Margaret Somerville, one of Canada’s preeminent public intellectuals, has been involved in some of society’s most intractable and heated debates about medical ethics—including issues such as abortion, genetic testing, euthanasia, pain management and palliative care, and more. In many ways, her work has focused on fundamental questions at the beginning and end of life. But in this conversation with Comment editor Jamie Smith, they spend time talking about health more broadly (including the way health can become a kind of idol in secular societies) and what gives her hope.
JS: A lot of your work as a scholar has explored questions at the beginning of life like reproductive technologies, genetics, and so on, and questions at the end of life like physician-assisted suicide and euthanasia. I’m intrigued to hear you say a little bit more on how we think about health between those momentous bookends of a life. Do you think we too narrowly associate health with medicine? Is that a fair question? Does that make sense?
MS: Yes, absolutely. And we too narrowly associate it with physical health.
JS: Yes, great point.
MS: I think that’s why the larger concept of “healing” is so important. Actually, there are some emerging terms in medicine. One of them is “whole person” medicine, which takes into account a much broader range. For example, here at McGill, we’ve got a new medical-school curriculum and it’s expressly called “The Healing Curriculum.” There’s an old saying that the doctor or the physician should cure where possible, care always, and never kill. Don Boudreau and I did some jointly authored papers about euthanasia. One of the questions we looked at was, What does healing mean? and one of our conclusions— although it sounds counterintuitive— was that you can actually die healed. So healing is different from curing.
JS: That gets into what I think used to be some tensions between the medical and nursing disciplines regarding cure and care. It sounds like the medical profession is also embracing the more holistic care paradigm, or one would hope.
MS: Yes, but you’ve got to be really careful with that tension between medicine and nursing. It still exists, Jamie, and it’s still very. . . . It’s very tense sometimes. What has happened is that nurses, I think with justification, saw applied ethics as a way of challenging medicine, and they became the standard-bearers for bringing applied ethics into the hospitals. They became the patients’ representatives and advocates, and that took away some of the hierarchical power from the physician. There’s still a tension in this hierarchy, I think.
JS: I’m intrigued by the healing metaphor. I hear in that a reactive paradigm: Of course healing is a wonderful thing, but it assumes health is a response to illness, injury. It’s a reactive model as opposed to a proactive one, fostering flourishing as health. I’m probably mishearing it, but do you know what I mean? It seems to me you only need to be healed if there’s something wrong, whereas “health” is something more positive—about fostering “wellness.”
MS: I don’t think you’re mishearing it, Jamie. I think that’s right, but we have to be careful about making words carry so much meaning that they no longer mean anything. I think that’s the danger of this very expansive definition of health.
JS: So do you want to keep the terms “health” and “healing” circumscribed precisely so the health-care industry doesn’t spill over and become responsible for everything? I’m thinking, for example, of a lot of the work involved in “community health.” In that case, a lot of what health-care professionals are trying to heal are the effects of destructive lifestyles and cultures. But if families function well, if communities function well, they will foster wellness. It’s not the responsibility of a health-care industry to do that.
MS: Yes, but I think there’s a difference between using “health” as a noun and “healthy” as an adjective or as an adverb. We can’t make it everything. We’ve got to be clear what we mean. We can talk about a healthy society and ask, What are the conditions that a society would have to have to be what we might want to call “healthy”? Or we can talk about acting in a healthy way, which is your adverb, and say, what does that mean? Not smoking, perhaps. Drinking less alcohol in my case. [laughter]
JS: Is the point to make sure that the responsibility for a healthy society is widely dispersed?
MS: Yes. But the question is, To what extent does our ubiquitous use of the word “health” mean that we’ve lost fulfilling other goals that a narrower and more precise concept of health would help us to achieve? This expansive definition is what I call “healthism.”
I’d been writing about the emergence of “secular religions” and there’s scientism and nationalism and sportism. Then suddenly it occurred to me: this healthism is a secular religion, and it’s remarkable when you go through it. It has its mortal sins and its venial sins. You’ve got the search for additional life, if not immortality. It’s got a lot of parallels.
One of my theses is that for a lot of people in a secular society, this pursuit of health has replaced religion. For example, there’s the idea of original sin in religion, that there’s some innate fault in us. There’s a version of this in healthism. I was talking to one of my physician friends and he said to me, “You know, Margo, the well are only the undiagnosed sick.” It used to be that we had a basic presumption that we were well until we got sick. Now we’ve got a basic presumption that we’re sick and we’re trying to hang on by our fingernails, to try and be a little bit well. Imagine what that does, not just to each of us individually, but to our collective psyche, because I believe that societies have a psyche as well as individuals. Paradoxically, in so obsessively pursuing health we become sick. But that fits with the side effects of medical treatment: we can end up sicker from having interventions than before them. As with everything, we need to choose wisely and to realize it’s a matter of balancing benefits and risks and harms. I’m quite interested in that whole area of the role that our imaginings about health play in our current sociocultural paradigm.
JS: I just read an article in the Virginia Quarterly Review that analyzed the health-food scene in San Francisco. The author describes it as the way for Bay Area people to grasp a quasi-transcendence. It comes with a new Puritanism about it as well, so there’s a haughty, moral affect that comes along with it. This would be part of the “healthism” you’re talking about. What you’re calling “healthism” is, I suppose, what’s left to a society that has enclosed itself within the material world and yet can’t shake the sense of looking for a kind of immortality. “Health” is almost the last good that we can imagine, so we try to roll all goods into it.
MS: Yes, but it’s not just that. It’s also possibly, and I do argue this, that it’s the last good in relation to which we can all agree it is a good because everybody, every single person, has a personal interest in it. That’s not true for almost anything else anymore. It used to be different. The reason I call it “healthism” and why I call it a secular religion is that a lot of the individual, communal— family particularly—and societal functions that religion used to construct and carry we’re now using health care to do. That’s healthism.
JS: That is an important insight that I think illuminates a number of cultural trends.
I was looking again at one of your earlier books, The Ethical Canary, and was intrigued by a powerful line. You say, “We are never more alone than when we are ill.” It struck me that this gets at how inherently social health is and flourishing is. Would that mean that our society’s fixation on autonomy and independence already undercuts health, in a way?
MS: Yes. It’s not that autonomy and independence are bad. They’re not. They’re good. When they become the only thing that matters and the only value, and the value that always take priority, then there is a problem. I just saw an extreme example of this, a new book called Autonomous Motherhood. It’s about women intentionally deciding to be single mothers. I believe that makes the child vulnerable, more alone, than a child with a mother and a father. And no matter how strong we are, illness makes us all vulnerable. When you become ill, you become a vulnerable person. Being alone and vulnerable is very frightening. Very frightening. It’s interesting that some feminist scholars are developing concepts such as “relational autonomy”; they’re recognizing we can’t flourish just as isolated autonomous human atoms, and they’re seeking to remedy such situations.
JS: Which is why, if we lose the ability to imagine a sense of community and the common good, all of us are going to find ourselves isolated and frightened in the face of that illness, because we will be more and more vulnerable.
MS: Yes. The best body of both work and literature on this is in the fields of palliative care and hospice. In fact, I’m thinking of a quick trip to Australia next week. I go to Australia like most people go down the road. My ninety-four-year-old aunt is extremely weak and, as she phrases it, on the way to heaven, what we call on your “last legs” in Australia or “about to fall off the perch.” (Australians have colorful language for many realities including death.) I have a very close friend there who is a physician and was the head of palliative care for two major hospitals in Adelaide and is currently the chair of the Palliative Care Council of Australia. She’s also a very close friend of my aunt and visits her daily. It’s as though my aunt has her own private palliative-care physician.
When I was there a couple of weeks ago and observed what she does, it is so intelligent and insightful and supportive. Unless you knew what you were looking at, you wouldn’t recognize the therapies she’s using. The way she asks my aunt difficult questions when I’d blunder in and put it in a way that I’m sure could probably be upsetting. Yet she can talk to her about what she wants and ask her if she wants treatment and what it means. It’s just amazing. I think, Jamie, that one of the things we’ve got to do is find the appropriate words and the appropriate means of communication to talk about the big things in life such as death, and I think a lot of us have lost that. It’s really sad.
JS: Are you generally encouraged by the development of palliative care over the past decade?
MS: Yes, but I’m appalled that in Canada, for instance, at best 30 percent of people get palliative care. Actually it’s probably between 16 and 30 percent. I think that’s a breach of fundamental human rights. It’s not just a breach for that person who’s dying. It’s a breach for the family, to see somebody you love in serious pain and to have no health care or health-care professionals available to do something about that.
I was pulled into this debate. My dad was dying of disseminated prostate cancer in the early 1980s. I flew home to Australia to see him because they told me he was going to die. When I got there, he was in a university hospital, so it wasn’t some little outback place. He was in excruciating pain, and I went ballistic and got a top pain specialist and he came within a few hours, got my dad out of pain, and my dad lived for another nine months pain free.
My father said to me, “You know, Margo. I didn’t want to live. I wanted to die if I had to be in that pain. But if I wasn’t in the pain, it was okay.” He said, “It was wonderful you could come home and do this. But not everybody’s got a daughter who’s a lawyer and an ethicist and can turn a major hospital upside down.” He said,
“You’ve got to do something for everybody else.” I started writing on it as a result of that. I got invited to give the opening speech at the International Association for the Study of Pain in Paris in 1993. I gave a paper asking if we can use ethics and law to ensure that people get pain-relief treatment, and I worked out this scheme. My basic suggestion was that we should argue it’s—again, it’s the use of words—a breach of fundamental human rights for a healthcare professional to unreasonably leave somebody in serious pain. That was adopted through the work of a whole lot of other people as [the International Association for the Study of Pain’s] “The Declaration of Montreal,” asserting that access to pain management is a fundamental human right.
That’s what can happen. You use words, and if they’re words that people can relate to, they can say, “Gosh, that’s a breach of fundamental human rights. We’ve got to do something about that.”
JS: That’s so encouraging. There’s a lesson there about patience, because it took from 1993 until 2010 to have this impact.
MS: Well, actually it all started in 1981.
JS: Okay—so there was a long road from 1981 to 2010 before your work made a cultural dent. That in itself is an interesting lesson. That’s a very encouraging word about the nature of scholarship— and the work of a think tank like Cardus—that aims to contribute to society. There’s a trickle-down effect that you can’t control or even anticipate, and yet sometimes toiling away on things can have repercussions down the road.
You mentioned that a reporter once asked you what your favourite line was you’d ever written, and you cited a line from your Massey Lectures, The Ethical Imagination: “Hope is the oxygen of the human spirit.”
It’s so beautiful that you would affirm that when, in a way, so many of the issues you’re working on could make one despair. Are you hopeful for the ability of our societies to remember and recover some of the things you’re talking about? Are you hopeful that a coming generation will hear what you’re saying about, for example, what you call our metaphysical ecosystem?
MS: Well, you see, I think that’s language that will appeal to the younger people because they’re into environmentalism. That’s another secular religion. They’ve already experienced that as a religion. So, yes, I think it will.
Jamie, when you said that word “remember,” I thought, Gosh, isn’t that interesting? I’ve never thought of this before, but it’s re-member. Put back together, eh? And it’s very much like the Latin religare, “religion.” To rebind together.
JS: In a sense, that’s what your work is doing. We are indebted to you. Margo, this has been fantastic. Thank you so much for making the time. I really appreciate it.