The ethics of life and death continue to be an area for Christians to explore and seek to understand. I remember my first few weeks serving as a chaplain resident on trauma rotation at the University of Kentucky Health Care. The vicarious trauma that I witnessed left me paralyzed. More specifically, the fear of my own mortality became overwhelming. I witnessed the brevity of life each day with code blues, car wrecks, and traumatic brain injuries. We desire eternity, as we should. But here, the grass withers and the flowers fade. The shock of this pattern tells us that this shouldn’t be the norm, but it is for now.
I recently started exploring Atul Gawande’s work with some fellow chaplain colleagues and found his book, Being Mortal, to be especially helpful. Using research and personal experience, Gawande helps to remind us of the necessity of asking people what their wishes are with respect to medical writing. Gawande writes, “[L]acking a coherent view of how people might live successfully all the way to their very end, we have allowed our fates to be controlled by the imperatives of medicine, technology, and strangers.”[1]
While Gawande does not write from a Christian perspective, he does a wonderful job at illustrating how we should think through the intersection between medicine and technology and how these areas impact our lives in the end. Medicine is a gift, but it must be used with discernment.
Things Fall Apart
Gawande reminds the reader early on how there is “no escaping the tragedy of life, which is that we are all aging from the day we are born.”[2] Medicine has graciously found ways to extend life and help keep symptoms in check from terminal diseases. But the truth is, most of us don’t want to think about a time in our lives when we are no longer able to live independently. Honestly, we’d rather ignore the reality of how our bodies fall apart and age.
I genuinely appreciate how Gawande develops, throughout his book, the theme that we can live our lives with dignity, even in the downhill stretches. Medicine is meant to enable well-being, not simple survival. We often regard the end of our lives, stricken with failed joints and memory loss, “with a kind of embarrassment.” Furthermore, when bodies start to fail, “we feel as if we somehow have something to apologize for.”[3]
When things do fall apart—and they will—Gawande highlights the work in adult primary care and geriatrics. It’s unfortunate that “97 percent of medical students take no course in geriatrics.”[4] Regrettably, many areas in the medical field focus on fixing ailments rather than maintaining a quality of life. Sometimes fixing multiple conditions is not what is best for quality of life.
When things fall apart, Gawande offers helpful explanations for the relationships between medical professionals and patients. He explains that the oldest, most traditional kind is a paternalistic relationship. This relationship aims “to ensure that patients receive what we believe best for them.”[5] The second type of relationship is “informative” where medical professionals tell you the facts and figures, and the decision is up to the patient. A third type is “interpretive” where the doctor helps patients determine what they want. Gawande explains how “interpretive doctors ask, ‘What is most important to you? What are your worries?’ Then, when they know your answers, they tell you about the red pill and the blue pill and which one would most help you achieve your priorities.”[6]
Discernment in Letting Go
I believe the strength of Being Mortal is found in chapter six, where Gawande offers helpful insights into deciding when to stop trying to prolong life. What’s interesting is how we have responded historically to life-threatening injuries. “Death used to be accompanied by a prescribed set of customs,” explains Gawande. “People believed death should be accepted stoically, without fear or self-pity or hope for anything more than the forgiveness of God. Reaffirming one’s faith, repenting one’s sins, and letting go of one’s worldly possesions and desires were crucial. . . . Last words came to hold a particular place of reverence.”[7]
However, these days, Gawande writes,
death comes only after long medical struggle with an ultimately unstoppable condition—advanced cancer, dementia, Parkinson’s disease, progressive organ failure. . . . So everyone struggles with this uncertainty—with how, and when, to accept that the battle is lost. As for last words, they hardly seem to exist anymore. Technology can sustain our organs until we are well past the point of awareness and coherence.[8]
Later in the chapter, Gawande highlights the benefit of palliative care specialists who help patients and families with serious, complex illness. Citing a 2010 study from the Massachusetts General Hospital, the results show that “those who saw a palliative care specialist stopped chemotherapy sooner, entered hospice far earlier, experienced less suffering at the end of their lives—and they lived 25 percent longer.”[9] These conversations can certainly be difficult, but simply listening to patients and creating space for them to name their wishes is important.
Later in Being Mortal, Gawande gives insight into this connection between assisted suicide and assisted living. While I appreciate the space that he gives to the topic, since it connects with how we use medicine, I felt that he could have developed it more. Gawande points out how he “fears what happens when we expand the terrain of medical practice to include actively assisting people with speeding their death” but then, on the next page, writes “Certainly, suffering at the end of life is sometimes unavoidable and unbearable, and helping people end their misery may be necessary.”[10]
I would have appreciated examples here, but I don’t think our motive should ever be to speed up the natural process of dying. It certainly may not always be ethically necessary to start or even continue every available medical treatment, but the danger is the possibility of active, voluntary, physician-assisted suicide leading to involuntary euthanasia.
Conclusion
We don’t like to face death. We avoid the topic and, if at all possible, we would avoid the experience. But our world is filled with sorrow, pain, and death. And when it does happen, we are left speechless and empty. The experience makes us want to ask questions to which we can’t seem to find answers. I believe that Being Mortal by Atul Gawande is especially helpful for both those in the medical field and local church ministry. People in both areas practice their professions in a world where they must discern between what medical technologies are helpful and what is best for the person involved. I encourage every pastor to pick this book up as families look for spiritual guidance during these hard conversations.
[1]Atul Gawande, Being Mortal: Medicine and What Matters in the End (New York: Picador, 2014), 9.
[2]Ibid., 8.
[3]Ibid., 28.
[4]Ibid., 52.
[5]Ibid., 200.
[6]Ibid., 201.
[7]Ibid., 156.
[8]Ibid., 156–57.
[9]Ibid., 177–78.
[10]Ibid., 244–45.
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