Article

Awe and wonder

Christmas culture

Culture

Music

12 December 2024

7 min read

If you think Christmas is ‘right’ you’ve got it wrong

Contrasting cathedral Christmases conjure world-changing subversion.

Katherine Amphlett

Katherine is a counsellor based in the West Midlands.

A carol singer looks down while candles flicker.

Coventry Cathedral.

Christmas.

The very word is loaded with associations and memories and history and meaning. Just looking at it written down conjures up years of my childhood and particular feelings and impressions and smells. And for good or ill, it seems that that’s the case for most people. Ask any group of individuals for the three words that represent Christmas to them, and you’ll end up with myriad different answers – and an argument about why each person is right and everyone else is wrong!

Interestingly though, Christmas has changed in meaning for me in recent years. Ever since Covid in fact – that weird, strange, historic, awful-in-many-ways-but-unexpectedly-good-in-others period, that already feels like quite a long time ago. Christmas had one significance before it and another afterwards, and the latter is actually much more important.

It was a place that stamped it into my mind; two very different experiences of it, with the second one over-writing and enriching the first. It was Coventry Cathedral.

So. Every year for the 20 years before Covid, we went to the cathedral on Christmas Eve for an afternoon service called The Road to Bethlehem. My husband had been going nearly all his life, having been a chorister there from the age of seven. We gathered with a big group of friends and acquaintances into an enormous rag-tag choir, first for a rehearsal in the undercroft beneath the cathedral before going upstairs to join the equally enormous orchestra for a bit more practice before the service itself. Everyone was in Christmas jumpers and antlers and sparkly earrings, and the conductors of both choir and orchestra had to stand on boxes so we could see them and they could see each other. It was the only time each year that all the singers and players came together, many of them teenagers home from uni, and the whole atmosphere was buzzy and excited.

In addition to all the hundreds of musicians, gradually then the congregation began to pour in – masses and masses of children among them, nearly all dressed up in nativity costumes. There were crowds of shepherds and angels, hordes of wise men, smatterings of Marys and Josephs and a good crop of baby Jesuses, along with Batman and Spiderman and plenty of princesses who came along for the ride. And all of them during the service moved round the cathedral, from Nazareth at the start, via the nasty innkeeper who told them to clear off, no room in the inn (aka the Lady Chapel), to the hills full of sheep behind the altar, and fetched up in the stable down by the font at the end – with the choir and orchestra belting out appropriate carols at each stage. It was absolute mayhem, with babies yelling and small shepherds whacking each other with light sabres and our friend Mark – a professional tenor – singing sublimely overhead as Angel Gabriel. The cathedral was packed to groaning and at the close, when everyone was asked to light the candles they’d been holding throughout, it was also filled with light and heat and noise as everyone bellowed ‘Oh Come All ye Faithful’ at full volume, the trumpets and tubas giving it large and the kettledrums and cymbals thundering and crashing. It was exhausting, but so wonderful.

And then, 2020.

We didn’t think we’d get to the cathedral at all that year, but the decision was made to hold mini carol services – five of them – across two weekends, sung by small groups from the cathedral’s own choirs, with congregations being admitted by ticket to sit in household clumps, face masks on and no joining in please. It was dark when we got there, and raining, and the streets in Coventry were empty. The people attending the service, not many of them, were stretched in a silent line outside the doors, big gaps between them, masks on, no talking. Inside too, the lighting was low and chairs stood in lonely islands of two, empty acres of space between them (though my husband did firmly go and get a third chair so he and I and our daughter could sit together). I didn’t realise that the lady who let us in was someone I’ve sung with for years – her hair had grown and I couldn’t see her face or hear her voice properly, and when a small choir of girls filed silently in followed by the director of music looking extremely severe, I found it difficult not to cry. In fact for a considerable part of the service I did cry, which was such a pain as it misted up my glasses and I couldn’t wipe my eyes or nose because of the wretched mask.

But something interesting happened as I sat there struggling with all of this. Because, I think, of the quietness and the emptiness, I started to notice the cathedral itself – to feel its presence around me, to see its bones. There is an enormous tapestry there behind the altar, a vast portrait of Christ – strange and distorted and Picasso-like, full of symbols and odd colours – and it is very cleverly lit so that nearly all of it is in shadow except for Christ’s face, with piercing eyes that seem to look directly at you wherever you stand. In front of it are flights of highly stylised wooden doves fixed to the tops of the choir stalls, silhouetted against the tapestry as sharp crisscross shapes. There were lines and lines of tea lights on the ground along the steps, around the base of the pulpit, across the altar rail – like twinkling necklaces of light, reflected in the polished stone floor and casting strange upward shadows on the faces of the choir. And not singing and not joining in the spoken stuff meant I really began to listen – to the quietness of the building, to the sounds from the city outside, to my daughter breathing next to me, to the words of carols I know so well that I stopped hearing them years ago. It was like a sort of warmth creeping over me – I could almost feel it coming up from the floor and gradually making me feel better.

One of the canons gave the address. She looked as if she had been crying herself. ‘It’s not right, is it!’ she cried passionately. ‘That we’re separated from the people we love, that so many are afraid, or sick, that millions have lost livelihoods and now fear for the future, that our young people are missing out on friendships and education, that there’ll be empty places at so many tables.’ But, she went on to say, Christmas has never been ‘right’, not from the beginning. ‘Think of Mary’, she said. ‘So young and so vulnerable – having to give birth to her first child without her mother and aunties, not even with a proper roof over her head or a bed to rest on. Just a pile of straw and a man who wasn’t sure he even wanted to be with her at that point.’ I thought of my colleague, about to have her first baby, with her birth plan and her ‘nesting’ and her husband spending half the night wrestling with the new pram – so loved and precious, not lonely or homeless or disgraced.

‘And what about the shepherds?’ the canon continued. ‘Outcasts, forgotten ones, the lowliest of lowlies, poorest of the poor – but it was they who the angels visited. And it was only common sense that took the Wise Men to Herod’s palace. They were seeking a king after all… but they couldn’t have been more wrong, could they!’

Christmas is always all wrong, in other words. It’s meant to be. It’s meant to subvert the order of things, to teach us new lessons, to get us to think differently. So in many ways, the horrible upside-down 2020 Christmas with the world in disarray was just like the first one. And as with that one, there was light and wonder to be found, which darkness has never quenched yet.

It doesn’t matter, I don’t think, whether you believe or don’t believe in the existence of God: the fact is that the nativity is an extraordinary story that has guided millions of people for centuries, and inspired and comforted and influenced them in all kinds of ways. Even by itself, that is amazing. And the miserableness of Covid and upset and disruption and spoilt plans were – weirdly – the reason that I heard the story differently that year.

It is all right for things to be all wrong.

And because of hearing it like this, I have found that it’s given me a new kind of resilience – a higher capacity for tolerating wrongness; a cheerfulness that is not entirely centred in everything being fine and everyone behaving beautifully. Which, let’s face it, is just as well… and probably the very best gift that Christmas can give to anyone.

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Article

Assisted dying

Care

Culture

Death & life

13 November 2024

8 min read

The deceptive appeal of assisted dying changes medical practice

In Canada the moral ethos of medicine has shifted dramatically.

Ewan Goligher

Ewan is a physician practising in Toronto, Canada.

A tired-looking doctor sits at a desk dealing with paperwork.

Francisco Venâncio on Unsplash.

Once again, the UK parliament is set to debate the question of legalizing euthanasia (a traditional term for physician-assisted death). Political conditions appear to be conducive to the legalization of this technological approach to managing death. The case for assisted death appears deceptively simple—it’s about compassion, respect, empowerment, freedom from suffering. Who can oppose such positive goals? Yet, writing from Canada, I can only warn of the ways in which the embrace of physician-assisted death will fundamentally change the practice of medicine. Reflecting on the last 10 years of our experience, two themes stick out to me—pressure, and self-deception.

I still remember quite distinctly the day that it dawned on me that the moral ethos of medicine in Canada was shifting dramatically. Traditionally, respect for the sacredness of the patient’s life and a corresponding absolute prohibition on deliberately causing the death of a patient were widely seen as essential hallmarks of a virtuous physician. Suddenly, in a 180 degree ethical turn, a willingness to intentionally cause the death of a patient was now seen as the hallmark of patient-centered doctor. A willingness to cause the patient’s death was a sign of compassion and even purported self-sacrifice in that one would put the patient’s desires and values ahead of their own. Those of us who continued to insist on the wrongness of deliberately causing death would now be seen as moral outliers, barriers to the well-being and dignity of our patients. We were tolerated to some extent, and mainly out of a sense of collegiality. But we were also a source of slight embarrassment. Nobody really wanted to debate the question with us; the question was settled without debate.

Yet there was no denying the way that pressure was brought to bear, in ways subtle and overt, to participate in the new assisted death regime. We humans are unavoidably moral creatures, and when we come to believe that something is good, we see ourselves and others as having an obligation to support it. We have a hard time accepting those who refuse to join us. Such was the case with assisted death. With the loudest and most strident voices in the Canadian medical profession embracing assisted death as a high and unquestioned moral good, refusal to participate in assisted death could not be fully tolerated.

We deceive ourselves if we think that doctors have fully accepted that euthanasia is ethical when only very few are actually willing to administer it.

Regulators in Ontario and Nova Scotia (two Canadian provinces) stipulated that physicians who were unwilling to perform the death procedure must make an effective referral to a willing “provider”. Although the Supreme Court decision made it clear in their decision to strike down the criminal prohibition against physician-assisted death that no particular physician was under any obligation to provide the procedure, the regulators chose to enforce participation by way of this effective referral requirement. After all, this was the only way to normalize this new practice. Doctors don't ordinarily refuse to refer their patients for medically necessary procedures; if assisted death was understood to be a medically necessary good, then an unwillingness to make such referral could not be tolerated.

And this form of pressure brings us to the pattern of deception. First, it is deceptive to suggest that an effective referral to a willing provider confers no moral culpability on the referring physician for the death of the patient. Those of us who objected to referring the patient were told that like Pilate, we could wash our hands of the patient’s death by passing them along to someone else who had the courage to do the deed. Yet the same regulators clearly prohibited referral for female genital mutilation. They therefore seemed to understand the moral responsibility attached to an effective referral. Such glaring inconsistencies about the moral significance of a referral suggests that when they claimed that a referral avoided culpability for death by euthanasia, they were deceiving themselves and us.

The very need for a referral system signifies another self-deception. Doctors normally make referrals only when an assessment or procedure lies outside their technical expertise. In the case of assisted death, every physician has the requisite technical expertise to cause death. There is nothing at all complicated or difficult or specialized about assessing euthanasia eligibility criteria or the sequential administration of toxic doses of midazolam, propofol, rocuronium, and lidocaine. The fact that the vast majority of physicians are unwilling to perform this procedure entails that moral objection to participation in assisted death remains widespread in the medical profession. The referral mechanism is for physicians who are “uncomfortable” in performing the procedure; they can send the patient to someone else more comfortable. But to be comfortable in this case is to be “morally comfortable”, not “technically comfortable”. We deceive ourselves if we think that doctors have fully accepted that euthanasia is ethical when only very few are actually willing to administer it.

We deceived ourselves into thinking that assisted death is a medical therapy for a medical problem, when in fact it is an existential therapy for a spiritual problem.

There is also self-deception with respect to the cause of death. In Canada, when a patient dies by doctor-assisted death, the person completing the death certificate is required to record the cause of death as the reason that the patient requested euthanasia, not the act of euthanasia per se. This must lead to all sorts of moments of absurdity for physicians completing death certificates—do patients really die from advanced osteoarthritis? (one of the many reasons patients have sought and obtained euthanasia). I suspect that this practice is intended to shield those who perform euthanasia from any long-term legal liability should the law be reversed. But if medicine, medical progress, and medical safety are predicated on an honest acknowledgment about causes of death, then this form of self-deception should not be countenanced. We need to be honest with ourselves about why our patients die.

There has also been self-deception about whether physician-assisted death is a form of suicide. Some proponents of assisted death contend that assisted death is not an act of deliberate self-killing, but rather merely a choice over the manner and timing of one's death. It's not clear why one would try to distort language this way and deny that “physician-assisted suicide” is suicide, except perhaps to assuage conscience and minimize stigma. Perhaps we all know that suicide is never really a form of self-respect. To sustain our moral and social affirmation of physician-assisted death, we have to deny what this practice actually represents.

There has been self-deception about the possibility of putting limits around the practice of assisted death. Early on, advocates insisted that euthanasia would be available only to those for whom death was reasonably foreseeable (to use the Canadian legal parlance). But once death comes to be viewed as a therapeutic option, the therapeutic possibilities become nearly limitless. Death was soon viewed as a therapy for severe disability or for health-related consequences of poverty and loneliness (though often poverty and loneliness are the consequence of the health issues). Soon we were talking about death as a therapy for mental illness. If beauty is in the eye of the beholder, then so is grievous and irremediable suffering. Death inevitably becomes therapeutic option for any form of suffering. Efforts to limit the practice to certain populations (e.g. those with disabilities) are inevitably seen as paternalistic and discriminatory.

There has been self-deception about the reasons justifying legalization of assisted death. Before legalization, advocates decry the uncontrolled physical suffering associated with the dying process and claim that prohibiting assisted death dehumanizes patients and leaves them in agony. Once legalized, it rapidly becomes clear that this therapy is not for physical suffering but rather for existential suffering: the loss of autonomy, the sense of being a burden, the despair of seeing any point in going on with life. The desire for death reflects a crisis of meaning. We deceived ourselves into thinking that assisted death is a medical therapy for a medical problem, when in fact it is an existential therapy for a spiritual problem.

We have also deceived ourselves by claiming to know whether some patients are better off dead, when in fact we have no idea what it's like to be dead. The utilitarian calculus underpinning the logic of assisted death relies on the presumption that we know what it is like before we die in comparison to what it is like after we die. In general, the unstated assumption is that there is nothing after death. This is perhaps why the practice is generally promoted by atheists and opposed by theists. But in my experience, it is very rare for people to address this question explicitly. They prefer to let the question of existence beyond death lie dormant, untouched. To think that physicians qua physicians have any expertise on or authority on the question of what it’s like to be dead, or that such medicine can at all comport with a scientific evidence-based approach to medical decision-making, is a profound self-deception.

Finally, we deceive ourselves when we pretend that ending people’s lives at their voluntary request is all about respecting personal autonomy. People seek death when they can see no other way forward with life—they are subject to the constraints of their circumstances, finances, support networks, and even internal spiritual resources. We are not nearly so autonomous as we wish to think. And in the end, the patient does not choose whether to die; the doctor chooses whether the patient should die. The patient requests, the doctor decides. Recent new stories have made clear the challenges for practitioners of euthanasia to pick and choose who should die among their patients. In Canada, you can have death, but only if your doctor agrees that your life is not worth living. However much these doctors might purport to act from compassion, one cannot help see a connection to Nazi physicians labelling the unwanted as “Lebensunwortes leben”—life unworthy of life. In adopting assisted death, we cannot avoid dehumanizing ourselves. Death with dignity is a deception.

These many acts of self-deception in relation to physician-assisted death should not surprise us, for the practice is intrinsically self-deceptive. It claims to be motivated by the value of the patient; it claims to promote the dignity of the patient; it claims to respect the autonomy of the patient. In fact, it directly contravenes all three of those goods.

It degrades the value of the patient by accepting that it doesn't matter whether or not the patient exists.

It denies the dignity of the patient by treating the patient as a mere means to an end—the sufferer is ended in order to end the suffering.

It destroys the autonomy of the patient because it takes away autonomy. The patient might autonomously express a desire for death, but the act of rendering someone dead does not enhance their autonomy; it obliterates it.

Yet the need for self-deception represents the fatal weakness of this practice. In time, truth will win over falsehood, light over darkness, wisdom over folly. So let us ever cling to the truth, and faithfully continue to speak the truth in love to the dying and the living. Truth overcomes pressure. The truth will set us free.