This special report marks the first supplement of Dignitas, the quarterly publication of The Center for Bioethics & Human Dignity. Dignitas began over 20 years ago as the Center’s newsletter Dignity, and has expanded to include both bioethical commentary and original scholarship, along with quarterly bioethics news, updates on developments in medicine, science, and technology, and highlights from cultural touch points with bioethics in fiction and film. In the next evolution of Dignitas as a publication, we look forward to periodically offering supplements such as the one before you that explore contentious areas of bioethical inquiry from within a Judeo-Christian Hippocratic framework. For our inaugural special report, we selected a topic of perennial bioethical concern—end-of-life care planning—and focused the discussion on an area of recent controversy within the contemporary Christian bioethical conversation: POLST (Physician Orders for Life-Sustaining Treatment).
Christians have long believed, as the Apostle Paul claims, that death is a defeated enemy. Or as Dietrich Bonhoeffer boldly decreed, “The miracle of Christ’s resurrection makes nonsense of that idolization of death which is prevalent among us today.”[1] And yet, the current reality remains that our death is an inevitable certainty amidst all the possibilities of our lives. In the broken frailty of our fallen world, we might agree with the philosopher Martin Heidegger, who noted in his seminal work Being and Time, that “death is the ownmost possibility” of being.[2]
This death exists awkwardly in God’s creation. It is awkward, precisely because God is the author and giver of life. The story of redemption is a story of the living God offering blessing in the face of the curse’s ultimate consequence—our ownmost possibility. Right at the beginning of this redemption story, this incongruity was especially acute: How can the living God dwell near and among a dying people? The answer to this question is offered in what are, to contemporary readers, some of the most obscure of the biblical texts: the laws of Leviticus. The laws regarding skin diseases, mold, and bodily discharges seem especially foreign to us. But these laws offered guidance for people to dwell near the living God. Or, stated another way, these laws gave God’s people a way to ‘deal with’ death.
Despite the passage of millennia and the rising power of modern medicine to extend life, we too must still ‘deal with’ the reality and inevitability of death—the death of friends and family, and ultimately our own demise. Our ability to address the frailties of human life and to delay death through ever advancing medical technologies and interventions has increasingly led to a cultural discomfort and odd ambiguity with death—a strange mix of death-denial and macabre fascination.[3] For many, the ravages of death and dying have been sanitized from our everyday lives. Moreover, we find our own mortality difficult to talk about, something that is attested to in many of the following articles and responses.
Yet as our society ages, conversations that force us to deal with death in a particular manner, specifically how we die, become more pressing. Our ever-increasing technological capabilities allow us to prolong life, even if only a sort of bare life might remain. Here we are confronted with the bald reality of needing to talk about how one might die well with all of these medical options before us.
But neither is the church immune to these cultural tensions and tendencies to avoid conversations about death and dying.[4] Unfortunately, many churches are not places that speak openly of how everyday Christians might die well. Where do clergy and laity go to seek wisdom to questions of dying in our advanced medical age? Questions such as: Does Christian hope require that I undergo certain kinds of burdensome or even unwanted treatments? What of the withdrawal of life-sustaining treatments? Am I obligated as a surrogate decision-maker to authorize artificial nutrition and hydration for my relative? What of voluntary stopping of eating and drinking?
Thankfully, ways that our culture deals with death and dying do not reflect current legal, medical, and bioethical conversations. These conversations regarding the ethics and legalities of the end-of-life have been ongoing for centuries. Albert Jonsen reminds us,
From ancient times, everyone—doctors and patients alike—knew that medicine killed and injured. A standing joke called doctors ‘unpunishable murderers.’ The new medicine, particularly in the forms that sustained living processes, put a new twist on that old, sad joke. Now a patient’s continued life could depend on persistent application of the supporting technology.[5]
The conversation continues in the medical literature. A recent “perspective” piece in the New England Journal of Medicine argues that end-of-life care should be evidence- based:[6] an old conversation (i.e., end-of-life care) should meet a modern form of an ancient concept (i.e., evidence-based medicine, itself standing in the lineage of observational medicine leading back to Hippocrates and Galen).
Christians, too, have made several recent contributions to the conversation, reflecting a Christian approach to death and dying.[7] In these venues, and many others, a serious conversation about dying is alive and well—even if it has not reached the awareness of the general public.
Yet even though this ongoing conversation is old, it is still in many ways new to us. The technological advances of our historical moment demand that we continue to engage the conversation. And we find that the conversation can be guided by the familiar paths of bioethical inquiry: What is the role of patient autonomy—even when the patient is unable to express her wishes? How does a physician fulfill her obligation to “do no harm” in the face of death? Should every medical intervention at our disposal be used in the face of imminent death?
We are interlocutors in an ancient conversation—from the laws of the Old Testament to Christian-Hippocratic physicians to more recent conversations ranging from American legal discourse about advance care planning to palliative care. We must talk about dying, about our preferences for end-of-life care, and about what it means to die well. Moreover, we must do so in a way that takes into account the ever evolving armament of increasingly costly medical interventions available to us. And we must do so in such a way that honors the particular dilemmas and complexities of deciding individual end-of-life care. In other words, we must frame the conversation in a way that honors the dignity of the dying individual living in life’s final moments.
This special issue of Dignitas is offered as a contribution to this broader conversation. More specifically, this issue offers reflection on this relative late-comer to the repertoire of advance care planning options: Physician Orders for Life-Sustaining Treatment. Understanding that this is an ongoing conversation with diversity of assessments even within the broader framework of commitment to Judeo-Christian Hippocratism, we have sought to offer scholarly treatment of the issue in a dialogical format. Two lead authors (Edward Grant and Lisa Anderson- Shaw) present extended discussions of the POLST Paradigm, unpacking the legal, ethical, and clinical dimensions of POLST in particular and advance care planning in general. Four invited commentaries then offer responses to these lead essays. These commentaries represent a diversity of ecclesial (Roman Catholic and Evangelical) and professional backgrounds (from moral philosophy and bioethics to law and policy, from a clinical ethicist and medical educator to a philosopher/ theologian and lawyer/bioethicist), as well as a spectrum of assessments with respect to the POLST Paradigm itself. While there are areas of disagreement between the various contributors regarding the particularities of the benefits and concerns of POLST, what is shared is striking: each contributor recognizes the importance of actively engaging in conversations, particularly within the church, about end-of-life decision-making in a way that honors the dignity of the person. It is to this end that we offer this first supplement of Dignitas.
[1] Dietrich Bonhoeffer, Ethics (Minneapolis: Fortress, 2009), 91.
[2] Martin Heidegger, Being in Time (Albany, NY: State University of New York Press, 1996), 243.
[3] Cf. Ben Peays, “Fantasy Funerals and Other Designer Ways of Going Out in Style,” in Everyday Theology: How to Read Cultural Texts and Interpret Trends, ed. Kevin Vanhoozer, Charles Anderson, and Michael Sleasman, 209–226 (Grand Rapids: Baker Academic, 2007).
[4] Cf. Lucy Bregman, Preaching Death: The Transformation of Christian Funeral Sermons (Waco, TX: Baylor University Press, 2011), and Fred Craddock, Dale Goldsmith, and Joy Goldsmith, Speaking of Dying: Recovering the Church’s Voice in the Face of Death (Grand Rapids: Brazos, 2012).
[5] Albert Jonsen, The Birth of Bioethics (New York: Oxford University Press, 2003), 266. See Edward Grant’s overview of this history in his article in this volume, or, for a more extended discussion of the history of advance medical directives, see Edward Grant, “Advance Medical Directives in the Era of Health Care Reform: Who Decides?” Dignitas 20, no. 4 (Winter 2013): 1, 4-7, 10-12.
[6] Scott Halpern, “Toward Evidence-Based End-of-Life Care,” New England Journal of Medicine 373, no. 21 (2015): 2001–2003.
[7] See for instance Rob Moll, The Christian Art of Dying: Living Fully into the Life to Come (Downers Grove, IL: InterVarsity Press, 2010), and Allen Verhey, The Christian Art of Dying: Learning from Jesus (Grand Rapids: Eerdmans, 2011). Note also the strong critique of contemporary medicine and its orientation toward death in Jeffrey Bishop, The Anticipatory Corpse: Medicine, Power, and the Care of the Dying (Notre Dame, IN: University of Notre Dame Press, 2011).
Michael J. Sleasman and Michael G. Cox, "Introduction,” Dignitas 22, no. 4 Supplement (2015): S1–S2.
