Liberalism’s Troubled Search for Equalityundpress/excerpts/P01143-ex.pdf3. Euthanasia—Religious...

Liberal i sm’s

Troubled Search

for Equa l i t y

Religion and Cultural Bias in the Oregon Physician-Assisted

Suicide Debates

ROBERT P. JONES

University of Notre Dame Press

Notre Dame, Indiana

Jones 000.FM 1/16/07 1:17 PM Page iii

© 2007 University of Notre Dame Press

Copyright © 2007 by University of Notre DameNotre Dame, Indiana 46556

www.undpress.nd.eduAll Rights Reserved

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Library of Congress Cataloging-in-Publication Data

Jones, Robert P.Liberalism's troubled search for equality : religion and cultural bias in

the Oregon physician-assisted suicide debates / Robert P. Jones.p. cm.

Includes bibliographical references and index.isbn-13: 978-0-268-03267-8 (pbk. : alk. paper)

isbn-10: 0-268-03267-x (pbk. : alk. paper)1. Assisted suicide—Religious aspects. 2. Right to die—Religious aspects.

3. Euthanasia—Religious aspects. 4. Assisted suicide—Social aspects.5. Right to die—Social aspects. 6. Euthanasia—Social aspects. I. Title.

r726.j6635 2007179.7—dc22

2006039827

∞ The paper in this book meets the guidelines for permanence and durability of the Committee on Production Guidelines for Book Longevity

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Acknowledgments

While research and writing often feel like solo projects and books like indi-vidual accomplishments, they are social endeavors, requiring support froma number of sources, both professional and personal. I have been fortunateto have had both during my work.

I wish to thank first Jon P. Gunnemann, who taught my first graduateseminar, a course in political theory, at Emory University’s Graduate Divi-sion of Religion over a decade ago. Jon served as a trusted teacher, mentor,friend, and director of my thesis, which laid the foundation for this book.I also benefited from an outstanding and dedicated thesis committee. I amgrateful to Elizabeth M. Bounds for conversations about social theory andfor reading critically the final manuscript; Timothy P. Jackson for lively,ongoing discussions about John Rawls, Ronald Dworkin, and physician-assisted suicide; and Steven M. Tipton for discussions about Emile Durk-heim, Mary Douglas, and his own work in sociology of morality. A specialword of gratitude is warranted as well for Jeff B. Pool, who, as my system-atic theology professor during some tumultuous years at Southwestern Bap-tist Theological Seminary, modeled scholarly integrity, introduced me totheological and philosophical ethics, and encouraged me to pursue an aca-demic career.

Chris Scharen and Graham Reside provided crucial support duringthe first year of writing. The blend of generosity, encouragement, and hon-esty at our Friday meetings provided just the right amount of threat, commu-nity, and encouragement to help me first “put something on the page” and

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then have the patience to identify connections and gems of truth amidstmany drafts that were hardly worthy of the word “rough.” Others have beenhelpful as teachers, critics, friends, and supporters at various stages alongthe way: Dan Cox, Nancy Eiesland, Martha Finch, Richard Glen, James M.Gustafson, Brad Hadaway, Karey Harwood, Ken Hester, Chris Libby, MarieMarquardt, Peter Montgomery, John Schmalzbauer, David Saperstein, TedSmith, Melissa Snarr, Melissa Stewart, and Alan Wright.

I have also been the fortunate recipient of strong institutional support.Emory University provided a graduate fellowship, a Dean’s Teaching Fel-lowship, and two field research grants, which made possible my fieldworkin Oregon in 1999 and 2000 among religious and political activists in thedebates over the Oregon Death with Dignity Act. Missouri State Univer-sity provided both a first academic home with great colleagues and a Fac-ulty Fellowship that supported additional research and writing time thattransformed the thesis into a book. Finally, the Center for American Valuesin Public Life at People for the American Way Foundation provided supportfor the final revisions of the book. Micha Rieser, an intern at the Center,read the entire manuscript with a careful eye.

I dedicate this first book to my daughter, Riley, who arrived in the worldafter the anticipated but before the actual completion of my thesis. She’sheard about “daddy’s book” her whole life, and it is particularly meaning-ful that it is coming into being in a public way just as she’s learning how toread. I hope that this book provides some modest contribution to makingthe world in which she will live more equal and more just. I also want tothank Riley’s mother, Amy, who supported me financially during graduateschool. My parents, Pat and Cherry Jones, instilled in me a love for learn-ing and challenged me to do my best from my earliest days; I trust they willrecognize the fruits of their many gifts to me in these pages. Finally, I amdeeply grateful for my wife, Jodi, whose presence as a partner in every sensehas so deepened my life and whose own sense of what it means to workcreatively for the healing of the world has enriched my understanding ofjustice.

In closing, I want to thank the thirty-one Oregon activists who par-ticipated in my research by providing personal interviews, campaign mate-rials, and current literature about the organizations they represent. Theirpassion, articulate insights, personal stories, interpretations of events, and

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understandings of key terms such as “dignity” and “compassion” enrichedmy own understanding of the debates over the legalization of physician-assisted suicide, and challenged me to move beyond a simplistic binary un-derstanding of the debates in order to understand the cultural complexityat play. While I am certain that even my best attempts to present theirpositions faithfully do not fully capture the depth and complexity of theirperspectives, I trust they will recognize themselves in what I wrote.

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Introduction

Liberalism and Moral Vision

On the sunny but bitterly cold morning of Wednesday, January 8, 1997,lawyers for Compassion in Dying, the “right to die” organization that filedchallenges to the Washington and New York state laws banning physician-assisted suicide (PAS), argued before the U.S. Supreme Court that the U.S.Constitution guaranteed a “right to die” via PAS. Outside on the steps ofthe court, about 250 opponents of PAS from the disability rights organiza-tion Not Dead Yet gathered, chanting, “We’re not dead yet!” and carryingsigns that read, “I don’t have to die to have dignity,” and “Don’t put me outof your misery.”

In an interview following the demonstration, Not Dead Yet cofounderand Colorado resident Lucy Gwin explained that the organization wasformed to oppose the legalization of PAS in two main ways: by combatingan image of people with disabilities put forward by PAS advocates—thatdisability itself constitutes a rational reason for suicide—and by bringingattention to the dangers that legalized PAS could have for people with dis-abilities. Citing public portrayals of people with disabilities by groups suchas the Hemlock Society and Compassion in Dying, Gwin noted, “It got tobe so that any time you saw [a disabled person], it was [as] a poster child for

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assisted suicide” (Willing and Castaneda 1997). Thus, the name “Not DeadYet” was chosen as a direct challenge to attitudes that assume that “beingin control” is the central defining characteristic of human life and thatpeople would be “better off dead than disabled.” On this day, members ofNot Dead Yet came out to voice their fear that, in a climate of budget cut-backs and capitated medicine in which many persons with disabilities havedifficulty securing needed services, and in a culture that already devaluesthe lives of people with disabilities, legalized PAS would make it easier todispose of people with disabilities, especially if their prognoses and pocket-books were poor. Not Dead Yet summarized its opposition to PAS as follows:“When all the facts are considered, any alleged ‘benefit’ to a few through le-galization of physician-assisted suicide is far outweighed by the threat tothe many people with disabilities, terminal and not terminal, who live ina society which devalues our lives” (Not Dead Yet 1998).

Meanwhile, inside the courtroom, Compassion in Dying attorneys ar-guing for the “right to die” via PAS were drawing on arguments presentedin an amicus curiae brief, filed in support of a Constitutional “right to die”by six of the most prominent moral philosophers in the country, includingegalitarian liberal philosophers Ronald Dworkin and John Rawls. Borrow-ing heavily from the liberal solution to the abortion debate as laid out inCasey v. Planned Parenthood, the brief admonished the Supreme Court touphold two Court of Appeals rulings, which had held that states could notban PAS completely (State of Washington et al. v. Glucksberg et al.; Vaccoet al. v. Quill et al.). The brief argued that these rulings properly saw the par-allel between abortion and PAS, and that the Court should, on the basis ofthe same “liberty interest” that grounds the right to legalized abortion, estab-lish a constitutional “right to die” on one’s own terms, which would entail ata minimum the right to secure assistance in the form of a lethal prescrip-tion from a willing physician.

The central position of what came to be known as “The Philosopher’sBrief,” after the title of its publication in The New York Review, strikes a coolcontrast to the fervent concerns of Not Dead Yet.

These cases do not invite or require the Court to make moral, ethi-cal, or religious judgments about how people should approach orcontrol their death or about when it is ethically appropriate to has-

2 � L i b e r a l i s m ’ s T r o u b l e d S e a r c h f o r E q u a l i t y



ten one’s own death or to ask others for help in doing so. On thecontrary, they ask the Court to recognize that individuals have aconstitutionally protected interest in making those grave judgmentsfor themselves, free from the imposition of any religious or philo-sophical orthodoxy by court or legislature. . . . Denying that oppor-tunity to terminally ill patients who are in agonizing pain or other-wise doomed to an existence they regard as intolerable could onlybe justified on the basis of a religious or ethical conviction about thevalue or meaning of life itself. Our Constitution forbids governmentto impose such convictions on its citizens (Dworkin et al. 1997, 43).

In many respects there is nothing remarkable about protests by an activ-ist group on the steps of the Supreme Court or philosophers being partiesto amicus briefs, although, as Dworkin himself notes in The New York Re-view introduction to the brief, the filing of a brief by philosophers “solely asgeneral moral philosophers” may be unprecedented (Dworkin et al. 1997).I want to focus attention, however, on the paradoxical juxtaposition of theparticular participants on this day—participants who, on many other is-sues, are typically allies. I contend that the opposition of arguably the mostthoughtful American liberal philosophers, including two of liberalism’smost egalitarian thinkers, John Rawls and Ronald Dworkin, to a group ofdisability activists, for whom liberals consistently claim to advocate, signalsthat something peculiar—something that deserves more careful attention—is occurring.

Somewhat perplexed by the abandonment by their liberal allies, NotDead Yet member Gwin noted that in the abortion debate, the battle lineswere drawn generally between “the usual suspects,” liberals on one sideand conservative “right to life” groups on the other. Likewise, policy bed-fellows on issues of disability offer few surprises, with liberals typically ad-vocating for laws that guarantee, via mandated accommodations, a greaterrange of life prospects for people with disabilities. What might it meanthat, in the case of PAS, liberals find that their strategy of advocating forchoice places them in opposition to a group of disadvantaged citizens withwhom they are typically allies? How has it happened that the allegedly neu-tral appeal to choice did not cut the Gordian knot as it seemed to do in thepresumably similar case of abortion?

I n t r o d u c t i o n � 3



I argue that the PAS debates reveal critical unresolved tensions betweencommitments to liberty and equality that lie at the heart of contemporaryAmerican liberalism. On one hand, liberalism has continued to generatestrong egalitarian theory over the last three decades. Rawls’s conception of“justice as fairness,” with its concern for the least advantaged, remains themost robust representation of egalitarian liberalism (Rawls 1971). More re-cently, Dworkin has joined the egalitarian push in what may well becomea classic itself. In Sovereign Virtue: The Theory and Practice of EqualityDworkin makes a strong case for the primacy of equality in modern demo-cratic societies, claiming that “equal concern” is the “sovereign virtue of po-litical community” (Dworkin 2000, 231). Specifically Dworkin argues thatsociety has come to accept what he calls the “abstract egalitarian principle”that “government must act to make the lives of those it governs better lives,and it must show equal concern for the life of each” (Dworkin 2000, 128).Moreover, because of this sovereignty of equality, Dworkin unflinchinglyconcludes that “any genuine contest between liberty and equality is a con-test liberty must lose” (Dworkin 2000, 128–29). Thus, Dworkin claims thatequality has come to hold a sacred place in modern Western democraciesand, as such, is the key to political legitimacy (Dworkin 2000, 1). On theother hand, none other than Rawls and Dworkin were central supportersof not just the legalization of, but a constitutional right to, assisted suicidein spite of repeated objections that such a policy would make the disadvan-taged susceptible to coercion to end their lives because of a devaluing ofthe lives of people with disabilities or inadequate financial resources. Un-raveling this paradox is a critical step on the path toward a more egalitarianliberalism.

NEUTRALITY, RELIGION, AND MORAL VISION

Moving liberalism successfully in an egalitarian direction requires rethink-ing what have been two central and related components of American lib-eral theory, its commitment to its own neutrality and, by implication, itsconflicted attitude about the role of religion in public debate. I argue thatone of the insights that the PAS debates concretely demonstrate is that lib-eralism’s overconfidence in its own neutrality undermines its ability to hear




the real voices of the disadvantaged it promises to champion. If liberalismbacks away from its claims of neutrality, it must also come to terms with anarea of human culture that served as its doctrine of neutrality’s raison d’être:religion. Becoming more “religiously musical,” to use Max Weber’s famousphrase, and I would add “culturally musical,” is a prerequisite for a liber-alism that would be both inclusive and egalitarian. A truly egalitarian lib-eralism will be achieved only if liberalism replaces a misguided quest forneutrality with a more reflexive and inclusive theory of culture. Such a cor-rection supports a more adequate view of religious and other thick morallanguages not simply as problems but as potential resources supportingegalitarian commitments.

Religion, then, plays an essential if indirect role in the analysis of lib-eralism’s troubled search for equality because it has so often served as thefocal point—indeed it is often viewed as the root—of conflicts that havesupposedly necessitated the creation of a neutral space; this space is manu-factured via a separation of the right, values that can be known by all, andthe good, values that only register within particular communities. Politicalliberals, citing the historical “wars of religion,” have largely seen religionprimarily as a “problem,” something that leads to incommensurable andconflicting positions (Rawls 1993, xxiv, 10, 154). Religion is, in other words,something that presents difficulties that must be overcome or bracketed inorder to arrive at shared principles of justice and to maintain civility amongradically incommensurable and mutually hostile conceptions of “the wholetruth.”

Religious critics of political liberalism, including many who considerthemselves nonetheless liberal, argue that such a bifurcation of the rightand the good is problematic on at least three fronts. First, these critics doubtthat “liberalism is capable of sustaining the conditions necessary for its ownsupport,” and thus needs strong religious views in civil society to support itsown commitments (Coleman 1997; Elshtain 1997; Hollenbach 1997). Sec-ond, critics charge that the division comes at too high a price; that is, ex-cluding religious argument from the public results in the loss of criticalvoices and the alienation of religious citizens (Jackson 1997; Quinn 1997).Finally, critics argue that strong right/good distinctions are nonsensical toreligious persons who seek to live ethically integrated lives and thereforetreat them unfairly (Wolterstorff 1997). All of these perspectives argue that




religion is not “a problem” but in different ways may provide the very sourcesneeded to realize liberal commitments.

Thus, these arguments contend that the right/good division is self-undermining, unnecessary, and alienating or unfair to some. While I amsympathetic to these critiques, my argument takes a different turn; I main-tain that liberalism’s own success in implementing an egalitarian agendadepends upon its willingness to give up its quest for a utopian neutral space.There is a fundamental correlation between sensitivity to inequality thatliberals value and attention to questions of the good life that liberals are socareful to avoid. Policing the boundary between the right and the gooddulls liberalism’s sympathy to subtle but powerful forms of inequality; anyliberalism that seeks, as I think it ought, to embrace equality as well as lib-erty must shift its strategy from conflict avoidance through alleged neu-trality to conflict resolution through cultural engagement.

The problem is not so much that the right/good distinction is theoreti-cally nonsensical; in practice, however, and especially in hard cases, thedistinction is never simply “objective” but is always culturally grounded andcontested. Thus, any hard division between the right and the good neces-sarily stifles egalitarian commitments in practice because it creates an in-sider group whose justice claims are validated and an outsider group of “oth-ers” whose justice claims are at least potentially redefined by the insidergroup as questions of the good life and thereby dismissed or rendered in-visible. Unless this connection is acknowledged, liberal commitments tosubstantive equality will remain unrealized, and the danger will remain thatliberals will run roughshod over legitimate concerns of the disadvantagedwhile marching confidently under the banner of equality.1

The debates over the legalization of PAS are uniquely suited to castlight on this hidden fault line within egalitarian liberalism. Because PAS in-evitably raises the kind of “ultimate questions” that have traditionally beenthe purview of religions (e.g., the significance of human finitude, the mean-ing of a good human death and a good human life), the issue invites involve-ment by a wide variety of religious organizations and therefore brings intofocus the tensions between religious (and other cultural) appeals to thickmoral languages and liberalism.

A close analysis of the PAS debates also reveals that in liberal argu-ment, religion often functions as a stand-in for culture. For example, despite




the popular media construal of the debates as a conflict between politicalliberals on one side and religious persons and groups on the other, therewere in fact religious persons and groups represented on all sides of the de-bate. To take just the most prominent example, the first serious ballot ini-tiative to legalize PAS in Washington state was begun in the church base-ment of a Unitarian-Universalist church in Seattle, and was directed by thechurch’s Community Volunteer Minister, the Reverend Ralph Mero (Big-gar 1995, 7J); Reverend Mero also formed what is perhaps the most promi-nent “right to die” group, Compassion in Dying, which played a major rolein passing ODDA.

This insight leads to the conclusion that what really presents a prob-lem for liberal supporters of PAS is not religion per se but the particular re-ligious forms that do not share their cultural worldview. This conflation ofreligion and culture was easy for liberals to make simply because religiousgroups were often the most visible opposition groups in the debate. It alsoprovided a rhetorical advantage: portraying the conflict as one betweenreligion and liberalism allows liberalism to mask its own cultural particu-larity. A more fruitful analysis, however, would understand the debates notas a conflict between liberalism and religion but as a conflict between com-peting cultural biases—styles of moral reasoning embedded in social loca-tion that generate competing assumptions about the world, institutions,and the self.

While liberals have historically believed that such openness to reli-gious and other thick moral languages would lead to the demise of the lib-eral project, I argue on the contrary that such reflexivity is the key to the re-alization of liberalism’s egalitarian aspirations, since it prevents prematureclosure on what qualifies as an issue of justice. Such a correction wouldprevent the curious constriction of moral vision evident in the PAS debate,where liberals dismiss both the claims of the disadvantaged themselves andthe arguments of many who speak from a religious perspective on behalfof the disadvantaged. By insisting that such personal and religious claimswere “private values” and by construing the debate almost exclusively interms of individual liberty, liberals were unable to see two important andinterrelated aspects of the PAS debates: (1) the way in which the legalizationof PAS may have unjust outcomes because of underlying social inequali-ties; (2) the validity of multiple moral languages and forms of reasoning,




including the religious, which have the potential to provide resources forperceiving these inequalities. Thus, in this book I offer a detailed analysis ofthis failure of moral vision and propose a theory of culture as a correctivelens for current egalitarian liberal proposals in order to reorient liberalismtoward a neglected aspect of its historical tradition, its emphasis on equality.

KEY CONCEPTS

Three concepts are essential to the argument of the book: liberalism, cul-tural bias, and physician-assisted suicide. I explain my use of each below.

Liberalism

I use two terms that incorporate the concept of liberalism. The term “philo-sophical liberalism” refers to a political and intellectual tradition that tracesits lineage to the political philosophy of John Locke and John Stuart Milland is constituted by a family of theories that are principally marked by theirtwin commitments to individual liberty and equality. Liberal theories, asthe name implies, are generally known for their dominant commitmentto individual liberty, typically requiring government by consent of the gov-erned, the centrality of private property, the securing of civil liberties, andtolerance of different views of the good life via neutrality on questions of thegood. Historically they have also emphasized important egalitarian prin-ciples, such as a commitment to formal equal distribution of liberty or tothe material equalities necessary as preconditions for liberty.

I also use the term “popular liberalism” to connote a less precise usage.Popular liberalism refers to liberalism as the dominant American politicalethos, which tends consistently to emphasize rights, choice, autonomy, andlimited welfare commitments based on the principle of formal rather thansubstantive equality of opportunity. Although popular liberalism is to someextent the concrete expression of philosophical liberalism, it is perhaps bestrecognized as a loose cluster of policy positions that are perceived to beexpressions of liberal themes. For example, popular liberals support a lim-ited welfare state and civil rights. Perhaps the most defining characteristicof popular liberals over the last two decades is that liberals have interpreted




their commitment to tolerance as being “pro-choice” (the popular analog tothe philosophical position of neutrality) on controversial moral issues suchas abortion and, more recently, PAS.

One of the themes of my central argument is that liberals, both philo-sophical and popular, have not been sufficiently reflective about their com-mitments to equality. Even the more disciplined philosophical forms of lib-eralism have relied too easily upon an intuitive cluster of policy positionsthat “seem liberal,” a strategy that has co-opted their egalitarian promise.

Cultural Bias

It may seem strange at first reading to accuse liberalism of bias, since I havealready noted it as a tradition that embraces the virtue of tolerance. Thekey to unraveling this apparent contradiction is to distinguish between twotypes of bias: individual bias, which liberalism acknowledges and combats,and cultural bias, which largely remains invisible and even lurks in the shad-ows of a tolerance built on the avoidance of individual bias. Liberal philo-sophical theory has generally guarded against individual bias by abstract-ing from the particularities of the situation under consideration throughvarious theoretical devices, such as the “original position” of John Rawls, the“ideal auction” of Ronald Dworkin, or even the “ideal speech situation”of Jürgen Habermas.2 These devices are meant to guard against forms ofindividual bias by introducing a level of reflexivity into reasoning aboutissues of justice. They are, in effect, theoretically sophisticated versions ofThe Golden Rule, filtered through Immanuel Kant’s principle of univer-salization, which ask, “What would you want done to you if you were notyou with your concrete, historical particularities?”

The hypothetical abstraction (the assumption that you are not you)necessary to guard against the dangers of overt individual bias, such as ra-cial prejudice or religious intolerance, however, has the unintended conse-quence of opening the door to cultural bias (because others are not trulyothers either), which is often more insidious in its effects because it is moresubtle. Mary Douglas, an anthropologist who has developed the idea of cul-tural bias, notes that one of the central problems of contemporary politicaland social theory is that it has a “generalized human individual conceived asnonsocial or presocial” at the heart of its theory (Douglas and Ney 1998, 5).




While the interests of this theoretical abstract self are assumed to be univer-sal, this assumption hides the ways that “ideas are wrapped up in and pro-tected by and receive their support from the institutions that embed them”(Douglas and Ney 1998, 6). Cultural bias occurs when cultural differences,which are rooted in institutions and social location, are ignored or silenced,resulting in a covert form of censorship: “Some questions cannot be raised;some ideas cannot even be phrased so as to go across the boundaries” (Doug-las and Ney 1998, 8).

Thus, although persons in different cultures within the same society areinterpreting the arguments and behavior of other persons, “they are onlyseeing the alien behavior through their own cultural lenses” (Douglas andNey 1998, 106). The inevitable result is that the privileged who wield powercan, even in the name of tolerance, paternalistically dismiss these “alien”gestures as mistaken, paranoid, unmannered, irrational, or, as is popularamong liberals, ultimately grounded in some individual bias (such as strongreligious or moral belief ) that the protestors lack the discipline to muzzle.As Douglas notes, cultural bias remains unrecognized principally throughthe conception of the self at the center of the theory: the liberal individual,who shares the attributes of the privileged theorist who created him or her,has installed him or herself as “the universal individual,” and the intelligi-bility of all claims are measured from his or her perspective. This form ofcultural bias is precisely what lurks beneath liberal claims to neutrality.

Physician-Assisted Suicide

As with most political debates, debates over policies concerning the end oflife are often blurred by competing terms used by activists for rhetoricaladvantage. For example, supporters of PAS object that the word “suicide”carries inappropriate negative connotations and argue that the offendingterm should be dropped in favor of “physician aid in dying.”3 On the otherhand, opponents of PAS object that categorizing practices of withholdingor withdrawing treatment as “voluntary passive euthanasia” paves the wayfor acceptance of voluntary active euthanasia.4 Both parties are surely rightthat no terminology is neutral.

While I do not claim to avoid this problem altogether, I have chosen tofollow the most common terms in the medical literature. “Euthanasia” refers




to the administration of drugs by a physician “with the explicit intention ofending the patient’s life on his or her explicit request.”5 “Physician-assistedsuicide” refers to the prescription of drugs by a physician “with the explicitintention to enable the patient to end his or her own life” (Onwuteaka-Phillipsen et al. 2003). The use of both of these terms corresponds to the es-tablished terminology in the Netherlands, and “physician-assisted suicide”is also the term used by the Oregon Health Division in its official reports,which are required by ODDA itself (Leman and Hopkins 2004).

OVERVIEW

In chapter 1, I sketch a brief history of liberalism and argue that RonaldDworkin’s conception of “equality of resources” is an important develop-ment within philosophical liberalism’s egalitarian movement. I focus onDworkin because he is the lead author of “The Philosopher’s Brief ” and aleading voice in egalitarian liberalism; moreover, he explicitly uses his sup-port of PAS as an example of the application of his egalitarian commitment.Thus, Dworkin makes a strong test case for demonstrating that egalitarianphilosophical liberals at present suffer from a similar contraction of moralvision to popular liberals, despite their explicit theoretical commitment toequality.

In chapters 2 and 3, I lay out the important empirical, historical, andlegal context for reconceptualizing PAS as an issue of social justice. In abrief chapter 2, I illustrate the gravity of increasing income and wealth in-equality in America and in Oregon. In chapter 3, I give a short history ofODDA as a part of the contemporary “right to die” movement, attending tothe key organizations, persons, campaigns, and court decisions that led toits passage in 1994 and implementation in 1997. I argue that PAS was legal-ized not because it was an inevitable outcome of a historical trajectory, “anidea whose time has come,” but because its supporters were able to portraya highly particular cultural solution as universally rational by harnessingwidely shared fears about “medicalized” dying and appealing to the culturalvalues of “rights” and “choice.”

In chapters 4 through 7, I turn to the social sciences, specifically toEmile Durkheim and the Durkheimian tradition as represented by cultural




anthropologist Mary Douglas and sociologists Robert N. Bellah and Ste-ven M. Tipton, for theoretical models that provide two things: (1) a lens forunderstanding the influence of social location and culture on requests forand opinions about PAS, and (2) a social framework for a revision of Ameri-can liberalism in an egalitarian direction. In chapter 4, drawing on EmileDurkheim’s Suicide and the large body of empirical literature based on hiswork, I argue that, despite the tendency of liberals and others to argue thatrequests for PAS are private, individual events, there are identifiable socialsources of requests for physician-assisted suicide. I draw two conclusions.First, PAS is a multifaceted phenomenon whose complexity was not appre-ciated in the PAS debates. Second, social inequalities stemming from so-cial structures make some of these dynamics morally objectionable, forexample, when social supports are insufficient to sustain fully free andvoluntary choices. No just social policy regarding PAS may be crafted with-out accounting for this complexity.

In chapters 5 and 6, I draw on my own ethnographic interviews withkey Oregon activists, and I utilize Tipton’s “sociology of morality” frame-work to map the dominant “moral logics” of the ODDA debate between1994 and 1998, attending to worldview, attitudes toward institutions, style ofmoral reasoning, and conceptions of the self. In chapter 5, I focus on thedominant voices in the debate and find three results. First, and most strik-ing, is what is missing: egalitarian discourse from liberal theorists and ac-tivists that might ground a liberal opposition to the legalization of PAS. Sec-ond, many of the voices opposed to PAS, such as Oregon Right to Life,based their opposition primarily on a deontological commitment to a “rightto life” principle, and only secondarily appealed to the plight of vulnerablepeople. Third, even when arguments about the effects of social inequali-ties were raised, for example by the Roman Catholic Church, an organi-zation with a solid track record of advocating for the disadvantaged insociety, liberals largely dismissed these arguments by attributing them toreligious bias.

In chapter 6, I focus on missing voices in the debate. First, the additionof these neglected voices (e.g., disability rights activists from Not Dead Yet,labor organizers from Northwest Friends of Seasonal and Service Workers,and Protestant religious activists from Ecumenical Ministries of Oregon)highlights the cultural particularity of the dominant voices. It reveals thatall of the arguments put forward in the debate—including the allegedly




neutral liberal argument for choice—are necessarily culturally biased, in-fluenced by the subculture in which the actors reside. It is precisely by lis-tening to these suppressed voices and to the reasons given for dismissingthem that the power of cultural bias and the legitimacy of worries aboutPAS by the disadvantaged come to light.

In chapter 7, I utilize Mary Douglas’s cultural theory, which sorts cul-tural differences into four ideal types: the pioneering individualists, the so-cial isolates, the hierarchists, and the sectarians; each of these represents acompeting cultural bias. I demonstrate briefly how this cultural map cor-relates with the social sources of PAS developed in chapter 4 and how itlocates the rhetoric of PAS activists developed in chapters 5 and 6. Afterdemonstrating its usefulness in the PAS debates, I argue that Douglas’scultural theory also provides a more general theoretical lens that can beused to correct liberalism’s moral vision by providing a scheme for ensur-ing a basic level of cultural reflexivity. It pushes theorists and activists toseek alternative cultural viewpoints on policy questions proactively, ratherthan simply evaluating the legitimacy of competing claims on the basis ofliberalism’s own cultural criteria.

In chapters 8 and 9, with the sociological analysis on hand, I return toDworkin’s “equality of resources” with an eye to reconstructing a more ap-propriate egalitarian position on PAS within the bounds of his own theory. Iclaim that PAS is not a fundamental liberty interest but rather, in Dworkin’sown terms, “an expensive taste”: a social good whose availability must bemeasured in terms of costs to others, particularly disadvantaged people. Iconclude by sketching the contours of an egalitarian liberalism that incor-porates cultural theory as a practical means of testing whether its formalgoals of inclusion have been adequately implemented. Finally, through thelens of this improved egalitarian liberalism, I return to the question of PASto argue that legalizing PAS in the absence of guaranteed access to health-care is fundamentally unjust to disadvantaged people, who may be coercedto request PAS by social or financial forces.

THE CONTRIBUTIONS OF THIS BOOK

I hope to make three substantive contributions with this book. First, theethnographic work itself is an important contribution for understanding the




complex moral worlds that clashed during the PAS debate. To date therehas only been one study that extensively interviewed the key actors in thedebate, and that work only interviewed proponents of ODDA (Hillyardand Dombrink 2001). Moreover, perhaps due to this one-sided approach,it largely accepted the liberal framing of ODDA as a much-needed “re-form movement for the right to die,” an interpretation that my analysischallenges.

Second, this study has the potential to transform the framing of the de-bates over the legalization of PAS at a time when several states are poised toconsider the issue and general health care reform has been tabled. Mostarguments both for and against the legalization of PAS remain at the clini-cal level, focusing on factors that are tied to the individual, such as patientautonomy and choice, the doctor-patient relationship, the specific contoursof the individual case, or the ethical status of the act itself. From an egali-tarian liberal perspective, however, the main question about PAS should notbe the clinical question of whether an individual has a “right to die” viaPAS or whether an individual is exercising “voluntary choice” in request-ing assistance from his or her physician in dying. Rather, because all suchchoices are socially conditioned, the question becomes a social one: do wehave sufficient equality in access to health care and in distribution of re-sources more generally to consider such a law, which may put vulnerablegroups at risk? Thus, egalitarian liberalism ought to push liberal support-ers of the “death with dignity” movement back onto their egalitarian com-mitments, forcing them to address the prior question of providing univer-sal access to basic health care and a more just distribution of resources.

Third, and most broadly, my analysis makes a major contribution tothe important, if stumbling, movement within liberal political theory to re-cover its historical emphasis on equality as well as liberty. One way of read-ing the broad contours of this project is as a Durkheimian critique of lib-eralism. As I explicate below, Dworkin’s attempt at an egalitarian liberalismimportantly incorporates an emphasis on participation, community, andeven limited aspects of the good life. However, despite these important in-novations, Dworkin ultimately retains and privileges the old liberal strate-gies of individual choice, neutrality, and a bright line between the right andthe good. I argue that an egalitarian liberalism needs cultural reflexivity tohonor its commitments to inclusivity in practice and that the Durkheimian




tradition provides these resources. Replacing the model of the unfetteredindividual with a model of a culturally embedded person has greater po-tential to achieve the kind of sensitive moral vision that an egalitarian poli-tics demands.

The heart of my argument is that in order for liberalism to respondto the crisis of increasing inequality and the accompanying hardships thisentails for widening circles of Americans, it must correct its inability to seetheir circumstances. Such correction requires an egalitarian liberalism tobe open to the prima facie legitimacy of a broad range of public speech—including religious argumentation and, as I demonstrate below, evenconspiracy theories. While a theory of culture itself cannot fully “fix” thisproblem (as it is ultimately a problem of moral perception, something thatdepends on the development of the virtues necessary to “see” and construewhat one sees in a just manner), at the very least this enlargement of visionmay chasten liberals who mistakenly conflate their own narrow cultural in-terests with the realm of justice. If adopted and institutionalized sufficiently,a more reflexive egalitarian liberalism can promote the conditions in whichsuch virtues can be schooled among citizens.




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