Holy Living Holy Dying Redux

J. Warren Smith

In the documentary for PBS’s Frontline, Atul Gawande — the author of Being Mortal: Medicine and What Matters in the End — reveals two troubling facts about medicine in twenty-first-century America: how hard it is for physicians to tell patients that they are dying and how quickly patients grasp at experimental treatments that hold out only the slimmest of chances of overcoming their disease.

Gawande, a physician at Brigham and Women’s Hospital of Boston and member of the Harvard Medical School faculty, begins his book with a refreshingly frank and humble confession: “I learned about a lot of things in medical school, but mortality wasn’t one of them.” He goes on to recount his experience as a medical student reading Tolstoy’s The Death of Ivan Ilyich for a class on physician-patient relations, and tells of his classmates’ sense of horror at Tolstoy’s brutally honest account of Ivan’s deteriorating physical health and his anger at the obviously (self-)deceptive assurances of his family and physicians that the treatments were working and eventually would restore him to health. They avoided any discussion of Ivan’s death, yet all the while anxiety about the inevitability of his death intensified. Gawande recalls how superior he and his classmates felt when they considered the “primitive” treatment Ivan received from his nineteenth-century Russian doctors. Surely they would be more compassionate and honest, and certainly more skilled at treating an illness that places us at the edge of death’s precipice. Then Gawande describes his encounter with a twentieth-century Ivan Ilyich, a cancer patient whom he names Joseph Lazaroff. The cancer was incurable. Yet when the team of doctors gave Lazaroff the option of a highly risky operation that would neither cure the disease nor restore the bodily functions the cancer had stolen from him, Lazaroff demanded, “Don’t you give up on me. You give me every chance I’ve got” (p. 4). Lazaroff did not die on the operating table — as he might well have done — instead he lived out his remaining fourteen days in an ICU in worse physical and mental condition than before the surgery.

Reflecting on his medical school discussion of Tolstoy and his own encounter with a terminally ill patient, Gawande reflects, “We did little better than Ivan Ilyich’s primitive nineteenth-century doctors — worse, actually, given the new forms of physical torture we’d inflicted on our patients. It is enough to make you wonder, who are the primitive ones” (p. 6). Gawande make the case that all physicians need to learn from palliative care specialists. Specifically, they need to learn how to talk with patients about the reality of their mortality, the inevitability of their impending death, and the options for living out their days in a way that will maximize their enjoyment of the goods they value most and that are within their physical and mental capacity.

As I read Being Mortal and watched the documentary, two things kept stirring my thoughts. The first was the recollection of my mother’s final month in hospital. Her renal doctors, who had known her and cared for her the longest, were compassionate. They were gentle and respectful; for that I will always remember them with gratitude. Yet they never once said, “This is the endgame. Your mother is dying.” They simply said, “Your mother is very sick.” And I never asked, “Is she going to die soon?” When she finally went into cardiac arrest, they knowingly disregarded the DNR and so placed in my hands the decision to remove her from life support. How much better it would have been for us to have spoken the dreaded “D” word and have moved her into hospice care. There she could have lived out her final days in a place other than a sterile cubical in the ICU. The doctors’ reluctance to name a condition as terminal and discuss honestly my mother’s immanent death is understandable. The telos of medicine is healing, holding at bay the forces of degeneration, disease, and decay that snatch our life from us. Death marks the failure of medicine to accomplish its telos. It exposes both our physical finitude and the finitude of human technology. It confronts us with the reality that life fundamentally is not ours; it is gift. We cannot exercise absolute control over it.

The second thought that came to me was how profoundly un-Christian was the doctors’ inability to speak of death. The locus of a Christian’s identity — her self-understanding — is baptism. At the font, a child of the first Adam is put to death — dying with Christ, dying to sin and the world — so that a child of God may be born, raised by the power of the Holy Spirit a new creation, remade in the image of the second Adam. While the dying of baptism has a moral dimension that defines the Christian’s life in relationship to the world — as Paul says, “We were buried therefore with him by baptism into death, so that as Christ was raised from the dead by the glory of the Father, we too might walk in newness of life” (Rom 6:4) — it dramatically depicts our eschatological future. As we are sacramentally buried with Christ in the waters of the font, so too will our perishable body be buried in the earth. And as we are sacramentally raised from the font, so too shall our body that is sown in corruption be raised incorruptible like Christ’s body. Baptism is God’s promissory note that as Jesus was raised from the dead so shall we be also. As we sing on Easter morning, “Soar we now where Christ has led . . . following our exalted head . . . made like him, like him we rise . . . ours the cross, the grave, the skies.” Baptism is the sacramental confession of our identity as Easter people whose telos lies not in the preservation of life in this age but in the resurrection, when we shall abide with the saints in the Lord’s luminous presence.

Even as there is no entry into the joy of Easter except by going through the cross of Good Friday, so too there is no resurrection without death. (I bracket the question of how those who are alive at Christ’s return will be transformed and put on his glory.) Christ’s victory over death, as David Kelsey put it, proves redemptive for our lives in the present because it reframes our thinking about suffering and death (Imagining Redemption [Westminster John Knox, 2005]). Death — which was the final enemy — we now see has become God’s instrument for the ultimate healing and raising of our body. An Easter people should not fight against death. Ours is not the desperate defiance of Dylan Thomas, “Do not go gentle into that good night,/ Old age should burn and rave at close of day;/ Rage, rage against the dying of the light.” Nor is it Stoic resignation. No, ours is surrender and confession: surrendering one’s life and the pretensions to control over life to the One from whom life comes and in faith confessing the hope of resurrection.

What does Easter’s reframing of death look like? What is the Christian alternative to the denial of death that marks modern American medicine? In graduate school, I had a classmate who was dying of AIDS. His gaunt form gave startling testimony to Paul’s words, “the outer man wastes away.” Yet in his final days, the inner man was being renewed. His pastor and closest friends gathered around his bed to journey with him toward death. They kept their vigil by singing every hymn in their hymnal, starting at the front, singing right through to the end, and then starting all over. My friend was surrounded by the words and music of the Church bearing witness to the healing power of the risen Christ. That is the counter-cultural witness of holy dying.

Posted Jun 05, 2017

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