Reflections

Death and dying, it would seem, are out of the closet, taboos, we are told, that we enlightened moderners have overcome. I am not so sure. Granted, evidence abounds that we have raised the volume of social conversation about matters of dying and death in recent years. Most of us, by now, have heard about living wills and durable powers of attorney for health care, even if the majority of us, apparently, have yet to discuss them with family members, fill them out, or leave them with our doctors. Granted, many of us, seemingly with great profit, have learned about the various "stages" of dying outlined by Dr. Elisabeth Kubler-Ross, a pioneer in the field we now call "thanatology," the study of death. Granted, many of us have strong opinions about the morality or immorality of what Dr. Jack Kevorkian is up to, as the spokesman for "medicide," his term for physician-assisted death.

And yet, I am of mixed mind about the depth of this broad-ranging conversation. As academic director of the Institute of Religion, I often have the opportunity to speak to groups about the ethical and pastoral issues that arise at the end of life. I often find those experiences sobering, and not just because of the nature of the subject. For the conversations, while generally interesting, often offer little evidence that the audience has confronted the deepest dimensions of dying. Indeed, I often find that the settings where I would most expect dying to be dealt with honestly, and with a sense of calm assurance - communities of religious faith - remain largely places of silence, even of denial.

In thinking about the "hard cases" in clinical ethics that I've dealt with, or heard about, during my last decade at the Texas Medical Center, I have been struck by two ironies. First, while we may, as a culture, be more ready to engage in armchair conversations about the "phenomena" of death and dying, it seems very hard for us to personalize the truth of mortality, to face death squarely as the termination not of life in general but of my life. As the title character in the best-selling Tuesdays with Morrie puts it, "Everyone knows they're going to die, but nobody believes it." Despite the violence that sells so well in our popular culture, our fascination with what some sociologists have called the "pornography of death," we are, for all of that spectacle, probably less familiar with the existential reality of dying than were our forebears. The death we talk about, and theorize about, is death in the abstract, death as an "ideal type," to be managed and controlled as a problem but not to be confronted, and lived toward, as what it always must remain for us, a mystery.

The medieval monks are sometimes pictured at their desks, with Bibles open before them, and skulls resting nearby. The skull is there to remind them, on a daily basis, of the facts of their finitude, of their rowing toward eternity, of their need to be prepared, to come to terms with their status as creatures. How little in current culture offers the same invitation. Instead, such thoughts are often belittled as morbid preoccupations. But precisely the opposite is true. To remind ourselves periodically of our own mortality, rather than being morbid, can be an exercise in sanity of the best sort. To be sane, after all, is to know who you are, where you've come from, and where you're going. To be sane is to recognize your limits as well as your opportunities. Death remains the ultimate limit. To pretend that it will not come, or to fail to face it honestly as the ultimate personal experience, is to fail to address my destiny. Alternatively, to reflect on my death prompts a sense of perspective on what is important to do now, how to set my priorities in ways that matter, how to live today in a way that is authentic. To live today well, with a sense of doing what one should do, makes any day, as captured in the line from the movie Little Big Man, "a good day to die." The best of hospice care is dedicated to this very philosophy: by accepting their terminal prognosis, many patients make their last days, in Kubler-Ross's words, the "final stage of growth."

The second irony remains a puzzle to me. A number of studies suggest that religious believers, as one would expect, tend to express greater resistance than the secular public to the idea of legalizing physician-assisted suicide and euthanasia. There are strong traditional arguments, involving the sovereignty of God and the illegitimacy of killing (even at the patient's request) that support such resistance. However, many religious persons also tend to insist on life-sustaining treatment, even past the point of any plausible benefits. Their vitalism here, however, is not supported by most traditional religious arguments. The Roman Catholic tradition, for example, has long distinguished between treatments that are ordinary and those that, because of their burdensomeness or their low probability of success, are deemed extraordinary. And most Protestant statements in recent years have talked about the propriety of "allowing nature to take its course" at some point in the process of dying. However, numerous recent articles, and my own anecdotal evidence from work at the Medical Center, confirm a point that I cannot explain: oftentimes "religious" patients seem more intent than atheists and agnostics upon receiving any and all forms of treatment to stave off imminent death.

Why should that be so? Believers speak, after all, of their confidence in an afterlife. Is it that many are ignorant of the clear teachings of their own traditions about the conditions under which treatment can legitimately be withdrawn? Is it that they confuse maintaining the "full court press" with doing the will of God? Or is it, perhaps, that their faith is weaker than they proclaim, and that they are prone to the same fears as others about what comes next?

I do not have an explanation. But I do find this second irony profound, and puzzling.

---

©2006 Texas Medical Center

---

E-Mail: tmc-info@tmc.edu
URL: http://www.tmc.edu/tmcnews/03_15_99/page_11.html