The Troubled Dream of Life: Living with Mortality
Daniel Callahan
Simon & Schuster, New York City, 1993, 255 pp., $21
This is an extraordinary book, written with power and insight. At last we have a book that uncovers the foundations of the euthanasia movement, as well as the movement toward a just healthcare system.
Daniel Callahan discloses that the euthanasia movement stems from and contributes to a desire to avoid facing death. Enthusiasts for euthanasia want to deal with the pain and suffering of dying and the burdens of dependence by opting out of life. Callahan argues that we need to cultivate virtues that enable us to live with our mortality. His argument forces us to ask, How can we know what kind of life to promote through healthcare reform unless we have an adequate understanding of the place of death in human life? In these ways, The Troubled Dream of Life can be read as a sequel to Callahan's What Kind of Life: The Limits of Medical Progress (1990) to form a trilogy with his Setting Limits: Medical Goals in an Aging Society (1987).
A plethora of books exists on death and dying, dealing with legal, ethical, and medical case analysis or with the shaping of public policies. As yet, none to my knowledge has taken these analyses to such a depth, reflecting on the place and meaning of death itself and how we might integrate the fact of death into who we are and how we approach life or practice medicine. Having tried to follow the debates about appropriate care of the dying, I regard this book as one of the best on the subject.
The Troubled Dream of Life is a masterful work about the foundations of morality and policy. Needless to say, its timing is perfect, appearing as it does in the midst of debates about the future of healthcare reform and on euthanasia and assisted suicide policies. It uncovers the wisdom behind the principles guiding case analysis and sketches the spiritual vision and philosophical framework for shaping social policies. The book demonstrates Callahan's belief that many of the medical, ethical, and legal problems we face in trying to decide about care of the dying stem from mistaken views of death (e.g., that we can control it) and from our ambivalence about whether to accept or reject death.
If it is true, as virtue ethics contends, that morality begins with the cleansing of vision, then The Troubled Dream of Life begins in the right place. The first half of the book illustrates the relationship between perception and action. Callahan demonstrates that society needs to see the true shape of scientific medicine and clinical practice if we are ever going to live differently with death as a fact of life and change the way we care for the dying. The first three chapters analyze the dominating illusions about the use of technology in medicine, about the powers of nature being replaced by human agents, and about the self in need of control. The second half of the book is his creative proposal. Here Callahan offers a compelling image of the self that is not obsessed with the need to be in control; he addresses the appropriate use of technology in medicine; and he reflects on the meaning of death in our personal and communal lives.
Callahan's hope is that medicine will begin to use the fact of death as its focal point so that medicine's aim would be not to struggle endlessly against death but to help humans best live a mortal life. To this end, Callahan recommends that we stop asking, When is a patient dying and thus no longer a candidate for life-extending treatments? Rather, the more appropriate question is, When should the presumption to treat be changed to enhance the likelihood of a peaceful death? He believes we will begin to move in this direction when the acceptance, management, and understanding of death become just as integral to medicine as is the pursuit of health. As a result, hospice would not remain a sideshow to medicine's main event — the pursuit of health. Hospice would have full status under medicine's big top.
Callahan also argues strongly against the need for euthanasia to achieve a peaceful death. He believes that more people would be able to die peacefully if we as a society integrated the fact of death into life and changed our attitudes and expectations of what medicine can do. He doubts that advance directives will do enough to allay fears about dying or to secure limits to treatment. Callahan's response is the best response I have seen to the basic claims of the euthanasia movement, namely, the right to self-determination and the obligation healthcare providers (especially physicians) have to relieve the suffering of others if they can. For this section alone, the book deserves attention.
A unique feature of The Troubled Dream of Life is its judicious use of autobiography. Callahan has obviously been personally affected by his efforts to face death in his own life and in the lives of people around him. Occasional references to how death has challenged him (especially in matters of control and dependence) or changed him show how one can move back and forth between personal issues and larger questions of philosophy, religion, and social policy. In doing this, Callahan provides a model for all of us to do the same kind of soul-searching.
Christian believers who know that they are blinded by the same illusions which Callahan discloses want to turn to their religious convictions and symbols (such as the cross, resurrection, redemption, paschal mystery) to have their vision healed. Callahan's book, valuable in so many other ways, will not help them there. His argument shows that one does not have to be a believer to integrate death into life or to die a peaceful death. Because the book is thoroughly philosophical, its principal arguments and proposals address people of all faiths or of none. For this reason, it has broad appeal.
Yet a theological case can also be made. For example, a theology of letting go (arising out of our ascetic tradition) tells us that we need to grasp life lightly and sometimes let go of personal interests for the sake of other people. Such a theology offers a crucial perspective for integrating death into our lives. Belief in the resurrection, with its hope that there is more to life than what we experience on earth, can also ready us to face death and focus on its meaning. Although these perspectives are compatible with those of Callahan, he does not name or use them to support his proposal.
The Troubled Dream of Life deals with complex concepts and arguments, but it is not a book just for philosophers. In part it functions as a kind of "spiritual reading," especially when asking the big questions about the meaning of death, about pain and suffering, about living with the fact of death, and about the character required to die as we would wish. Callahan writes so clearly that his concepts and arguments are readily accessible to all readers.
This book is required reading for everyone at every level of healthcare ministry, since its central concern — how we might think about death in our lives — is everyone's concern. We cannot expect to see any substantial changes in the way we deliver care until we, individually and as a culture, integrate the fact of death into who we are and how we approach life. Callahan helps us look more realistically at death and think more clearly about how we might integrate death into the practice of living and into the science-art of medicine.
Reviewed by Rev. Richard M. Gula, SS, Professor of Moral Theology, St. Patrick's Seminary, Menlo Park, CA