The Common Good
June 2010

The Art of Dying

by Lisa Sowle Cahill | June 2010

At the end of life, how can people of faith prepare for a good death?

Death is a human reality that eventually catches up with all of us. Scripture and Christian tradition remind us that we are living with death from the moment we are born. Through the Christian tradition of ars moriendi, or the art of dying, we are taught to die well by trusting in God, repenting for our failings, forgiving others, and having compassion for those whose needs exceed our own.

But Christians must also admit that death is a mystery and a problem. What will really happen at death, and after it? Though our belief in God may be strong, death’s approach warrants a keen sense of threat.
In today’s modern age, often the value and meaning of a good death are equated with prolonging life as long as possible. Americans in particular are fascinated by life-prolonging technology. This fascination, however, blinds us to the fact that we are allowing science and medical technology to answer our most profound questions about faith and bioethics: What do we really need to live well to the very end, say goodbye to those we love, and meet our God with dignity? Should life be prolonged through any means necessary? How should we deal with pain at the end of life?
These are the questions that go to the heart of what it means to live and die as a person of faith, and we must look to Christian teaching on the end of life to provide the bioethical guidelines to end-of-life issues. Here are some ways in which Christian teaching can inform the difficult questions that we grapple with at the end of life.

A virtually inevitable question in end-of-life care is how to determine when “enough is enough” in terms of treatment options. Family members often assume that telling hospital staff that they want everything done for a dying relative is a sign of the family’s love and devotion. Doctors and other caregivers also often feel obligated to pull out all the stops if the patient and family do not draw clear lines, partly out of fear of lawsuits, and partly because medical training focuses on saving life rather than accepting limitations.
Doctors have a notoriously hard time broaching the topic of death with people in their care. But when it gets right down to it, how many of us want to spend our last days in a strange environment, hooked up to lines and monitors, stalled halfway between consciousness and our final transition? And for those caring for a dying person, when should we draw the line on medical care?
The answer depends on individual factors including state of disease or decline; medical choices available; usefulness, risk, or futility of increased medical care; and the degree to which treatments improve the patient’s quality of life. Not all treatments are proportionate and helpful to quality of life, so not all must be used. Treatments that are useful and not burdensome are considered morally “proportionate” or mandatory; while useless or burdensome treatments are “disproportionate” and not morally necessary, even if they could help other patients in other circumstances, and even if rejecting them will cause death to arrive sooner.
From a Christian perspective, it is appropriate to decline life-prolonging measures if the burdens outweigh the benefits. Drawing the line should be the cooperative decision of the patient, family, and expert caregivers. Pastoral counselors can also have an important role in facilitating this process.
Even when met with appropriate medical measures, counseling, and family devotion, the process of death cannot be totally controlled. There is the uncomfortable physical reality of one’s body shutting down, causing great suffering to the dying. Although some suffering is inevitable, and suffering can join us with Christ, suffering is not a goal. God does not will us to suffer; human suffering is not God’s plan. Thus, most people will need and should use pain relief. This is acceptable even if medications cause reduced lucidity or even unconsciousness and an indirect hastening of death. Today, it is possible with very strong medication (sometimes called “terminal sedation”) to alleviate even very severe physical pain, hallucinations, and disorientation.
 
On the other hand, direct killing (euthanasia or physician-assisted suicide) is not an acceptable answer to the stress of human death. It may be understandable to see assisted death as preferable to prolonged suffering, the degeneration of mental and physical identity, or being held captive in an intensive care unit. But direct killing is qualitatively different from indirect measures such as refusing further treatment. Euthanasia involves human agency in the destruction of life, an option that traditional wisdom holds to be justified only when another life is at stake.
True, it may be hard to show conclusively just why direct killing of the innocent is always wrong, if both indirect killing of innocent life and direct killing of those who threaten innocent life is justified by some. However, respect for life’s sacredness, respect for medicine’s healing role, and concern that normalized medical killing could be used to eliminate those considered a “burden on the system” all combine to create deep wariness of direct euthanasia. As Reformed theologian Allen Verhey writes in his text Reading the Bible in the Strange World of Medicine, Christians should be able to find “a better way.”
Christians, therefore, are called to solidarity through the dying process, just as God in Christ is in solidarity with us. A dying person should never be left alone. Even those who are apparently unresponsive may hear the voices of companions who recount memories, read from scripture, or share beloved hymns, music, or poetry. A grasped hand or embrace, even lying down alongside a dying loved one, underlines our connection. Faithful presence conveys to the dying person the presence, compassion, and consolation of God. A “good death” is the responsibility of all of us, a good for which we all depend on others.
Although surveys show that about three-quarters of Americans would prefer to die at home rather than in a hospital or nursing home, fewer than half accomplish this goal. And according to a study in the Journal of Palliative Medicine, only about 30 percent of hospitals have palliative care programs, the mainstay of hospice.
Hospice is a movement of care for the dying that has its origins in Christian ministries of hospitality to the sick. Palliative care and hospice help patients and their families deal with chronic illness and impending death, when cure is no longer realistic. Teams can coordinate medical services, teach families to give care at home, and provide counselors following a death. Palliative care and hospice are adept at alleviating severe physical pain and psychological distress, are open to religious faith, and have proven successful even in very poor countries where other resources are limited. This underlines an ancient lesson: Happiness in life and death is found in faith, love, and community. Christian wisdom brings a distinctive bioethical perspective: Protect and nurture life, while prioritizing care, companionship, and compassion.
In sum, Christian wisdom furnishes four guidelines for ethical discernment as death approaches: 1. Caregivers should provide holistic, personal care, offering experienced guidance of treatment choices, assuring patients of pain relief, and helping them to truly live while dying; 2. Refusing or withdrawing treatment that no longer serves the medical needs or personal dignity of the patient is acceptable, even if death will arrive sooner—this is not the same as killing; 3. A priority is that neither patient nor family meet suffering and death alone—all deserve human presence and solidarity; and 4. God’s mercy, forgiveness, and love remain constant through death as in life, for “who will separate us from the love of Christ?”
 
Lisa Sowle Cahill, a Roman Catholic theologian and professor at Boston College, is author of Theological Bioethics: Participation, Justice, and Change.
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