Who Lives?
A meditation in the snow

by Cliff Bostock
(Originally published in the "Paradigms" column of Creative Loafing, Atlanta, Dec. 13, 1997)

As I write this, I am sitting before my hotel room window in Stowe, Vt., looking over a snowy mountain landscape. This resort, famous for its skiing, looks eerily akin to a Currier and Ives lithograph -- especially during Christmas season -- and yesterday I even watched two horses, wearing bells, pull a sleigh in the field outside my window. (Right now, I'm watching a snow plow.)

No, I'm not here to ski, although, as I sink into the mood of the place, I'm feeling more inclined. I'm actually here to read and write while Wayne Johnson attends a two-week educational conference of the Burden of Disease Unit of the Harvard Center for Population and Development Studies. Wayne, who is with the CDC, is one of about 50 public health scientists from around the world gathered here for a rather curious purpose.

They -- and most are from other nations -- are here to study a statistical method for the quantification of human pain and suffering caused by disease and injury. This is an important departure. Historically, since pain and suffering are so difficult to quantify, attention in the development of public health policy has tended to focus on mortality rates. Harvard's method provides a way to accumulate and analyze data that can broaden the basis of public health policy development.

Yes, it sounds a little creepy. But the fact is that these are people who must regularly help make decisions about the way their governments are going to spend money on public health. This requires the consideration of ethical questions, because, of course, the allocation of resources to one population means another is being denied help. Thus, according to Wayne, the group has been engaged in some explicitly ethical exercises -- exercises that have kept him from sleeping well.

The denouement for him was a discussion of this problem, which boils down to the old ethical exercise of who gets saved when a boat is sinking: You have two populations, the blind and the sighted who have normal health. A public health emergency of some sort arises and you have limited funds. Do you regard the blind's right to survive equal to that of the sighted? If not, what is the value of a blind person's life compared to that of a healthy sighted person's? In the exercise, participants were asked to assign a value to the blind population in terms of the sighted.

Wayne called them even: 1,000 blind people and 1,000 sighted people deserve an equal chance of survival. Thus, access to treatment would be based on a coin flip. But, in his group of 17 scientists, he stood completely alone. Everyone else assigned a lower value to the blind's life, so that, say, a population of 1,500 blind people might have the value of 1,000 sighted people. Wayne was astounded by their response and they were equally astounded by his. In fact, they accused him of not even believing his own statement.

Now, it is easy to dismiss this as a game but it is nothing of the kind. All over the world, people are regularly required to decide who will live and die because of limited economic resources. It is probably true that the poorer the country, the starker the choice. I recall that chilling statement made at the last World AIDS Conference: "If the cure for AIDS were a single clean drink of water, most people of the world would still not have access to it." But this is not just a third-world issue. The question of who gets the most dollars for research and care -- say, AIDS patients or cancer patients -- gets debated in this country constantly.

Wayne's surprise was not that public health officials have to make brutal real-life decisions but that the other scientists ridiculed his own ideal. While the varying economic conditions of each society give rise to understandably different solutions to the delivery of care, he presumed there was an equal devotion to the ideal that all human life is fundamentally of the same value. In fact, the other scientists didn't share that ideal at all.

What this points to -- and here I take off completely on my own commentary, unrelated to what Harvard is teaching -- is the way we assign value to life, all over the world, on the basis of productivity. (That obviously is what was going on in those scientists' minds.) Yes, you can argue that civilization would collapse were productivity not esteemed, that one's contributions to the family and community are even psychologically foundational in the creation of selfhood and happiness.

And, yes, a countless number of books are written every year about the reclamation of self-esteem through the Joy of Work. Do What You Love and the Money Will Follow is the title of one prosperity pot boiler of a few years ago. Even the classic empirical study of happiness, Flow, suggests that working is the main source of contentment in life. (Of course, it is a study of people living in a capitalistic, competitive society, isn't it?)

But doesn't this all fail to account for an important fact? Indeed, doesn't it tend to suppress the fundamental fact of existence? Disabled or healthy, idle or working, we're all going to die. Thus, in the cosmic scheme of the things, deciding how many blind people equal one sighted person is a little like comparing dancing angels to rhythm-impaired angels on the head of a pin. The real difference here is time.

In other words, there's nobody who doesn't inhabit a sinking ship.

Those of us who have stood by while countless friends die of epidemic disease or had a close brush with death ourselves know this quite well. We really do hang by a thread, and living well means keeping the ship in order as you, inevitably, go down. The fantasy of life as production -- grounded in the capitalist ideal of wealth that outlives us -- is just as fueled by the thirst for immortality as any religious vision of an afterlife free of the body's pain.

I confess that school has kept me steeped in psychoanalytical theory lately. Freud's notion that we are all driven instinctually toward the will to life and the will to death comes very alive in this snowy setting where world health policy-makers consider how to decide who, like the Eskimo elders, is abandoned to die on the ice when maintaining their lives is no longer cost-effective. Oh, the suffering the idle and dependent must endure ... and, far more to the point, cause the rest of us!)

There is, I propose, a way to look at this issue by which the will of our own destructiveness, the way in which we all bring suffering upon ourselves, is revealed. If you consider the death wish in its collective expression and look at the choices we make about whom we sacrifice as projections of the collective death wish, we might have a clue to the pathological aspects of our psyches, our psychological priorities -- what most needs healing in us.

It interested me enormously, for example, that Wayne's debate settled around sight. (Other exercises did involve other disabilities.) Why not hearing? Because for the last few centuries, sight has had absolute primacy of the senses. (This was not always so.) If we give utmost primacy to sight, it naturally follows -- quite unconsciously -- that the blind will be regarded as most handicapped and therefore most dispensable -- most likely to be rendered unseen. I suggest that this goes even deeper, though. By immediately sacrificing the blind, we sacrifice the blind portions of ourselves. We disown the fact that much in our lives cannot be seen clearly and explained.

If we look at each population we decide not to treat or to which we give low priority, something is revealed about ourselves. Could the despicable argument that gay men deserve their fate because AIDS is sexually transmitted in an unnatural way be a way that its proponents suppress their own homosexual impulses? Does the endless debate against funding of medical care for the indigent reveal how, in the depth of our own pathology, we equate dependency with death? Is it infantile rage and revenge for having to become independent ourselves?

Last July, on I-75, my tiny MGB was sent spinning out of control when it collided at 60 m.p.h. with a tractor-trailer. The car, top down, was thrown across four lanes of traffic, into another car, and then it bounced back across the lanes, still spinning, into a guard rail. To my utter amazement, I got out of the car and walked away. During the accident I had the usual experiences: time slowed dramatically, my consciousness seemed to lift out of my body in preparation for death, I felt an enormous amount of compassion for myself, seeing myself about to die.

The strangest part of this, though, was that I did not see myself as an adult about to die. I saw myself as a kid about to meet death. Isn't that strange? This kid lives forever within us. In the moment of crisis, we regress. We are thrown back to that relatively helpless being we once fully were -- a child born fated to die.

So, it is natural in the face of this regression -- it's been written about many thousands of times -- for the psyche to reveal itself in a kind of life review. That is a poor way of putting it, because the experience is more feeling-based than a narrative review. (For me, as I said, it was an experience of overwhelming compassion.) I am guessing that this same impulse to behold the central feeling of our own lives is stimulated in us when we look at the suffering and dying of others. I'm guessing that it is too overwhelming in its demands for most: an open heart, a confrontation with the reality of death's inevitability. Affixing value to the lives of the suffering for purposes of delivering care furnishes a fantasy of control and sublimates the fact of our own dying and the revelation of what we disown in ourselves -- our natural and mystical blindness, - the cloud of unknowing,- our perverse and wonderful capacity to love everything and everyone.

My life was forever changed the morning 10 years ago I woke up and realized that every one of my closest friends had died. Quite honestly, it was only then that I began to behold my own blindness and the folly of my moral judgments. I've been stumbling, more happily than ever, since then. I believe it was coming to that that led me in July to greet my own expected death not with fear but with compassion.

Copyright 1997 by Creative Loafing | Published Dec. 13, 1997

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