* I am really hoping in that experimental chemotherapy. That’s what will beat this tumor! * What do you mean my mother is dying? This is your fault!
*Why won’t you put in a feeding tube? Just because he has cancer doesn’t mean that it is right to let him starve or die from thirst. After all, we’re Catholic!
These three snippets of conversation, and variations on these themes, can be heard around many medical centers in the United States. They have a peculiar ring in the ears of believers brought up in a tradition of praying for the grace of a happy death, a recognition that death is part of our life and a hope that, as the liturgy tells us, for God’s faithful people life is changed, not ended. The Catholic Church in the United States is deeply concerned about a variety of threats to life, including the clamor for assisted suicide and euthanasia. But there may be a need for increased evangelization on one part of the core of our faith: We are destined to die, and that dying is our birth into eternal life.
The conversational fragments mentioned above are understandable in the context of illness, family struggles and the confusion and sadness that are part of life-threatening illness. It is also true that many problems result from doctors who are not good at communication and who avoid talking to patients about death and dying. But I worry that American Catholics, like the larger culture of which they are a part, are unconsciously replacing hope in Jesus and the power of the resurrection with the false gods that fill contemporary American culture. Let me point out what appear to me to be three manifestations of that idolatrous culture: an unrealistic faith in technology; the view that death is always someone’s failure; and a moral sense that pays little attention to clinical realities but veers from wildly lax to painfully scrupulous.
False Gods at the End of Life
Technology is a favorite target for those who like to criticize medicine. Technology is part of who we are as Americans; our lives are made very good and very full by our responsible use of the advances of the last century. But technology has its limits, and death is one of those limits. My concern is with patients and families whose hopes are limited to the next treatment, the new medication, the advance in surgery, the doctor who has the latest therapy. Of course, when one faces serious illness, one reasonably wants the best that is available. But hope is more than gifted doctors, pharmaceutical wonders and amazing diagnostic and therapeutic options. No matter how spectacular the treatment, everyone eventually dies. Our hope in technology will ultimately be disappointed.
So what is there to hope in when the tumor keeps on advancing, the dementia progresses, the congestive heart failure worsens, the thousand natural shocks that flesh is heir to begin to overwhelm the person and his or her loved ones?
A mistaken response, closely allied with an unsound faith in technology, is to turn to the doctor, the health care team or the latest treatment, whether orthodox or alternative. Perhaps this reflects another American obsession: a reliance on expertise and special knowledge coupled with an expectation that there are no limits on what is possible. When events seem out of control, there must be someone who can control the chaos that threatens to overwhelm.
My clinical practice is in geriatric medicine, and I see patients in referral who are extremely frail or sick, or who have progressive dementing illnesses. It is humbling to see the hope and faith that my patients and their families bring to their doctor. They hope to be helped, they have faith in my skills and my character, they have come to be healed. My greatest privilege as a physician is to work to improve function, relieve discomfort, treat bothersome symptoms and accompany my patients with the care and concern I can muster as they live with illness.
But chilling are the encounters when patient and family are angry that there is no magic treatment, that medicine does not always work and that this doctor cannot definitively repair the ravages of disease. Thus, for these individuals, pneumonia, myocardial infarction, metastatic cancer, advanced dementia are not part of lifethey are a mistake. There is someone to blame, and death is always avoidable. The end of life is not viewed as a tragedy with the doctor being but a supporting player; rather, illness has become an action-adventure, in which the physician who cannot bring life from death is a villain or a buffoon. In whom, then, do we have faith when the doctor disappoints?
Our problems with hope and faith in the setting of very serious illness also play out in the moral arena. There are two extremes. One is the mind-set that nothing need be done to preserve life in circumstances where death is a real possibility and there are concerns that the person who is sick may not recover to a fully active life. One evening, in a busy emergency room, a daughter told me: Nothing extraordinary is to be done.... It is my father’s time to die; just make him comfortable. Her father, who was in his 80’s and moderately demented, had a bad cold. I was able to convince the gentleman’s daughter that Tylenol and chicken soup constituted reasonable measures. More wrenching are situations of real clinical uncertainty, where decisions require time and thought and are not without anguish. One can encounter family members and patients who reject even the simplest of therapies that might prolong life when there is chronic illness, or decreased function or less than perfect cognitive abilities. It is not loving to reject any type of potentially life saving treatment because we cannot bear disability.
The other extreme comes into play when Catholic faith is transformed into legalism and scrupulosity. One encounters an attitude that everything must be done for reasons that suggest homage to a vengeful god rather than faith that death is not the end for a Christian. This may take the form of insistence on treatments that will prolong dying and actually have the potential to increase suffering. An example is the situation of a person in the last stages of cancer who stops eating and drinking. The use of feeding tubes or aggressive intravenous therapy in such a setting carries with it the potential for fluid overload, discomfort from the tube or intravenous catheter and worsening shortness of breath as the lungs fill with fluid that the weakened heart cannot pump or the kidneys cannot excrete. An appropriate respect for the sanctity of life does not require therapy that increases suffering. Our love of God and love for our family members does not require that life be endlessly prolonged. Our moral life as Catholics allows the recognition of ambiguity and is grounded in a God whose love calls us not only to difficult choices, but to forgiveness, acceptance and eternal life.
Resources at the End of Life
The end of life requires faith, hope and love. What place does our Catholic tradition play in assisting American Catholics in facing death? As always, the church, through its people and its ministers, proclaims the Gospel, administers the sacraments and provides comfort for the sick and those who mourn. Looking at how Catholicism can address dying is not a suggestion that something radically new and different must be developed. It is a question of emphasis. I would put emphasis on five points.
First, preaching the good news that dying is part of our journey to Christ adds urgency in a culture that pretends that death is something under human control and not to be talked about, unless it is to legalize assisted suicide. I am continuously surprised by patients and families who are Catholic who tell me that we don’t think about death and greet my discussion of planning for death with advance directives with a response that suggests I am totally nuts. I am not suggesting a lugubrious emphasis from the pulpit on morbidity and mortality. But the death of Christ is not a minor theme in Catholicism. Facing who we are and seeing the end of our life journey in the light of Jesus’ life, death and resurrection is an important part of Christian preaching.
Second, emphasizing our respect for life as Catholics is also part of recognizing that life on this earth is not an absolute value, as John Paul II made clear in the encyclical Evangelium Vitae. The pope writes of the relative character of each individual’s earthly life...life on earth is not an ultimate’ but a penultimate’ reality. Catholic moral teaching is meant to empower Christians to make choices in the light of reason, the Scriptures and church tradition. All of those sources recognize ambiguity, and none requires a servile fear that God will punish the honest person who does his or her best to follow an informed conscience. This is not a license that anything goes in serious illness. One needs sensitivity and concern that reasonable measures are taken to preserve and prolong life. The realization that dying is a natural process and ultimately inevitable is a key element in Catholic teaching. It allows for a flexibility in decision-making that permits the limitation of medical therapies without ever seeking the death of a person. In 1998, John Paul II, while touring a hospice in Vienna, Austria, neatly related the push for assisted suicide and euthanasia to the argument that everything must be done, regardless of the clinical situation: Both the artificial extension of human life and the hastening of death, although they stem from different principles, conceal the same assumption: the conviction that life and death are realities entrusted to human beings to be disposed of at will. This false vision must be overcome. It must be made clear that life is a gift to be responsibly led in God’s sight.
Third, our faith can deepen its witness to the responsible living of God’s gift of life by proclaiming the value of suffering, the evangelical imperative of care for the sick and dying and the necessity of expert care for those who are facing the end of life. Dorothy Soelle, a German theologian, has critiqued some of the emphasis on suffering in Christianity as theological sado-masochism. My point is not that suffering by itself is valuable, but that the life of the individual who endures, struggles, loves and chooses faith and love in the midst of suffering is a powerful sign of grace and an instrument of God’s love in our midst. One wonders if the current peculiar stance toward dying in our culturewhere we vacillate between insanely aggressive care and a supposed right to take lives deliberatelyis not part of our own discomfort with the untidiness of life and the obnoxious reality that everything is not under our own control. The Catholic Church in the United States has extraordinary opportunities to give witness to the meaning of a civilization of love in the midst of a culture of death.
Many favor assisted suicide and euthanasia because of concerns that dying necessarily involves terrible pain, horrible symptoms and suffering unrelieved by human contact. In other words, dying means pain, being a burden and having your dignity stripped away. Those are all big lies, and Catholic health care has the resources to prove it. In fact, many Catholic medical centers are cooperating with a variety of ventures to improve care of the dying with good pain control, symptom relief and a focus on patient and family centered efforts to provide human comfort and maintain dignity. Increased emphasis on the abilities of medicine to provide the conditions for a more peaceful dying can be an important counter to those who are zealous for euthanasia. The vigorous relief of pain and other symptoms will not erase every trace of the suffering that is part of the human condition. But it can make dying a more peaceful process where we can attend to those whom we love and help them prepare to meet our God.
Fourth, and at the heart of our experience as Catholics, we need to recapture our sense of dying with a deepening appropriation of our spiritual traditions. Much of Catholic culture is filled with reminders that our lives will come to a close. Re-exploring these devotions and rediscovering the gentle recollection of our mortality can be a way to strengthen us and those who love us when life draws to a close. Our liturgical traditions speak to us of God’s nearness in illness. Many parishes communally celebrate the sacrament of the sick in gatherings that provide witness of the community’s solidarity in caring for the seriously ill. Wake services and funerals are filled with the promise of resurrection, even at a time when grief may numb our faith.
Fifth, and finally, is a call that we as Catholics take seriously our own dying. An ever-present theme of my Catholic childhood was that death is something for which one prepares and that one expects. As a Jesuit on retreat with the Spiritual Exercises of St. Ignatius, I was called to contemplate my own dying. The point was not to be morbid but to take stock, recognizing the limits of my life, and also the need to seek God’s love, amend my failings and live my life more fully in the light of the love that Jesus has for me. Prayer and contemplation are important in taking our own death seriously. But equally important is honest family conversation about desires for health care in the event of serious illness and formulating advance directives that allow those desires to be carried out even if the person is too ill to speak. It is more than prudent planning that suggests these conversations. In our families, we need to think about how our faith in the resurrection informs our choices. In a culture where so many are free to talk on any topic but death, the witness of a home where dying is talked about and the fullness of life is celebrated is a powerful antidote to contemporary forces that would devalue our death.
Instead of faith in doctors, hope in technology and a fear that love consists only in aggressive life-sustaining treatments, we as Catholics have a treasure. Our faith in the resurrection, our hope in the promises of Christ and our love for God give us the resources to transform America’s way of dying. Rediscovering the riches of our heritage can be a source of great comfort for all of us on our way to meet God, as well as a powerful sign to a culture that is desperate for true hope.