may come after death frightened Hamlet to paralysis. Contemplating suicide, he explores realities far worse than death: a perpetual nightmare of greater terror than any in waking life

To die, to sleep;
To sleep: perchance to dream: ay, there’s the rub;
For in that sleep of death what dreams may come
When we have shuffled off this mortal coil,
Must give us pause.

                                            (Hamlet III, i)

In the context of Physician Assisted Suicide (PAS) and euthanasia, a perpetual nightmare of decisions and revisions (which a minute will reverse) should give us pause to reflect on what physicians do for patients, what patients ask of physicians, and why both do either. Despite the shift in values from what doctors do 'to' patients to what they do 'for' them, doctors nonetheless must consider that whatever they seek to do for patients, they often achieve this end by doing something 'to' them. The issue generates passions on either side, and the language we use points to the ground on which we stand: shall we continue to say PAS, or shall we say, perhaps more neutrally, Physician assisted Dying, or Physician aid in Dying?



As I sit through the many presentations here at the 2016 Annual Assembly of the American Academy of Hospice and Palliative Medicine and the Hospice & Palliative Nurses Association, I encounter choices considered and made, protocols considered and implemented (or not), discussions of collaborations and near-misses, issues of living and dying, and the intersection of medicine and death. As a physician-member of the Hospice and Palliative Medicine community, I share in a commitment to life, to life at the end of life, and in the perceived threat to that commitment by the process of legitimation of PAS. Certainly the formal venue the AAHPM provided for critical reflection on the matter was charged with tension and uncertainty, as genuine division played out, even if in a field of collegiality and palpable mutual respect.



What shall we do when our patients choose death and ask us for our help in achieving that goal? The choice for death in the face of illness is at once an expression of sovereignty and an expression of valediction. Yet, how are we of the good death, the death with dignity,  death and dying with compassion and comfort, to participate in the circumvention of the platform of our commitments?



Perhaps no case compels us more to consider the complexity of such matters than patients who suffer from neurodegenerative diseases, diseases where the 'body' disintegrates in the presence of a sound mind; the paradigm for such illness is amyotrophic lateral sclerosis (ALS), more familiarly known as "Lou Gehrig's Disease." In ALS, all the kinesthesias of the lived body cease; the body itself becomes the field of medical mayhem, from infection, tissue break-down and even multi-system failure. All the abandonments of the body confront a vibrancy of the mind.

Surely PAS, if it is to achieve full legitimation and broad reception throughout all cultures and sub-cultures, will achieve it in the context of the management of the end of life of those suffering in the provocative and poignant example of ALS. What compassionate spirit would not empathize with the unspeakable horror of awareness beyond the reach any instrumentality, beyond the kinesthesia of the lived body? Who but we providers of compassionate care can conjure an ear to hear the screeching silent scream of a vibrant mind howling 'hold enough'?



Moreover, that mind might present its concern to us in a full-blown personhood, well in advance of end-stage disease, in the form of a thoughtful consideration of its request for death couched in a sense of dignity and authentic values. Such values might privilege instrumentality in the hierarchy of the elements of personhood, and the human person before us might present a structure of autonomy and dignity that crumbles in light of foreseeable, total custodial care. The sheer desire of control over one's own lived life, or a desire to avoid becoming a burden to loved ones, or even to 'society' could buttress the sanest of arguments for such an exercise of personal liberty. All sympathy and empathy aligns with this projected view upon suffering, and instinctively understands the horror of being unable to influence one's world. To be clear, that deafening screech grates most profoundly in the context of a change of heart, a change from one decision, to hold the course of palliation, to another decision, where, once unable to communicate, another change of heart occurs, to abandon the palliative course and choose the pursuit of death.



Yet, something is incomplete here; things are less than resoundingly clear. The judgment that comes into view denies the possibility of an inner life within a body dying from ALS. When an attitude of the understandability of a locked-in vibrant mind detached from the body collapses, or becomes bracketed, and the inner life of the mind, spirit and the flesh appears,  another encounter sets the stage for experience. The vibrancy of mind surviving the devastation of the body might very well embrace a life of sight and sound, a life filled with music, visual arts, film, and sights and sounds, such as those of the voices and visages of loved ones, family and professional care-givers. Such values and possibilities haunt the natural attitude of the righteousness of asserting autonomy and even extreme expressions of freedom. The natural history of diseases like ALS does not occlude death, but neither does it occlude another version of quality of life that privileges the life of the mind and spirit.

Admittedly, the example of ALS has its limitations in grounding the suffering at the end of life, and is does not reflect the more immediate injury to the body that end-stage cancer does, or as heart failure or lung disease might do with their relentless dyspnea, anxiety, intense fatigue and asthenia. Yet, diseases like ALS can give a leading clue to what its sufferers think of it as they think of it in the flesh, in the self,  in the spirit and in personhood that all may be operative in the experience of other terminal illnesses. Though there might be many other points of departure here, two come to mind, and they come to bear on how one's own life is experienced in one's lived life. On the one hand, life can be thrust upon someone: I find myself thrown, without any say, power or will, into 'life' as a random event in absolute contingency. What I have not chosen I do not receive. On the other hand, my flesh gives my very self to myself, where life is given as a gift, which I do receive as a receiving self, a self 'gifted' with life. When I see myself as a random event, I have no given that brings my flesh to give a self to myself, and I can reciprocate the randomness of my facticity by rejecting life. When I am the recipient of life as a gift, I receive as the 'gifted' a gift outside any economy of exchange; I cannot return the gift. There are no givebacks when the given moves my flesh to give my self to myself.



As providers of compassionate care for patients with life-limiting and life threatening illness, we should remain open to a version of life that values life despite the loss of the body. Furthermore, as professionals treating patients whose lives are such that the stakes are so very high, we should explore, if not challenge the value systems of our patients whose suffering, or anticipated suffering, brings them to ask for death. The hospice movement and community embraces life, especially life at the end of life, and we should adopt an acutely analytical attitude when exploring the demand for death as an exercise of freedom in choosing how and when one dies. Such a critical approach cannot be limited to ruling out clinical depression, or adjustment disorder, or characterizing the various coping mechanisms that mitigate the onslaught of loss, devastation and suffering.

If our patients do indeed convince us of their judicious approach to their own autonomy, of their own critical process of evaluating their own personhood and freedom, and that their request for death is rational in their own system of judgment, then our response must, of course, be compassionate understanding and unwavering support. Still, as professionals in a discipline dedicated to the alleviation of the symptoms of suffering, we cannot choose to provide the means of death. We cannot remain true to our commitments to life at the end of life, and directly cause the end of life.

Respectful dialogue among physicians and patients in which all judgment is suspended and communication is radically free can lead to greater understanding of the issue of requesting death near the end of life. There must be a place between 'abandonment' and acquiescence in the relationship between a physician and her patient. All the legalizations and decriminalizations of physicians' acts upon their patients do not exonerate either party from their responsibility in their acts and interactions. The instant the phenomenality of the request for death enters upon the stage of medicine, we must already have seen it on the horizon. What shall we at the intersection of two selves do?

The Apotheosis of Suffering, the Trinity and the Cross---A Lenten Reflection

Lately I have referred to the Realism that pertains to Christianity rooted in the Cross as 'Catholic' or 'Christian' Realism.  These terms are interchangeable in the tradition but I will henceforth refer only to Christian Realism to avert any confusion and to confirm that this particular kind of realism does indeed have its roots the Gospels (certainly in their literary realism) and certainly in Aquinas, in the thought of Karl Rahner, in Karl Barth and in Bernard Lonergan's critical realism which itself is within the notion of Christian Realism. While Lonergan, and the like-minded Gilson, could not be mistaken for phenomenologists, the phenomenology considered in this blog is certainly rooted in Christian Realism, and offers its own kind realism; and Marion's vision of rationality is not foreign to the rational, intelligible universe of critical realism. At the center of this deployment of phenomenology is the flesh of Christ and the mystery of the Trinity.



Whatever suffers is redeemed. Because the endurance of the hypostatic union is fundamental for Christian realism, however 'mysterious' that is, the flesh that has taken upon itself all the capriciousness of the universe, all sources of suffering, is in turn taken into the Trinity itself, where it is 'cashed in', 'redeemed', for the absolute love that is the simplicity of God, the simplicity of the processions and relations within the Godhead. Capriciousness as suffering of the flesh is suffered by the Father in the Spirit as the Logos-sarx-Anthropos suffers it--- in the flesh--- 'once and for all' on the Cross. In a sense, there is nothing left of capriciousness in the Cross; it finally disintegrates in the Father's witness of the Son's flesh. The secular theme of 'redemption through love' as it courses through Goethe, Wagner and Mahler among other perhaps equally powerful currents, has this basis of its reality, its ground in the divine simplicity of love, in this analogy from 'above.'

No horizon searches with more urgency and immediacy for the horizon of meaning than the horizon of suffering. Suffering without meaning, or the hope for meaning, is not merely hopeless; it is absurd. A world of absurdity would have it that the words 'meaningful' and 'meaningless' mean the same thing. Not that the words would be synonymous, but that the thing would be either meaningful or meaningless willy-nilly in a world constituted by something other than meaning. For Christian thinking, the world is intelligible, imbued with a real rationality, and as such commands a posture of realism. For Christianity, the world makes sense.

The horizon of suffering seems to recede, withdraw endlessly into the deepest corners of reality as if it were constituted by receding and withdrawing. Because meaning is elusive, suffering become reflective, reduplicative, overwhelmed by the aporia of distance. The elusiveness of meaning holds suffering up to a mirror, and all it can see, it seems, is itself, its blinding self, its multiplying self, a self of pure suffering, unbearable and uncontainable. The horizon of meaning, just as powerfully real, also recedes and withdraws from the reality of suffering, at least from the perspective of a receding and withdrawing suffering.

Hope, oriented toward the future, envisions the intersection of the horizons of suffering and meaning at the infinite. For Christians, this infinite becomes historical in the Cross, the instantiation of suffering and meaning, the instantiation of the union of the human and the divine in the Incarnation whose purpose takes on and dissolves suffering in itself. The horizon of meaning is always on the threshold of the multi-layered chiasmus of the reality of the Trinity, where the logos-sarx-anthropos finds its nexus with the Father-Son-Spirit. Such chiasm defies articulation, but analogy can approach its description---logos-flesh/human::logos-father:/:spirit. As suggested above, the unity of the Logos provides the nexus for the entry of the flesh into the divine oikos. The inadequacy of this model, however, is at least partially addressed, and insightfully so, by Jean-Luc Marion, for whom the intersection of horizons might involve their dissolution, or perhaps their solubility, in faith, hope and charity.

Nonetheless, the union of all suffering in the Cross as enfolded within the Incarnation and the Trinity is the paradox of Christian faith itself. If a 'lesson' emerges from the experiences of the Christian mystics, it is that while one might initially strive to unite human suffering with the Cross, one discovers that the suffering flesh is already united to Cross of Christ. To seek union is therefore to find it already accomplished. The receding horizon of suffering finds its way forward, into the future foreseen by hope, by 'backing into' signification, into meaning.

Because hope (and love, too) orients itself toward the other, its motion is interpersonal and inter-Personal, as Steinbock has noted both in his Phenomenology and Mysticism and Moral Emotions. Because, as Steinbock has explicated, the Myself is not self-grounded, the suffering in the flesh (which itself is inseparable from the Myself) cannot rest in the idol as a self-reflexive suffering might indicate as noted above. The mirror held up by elusive meaning becomes translucent as the gaze catches a glimmer of the icon whose translucency refracts the gaze to what can be found beyond the reflective surface of the idolic mirror. In order, though, to find what already rests in the icon, the flesh must discover its porosity, the points where it bleeds. This uncontainability is the event of the flesh and the event of the redemption of the flesh, both saturated phenomena par excellence.

We experience this saturation and verticality in the experience of the Church as the body of Christ. This unity of our flesh with the flesh of Christ gives the flesh its meaning at the nexus of the horizons of suffering and meaning. There is no meaning of salvation beyond this: being 'saved' is finding our flesh united in the Cross and received into divinity itself. Phenomenologically, I hope with great effort to unite the suffering of my flesh to the Cross. At first,  I experience the saturated phenomenon of the idol: I am reflected back upon my self and the horizon of meaning recedes as my hope is disappointed; and I as 'subject' attempt but fail to constitute the meaning of my own suffering. Then I experience the icon: I hope for the givenness of the Cross as it gives itself as pure gift. I become the gifted when I find the Myself (as not self-grounded) in the flesh already there in the crucified Christ, who suffered the flesh once and for all. My flesh, subsumed into the flesh of Christ, discovers its meaning in the logos-sarx-anthropos, and therefore enters into the receiving breast of the mystery of the Trinity in its ever-dancing perichoresis.

The giving way of the idol to the icon perhaps play out in the phenomenal field of the body and flesh in the temptation of Christ in the desert, the pericope that traditionally opens the Lenten season.

Filled with the Holy Spirit, Jesus returned from the Jordan
and was led by the Spirit into the desert for forty days,
to be tempted by the devil.
He ate nothing during those days,
and when they were over he was hungry.
The devil said to him,
“If you are the Son of God,
command this stone to become bread.”
Jesus answered him,
“It is written, One does not live on bread alone.”
Then he took him up and showed him
all the kingdoms of the world in a single instant.
The devil said to him,
“I shall give to you all this power and glory;
for it has been handed over to me,
and I may give it to whomever I wish.
All this will be yours, if you worship me.”
Jesus said to him in reply,
“It is written:You shall worship the Lord, your God,
and him alone shall you serve.”
Then he led him to Jerusalem,
made him stand on the parapet of the temple, and said to him,
“If you are the Son of God,
throw yourself down from here, for it is written:He will command his angels concerning you, to guard you,
and:With their hands they will support you,
lest you dash your foot against a stone.”
Jesus said to him in reply,
“It also says,You shall not put the Lord, your God, to the test.”
When the devil had finished every temptation,
he departed from him for a time. [Luke 4:1-13; NAB]



At each invitation to sovereignty in this world, Jesus responds with the unconditional call of God. This rejection of sovereignty presented in Christ's rejection of temptation underscores his being in the world and his not being of the world. The turning from the idol toward the icon, as the flesh suffers the thirst of the body through its mortification in the desert, structures metanoia and the turn from worldly sovereignty toward the unconditional call. This call for us comes from the completed work of Christ, from the Cross where the experience of the call does not locate a God who chooses omnipotence's flexing the power of sovereignty, but the unconditional: the saturation of divine love in the erotic reduction. All temptation offers the idol of sovereignty; in the change of heart commanded by the Lenten season that anticipates the Passion-Resurrection of Christ, Christians hearken to the pure call, to the starkly different invitation of the divine insistence to love, to redemption of the flesh and the resurrection of the body.

Such an invitation is also found in Matthew's goats and sheep, where the evangelist offers the possibility that the invisible Christ is made visible in acts of hope and love. Such transitions from the invisible to the visible share the grammar of the shift from one saturated phenomenon to another (idol to icon), as the flesh, the Myself, not grounded in the self, finds itself already grounded in the experience of the other. In this sense, the version of intertextuality finds its analogue in the Myself whose play as object and subject in its grounding in the interpersonal and inter-Personal, reveals a strange intersubjectivity, where subjects are now objects, at once recipients of givenness, hearers of the call, accused and chosen.

Death of the Flesh: The Way of All Flesh as the Calling of Religious Community

The natural disposition of the flesh rejects non-self. Auto-immune disease results from the flesh's self mistaking itself for non-self: the flesh rejects itself. Since I provisionally accept that the body can become diseased, but we always suffer in the flesh, the self never finds itself in the body. The self and the flesh form a unity. Immunology, though, occludes the possibility of any kind of dualism in this state of affairs.

When we declare the death of the body, the body, or parts of the body often remain viable; transplant medicine bases its project on this condition. Transplantation poses problems for the flesh, as it sets up a collision of two selves. The donor's self remains in the organ (the graft) that survives the death of its body, and when transplanted into the body (the host) of another imbued with flesh, self and non-self reject each other, in the clashes of host versus graft and graft versus host. The solution to this problem is to alter the host (and graft), via immune-suppression, so that it does not recognize non-self.

As we keep the matters of the self (or selves) in mind, we can return to death. That the body, or parts of the body remains viable, we continue to note that the body experiences disease and dying, but only the flesh experiences death. Dying of the body implies cessations of functions, shutting down of systems resulting from disease. But death never completely comes to the body until every process within it ends. Such is death for the body: absolute cessation of processes. I think HAL had it right as it flashed: "life functions terminated."

The flesh suffers, and it eventually suffers death. This death is the death of the self, as the flesh and self saturate each other: there is no room for another flesh or self: relationality, saturated with the flesh, in its very excess precludes another self in the same place. Self rejects non-self.

Which is the richer phenomenon, the living on of the body, with all its life-processes and genetic coding for more function and more life, albeit in the flesh of another, or the "living on" of the flesh and self, in their excess of relationality, after the suffering of death? We cannot speak here of an "afterlife," for otherwise we would not be speaking of a saturated phenomenon: we speak therefore of the life of the flesh, and the death of the flesh. The saturated phenomenon of the flesh achieves a negative certainty that the death of the flesh and death of the body are different phenomena. Better we should speak of something like an "afterdeath," or come up with a more robust understanding of death as it applies to the flesh. The reader should abandon this reflection now if she expects a discussion of 'consciousness after death' to ensue.

The event of death forecloses on disclosure. We defer any exploration of the relationship between self and consciousness. Instead we maintain the location of consciousness in the flesh and body of living creatures. So our question[s]: does the givenness of death constitute the self of the recipient in the phenomenological moment? Is that constitution fatal, or does it itself impart 'mortality?' Because we do not experience death as the death of our own flesh as a counter-experience, we are open only to the experience of the death of the other as death of the flesh. This is not to say that we do not have some experience of some aspect of death as our own, and in this regard, imaginative variations of the reduction can be in play; but because of the foreclosure of the event to us, that is, the necessarily incomplete 'reportage' of this event, the reception of death has no place to project itself.

If the flesh grounds Dasein's being in the world and its authentication through its being toward death, then at least one response of the self to the givenness of death is expectation. This is the way of all flesh: to receive formation of the self from the givenness of death, not in its lethality but in its invitation to authenticity, albeit in the manner of a special case of expectation: of advent and a messianism. The givenness of death calls the self into being, the self into a formation. The community, grounded in the experience of the self as the witness of phenomenality of the death of the other, arises in response to the same call.

The death of the other discloses terror or hope; if terror then a community of magic and superstition arises. If hope, a community of advent, of a messianism of an anonymous religion, an unthematic religion, arises. The former community is poised for a pantheon, the latter for Mashiach. The former is poised for rejection of non-self; the latter is poised for the self of the other as another in the flesh that is the image and likeness of my flesh. In this manner the phenomenality of death, the event of death, recapitulates the call of a community into the event of religion in each and every death; as the 'called' community recapitulates the givenness of death in the phenomenological moment. It is through religion that expectation, the response to the givenness of death, opens upon the possibility of revelation.