Leaving: A Narrative of Assisted Suicide
University of California Press, 2020. 248 pages.
Everyone discovers an academic doppelgänger at some point. We invest time in projects that take years to develop with requisite hunts for external funding, time-consuming efforts to carry out research that aspire to some kind of broadly defined depth, the subsequent endless transcribing, analyzing and writing out and revising drafts; all before the peer review process takes its invariable time and toll. Developing any kind of ‘original’ project invariably requires a prior scouring of the existing academic literature to find ‘gaps’ that may allow novelty, a minor yet distinctive contribution to the given subfield, topic, or theoretical intervention. But then, almost invariably, somewhere along the process, sometimes sooner, sometimes later, via the grapevine or at an academic conference, we discover an other out there working on a similar or even the exact same subject.
This can be a bewildering and dismaying experience in graduate school that provokes all sorts of nagging existential questions– from demoralization and feelings of general futility to invoking a completely inappropriate proprietorial feeling of territorial trespass that mirrors in a minor way the lingering and haunting presence of the robber after a robbery. And then far more practical considerations – anxiety over being out on the job market with that very same person competing over already scant resources. I can relate because I had such an awkward encounter with a doppelgänger during my final year working on my doctoral dissertation. Fast forward to the soft landing of post-tenure, mid-career acquiescence with anxieties assuaged and the nagging insecurities and the real and imagined humiliations that comprises the graduate student and early-stage researcher experiences hopefully overcome if they have not yet scarred us for life. Now encounters with doppelgängers can become small modernist wonders of both Borgesian significance and Levinasian ethical reckoning. The horror and anomie give way to the pleasure of reading a work that views the same topic via a separate presence. Encountering a doppelgänger can become a beautiful experience.
This brings us to book reviews. Because topical proximity binds us around concentric circles of expertise, sooner or later we may be invited to review a doppelgänger’s work. The default but empty civility of academic book reviews and blurbs often jars uneasily against the experience of anonymous peer review, especially when considering the same people requested for the former are invited to the latter, suggesting the default academic practice is a shiv in the back. The generic niceties and platitudes (“makes a significant contribution” or “raises important questions”) of academic book reviews appear as superego modulated outward politeness forcing a Jekyll and Hyde-esque reckoning for unrestrained academic ids with the guns ablaze, no holds barred violence of anonymous peer review.
All this is my longwinded and hopefully not too self-indulgent way of reviewing Anthony Stavrianakis’ Leaving: A Narrative of Assisted Suicide, an ethnography of medically assisted dying in Switzerland that mirrors my own research, albeit in a different part of the world but through a very recognizable frame of interests. If this ethnographic review documents the reviewer’s own relationship to the reviewed, it’s also my way of consciously mirroring Leaving which is deliberately written as Stavrianakis’ own meticulously self-reflexive ethnography on the subject. While consisting of a series of riveting and novelistic narratives of why people choose to end their life through Swiss right to die organizations like Exit, Leaving is as much a documentation of Stavrianakis’ own journey through their journeys, a book as much about the process of doing anthropology on assisted suicide as it is on assisted suicide.
The subtitle of the book, after all, is a singular narrative that both encompasses how Stavrianakis sees the process as creating a narrative form that subsumes the individual subject’s experience (“a form through which to leave the experience of suffering” ) to Stavrianakis’ own ethical excursion and dense conceptual work on the meaning of this form for contemporary dying. In this way, Leaving provides a perfect doppelgänger that pushes one less, as academic debates so often go, to obsess over narcissisms of minor difference but to revel in minor epiphanies that highlight both recognition of shared experiences but also distinctive insight (“why didn’t I think that?”).
The book’s three-part structure is both rigorous and perfectly formed, moving from larger context to individual narratives to theoretical analysis. If one were to pigeonhole Leaving’s general orientation, I would characterize it as counterintuitive, the best way of approaching a subject matter that bases itself on taken-for-granted slogans such as dignity, autonomy, and rights. Stavrianakis sets the stage by opening with an ethnographic description of what ‘normal’ contemporary dying consists of within the dominant palliative care and hospice approach in Switzerland. While the practice of assisted suicide can be better understood by the more dominant approach, they are not mutually opposed dichotomies as they are so often depicted but better represent complimentary continuities in a spectrum of dying processes. That the book’s subtitle uses “assisted suicide” is jarring at first glance given the term is widely considered ‘dated’ having been supplanted by “medical assistance in dying,” even coming with the pleasing acronym MAiD. Yet the practice in Switzerland exists in a legal grey area since assisting someone to end their life is not a criminal act if no motive for profit exists; what Stavrianakis terms a ‘parazone.’
Like the apparent difference between a death via palliative care or assisted suicide, the ‘parazone’ becomes another ambivalent ambiguity to unravel over whether assisted suicide as practiced in Switzerland represents a distinctive break from MAiD practices elsewhere where they exist within a state regulated medical system. Stavrianakis will later circle back to this issue obliquely by positing his theoretical analysis conceptually around suicide. Again, this is a counter-intuitive argument because the argument in favour of a “medically-assisted death” constructs it in direct opposition to “suicide” by taking away its voluntariness and attributing both agency and cause of death onto the disease state that is causing the person to wish to end their life. Although seeing the issue through the lens of suicide would displease and even offend many right to die activists and advocates, Stavrianakis is absolutely correct to question this dichotomy, and I have done the same in a far less theoretical way. While at first the analysis might seem jarring, given how counter-intuitive it is, Stavrianakis weaves through various conceptual understandings of suicide to ultimately capture the distinctiveness of what a death via MAiD or assisted suicide looks like.
This raises some questions over how much Stavriankis intends us to read the material as particular to its specific context or not. If assisted suicide is distinct in Switzerland from other places where MAiD medicolegal regimes have been instituted (like the Netherlands, Belgium, Canada or U.S. states like Oregon and Vermont), the Swiss approach mostly operates in a similar fashion. The major difference is that it exists non-sanctioned and outside of the state but also open to non-Swiss citizens that allows for the more ethically fraught issue of ‘suicide tourist’ (obliquely invoked in the work since it features several French citizens.) So Switzerland presents an anomalous legal situation in this case (just as it represents its own European anomaly more generally), but is there anything specific to the setting in the analysis? Stavrianakis, like most of us these days, acknowledges but eschews the question of any culturally distinctive ethos. Perhaps the more important question is: does the practice become a different kind of death when it is embedded firmly within the medical system as one end of life “choice” amongst other options? Although Stavrianakis flirts with the idea of difference through his concept of ‘parazone,’ he seems to conclude with loosely generalizable conceptual work that links both assisted suicide and MAiD as a specific contemporary ethical form of dying. This encompass an assisted death in Switzerland and, say, Canada.
I think he’s right, but I’m left wondering about this since Switzerland’s ‘parazone’ appears as much akin to the more radical fringes of right to die activism like Exit International, which advocate a DIY approach of learning and enacting the end of one’s life outside of the law or any medical control. In this framing, a DIY death becomes more of a purely individual act framed by autonomy. However, Stavrianakis insightfully points to a prime tension that asserts death as a ‘right’, itself a strange idea that distinguishes a ‘right to die’ from other rights. In the end, what is really being asserted is a right to assistance from others in the same way that there is a quasi-paradox that suicide is decriminalized in the same places where assisting one to commit that decriminalized act is still a crime.
That such practices are based on notions of freedom and autonomy when they are so predicated on assistance from others (and thus relational, involving both forms of dependency and care) comprises one of the larger paradoxes and apparent contradictions which surround assisted dying. Stavrianakis nicely unpacks them detouring through the ethical turn in anthropology. The movement’s foundational claims of freedom and autonomy are concepts whose very invocation nowadays require an almost default problematization within our discipline. This probably attests to why medical anthropologists have been loath to address the subject of assisted dying until recently, even if Leaving represents a recent wave of interest in the subject. This marginal status may be a result of assisted dying not involving marginalized identities, even if the question of suffering lies at its core. In fact, the issue seems to negate structural inequalities entirely by focusing on horizontal forms of suffering basic to our human (and non-human) condition rather than vertical forms that invoke power or racism or gender. There is a reason why disability rights activists are often (but not always) opposed to the issue or that much opposition is framed (ingenuously, occasionally, in my mind) in terms of vulnerable persons. That the evidence of assisted dying, on the other hand, reveals that most participants in the practice where it is available are upper-middle class and educated white people can both be used to deride the ostensible right to die (as some kind of white, elite privileged concern) but also defend it (if the most vulnerable people were being exploited by such laws certainly we would see it in the data).
If I started with a discussion of doppelgängers and how we recognize similarity and difference, I’ll take leave of Leaving with my own personal reflection on a key issue that provokes one of the ethnography’s ethical reckonings. Stavrianakis states that his initial ethnographic goal was to witness a death through assisted suicide – to accompany an individual through the process to its completion. When I started my own research, I thought about that possibility but unequivocally rejected it. Ethically, it made me feel queasy. Stavrianakis’ own discussion of his journey to reach this goal reaffirms my unease. The discussion is left slightly oblique, but he also comes to question his original intent. Accompanying someone to die is an affirmation; it is to be an accomplice and can risk becoming exploitative. Recording death is also one of the most important activist tools and sources of advocacy for the subject as the numerous documentaries that depict someone’s assisted death can attest. Stavrianakis explicitly rejects such a role for himself, but again, raises the issue of what it means to give the imprimatur of approval that, in one difficult case, he cannot give. Of course, his willingness to go there and my own unwillingness may be less a bold ethical stance on my part than a product of my own cowardice. After all, if confronting stigma of death itself is part of the larger context, he (and, by default, we) may need to go there. As we know, fear so often cloaks itself in moral judgment.
Leaving is a work to think with rather than to think against and should provoke more anthropological interest in the topic. Its critical destrangement teases apart the ethical contradictions of a thorny issue, and, in the end, yes, okay–I’ll say it–makes an important contribution to discussions of contemporary dying and anthropological discussions of ethics more generally. If death in a secular age has lots of its meaning, assisted dying provides a ritualized form of dying that re-signifies its meaning from its larger cosmology onto the process itself.
Ari Gandsman is associate professor in the School of Sociological and Anthropological Studies at the University of Ottawa.