Dax's Case: Death, Self-Assertion, and the Logic of Life
(I wrote this paper for my “Legal and Ethical Issues in Healthcare” class, in response to the film Dax’s Caseand the book of the same name. Dax Cowart was a bright and healthy young man of 25 who was in a terrible explosion which left him severely burned. Two thirds of his body were marred by third degree burns, and Dax said he did not wish to suffer through torturous treatments for the sake of an uncertain future. He said he wished to die. His doctor, mother, and lawyer, however, wished to keep him alive so that he might be rehabilitated, and so they forced treatment on him. Dax was unable to physically resist; his burns were too bad. He had no use of his hands, he could not walk, and he was blinded by the accident. Treatment was forced on him for many months, while Dax complained vociferously. At some point, he relented, and after about a year, his physical wounds were mostly healed. Then, after a number of years of a painful process of re-establishing a life for himself, which included two failed suicide attempts in the midst of slowly making his way through law school, he achieved a new identity for himself as a lawyer and advocate for patients’ rights, and even achieved, by his own statement, a greater degree of happiness than that possessed by most people he meets. What makes Dax so interesting to ethicists is that, to this day, though he freely admits to being a happy man and glad to be alive, he maintains that he should have been allowed to die. It is hard to grasp how horrific Dax’s situation was -- and how clear-minded Dax was about what occurred -- without seeing Dax’s Case, which contains burn-unit footage of Dax, looking almost like a skeleton, being dipped in a vat of Clorox solution, and screaming while nurses do various things with bandages and such, and also contains interviews with Dax after his rehabilitation talking about what occurred. Unfortunately, the DVD of the film costs $495; it is marketed mainly as a rental-DVD for university classes (rental cost: $80). That said, perhaps if you are not familiar with the film or the book you can imagine the situation well enough to grasp the basic context for this paper. There is also a video I refer to in this paper of Dax many years later, speaking before a college audience; in that video he is remarkably clear, and one also gets a sense of the graceful quality of his happiness.)
* * * Dax's Case: Death, Self-Assertion, and the Logic of Life by Andrew Schwartz
While many commentators on Dax’s case defend Dax’s right to choose death for himself, I have not come across a commentator who defends the potential moral rightness of the choice of death itself.
In this paper I wish to show in what way the choice to die can be seen as a legitimate expression of life itself in Dax’s case.
I will use Sally Gadow’s essay “Remembered in the Body” (1989) as a jumping off point to show that, in addition to the enhanced compassion and skill that would, as Gadow claims, emanate from more “embodied” caretakers, a whole different moral outlook, one at greater ease with death and the choice of death, would emanate as well. I wish to show that such an outlook would in fact be an expression of respect for the deep logic of life itself, rather than its opposite, but that it would also require a significant psychological reworking, a reaching back to deal with the developmental wounds — the fears and shames — that led Dax’s caretakers to become “disembodied” and blind to the logic of life in the first place.
While Gadow frames caretaker and burn victim as polarized largely by circumstances — the burn victim’s nakedness, inability to touch, grasp and see, and imprisonment in chronic physical pain, and the caretakers contrasting abilities to reach out, manipulate, and remain internally aloof from physical concerns — her recommendations for bridging the gap issue largely to caretakers. She recommends that caretakers reveal to the patient “the vulnerability that summarizes for them, as for [the patient], the body’s implications, disclosing to [the patient] their bewilderment, anguish, incomprehension, fear.” She also believes that this greater authenticity or “embodiment” on the part of caretakers would lead to greater skill on the part of caretakers to relieve the patient’s pain: out of acknowledged vulnerability emerges "an intensity of empathic regard and a corresponding refinement of physical ministration in which the smallest gesture, the least touch, is capable of easing the other’s suffering....Even at its worst [the patient’s vulnerability] can be assuaged, but only through the forms of caring that an empathic — because embodied — imagination creates."
It is easy for me to read into Gadow’s suggestions a wider criticism of medical professionals in general, perhaps because my own experience with medical professionals is that they are often aloof, disconnected, and in many cases, vaguely hostile.
But what are the developmental roots of this aloofness? On a philosophical level, the reductionist-materialist stance of modern medical tradition has something to do with it. But philosophy is only a piece of the puzzle; psychology is another important piece. Gadow deals with neither.
And what of the issue of Dax’s request to die and its legitimacy? Gadow doesn’t deal with this issue either.
Let’s now deal with all of these issues.
Life as Multifaceted
In the article “Dealing with Catastrophe,” William May (1989) posits that to see “life” as synonymous with physical survival of the organism is an error; that life is better understood as belonging to an organism with a particular personal identity, such that when a person such as Don Cowart looses in a tragic accident so many aspects of his personal identity, it makes more sense to consider him to have died; what is then necessary is a heroic struggle toward rebirth, supported by a community that understands this.
While I appreciate the tenor of May’s ideas, I approach the issue of the concept of life a bit differently. On the one hand, I think it is correct that limiting the concept "life" to refer to “the physical survival of the organism” is a reductionistic error. But I would not point instead to notions of personal identity.
Instead, I would simply describe life as multifaceted, such that the concept "life" is what in linguistics would be considered a “mass noun” — like “ocean water,” it contains depths, surfaces, shores in one place and shores in another; it makes up waves; and like ocean water, parts of it can be taken away from the ocean; it can be depleted .
To be less metaphorical and more every-day about the issue, consider the fact that we speak naturally of someone’s “love life,” or “work life,” or “social life.” The concept life in every day speech refers not only to physical survival, but to any and all of the various processes of life, including as viewed from the inside.
It is only due to our entrenched philosophy of reductionistic materialism that, when thinking medically, we are inclined to consider these broader uses of the concept life mere literary or colloquial uses. If we let go of the reductionism — if we can see it as the intellectual imposition on actual human experience that it is — we enter back into the richness of life as it actually confronts us.
Self-Assertion and its Subversion
It is not only a philosophic reduction of the concept life to mere physical survival that keeps caretakers dissociated from the richness of the life process. Developmental assaults on the children who will become caretakers, and their internalization of those assaults, also must be examined.
Inherent in the process of life is the principle that living organisms move toward pleasure and fulfillment and away from pain and destruction . Prior to developmental insults, pleasure is both psychologically fulfilling and associated with boons to the overall organism: the child takes pleasure in food and takes pleasure in locomotion (and the learning of locomotion) as well. Pain on the other hand is psychologically wrenching and associated with insults to the organism’s functioning: we experience it when our food is rotten and we experience it when our sensory-motor system is out of alignment.
The human organism, though, is complex; along with the human’s expanded capacity for conceptual knowledge and creative manipulation of the environment come both a need for more consciousness and vision than the pleasure/pain impulses by themselves provide (Rand 1964), as well as a capacity for conceptually rooted fears and a facility for dissociation of some aspects of consciousness from other aspects of consciousness as a way to quell those fears.
Looking at the issue as it presents itself most readily, parents, teachers, and other caregivers can subvert a child’s self-assertive capacity by instilling fear in the child — fear of disapproval, fear of punishment, fear of loss of love. When a child’s belly is full, a parent can nonetheless shout angrily, “finish the food on your plate!” When a child’s physical energy is high, a teacher (indeed an entire educational system) can nonethless shout angrily, “sit still and study your lessons!” When a child has lost a treasured toy and seeks to relieve the frustrated yearning through sobs, a caregiver can nonetheless shout angrily, “stop crying!” Such assaults on the child’s integrity are commonplace.
Some children with a robust nature are perhaps able to withstand these assaults and keep their wits about them throughout childhood; they eventually escape into the freedom of adulthood and make their way self-assertively in the world (Branden 1995).
To the extent a child lacks the constitution and/or willingness to maintain awareness of and interest in honoring his or her basic pleasure/pain mechanism, though, that child will tend to internalize the prescriptions and prohibitions of his or her caretakers. “I should finish the food on my plate.” “I should sit still and study my lessons.” “I should stop crying; crying is for babies.” The child stuffs down the problematic impulses, and at some point forgets them entirely; in their place are moralistic or intellectualistic notions about what is right and wrong .
Of course, the impulses themselves do not go away. They can’t: they are of the central nature of the organism. When these children become adult caretakers themselves, the impulses — along with all the shame and fear associated with them — remain within them. Because they are not recognized for what they are, though, because the new adult caretakers cannot see them as their own, they easily project the dynamics associated with these impulses onto innocent others — such as our Dax.
Oppressive Forces Within, Oppression of Those Without
Dax’s mother, no doubt, was placed in a terribly difficult position, and in offering the following thoughts I do not mean to cast aspersion on her. I do believe, though, that in colluding with the doctor to force treatment on Dax, she was likely operating on the basis of submerged, troublesome dynamics.
It strikes me as likely that Ada Cowart, like many of her generation, was at some point in her development made to fear hell if she did not follow the rules of her religion. I base this on scanty evidence, and the reader can take my proposals as a thought experiment if nothing else. I observe, though, that Ada Cowart was concerned over the fact that her son had not “made his peace with God.” What was the meaning of this concern on Ada Cowart’s part? Was her concern that her son was not a being at genuine peace with himself and the world? Or was her concern that her son had not yet submitted to her rules and the rules of the societal order? While I don’t wish to be overly dramatic, these are the only two interpretations I can imagine: either “peace” refers to a genuine experience of peace, or it refers to a person’s willingness to, metaphorically speaking, go to church on Sundays.
Let us then look at the Dax’s Case film. When I see Dax Cowart speaking, I see a man who is, more or less, at peace with himself, at peace with his convictions, undefensive, willing to acknowledge and understand the point of view of those who forced treatment on him, and even, at the time of the filming, at peace with the state of his life.
I do not see a similar kind of peace in the person of Ada Cowart. I see a strong woman and a concerned mother, yes, but when she says “now that he’s happy, I know that [what we did] was right,” I don’t see a genuine, peaceful certainty there; I see, rather, the body language of a woman who is working to intellectually persuade herself she did the right thing. In her body language I see doubt. When she says “it has been very difficult,” I see a struggle that continues within her. I do not see the same struggle within Dax (in the film).
When I then hear of Ada Cowart’s arguments with Dax about what clothes he would wear, and her initial insistence that there not be alcohol kept in the house, and when I put this together with her regular attendance at church, including Wednesday nights for a church class, I cannot help but see the image of a woman in whom church teachings and doctrine had been internalized at the expense of personal self-assertion and an appreciation for such in others.
There are two ways in which I believe the submersion of self-assertion in Dax’s caretakers translated into the oppression of Dax, one psychodynamic, and the other existential.
First of all, I want to make the case, on the basis of some of the preceding points, that if Dax had been allowed to refuse treatment and die according to his wishes, his refusal and subsequent death would have been an act of self-assertion and could be seen as in accord with the basic logic of life itself. Some authors writing about Dax’s case, such as Dax’s psychiatrist Dr. White, wonder whether Dax’s requests to die were in fact his best attempt at asserting his autonomy in the face of his helplessness with respect to his caretakers and his situation. And I actually think this might indeed be true. But that is not the point I am here making. Here I wish to make the point that his refusal of treatment could be seen as, not a mere attempt to assert autonomy, but a genuine, natural, we might even say “reasonable,” expression of human life asserting itself in a healthy way.
Self assertion involves both moving toward pleasure and fulfillment and away from pain and destruction, and life cannot be reduced to mere physical survival. Nor is there any particular biological logic to placing physical-survival-with-hope-for-future-happiness on top of any other life value . In normal circumstances, we will surely rate physical survival highly, since it is the only way to allow for the acquisition of other values in the future, and we will also rate future happiness highly, since doing so involves us in the wider life process that makes up the lifespan. But it is only intellectualistic imposition of the idea that physical-survival-with-hope-for-future-happiness is the top value that would lead us to see it as inherent in the logic of life itself. The fate of the salmon that swims to its death in order to spawn is enough to deny that claim.
And so when an organism recognizes that it is the continuance of physical life that is itself the cause of a pain deemed not worth bearing in the context of any potential future value, it is an act of self-assertion to end that physical life, even if that means ending the psychological life at play in making the decision.
But to the extent that caretakers have stuffed their own self-assertion, through internalizing the fearsome commands of parents, teachers, or the institutions that generally raised and educated them, they will project all the fears of disapproval and loss of love onto a person like Dax, who does not share such fears (at least to the same extent) and who, presumably, does not wish to tolerate pain in the same way his caretakers were willing to tolerate it. Put into words, their objections might be stated as follows: “How could you possibly want to do something so socially unacceptable as kill yourself?” It is, in this way, merely another version of “How could you possibly want to do something so socially unacceptable as wear those clothes?” or “keep that beer in your room?” It is, in other words, a specific version of a more general oppressive orientation: “How could you possibly want to assert yourself when doing so conflicts with the rules of those in charge?” — and as a narcissistic addendum, “especially when that includes me?!”
And yet there is another reason for which those with stuffed self-assertion can fear and oppressively prevent another person’s attempt at suicide: fear of death. Death, in an important way, is a part of life . In addition to the physical death we all at some point will face, we experience deaths of aspects and elements of the ocean that is our life: we experience the death of childhood, or the death of a love affair, or the death of an unfulfilled ambition. To the extent we are generally self-assertive and open to life, we may mourn the loss, but we do not attempt to hold on to things that have died. We do not attempt to hold on to a love that no longer has any basis or source of energy; we do not attempt to remain children once we are adults; we do not attempt to achieve old ambitions that no longer have a motivational basis in the present. And because we experience a reasonable amount of fulfillment in our life, we are not afraid to let go.
When a person stuffs their self-assertion, though, death is a more fearsome prospect. A person with stuffed self-assertion is not as fulfilled, and thus is more apt to attempt holding onto those things that have heretofore given them some sustenance. The ultimate death of the physical body holds special fears: it means that all those unmet wants and needs from long ago, still frozen in time due to the stuffing and submergence (Wilber  2001), will never be satisfied.
These fears, though, get projected onto Dax. The hope of future happiness obtains perpetual significance for those who have stuffed their own self-assertion; to the extent of the stuffing, it’s their only hope! But for one like Dax who, by all accounts, had lived fully and self-assertively, and who, by all accounts and also by my estimation from his interviews, was always a profoundly autonomous and self-assertive person, hope of future happiness is not so over-riding a concern. Respecting his inner signals — his own “biological logic” — which indicate to him that nothing in the future can be worth this magnitude of extended pain, is more significant.
And so, to bring us back to Gadow’s (1989) essay regarding “embodiment,” for Dax’s caretakers to have acknowledged their own vulnerabilities to Dax, to whatever extent they might have been able and willing to do so, no doubt would have helped the situation. And perhaps such a suggestion is a good start. My purpose in this paper, though, is to make a more radical recommendation, as a push for a systematic shift toward a more self-honoring, life-honoring morality; I would like that caretakers who aren’t already in accord with my position look deeper within themselves to their own pleasure/pain mechanism, and the possible wounds that might be found in the vicinity, and then to put the kind of attention into healing those wounds as they deign to put into healing the wounds of others who are not always so enthusiastic about their ministrations.
My sense is that in doing so, they would not only be more compassionate and caring toward someone like Dax in their tone and the quality of their ministrations; they would also be more likely to respect and wish to honor a competently expressed wish to die. In acknowledging the deaths they themselves have lived, they would not be so afraid of and resistant to death in someone else. In acknowledging the life they have not lived, they would not be so afraid of and resistant to life asserting itself — in this case by refusing to passively accept pain — in someone else.
Epilogue: Dax Now
Many commentators appear to see Dax’s current happiness as a reason to say that if he had been granted his wish to be allowed to die, and if he had followed through with that wish, he would have made a mistake. How, these commentators seem to ask, can Dax say that he is happy to be alive, but unhappy that treatment was forced upon him?
On the one hand, I could make a moral-political argument about the ethics of forcing treatment on competent individuals, and I believe it would be a similar argument to one Dax would make. But my goal in this paper is not to deal with the issue of Dax’s right to decline treatment. My goal is to deal with the potential moral wisdom of the decision itself.
So in defense of Dax’s consistency, I will say this: It is possible for a poor man, looking to raise his station in life, walking home from work, and extremely hungry, to impulsively enter into a take-out restaurant and purchase a sausage for $4. Only while walking home, sausage in hand, does the man realize that, if he had but been willing to wait five minutes, he would have arrived at home, and could then have eaten one of his own store-bought sausages which only cost $1 per sausage. Being that he is poor, he regrets his impulsiveness, and feels upset with himself that he made a rash decision that does violence to his finances.
At that point, however, what is the man to do with his sausage? The deed has been done. Shall he not enjoy his sausage at this point?
I would say that if he is a self-honoring and generally self-assertive man, he will do just that. Embracing the value of the sausage that is now his is precisely the attitude of one who is embodied, living life in the present, not afraid of change, and not afraid of being called inconsistent by others. He can enjoy the sausage ... and still acknowledge that, in the grand scheme of things, it was not worth his $4.
Dax asserted his wish to die as best he could. That wish is now dead. Dax accepts the death of the wish. Dax can enjoy his life now ... and still hold that, in the grand scheme of things, its facilitation was not worth what he was put through.
A Poem by Dax
In seeking out additional video of Dax online, I found a video of a presentation Dax gave in a university setting in 2002 (University of Virginia), at the end of which he read the beginning and end of a poem he wrote. I reproduce it here as evidence that Dax is the kind of person I have portrayed him as; Dax titles the poem “The Dance of Life”:
Embrace the day - hold it close to you - like the fire and passion of a vibrant, beautiful woman, feel its warmth and energy flow through you.
Listen with the spirit, and you will hear the emotions of your brother’s heart. Speak with the spirit, and your brother will hear the emotions of your heart. And when you and your brother speak and listen to each other with the spirit, your spirits will touch.
Be real; step into yourself. Cling to all that is you; release all that is not. For it is here, in the deep blue heaven of these high places, that we soar on wings that are our own and ride the currents of our soul.
1. I am not certain the extent to which I can take credit for this metaphor; after thinking of it and reviewing my draft of this paper, I began to vaguely remember hearing a similar metaphor used, either as a way to describe life, or “spirit,” or consciousness, or something along those lines.
2. My views concerning the “pleasure-pain mechanism” owe something to those described by psychologist Nathaniel Branden ( 1979).
3. What I am describing here was described by Freud (and many others who followed him) in perhaps more general and limited terms as the formation of the “superego.”
4. I credit Engelhardt (1989) with alerting me to the issue of the relevance of value hierarchies to Dax’s case; he speaks of it in terms of “the collapse of the Enlightenment assumption that one can discover the morally authoritative ranking of goods and harms so as to judge how one ought to act in particular kinds of situations.” I would challenge Engelhardt that one can indeed possess a “morally authoritative ranking,” but would propose that such a ranking can only be generated from within, rather than from without.
5. My thoughts regarding death fear are heavily influenced by Irvin Yalom (1980).
Branden, Nathaniel.  1979. The Psychology of Self-Esteem: A New Concept of Man’s Psychological Nature. Los Angeles: Nash.
___.  1995. The Six Pillars of Self-Esteem. New York: Bantam.
Engelhardt, Jr., H. T. (1989). Freedom vs. Best Interest: A Conflict at the Roots of Health Care. In L. D. Kliever (Ed.), Dax’s Case: Essays in Medical Ethics and Human Meaning (pp. 79-96). Dallas: Southern Methodist University Press.
Gadow, S. (1989). Remembered in the Body: Pain and Moral Uncertainty. In L. D. Kliever (Ed.), Dax’s Case: Essays in Medical Ethics and Human Meaning (pp. 151-167). Dallas: Southern Methodist University Press.
May, W. F. (1989). Dealing with Catastrophe. In L. D. Kliever (Ed.), Dax’s Case: Essays in Medical Ethics and Human Meaning (pp. 131-150). Dallas: Southern Methodist University Press.