toys in the attic:
ideological furnishings for the
homeless mind
The "Gift of
Life" and Its Reciprocation
TALCOTT PARSONS, RENEE
C. FOX, AND VICTOR M. LIDZ
The
Judeo-Christian Symbolization of Life and Death
The
Moral Basis of Modern Medical Ethics
The physician's
involvement with problems of life and death
"Scientific"
medicine and the "existential" problem
Exacerbation of
strain by technical advances
Emergence of new
definitions of the situation
The restructuring
of medical ethics
The
"Existential" Problem of Death in Medical Perspective
The broadening of the
range of "concern "for medical decisions
Organ transplants and
the gift complex
A few years ago, two of us (Parsons and Lidz) ventured to write a
rather general article under the title "Death in American Society."1 For the present venture we have been joined
by Renee Fox, and the three of us have decided both to extend the analysis of
the earlier article and to narrow the focus.
The "extension"consists in going considerably deeper into the background of
current American orientations toward death and its meaning in the
Judeo-Christian religious tradition than was attempted in the earlier
paper. The "narrowing"
consists in trying to focus on the institutionalization in America of the
promotion of health and the care of illness, with special reference to the
medical profession and its ethical orientations.
This focus seems
particularly appropriate since the most important empirical argument of the
earlier paper concerned the distinction between the inevitability of the death
of every person, marking the completion of a full "life course," and
the "adventitious" components of the death complex. The latter includes two types of premature
death: that brought about by "impersonal" causes - for the most part
disease, but also accident - and that imposed by what is in some sense willful
human action, such as "violence." It is often difficult to draw a
line between accidental and violent death, but the analytical distinction is
crucial.
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The most dramatic
consequence of recent developments in health care has been - and within
somewhat more than a century in the "advanced" societies - the
doubling, if not slightly more, of life expectancy at birth. To a degree never before true, it has become
customary for the aware individual to expect that he will live to complete a
"normal" span of life and for parents, that their children, if born
alive and healthy, will also do so. The
differentiation of the inevitable from the adventitious aspects of death has
focused a more powerful light than before on the component of
inevitability. If so much is
controllable byhuman action, one must ask, what does it mean that there is
nevertheless an absolute limit to our control?
This problem of meaning, of course, bears with special cogency on members
of the medical profession because they are par excellence the
institutionalized trustees of society's interest in the preservation of
life.
We will note that
there has been in recent years a significant increase in both medical and
popular concern with the "existential" aspects of death and also
suffering. Indeed, the volume which Dr.
Shneidman edited - part of a rapidly growing literature - attests to this fact,
as does the greatly enhanced concern of
medical students and physicians themselves.
The earlier
Parsons-Lidz article used as a foil a paper by Peter Berger in which he claimed
that the "denial" of death was a basic aspect of the American
outlook.2 We still think we
were right in refusing that interpretation.
We now believe, however, that it is not necessary to make an either/or
choice between "acceptance" and "denial"; we believe that,
as in many cases involving underlying conflicts, what is often interpreted as
denial is in reality a kind of "apathy" - i.e., being in a situation of
not knowing quite what to say or do and thus minimizing overt expression or
action. This may also be reinforced by
the "stoical" component of the Puritan tradition. We shall attempt to show how certain
features of the medical situation and medical ethics have involved this kind of
conflict with this kind of result.
On the positive
side, we wish to re-emphasize what we consider the fully established view -
that it is biologically normal for all individual organisms to die. Death is now understood to be an important
mechanism enhancing the adaptive flexibility of the species through the sacrifice
of individuals; i.e., it makes certain that the bearers of newly emergent
genetic patterns will rapidly succeed the bearers of older ones. Death may be even more critically important
in contributing to cultural growth and flexibility than in supporting genetic
change. Thus, we may regard death as a
major contributor to the evolutionary enhancement of life, and thereby it
becomes a significant part of the aggregate "gift of life" that all
particular lives should end in death.
That is why it cannot be a rational pursuit of modern medicine to try to
end or even minimize the “inevitable'' aspect of death.
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Our approach will
emphasize theoretical continuity between the organic and the human
socio-cultural levels, through the premise that the mortality of individuals
has a positive functional significance for both human societies and the organic
species. Beyond that, yet intimately related to it, is the fundamentaldistinction between, on the one hand, the "phenotypical"
incorporation of genetic patterns in the lives of individual organisms and
populations, and the genetic components themselves, and on the other hand, the
modes and conditions of their preservation, implementation and development in
the evolutionary sense. It is in this
spirit that we devote our first substantive discussion to the field of cultural symbolization which in America bears on the
problem of the meaning of death and, of course, its opposite, life. We think that the most important themes are
found in the "constitutive symbolization" of the religious heritage.3 To be sure, a substantial part of our
contemporary population purports to "take no stock in religion." We feel, however, that the patterns of
symbolization which we shall review have come to be constitutive of the whole culture by which we live, and that their
relevance is by no means confined to the lives of self-consciously
"religious" people. As social
scientists we do not think that ''science'' in the usual sense has provided
''functionally equivalent'' symbolic patterns of orientation, though we think
that the evidence just cited of the positive biological function of death and
the recent enhancement of life expectancies is highly pertinent to our
problem.
We shall be
dealing with religious symbolism predominantly in the context of what has come
to be called myth, in the sense used by
Lévi-Strauss and Leach, and in another, related field, by Kenneth Burke and
Northrop Frye.4 We are not
concerned with the problem of the historical veracity of the Books of Genesis and Exodus,
or of the Four Gospels, but with clarifying
the "structure," as Lévi-Strauss would put it, of certain of the
themes expressed in such documents insofar as they bear on the problem of
orientation to the death-life aspects of the human condition. Neither will we be concerned with the
metaphysical question
of the "existence of God." For us this belief is simply a basic element of the myth.
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In addition, a
principal theoretical emphasis has become much more salient than it was in the
Parson-Lidz paper, and has been especially emphasized by Fox in connection with
her work with Judith Swazey on the ''existential'' problems involved in organ transplants,
which will be discussed below.5
This is the theme of the importance of the gift
and of gift-exchange, as it was classically introduced into social science
literature - though not without antecedents - a generation ago by Marcel Mauss.6 It will be remembered that Mauss stressed
not only the ubiquity, in human cultures, of the theme of the giving of gifts, but also how this giving creates, for the recipients of gifts, an obligation to reciprocate, which on occasion
can be onerous indeed.
In the following
section of the paper it will be our principal thesis that in the
Judeo-Christian tradition - and especially in the Christian phase - life, for
the individual, is defined in the first instance as
a gift,
directly or indirectly, from God. It may
be a niggardly gift, as with those born only to misery, want and suffering, or
a munificent gift, as with those born with great talent and good fortune. Yet in both cases the gift of life creates
an obligation to reciprocate. Our
second main thesis will then be that the trend of religio-cultural development
within this tradition has been toward defining the death of the individual,
especially in the fullness of a complete life, as itself the gift which
constitutes a full reciprocation of the original gift of life.
Not only may the obligation to reciprocate gifts be onerous, but the tragic view of the human condition has been in many vital respects structured about this onerousness. First, recipients must somehow be motivated to try to reciprocate: religiously, this commitment has, in our tradition, oftenbeen formulated as "faith." But the gifts, as we have noted, are by no means of equal value, and the sheer difficulties of reciprocation, except by "giving up," may be insurmountable. Particularly potent as a focus oftragedy is the fact that the fates of individuals are never neatly ordered in relation to those of the social collectivities in which they hold deeply meaningful membership. God is concerned not only with individuals but with "peoples" in the Old Testament sense. The problems of the beneficence or malevolence ofGod and of the shortcomings of individual human beings, religiously formulated as sin, are not to be neatly shoved aside by an equation of the reciprocity of gifts alone.
continued ...