End-of-life decisions: does faith make a diference?

Death and dying, it would seem, are out of the closet, taboos that we enlightened (post)moderners have overcome. I'm not so sure. Granted, we've nearly all heard about living wills and durable powers of attorney, even if, as polls indicate, many of us have yet to discuss them with family members, fill them out, or give them to our doctors. And many of us, surely to our betterment, have read about the various "stages" of dying outlined by Dr. Elisabeth Kubler-Ross. In addition, recent proposals for physician-assisted suicide have engaged many of us in debates about public policy in a pluralistic society.

Yet the depth of this apparently broad-ranging conversation is easily exaggerated. Over the years I've spoken with various groups about ethical and pastoral issues at the end of life. I find those occasions sobering, and not just because of the topic. While the discussions are invariably challenging, they provide little evidence that the deeper dimensions of dying and death are really being confronted. Ironically, faith communities--the very settings where dying should be dealt with honestly and with a sense of calm assurance--often remain places of silence, even of denial.

In thinking about the "hard cases" in clinical ethics, I've been struck by two ironies. First, while we may be prepared to engage in armchair conversations about the "phenomena" of death and dying, it seems very hard for each of us to personalize the truth of mortality. As the title character in the nonfiction best-seller Tuesdays with Morrie puts it, "Everyone knows they're going to die, but nobody believes it." Despite the violence that sells so well in popular culture and our fascination with what sociologists have called the "pornography of death," we remain far 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. It is 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 daily 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 musings emerge as pointless, even morbid, preoccupations.

Yet precisely the opposite is true. To remind ourselves of our own mortality 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 death will not come, to fail to confront it honestly, is to deny 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, how to live authentically. To live with a sense of calling makes any day "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."

Another irony remains a puzzle to me. Many religious persons insist on any and all life-sustaining treatments, even past the point of any plausible benefit. Ethicists call this attitude "vitalism," and it is not supported by mainstream traditions. Roman Catholic thought has long distinguished between treatments that are ordinary and those that, because of their burdensomeness or their low probability of success, are extraordinary. And most statements by Protestant denominations in recent years have talked about the propriety of "allowing nature to take its course." Yet, not infrequently, I've heard family members say that they need to keep a dying loved one alive long enough "for God to perform a miracle." That seems at best a peculiar, at worst a pernicious, understanding. God has his own timetable for working his wonders, and a commitment to vitalism is hardly a robust expression of faith. Instead, it seems to confuse wishes for a magical recovery with belief in the resurrection.

In my own experience, "religious" patients often seem more intent than atheists and agnostics on receiving any and all forms of treatment to stave off imminent death. Why? Is it that many are ignorant of the clear teachings of their own traditions about when 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 find this fact profound, and puzzling.