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How Then Should We Die?:
Two Opposing Responses to the Challenges of Suffering and Death

by s. kay toombs
colloquium press, 170 pages, $10

In 1936, C. S. Lewis’s friend and physician R. E. Havard penned a letter reflecting on the newly-introduced Voluntary Euthanasia Bill, a proposal rejected by the House of Lords later that year. Viewing attempts to legalize medically-sanctioned suicide as the “logical sequel to the secularization of society,” he mused that its legalization would “add to, not reduce, the distress . . . surrounding death.”1 Permitting euthanasia, Havard argued, would not only defy the medico-ethical tradition expressed in the Hippocratic oath and thereby harm the patient-physician relationship, but also worsen the suffering of the severely ill themselves, causing patients to feel that it was their “duty” to spare others the “burden” of witnessing their suffering. 

Nearly ninety years later, physician-assisted suicide (PAS) has become legal in over ten countries and a growing number of states in the U.S.: Oregon, Vermont, Washington, Colorado, California, Hawaii, New Mexico, New Jersey, and Maine. (It remains illegal in the United Kingdom.) The Western social imaginary surrounding medicine—and death—has clearly shifted. Have Dr. Havard’s predictions come to pass?  

Invoking Francis Schaeffer’s 1976 classic, How Should We Then Live?, S. Kay Toombs’s How Then Should We Die? dissects prevailing cultural attitudes toward illness, disability, and death. She draws two distinct portraits: 1) disability and illness as understood in a culture that considers autonomy a “cardinal value” and embraces physician-assisted suicide as “death with dignity,” and 2) how disability and terminal illness are accommodated in covenantal Christian community. Each likeness reflects its own predominant methodology. Parts one and two, “Cultural Values and a Loss of Dignity” and “Dying with Dignity: A Cultural Perspective,” draw on bioethics, popular media, survey data, and the legal landscape surrounding physician-assisted suicide, while the final part, “A Culture of Healing: Living and Dying with Dignity in the Context of Christian Community,” is pastoral and personal in tone. Throughout, Toombs draws from her own multi-faceted experiences: as a Christian “living in a nondenominational Christian community for more than twenty years,” as an associate professor emerita of philosophy, as an individual who has lived with disability—in the form of Multiple Sclerosis—for decades, and as a wife who supported her husband, Dee, through the terminal stages of cancer. 

Her goal is not to provide a comprehensive history of physician-assisted suicide but a primer for a Christian audience that examines the patterns of thought surrounding the practice—including the role of media and the rhetorical undertones of the “right to die” movement. Language is important here: Is it “physician-assisted suicide,” or something that avoids the connotations of “suicide,” a word whose meaning has remained stable since its English appearance in Thomas Browne’s Religio Medici (1643)? What happens when we shorten physician-assisted suicide to “PAS” or roll down the slope of euphemism? In Canada, for example, where “medical assistance in dying” has become “MAID,” persons suffering exclusively from mental illness will be eligible to end their lives next year. 

Toombs understands this shifting language as symptomatic of a new culture of death, a social imaginary that shapes not only the lived realities of those experiencing illness and disability, but also our society’s attitudes toward medicine and personhood writ large. Her judgment of physician-assisted suicide is harsh, yet her approach is sympathetic; she feels “a certain uncomfortable kinship” with patients who seek medically-furnished deaths. 

The first two sections of How Then Should We Live? rehearse a story familiar to those acquainted with the controversies tied to physician-assisted suicide. Toombs quotes the usual spectrum of bioethicists and discusses several notable cases, including that of Brittany Maynard, a twenty-nine-year-old American woman who ended her life in 2014 following a battle with brain cancer. Toombs’s book, however, is distinct for its implicitly phenomenological focus, reflecting her previous scholarship on the experience of living with illness and disability (including her 1992 The Meaning of Illness: A Phenomenological Account of the Different Perspectives of Physician and Patient). She stresses how contemporary discussions of death emphasize autonomy in a way that diminishes the mutuality of caregiving relationships, generating both caregiver resentment and self-recrimination on the part of the cared-for. When physician-assisted suicide is normalized, she argues, a natural death becomes unnatural, unimaginable, and abject. Confirming Havard's predictions, Toombs links the increasing push for physician-assisted death with our collective desire not to bear witness to suffering, suggesting that we self-kill out of obligation to spare others. She fears that while physician-assisted suicide is now elective, a sense of duty will transform it into an expected, even compulsory, path. 

The final portion of Toombs’s book rejects the “almost ‘magical’ confidence” our culture places in medicine and describes how covenantal Christian living transforms illness, disability, and death. In a community characterized by self-sacrificial love, she argues, “the incurably ill and dying are not separated from the community of living, but . . . remain at the center of a web of intimate and supportive relationships that continue to affirm the value of their existence.” She draws evidence from the experience of her community: Stevie, a child who suffered a rare form of muscular dystrophy; Perry, a young father with Lou Gehrig’s disease; Dee, who was cared for by church members for the final three months of his life. When he became too weak for Toombs to care for him alone, fifteen women from their community volunteered for round-the-clock shifts. In a context of radical self-giving, Dee’s growing physical limitations were not perceived as a burden but as an opportunity to enact love, transforming even his own perception of his illness. Toombs recounts a day in which Dee recast physical distress itself as a “healing experience,” an apparent paradox furnished by the experience of “supernatural love . . . expressed through the self-sacrificial service of others.” 

Such accounts of suffering-unto-death may sound aspirational to jaded ears; in claiming witness to supernatural grace, Toombs states that friends who faced terminal illness died with grace and peace, “without exception.” Yet Toombs’s willingness to bear witness to the realities of human suffering and death—and contextualize them in the Christian Story—challenges her reader to see differently, to understand terminal disability through the reality of the cross, the “ultimate symbol of dislocation and shared vulnerability” described by Michael Mayne. In affirming the centrality of the cross, Toombs does not “romanticize the rigors of dying” or turn away from the grim realities of physical suffering. If the Crucifixion—and the command of Matthew 16:24–26—radically changes the significance of human suffering, it also demands that we imagine death differently: not as an intolerable defeat or the violation of our cherished idols of self-determination, but as an opportunity to affirm and deepen our relationships with God and each other.

In providing a Christian response to euthanasia, R. E. Havard wrote of the “courage to face suffering,” a courage that “only Christianity can give.” In re-imagining death in the context of Christian covenantal community, Toombs’s courage is more than evident. 

Sarah O’Dell is an MD/PhD candidate and medical humanities scholar in Southern California.


1 Letter from R. E. Havard to Miss G. Cobb, November 30,1936. Robert Havard Papers, Folder 6, Wheaton College, Wheaton, IL. Used with permission. 

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