Beyond wealth and wellbeing: how nations flourish

As GDP data is increasingly scrutinised, Ryan Gilfeather asks how to measure the true health and wealth of a nation.

Ryan Gilfeather

Ryan Gilfeather explores social issues through the lens of philosophy, theology, and history. He is a Research Associate at the Joseph Centre for Dignified Work.

Two women sit behind a press conference desk against a backdrop, one listens as the other speaks and gestures.

A recent International Monetary Fund press conference on the world economic outlook.

IMF.

Discussions of GDP loom large in our current age. As we live under the shadow of the threat of a recession in the UK, ministers and commentators anxiously follow our country’s Gross Domestic Product, to see whether we are on the right track. Measuring the total value of goods and services produced in a country, this figure is a litmus test for the health of an economy. Crucially, many policymakers and leaders in government believe this figure reveals the health of a nation.

As we will see, not all agree. Opponents rightly highlight that an increase in GDP does not necessarily mean that ordinary citizens live better lives. There are good reasons to share this opposition from a Christian perspective. However, ultimately, the Christian tradition highlights a very different way to measure the health of a society.

In 2020 The Carnegie UK Trust, a think tank campaigning for greater welfare for all, published a new measure for social progress: GDWe (Gross Domestic Wellbeing). In brief, they gathered and processed ONS (Office for National Statistics) data on a variety of domains in life, giving them a single figure on a 10-point scale to rate well-being. These domains included personal well-being, relationships, health, vocational activities, living environments, personal finances, the economy, education and skills, governance, and the environment. When they plotted GDP against GDWe from 2013-9, they revealed that the two do not always line up. As GDP steadily increased from 2016, overall welfare in society dipped. From 2013-9 GDP increased by 10.34 per cent and GDWe only 5.19 per cent. Hence, measuring GDP does not necessarily reveal whether life is getting better for ordinary.

Economic resources are not useless... However, they are not sufficient unto themselves for us to live full and good lives.

This attempt to shift the conversation about social progress from predominantly centring GDP is commendable. The Bible does not legislate on whether to use GDP or GDWe. However, scriptures within it repeatedly decouple economic wealth from flourishing. For example, in the gospel of Matthew, Jesus says the following:

Do not store up for yourselves treasures on earth, where moth and rust consume and where thieves break in and steal, but store up for yourselves treasures in heaven, where neither moth nor rust consumes and where thieves do not break in and steal. For where your treasure is, there your heart will be also.

In life, we can either focus our efforts on attaining wealth or fostering our relationship with God. Only the latter will lead us to flourish. Economic resources are not useless; they are necessary for us to thrive in certain conditions. However, they are not sufficient unto themselves for us to live full and good lives. Furthermore, when wealth becomes the focus of our hearts and minds, our lives will be hollow and fractured. GDWe is a good measure, insofar as it acknowledges that economic flourishing is not the same as a good quality of life, and it attempts to shed light on the latter. However, the Christian tradition highlights a different framework altogether to grasp the health of a society.

Gregory of Nyssa, a fourth-century theologian and bishop, frames wellbeing as a human being reflecting the image of God to the greatest of their ability. The book of Genesis says that God made us all in His image. Gregory argues that this means that we can become like God in certain ways. God is the fullness of all good things, such as love, justice, peace, joy, and courage. Consequently, Gregory argues that when we act in good ways, we begin to share those characteristics, which in turn leads us to act well in the future. For example, if I defend someone who is under attack, I will become more courageous, and more likely to repeat the same action in the future. The more we reflect the image of God, by acting well and taking on His characteristics, the more we will flourish as individuals. In this vision of human flourishing, Gregory brings together an Aristotelian account of virtue, with a Christian understanding of people as the image of God.

This framework for the well-being of an individual also provides a good barometer for the health of a society. All of these actions and characteristics are building blocks for a healthy society. So long as we have a good sense of how to act appropriately with love, justice, peace, joy and courage, then our actions will build up our common life together. They benefit all, rather than one. They are not zero-sum actions. Accordingly, a society made up of individuals who are acting well and reflecting the image of God would be very healthy indeed.

As a measure of a society, we should ask whether it leads citizens away from virtuous actions and characteristics. For example, between 2019 and 2021, gun murders in the USA rose by 45%. Earlier this year, journalist John Burn-Murdoch argued this rise is partly due to decaying public trust in that country. This tells us that a culture marked by fear of others can lead some of its citizens to commit terrible actions and live lives full of violence. GDP may rise during this time, as may other markers of welfare. However, to see the whole picture we need also consider how societal forces are leading citizens away from flourishing in their reflection of the image of God. Then, we should go about addressing these malignant forces.

In times of adversity... individuals in societies marked by high levels of trust are more satisfied with their lives and act more benevolently.

At the same time, we should also consider how a society enables its citizens to reflect the image of God. Societies with high levels of social trust create space for a variety of positive actions and characteristics. The World Happiness Report studies people’s sense of life satisfaction worldwide. It routinely finds that in times of adversity, like the Great Recession in 2008 or the COVID pandemic, individuals in societies marked by high levels of trust are more satisfied with their lives and act more benevolently than others. Again, these social forces are not the same as GDP, yet they have a significant ability to shape the extent to which citizens can reflect the image of God, and thereby flourish.

In my work for the Joseph Centre for Dignified Work, I am particularly concerned with low-wage workers’ pay and conditions. As I have argued elsewhere, low pay leads to some workers needing to take on two or more jobs. They, consequently, have no time to see their children, nourish their faith, or participate in community institutions. It is clear, therefore, that the widespread pattern of paying below the Real Living Wage (£11.94 p/h in London, £10.90 elsewhere), hinders people in their expression of love for God, family and neighbour. Pay and conditions are but one further example, amongst many, of how societal forces can hinder or help our flourishing in the reflection of the image of God.

Needless to say, GDP and GDWe are still useful and necessary tools. However, they do not tell the full story. GDP only describes the progress of the economy as a whole, and GDWe can only describe the quality of an average person’s life. In contrast, when we set a goal that each citizen should reflect the image of God, we can begin to explore how societal forces enable or squeeze out this aim. With this greater knowledge in mind, we can strive for progress in our nation by fostering good structures and stamping out bad ones, so that all may reflect the image of God to the greatest of their ability.

Article

Assisted dying

Comment

Politics

25 November 2024

7 min read

Assisted dying hasn’t resolved Swiss end of life debates

Despite attempts to normalise it, new challenges still arise.

Markus Zimmerman

Markus is Professor of Moral Theology and Ethics at the University of Fribourg, Switzerland.

A single bed, wiith an unmade colourful duvet stands in the corner of a room. A hoist reaches over it from the corner.

The dying room, Dignitas Clinic, Zurich.

Dignitas.

While countries such as Germany, France or the UK are currently struggling to find a suitable regulation for assisted suicide, their peers in the Netherlands, Canada and Switzerland have years of experience with the controversial medical practice. Even if each state must explore its own ways of dealing with these ethically controversial issues, it is obvious that international experience should not be ignored as they try to find a way forward.

In Switzerland the discussions and challenges surrounding assisted suicide are increasing rather than decreasing. Contrary to the idea that a liberalisation of assisted suicide would lead to fewer debate, tensions and difficulties are increasing. My observation, and thesis, indicates that practices such as assisted suicide cannot be “normalised”, even in the medium and long term.

Developments

In recent years, one to two per cent of all deaths in Switzerland were due to assisted suicide. From an overall perspective, this practice is therefore still a marginal phenomenon. However, a look at the total number of assisted suicides per year gives a different impression, as this has increased more than fivefold in the years between 2008 and 2020, from an initial 253 to 1,251 deaths per year, a rising trend. The cause of death statistics for Switzerland only include those cases of assisted suicide in which persons resident in Switzerland were involved and the death was reported to the authorities. According to the Swiss Federal Statistical Office, in 2020, it was mainly people over the age of 64 who made use of assisted suicide. Detailed information on the underlying illnesses of the people affected in 2018 shows that about 40 per cent were affected by cancer, just under 12 per cent by diseases of the nervous system, a further 12 per cent by cardiovascular diseases and just over a third by other illnesses, including dementia and depression. There are currently seven right-to-die organisations in Switzerland which play a leading role in a typical assisted suicide procedure. They work closely with doctors who are prepared to prescribe a lethal drug, generally Pentobarbital. The data reflects an ambivalent picture: on the one hand, the proportion of assisted suicide cases is relatively low in relation to all deaths and, for example, in comparison to the large number of people who die in Switzerland in a state of deep sedation until death; on the other hand, the number of assisted suicides in Switzerland has risen sharply in recent years.

Perceptions and assessments

Since the 1990s, the public perception and assessment of assisted suicide in Swiss society has changed from an initially cautious and sceptical attitude towards broad acceptance. While the debates in other countries are characterised by relatively sharp controversies between those in favour and those against, public discourse in Switzerland has been less polarised. There are indications of a certain normalisation of the situation, the strongest sign is that Switzerland has so far refrained from regulating assisted suicide in a separate law. The results of a recently-published study on the opinions of Swiss people over the age of 55 regarding assisted suicide confirm these impressions.: The survey showed that over four-fifths of respondents support legal assisted suicide, almost two-thirds can imagine asking for assisted suicide themselves at some point, and that almost one-third are considering becoming members of an right-to-die organisation in the near future, with one-twentieth of respondents already being members at the time of the survey in 2015. Among people with a higher level of education and older people aged between 65 and 74, approval of assisted suicide and corresponding practices was higher than among less educated, younger and very old people; approval was also significantly lower among religious practitioners.

Sensitive topics

The fact that assisted suicide enjoys broad support in Swiss society as a whole does not mean that there are not difficult and controversial aspects relating to its practice. Relevant topics include, in particular, places of death, authorisation criteria and procedures.

Places of death: Assisted suicide is permitted also for mentally ill persons in psychiatric clinics, but the federal court recommends great caution here and requires two psychiatric expert opinions to ensure that the person willing to die is capable of judgement with regard to the desire to commit suicide. Although assisted suicide for children and adolescents has hardly been an issue in Switzerland to date, the corresponding debates are currently being held in Canada and elsewhere. The question of whether people in prison also have a right to make use of assisted suicide, has been the subject of intense debate in Switzerland for years, with a generally positive response. The question of whether right-to-die organisations should be given access to acute hospitals and nursing homes is still the subject of controversial debate, with regulations varying from hospital to hospital, nursing home to nursing home

Authorisation criteria: With regard to the admission criteria for persons willing to die, the capacity for judgement is at the centre of attention: while the importance of the criterion is undisputed in itself, there is a struggle for reliable standards and procedures to reliably test this criterion. Since the publication of the SAMS ethical guidelines Management of Dying and Death in 2018, the criterion for end of life and, depending on this, that of unbearable suffering have received new attention due to an objection by the Swiss Medical AssociationFMH. While the guidelines are based on the criterion of unbearable suffering, the FMH wants to stick to the near end of life. It is certainly difficult to diagnose the existence of unbearable suffering, as the international debate on the significance and assessment of existential (neither physical nor psychological) suffering shows. This difficulty is illustrated by the debate that has been going on for several years in Switzerland about so-called old-age suicide and the inherent criterion of tiredness of life. At the centre of the dispute is the legally difficult question of whether a doctor is also allowed to prescribe a lethal drug to a healthy person.

Procedures: Here the role of the medical profession and right to die organisations is by far the most important issue. In contrast to the physician-centred models in Belgium, Canada and the Netherlands, the Swiss model of assisted suicide is based on the idea that every person has the right to end their life and may call on the help of any other person to do so. Although the medical profession is usually involved in the process, the management of the procedure is normally the responsibility of a right-to-die organisation. This division of responsibilities is always up for debate when legal regulations are being considered, in which doctors should tend to take the lead in the process due to their professional background. There is also a debate about how and by whom compliance with the authorisation criteria should or could be monitored, whereby it remains to be decided whether this should be carried out before or after the death. At present, a certain amount of monitoring takes place following a suicide, insofar as the authorities investigate the cases afterwards. There is also debate as to whether Pentobarbital is a suitable means of suicide, especially if this barbiturate is not administered intravenously but taken orally; there is no knowledge of how many cases are currently administered intravenously and by whom an infusion is then set up. Last but not least, consideration has already been given to the use of lethal drugs, such as helium gas, which can be obtained over the counter.

Attempts at regulation

Political efforts to regulate assisted suicide in Switzerland in a more nuanced way than today have been made since the 1990s but have remain largely without consequences to date. In relevant judgements by the Federal Supreme Court or in statements by the Federal Department of Justice and Police, reference is regularly made to the ethical guidelines of the SAMS. These are classified as soft law and are therefore not legally binding, even though their content has become the subject of dispute. The National Advisory Commission on Biomedical Ethics (NCE) had already recommended more far-reaching legal regulation in 2005 as part of a detailed opinion on the subject; in the opinion of the NCE at the time, the review of authorisation criteria, a justifiable regulation of assisted suicide for the mentally ill, children and adolescents and state supervision of right-to-die organisations, should be ensured by law. The question is what form a legal regulation can take that grants the medical profession far-reaching powers but at the same time prevents medical paternalism (in favour of or against assisted suicide). From the perspective of Swiss experience, this is “a square circle”: either the doctors retain the final decision on who receives the barbiturate, or official access rules are established, the review of which does not generally require medical expertise.

The outlook

In the short and medium term, it can be assumed that the number of assisted suicides in Switzerland will continue to rise. The coronavirus pandemic and the particular difficulties faced by nursing homes during this time are likely to exacerbate this increase. In view of these expectations and the legislative processes in other European countries, pressure is likely to increase in Switzerland to create a legal regulation. Overall, I think politically it will be important to create a legal regulation, in order to ensure legal equality and legal certainty on the one hand and prevention of abuse and expansion on the other. At the centre of social-ethical reflection is the challenge of learning to deal with the pluralism of different ideas of a good death and to develop and establish alternative models to medically assisted dying. The thesis I mentioned at the beginning is confirmed today: assisted suicide in Switzerland can hardly be normalised; new problems, challenges and demands are constantly arising. Suicide, whether with or without the help of another person, always means an existential transgression that defies normalisation.