Consider a story of medicalized dying. During surgery to remove a blockage, Alan’s heart stopped. Then, his kidneys failed and he entered a coma with severe brain damage. Alan’s prognosis for recovery and return to consciousness is bleak. The medical team recommended removing life-support, but his religious family continued aggressive measures. Alan remained in a deep coma in ICU, hooked up to mechanical ventilation and dialysis until he died ten weeks later. The cost of his hospitalization was more than $500,000.[1]
Now take an account of doxological dying. As my dad approached death, he wanted no part of futile treatment. His only comfort in life and death was—in words from the Heidelberg Catechism—that he belonged in body and soul to his faithful Savior, Jesus Christ. One morning his family sat with his doctor who had just pronounced a terminal diagnosis, praying in a hospital conference room. Dad requested a song—and so we sang, weeping as we listened to his strong voice: “When I stand in glory, I will see his face; there I’ll serve my King forever, in that holy place.”[2] Months later, when the time came to forgo aggressive treatment, there were tears but no indecision. Dad’s final hope was in “the resurrection of the body and the life of the world to come,” not that medical science would save him from death.
Death is a key theological concern. In the patristic Church deathbed communion was viaticum—bread and wine for the journey to Paradise. In the medieval Church a complete death ritual emerged, including pre-liminal rites (anointing and penitential prayers) and post-liminal rites (burial mass and intercession for the departed). In the twelfth century the Church created ars moriendi—art-of-dying practices—that helped the dying reconcile with their survivors, repent of sin, and proclaim faith in Christ. The tradition faded in the seventeenth century. What Christians need today, in a world where medicalized death is prevalent, is an ars moriendi for dying doxologically.[3]
Christian medical ethics intersects with practical theology, which John Swinton and Harriett Mowatt define as “critical reflection on the practices of the Church as they interact with the practices of the world, with a view to ensuring and enabling faithful participation in God’s redemptive practices.”[4] Dying is one aspect of Christian life that bears scrutiny. Medicalized dying aims to avoid death through science and medicine.[5] Doxological dying expresses thankfulness to God for the loan of life by allowing imminent and inevitable death.[6] Doxological dying is more congruent with Christian truth than medicalized dying.
Bonnie Miller-McLemore contends that Christianity has contributed to the death-denial that produces medicalized dying. “Congregations and ministers seldom talk about mortality”—and chaplains often “water down their words, symbols and rituals,” speaking in generic terms about wholeness and hope. There is a better way. Dying can be enriched through updated ars moriendi practices—naming sorrow via lament, addressing God in prayer, evoking holy community through the Eucharist, wrestling with temptation to unbelief and despair, repenting for failure, and receiving forgiveness from God, others and self.[7] Fred Craddock and colleagues, Rob Moll, and Allen Verhey also challenge Christians to recover disciplines of dying well.[8]
This paper extends Miller-McLemore’s analysis in a different direction. Research indicates that religious faith correlates with aggressive end-of-life care and that such care creates poor quality of death. These findings warrant, Andrea Phelps and colleagues say, “discussion within religious communities.”[9] I engage the issue using Richard Osmer’s four tasks of practical theology.[10] First, I describe what is going on—religiously devout terminally ill patients are more likely to want doctors to do everything possible to keep them alive. Second, I explain why some Christians press on—beliefs about God, life, and suffering. Third, I define what ought to be going on—faithful dying allows natural death when end-stage illness is irreversible. Fourth, I suggest how the Church might respond—public worship is an ars moriendi practice that prepares us to accept death. Discussion is framed around the opening stories.
Before proceeding, I give three qualifications. First, it may at times sound as if I reject medical activism entirely. I do not—God works through science, and we should use medicine to control disease and premature death. Medical advances bring much good: successful treatment gave my dad six precious years after his cancer diagnosis.
Second, there is no single Christian position on end-of-life decisions. Aggressive care, which aims to prolong life, involves more procedures, specialists, and hospitalization than conservative care. Futile care is ineffective treatment that has no therapeutic benefit but only delays inevitable death.[11] Palliative care focuses on relieving pain and improving quality of life rather than extending longevity. While most Christians do not choose futile treatment, some do—that is morally and spiritually troubling.[12]
Third, it may seem presumptuous to claim that medicalized dying is based on faulty theology, while doxological dying is grounded in sound theology. But theology is a human construct that can be corrupted. Faithful theologies are true to God and promote human dignity and flourishing, while flawed ones betray God and harm human worth and well-being.[13] I cannot make dogmatic claims since Biblical language seldom has a plain meaning and there are doctrinal tensions within tradition. Alternative positions are defensible, even if the ones I commend are—to my mind—most adequate.[14]
The empirical task asks the descriptive question: what is going on? Identifying truth, Osmer says, requires “priestly listening” to narrative and research evidence “with openness, attentiveness and prayerfulness.”[15] In this section I summarize studies showing that medicalized dying often produces poor quality death and that religious faith correlates with aggressive end-of-life care.
The Coping with Cancer project finds it generally true that intensive efforts to delay death cause diminished well-being for the dying person, heightened grief for family members, moral distress for clinical staff, and unwise use of resources.[16] The Dana-Farber Cancer Institute confirms that maximum treatment “often entails a lower quality-of-life in patients’ final days.”[17]By contrast, talking about goals of care with hospice specialists leads to less suffering, better interpersonal relationships, and longer life.[18]
One research finding remains constant from the 1990s[19] through the early 2000s[20] and across the last decade[21]—religiously devout patients are more likely than less religious individuals to want doctors to do everything possible to keep them alive when death is near. Religious terminally ill patients use more aggressive interventions.[22] The Dana-Farber Cancer Institute reports that “those who draw on religion to cope with their illness . . . [have] nearly three times the odds of receiving life-prolonging care . . . in the final week of life.”[23]Religious trauma patients with acute disease or injury want intensive therapies and experience a 43% longer time to death compared with non-religious patients.[24] Religious maintenance dialysis patients are more likely to favor life-extending interventions and less likely to stop dialysis despite limited life expectancy and high comorbidity.[25]Strong religious faith is also associated with lower rates of advance care planning (having a do-not-resuscitate order, appointing a healthcare surrogate, or talking about end-of-life wishes). Conservative Protestants are least likely to engage in advance care planning, and Catholics are less likely to plan than non-religious individuals.[26]
There is, of course, nuance here. Christian faith is not a monolithic set of beliefs; instead, there are significant variations between traditions. Shane Sharp and colleagues find that theological orientation is more important than denominational affiliation in shaping preferences. “Fundamentalist Catholics and fundamentalist Protestants [are] significantly more likely than their non-fundamentalist counterparts to desire life-extending treatments.”[27] Intensity of religious commitment influences end-of-life preferences, as do race, socio-economic factors, and cultural context.[28]
The empirical task describes what is going on. Research indicates that medicalized dying often produces poor quality of death and that religiously active people want more life-sustaining measures.
The interpretive task asks the explanatory question: why is it going on? Interpretation, Osmer says, requires “sagely wisdom” that brings theological themes into conversation with empirical data.”[29] In this section I explain why some Christians prefer aggressive care.
I will suppose that Alan’s family are committed Christians and ask why they chose life-prolonging treatment past the point of plausible benefit. Lack of understanding (due to poor communication from doctor to family) and intense emotion (shock, anger, grief, and guilt) play a role in requests for futile treatment. But, so do background beliefs. Choices have an epistemic core—because we act on the basis of our beliefs, to understand an action we must examine the beliefs behind it. Tracy Balboni and colleagues identify four theological convictions that help explain why more religious patients want more aggressive treatment: divine sovereignty, the possibility of miracles, the sanctity of life, and sanctification through suffering.[30]
Kenneth Pargament identifies stances toward God control and personal control. The deferring approach to problem-solving assumes that events and outcomes are in God’s hands. The self-directingapproach assumes that God gives people freedom to manage their own lives and determine outcomes. The collaborative approach assumes that individuals and God jointly influence events. Deferring to God creates reluctance to disengage from heroic interventions, while self-direction and collaboration mean more willingness to forgo treatment.[31]
Alan’s family may choose aggressive treatment based on a particular understanding of divine sovereignty. Deterministic theism asserts that God ordains every life-event to happen exactly how and when it does (Isa 14:24).[32] This means that God determines time of death. Christians may request futile interventions because using medical tools respects God’s will while forgoing treatment usurps God’s control over life and death.
Alan’s family may also think that divine sovereignty means God can do miracles of healing. As powerful supernatural creator, God can interrupt natural laws (Jer 32:27). God is also benevolent—God desires physical health and long life for us. The prophets (1 Kgs 17:17–24), Jesus (Matt 9:35), and the apostles (Acts 3:1–8) healed—and church leaders are told to pray for healing (Jas 5:14–15). Christians may request aggressive care because they believe that God may heal even near death.
Alan’s family might, however, understand control differently. Non-deterministic theism asserts that God grants human beings freedom and a central role in determining what happens (Gen 1:28). Because of the Fall, we should not equate nature’s working with God’s will—cancer is not good simply because it is natural (Rom 8:19–23). We are meant to control natural processes that threaten human well-being. This implies to some Christians that death should always be fought with medical technology. They may request futile treatment because scientific ingenuity can and should delay death.
Alan’s family may think human freedom means individual autonomy should determine medical care. Christians value liberty of conscience (2 Cor 3:17). Patient autonomy means that competent persons have rights to refuse unwanted treatment and to receive desired treatment. The principle of family autonomy transfers these rights to next-of-kin and requires doctors to respect their substituted judgment. So, if Alan’s family wants to extend his life, they are entitled to disregard professional advice and make decisions based on their own reasons. Alan’s family may assume that autonomy includes the right to use limited healthcare resources as we like. Alan’s family may be forgetting that other people are denied medical care when scarce resources are spent on futile attempts to prolong life.[33]
Alan’s family may continue aggressive treatment because life is sacred. God has power over life (Job 12:10)—it is not ours to discard (Exod 20:13) by acts (assisted death) or omissions (forgoing treatment). Some Christians embrace a sanctity-of-life ethic where death is an enemy to be fought and every life should be preserved regardless of quality or chance for recovery. There is no moral difference between actively causing death and failing to prevent death. Vitalism—placing unconditional value on physical life—means doing anything to stay alive.[34]
Govert den Hartogh notes that grief is appropriate when someone is dying: it is “pathological . . . to be sad and not to suffer. Suffering . . . is sometimes and to some extent a condition to be respected.”[35] Christian teaching does not minimize suffering, but neither does it commend it. Outside the gift of faith, Pope John Paul II says, it is difficult to find meaning in the physical and psychological anguish that accompanies terminal illness.[36]
Alan’s family may tolerate suffering out of the belief that it can be redemptive—it has religious purpose by sanctifying us (Rom 5:3–4). Suffering, particularly during the last days of life, unites us to Christ’s saving death (Phil 3:10). Jesus submitted to his suffering as God’s will (Luke 22:42), and our suffering is a cross we bear. In it we experience God’s presence, depend on God’s grace, and prepare for judgment. While suffering is not good in itself, it brings about good to us and others. We should not hasten death to escape suffering.
Alan’s family may, however, have a different view—suffering can be gratuitous. Some suffering is pointless, not purposeful—it serves no good but is an evil to be avoided (Job 7:1–5). The compassion that motivates medicine assumes that suffering is bad. It is a Christian imperative to alleviate physical and existential pain—visiting the sick and comforting the sorrowful are Christian works of mercy. Death brings sadness to both patients and families. Alan’s family may be using technology to postpone the grief his death will cause them.
Convictions about control, life, and suffering make some Christians unable to deal with death except by trying to cure. Additional religious concepts—like martyrdom, the normative form of dying in early Christianity—may influence preference for life-prolonging care.[37] There may be distinct subtleties in belief: with miracles, someone may think “Could God heal me? Sure, God could, but probably won’t. Still, I don’t want to tempt fate or reveal doubts by saying ‘No’” to medical treatment.[38]
The interpretive task explains why what is going on is happening. Some Christians choose treatments that merely delay inevitable death because of particular theological assumptions.
The normative task asks the prescriptive question: what should be going on? Determining orthopraxis requires what Osmer calls “prophetic discernment” that involves theological interpretation, ethical knowledge, and examples of good practice.[39] In this section I outline doxological dying and the theological commitments behind it.
As death approached, my dad knew that God, not medicine, is sovereign. Doctors are not God and science cannot—Hessel Bouma and colleagues say—“deliver us from our finitude or to our flourishing . . . . The final victory over disease and death is a divine victory, not a technological one.”[40] Dietrich Bonhoeffer agrees that finitude is intrinsic to human creatureliness. Where
it is recognized that the power of death has been broken . . . . one doesn’t cling anxiously to life . . . . One is content with measured time and does not attribute eternity to earthly things. One leaves to death the limited right that it still has. But one expects the new human being . . . only from beyond death.[41]
God, not science, will at the last day swallow up death (1 Cor 15:54) and abolish mortality forever (Is 25:8; Rev 21:4). Since, Sondra Wheeler says, both life and death are “taken up into the story of a life lived in God’s care [we] can affirm the trustworthiness of God in and beyond death.” Forgoing futile treatment is not “‘giving up hope,’ but rather . . . placing one’s hope in a good [that is] larger and more enduring than forestalling death.”[42] Expectation of resurrection transforms the experience of dying (John 11:21–27).
Overcome by disease, my dad knew that God’s triumph over death is future, not through present miracles. When illness is moving steadily toward death, God seldom intervenes. We honor God’s will not by desperately resisting death hoping for a last-minute cure, but by letting it happen. God’s victory over death will come through resurrection at the end of history, not through miracles in this life.
Integrating God’s general sovereignty with human responsibility, my dad exercised human control over when and how death occurs. Medicine gives us power that formerly belonged to nature or God. We guide our dying and determine its timing—my dad could have lived several more days with aggressive care. We preempt God’s will both when we prematurely end life and when we excessively extend it. When death is near, yielding to it acknowledges that God is bringing life to a close. Refusing interventions that minimally prolong life shapes a dying process that is already underway—it does not create a new dying condition. Allowing death to happen is different from actively causing it since the illness, rather than withholding or withdrawing treatment, ends life.[43]
My dad believed that human control does not justify selfish dying. Instead, communal responsibility limits individual autonomy. The “individualistic fantasy” imagines lives as unconnected—others are not affected by our choices, so we have no duty to consider them.[44] But we do exist in a network of relationships—how we die impacts other people. Some Christians choose expensive technologies to stall inevitable death while basic healthcare services are not available to the poor. Christian ethics imitates the self-giving love of God (Mark 12:31; Phil 2:4–5). It is not our prerogative to make others go without care by using more than our fair share of limited resources simply to live a little longer.[45] Christlike dying looks beyond personal rights to interpersonal responsibilities.
My dad’s doxological dying balanced the sanctity of life (we should not hasten death) and the sanctity of death (we should not do everything possible to postpone death). There is “a time to be born and a time to die” (Eccl 3:2). While an enemy to be fought (1 Cor 15:26), death is also a friend that brings us home to God (2 Cor 5:8). Because death is not the last word, Richard Gula says, “life is not always an absolute good that must be preserved at all costs, and death is not an absolute evil to be avoided at all costs.”[46] Belief in our immortal destiny enables us to resist the idolizing of physical life and to let ourselves or a loved one go to life-beyond-life.
While dying my dad assumed that some suffering has redemptive possibilities. Christian faith is realistic about the fear and despair death brings. Rather than spiritualizing grief, the Bible gives us honest lament (e.g., Ps 130). A theology of the cross insists that God takes suffering into his own experience. By dying in pain and abandonment, Christ, our fellow human, shares in our suffering (Heb 4:14–16). The reverse is also true—our suffering is related to his suffering since we die in communion with the Lord (Col 1:24). From Jesus’ passion we learn how to suffer and die with faith, compassion, and courage.[47]
My dad also thought that some suffering serves no purpose and can be avoided. While suffering can be spiritually beneficial, there is no Christian duty to prolong agonizing dying. Providing physical care and spiritual support to the sick is serving Jesus (Matt 25:36). Sophisticated medications should be used to manage pain and symptoms so long as increased risk of death, while foreseen, is not intended. Whole-person hospice care should address physical discomfort, psychological anxiety, social isolation, and spiritual despair. But a miserable life need not be sustained, especially by exaggerated medical means, when death looms.
The normative task recommends what should be going on. Doxological dying is shaped by sound Christian understandings of control, life, and suffering.
The pragmatic task asks the strategic question: how should the Church respond? Through “servant leadership,” Osmer says, we consider what actions might contribute to revisions of practice.[48] In this section I argue that liturgy forms the beliefs that align end-of-life choices and God’s truth.
In Christian tradition liturgy, belief, and behavior are connected by the formula lex orandi, lex credendi, lex vivendi. The rule of prayer is the rule of belief and the rule of action. As we worship, so we think and live.[49] I have explained the credendi-vivendi connection, how beliefs shape medicalized or doxological dying. I now examine the orandi-credendi link, how public worship shapes doxological attitudes. Faithful dying, John Witvliet says, “requires an adjustment in our thinking about death. It requires that we cultivate habits that will support us when death takes away our ability to think straight.”[50] As in the Middle Ages, Christians today need ars moriendi practices that create true belief and prepare us to die well.
St. Paul recognizes that flawed actions result from being “futile in [our] thinking” (Rom 1:21) and that faulty convictions require cognitive restructuring—“the renewing of your minds” (Rom 12:1–2). We cannot change beliefs simply by deciding to see things differently. Instead, we must immerse ourselves in spiritual practices that gradually reframe reality (Deut 6:6–9). Vigen Guroian calls worship a “pedagogy of death” that equips us to die by setting our lives in the context of God and eternity.[51] My example is the regular Sunday liturgy in the Book of Common Prayer—other church traditions have comparable elements in their services.[52]
Doxological dying assumes that God, not medicine, is sovereign. Where some Christians trust doctors and machines to save them from death, the liturgy recognizes only one God. In the Gloria we sing “Lord God, heavenly King, almighty God and Father.” The collects often begin “Almighty God” and always end by affirming that Jesus Christ “lives and reigns with you and the Holy Spirit . . . now and forever.” The hymns remind us of God’s power—“Praise to the Lord, the Almighty, the King of creation” and “The God of Abraham praise, who reigns enthroned above.” The Creed affirms that there is “one God, the Father, the Almighty.” At the Eucharist we pray to “God of all power, Ruler of the universe” and in the Sanctus we bless the “God of power and might.” The communion prayer acknowledges that “you alone are God” who does “mighty works.” Liturgy reminds us that God is sovereign over life and death. This does not entail specific sovereignty. Other liturgical themes indicate that God’s triumph over death is future, not through present miracles, and that God’s general sovereignty authorizes wise and benevolent human control over death.
Doxological dying assumes that communal responsibility limits individual autonomy. Communitarian worship counteracts the individualism some Christians accept. We sing, pray, hear Scripture, recite creeds, confess sin, and receive communion as an interdependent congregation, not independent individuals. The songs remind us that “we die alone, for on its own each ember loses fire; yet joined in one the flame burns on.” They challenge us to serve each other: “I will hold the Christ-light for you, in the night-time of your fear, I will hold my hand out to you, speak the peace you long to hear.”[53] The Bible lessons teach that we are connected—from the Gospels giving Jesus’ word and example of neighbor love to the Epistles instructing that we are members of one body. The Creed affirms that we belong to “one holy, catholic and apostolic Church.” The Prayers of the People intercede for the needs of others and turn us away from preoccupation with ourselves. Confession acknowledges that “we have not loved our neighbors.” Passing the Peace includes everyone. At the Eucharist we pray that God “make us one body . . . in Christ.” Liturgy reminds us that our choices—including how we die—must consider other people.
Doxological dying assumes that this life is not absolute. References to God’s eternal future are ubiquitous in liturgy. The collects mention God’s unending reign: “O God, whose blessed Son came into the world . . . [to] make us . . . heirs of eternal life; grant that . . . when he comes again . . . we may be made like him in his eternal and glorious Kingdom.” The Creed declares that “we look for the resurrection of the dead, and the life of the world to come.” The hymns reference eternal life: “you, most gentle death, waiting to hush our final breath / you lead back home the child of God” or “at last the march shall end; the wearied ones shall rest; the pilgrims find their Father’s house.”[54] The Prayers of the People petition “for all who have died in the communion of your Church . . . that . . . they may have rest in that place where there is . . . life eternal.” The Eucharistic preface affirms life beyond death: “we . . . praise you for the glorious resurrection of your Son . . . . By his death he has destroyed death, and by his rising to life again he has won for us everlasting life.” It anticipates the final banquet: God will “bring us . . . to that heavenly country where . . . we may enter the everlasting heritage of your sons and daughters.” Liturgy reminds us death is not the end—we fall asleep in Jesus (1 Thes 4:13).
Doxological dying assumes that suffering has redemptive possibilities. The hymns acknowledge the reality of pain and affirm God’s faithful care: “Guide me, O thou great Jehovah, pilgrim through this barren land; I am weak, but thou art mighty; hold me with thy powerful hand” and “When through fiery trials your pathway shall lie, my grace, all sufficient, shall be your supply.”[55] In the Psalms (e.g. 22:1–2) we recite words of lament; from the Epistles we learn that trials produce maturity (Jas 1:2–4). The Creed reminds us of the “mystery of faith”—Jesus “suffered death and was buried.” Passing the Peace offers shalom to our hurting neighbors, and the Prayers of the People mention “the sick and the suffering.” At the Eucharist we hear how Jesus came “to live and die as one of us [and] was handed over to suffering and death.” Liturgy reminds us that we are sanctified through suffering. We should, like Jesus, sometimes accept suffering as our calling from God. This does not entail that painful dying should be postponed.
The pragmatic task considers how the Church should respond. Liturgy, Verhey states, “can help us form certain habits while we are healthy that, when we are dying, will help us to die well and faithfully.”[56]
Where spiritual distress contributes to hopelessness and depression, religious faith plays a positive role in maintaining well-being for people with advanced illness. They benefit from spiritual care by chaplains and pastors, and personal spiritual practices nurture hope, peace, and strength.[57] But religious coping also plays a negative role by motivating requests for futile treatment. Intensive efforts to delay death can diminish patient quality of life and distress family members.
Despite its salience, spirituality is often not addressed in clinical settings, even among seriously ill patients. Fewer than twenty percent of goals-of-care discussions include religious belief. When spiritual concerns are raised, clinicians redirect dialogue toward medical matters.[58] What is needed is open conversations in clinical settings about religious faith and end-of-life decisions.
Open conversations about life, faith, and death are also needed in faith communities. But churches are often silent about dying. Craddock and colleagues point out that “when the Church outsources the answer to questions of how one shall face dying to a narcissistic, individualistic over-reliance on science that is wasteful of morally-limited resources, the possibilities of sacramental [and] covenantal caring . . . are compromised.”[59] Ideas have consequences—both medicalized and doxological dying are embedded in sets of beliefs. Public worship is an ars moriendi that can address the research finding that patients who want to be treated under all conditions are more religious than others. We die into life—this is the spiritual horizon of doxological dying to which liturgy attunes our minds.
[1] Siang Tan, Bradley Chun, and Edward Kim, “Creating a Medical Futility Policy,” Health Progress 84, no. 4 (2003): 14–20, https://www.chausa.org/publications/health-progress/archive/article/july-august-2003/creating-a-medical-futility-policy. As a long-time member of a hospital ethics committee, I have seen similar situations.
[2] Melody Green, “There is a Redeemer” (1982).
[3] Beyond Christian circles there is interest in ars moriendi approaches to dying as a moral, social and spiritual—not just medical—experience. Lydia Dugdale [The Lost Art of Dying (New York: Harper Collins, 2020)] addresses the question of over-medicalized death and provides guidance on how we might die better. Her work is inspired by and aims to update the medieval ars moriendi tradition that helped people prepare for their deaths: recovering our sense of finitude, confronting our fears, accepting how our bodies age, developing meaningful rituals, and involving our communities in end-of-life care. Also see Carlo Leget, “Retrieving the Ars Moriendi Tradition,” Medicine, Health Care and Philosophy 10, no. 3 (2007): 313–19, https://doi.org/10.1007/s11019-006-9045-z; K. Thornton and Christine Phillips, “Performing the Good Death: The Medieval Ars Moriendi and Contemporary Doctors,” Medical Humanities 35, no. 2 (2009): 94–99, https://doi.org/10.1136/jmh.2009.001693.
[4] John Swinton and Harriett Mowatt, Practical Theology and Qualitative Research, 2nd ed. (London: SCM Press, 2016), 7.
[5] Allen Verhey, The Christian Art of Dying (Grand Rapids, MI: Eerdmans, 2011), part 1.
[6] Brent Waters, Dying and Death (Cleveland: United Church Press, 1996), ch. 6.
[7] Bonnie Miller-McLemore, “‘This is My Body’: Christian Wisdom on Dying in an Age of Denial,” Practical Theology 14, no. 5 (2021): 477, https://doi.org/10.1080/1756073X.2021.1889766.
[8] Fred Craddock et al., Speaking of Dying (Grand Rapids, MI: Brazos, 2012); Rob Moll, The Art of Dying (Downers Grove, IL: InterVarsity Press, 2010); Verhey, The Christian Art of Dying. The Catholic Church of England and Wales sponsors The Art of Dying Well program (online at https://www.artofdyingwell.org).
[9] Andrea Phelps et al., “Religious Coping and Use of Intensive Life-Prolonging Care Near Death in Patients with Advanced Cancer,” Journal of American Medical Association 301, no. 11 (2009): 1145, https://doi.org/10.1001/jama.2009.341.
[10] Richard Osmer, Practical Theology (Grand Rapids, MI: Eerdmans, 2008).
[11] There are legitimate concerns about how to define and address medical futility (Keith Swetz et al., “Ten Common Questions (and Their Answers) on Medical Futility,” Mayo Clinic Proceedings 89, no. 7 (2014): 943–59, https://doi.org/10.1016/j.mayocp.2014.02.005.
[12] Shane Sharp, Deborah Carr, and Cameron MacDonald, “Religion and End-of-Life Treatment Preferences: Assessing the Effects of Religious Denomination and Beliefs,” Social Forces 91, no. 1 (2012): 294, https://doi.org/10.1093/sf/sos061. In the remainder of this paper I develop and defend the claim that futile treatment is morally and theologically problematic.
[13] Leah Robinson, Bad Theology (London: SCM Press, 2023), ch. 3. The history of theology shows that doctrines are not an ahistorical, universal set of ideas. Instead, theology is fluid—it is influenced by the time and place in which it is developed. Human beliefs affect the theological conclusions thinkers draw.
[14] I call on those who embrace the theological views that I claim motivate medicalized dying to explain how their understandings of divine determinism, possibility of miracles, sanctity of life, and redemptive suffering do not encourage aggressive end-of-life care but support allowing natural death instead.
[15] Osmer, Practical Theology, 34.
[16] Alexi Wright et al., “Associations between End-of-Life Discussions, Patient Mental Health, Medical Care Near Death and Caregiver Bereavement Adjustment,” JAMA 300, no. 14 (2008): 1665–73, https://doi.org/10.1001%2Fjama.300.14.1665.
[17] Dana Farber Cancer Institute, “Link Found between Religious Belief, Intensive Medical Care at End-of-Life,” The Harvard Gazette, March 17, 2009, https://news.harvard.edu/gazette/story/2009/03/link-found-between-religious-belief-intensive-medical-care-at-end-of-life/. A wealth of research confirms that aggressive end-of-life treatment decreases quality of dying. See Mary Ersek et al., “Association Between Aggressive Care and Bereaved Families’ Evaluation of End-of-Life Care for Veterans with Non-Small Cell Lung Cancer Who Died in Veterans Affairs Facilities,” Cancer 123 (2017): 3186–94, https://doi.org/10.1002/cncr.30700; Estela García-Martín et al., “Aggressiveness of End-of-Life Cancer Care: What Happens in Clinical Practice?,” Supportive Care in Cancer 29 (2021): 3121–27, https://doi.org/10.1007/s00520-020-05828-9; Zhuo Ma et al., “Prevalence of Aggressive Care Among Patients with Cancer Near the End of Life: A Systematic Review and Meta-Analysis,” eClinical Medicine 71 (2024): 102561, https://doi.org/10.1016/j.eclinm.2024.102561; Holly Prigerson et al., “Chemotherapy Use, Performance Status and Quality of Life at the End of Life,” JAMA Oncology 1, no. 6 (2015): 778–84, https://doi.org/10.1001/jamaoncol.2015.2378.
[18] Joseph Greer et al., “Effect of Early Palliative Care on Chemotherapy Use and End-of-Life Care in Patients with Metastatic Non-Small Cell Lung Cancer,” Journal of Clinical Oncology 30, no. 4 (2012): 394–400, https://doi.org/10.1200/jco.2011.35.7996.
[19] Russel B. Connors, Jr. and Martin L. Smith., “Religious Insistence on Medical Treatment: Christian Theology and Re-imagination,” Hastings Center Report 26, no. 4 (1996): 23–30, https://doi.org/10.2307/3527604; Robert D. Orr and Leig B. Genesen, “Requests for ‘Inappropriate’ Treatment Based on Religious Beliefs,” Journal of Medical Ethics 23, no. 3 (1997): 142–47, https://www.jstor.org/stable/27717930.
[20] Tracy A. Balboni et al., “Religiousness and Spiritual Support Among Advanced Cancer Patients and Associations with End-of-Life Treatment Preferences and Quality of Life,” Journal of Clinical Oncology 25, no. 5 (2007): 555–60, https://doi.org/10.1200/jco.2006.07.9046; Allan Brett and Paul Jersild, “‘Inappropriate’ Treatment Near the End-of-Life: Conflict Between Religious Convictions and Clinical Judgment,” Archives of Internal Medicine 163, no. 14 (2003): 1645–49, https://doi.org/10.1001/archinte.163.14.1645; Bernard Lo et al., “Discussing Religious and Spiritual Issues at the End-of-Life,” Journal of American Medical Association 287, no. 6 (2002): 749–54, https://doi.org/10.1001/jama.287.6.749; Andrew Lustig, “End-of-Life Decisions: Does Faith Make a Difference?” Commonweal,May 23, 2003, 7; Phelps et al., “Religious Coping and Use of Intensive Life-Prolonging Care”; Maria Sullivan et al., “Effects of Religiosity on Patients’ Perceptions of Do-Not-Resuscitate Status,” Psychosomatics 45, no. 2 (2004): 119–28, https://doi.org/10.1176/appi.psy.45.2.119; Gala True et al., “Treatment Preferences and Advance Care Planning at End-of-Life: The Role of Ethnicity and Spiritual Coping in Cancer Patients,” Annals of Behavioral Medicine 30, no. 2 (2005): 174–79, https://doi.org/10.1207/s15324796abm3002_10; Peter van Ness et al., “Religion, Risk and Medical Decision-Making at the End-of-Life,” Journal of Aging and Health 20, no. 5 (2008): 545–59, https://doi.org/10.1177%2F0898264308317538; Laraine Winter, Marie P. Dennis, and Barbara Parker, “Preferences for Life-Prolonging Medical Treatments and Deference to the Will of God,” Journal of Religion and Health 48, no. 4 (2009): 418–30, https://www.jstor.org/stable/20685229.
[21] Hans-Henrik Bülow, “Are Religion and Religiosity Important to End-of-Life Decisions and Patient Autonomy in the ICU? The Ethicatt Study,” Intensive Care Medicine 38, no. 7 (2012): 1126–33, https://doi.org/10.1007/s00134-012-2554-8; Marc Romain and Charles Sprung, “Approaches to Patients and Families with Strong Religious Beliefs Regarding End-of-Life Care,” Current Opinion in Critical Care 20, no. 6 (2014): 668–72, https://doi.org/10.1097/mcc.0000000000000148.
[22] Tracy Balboni et al., “A Scale to Assess Religious Beliefs in End-of-Life Medical Care,” Cancer 125, no. 9 (2019): 1527–35, https://doi.org/10.1002%2Fcncr.31946.
[23] Dana-Farber Cancer Institute, “Link Found;” cf. Phelps, “Religious Coping.”
[24] Myrick C. Shinall, Jr. and Oscar D. Guillamondegui, “Effect of Religion on End-of-Life Care among Trauma Patients,” Journal of Religion and Health 54, no. 3 (2015): 977–83, https://doi.org/10.1007/s10943-014-9869-4.
[25] Jennifer S. Scherer et al., “Association between Self-Reported Importance of Religious or Spiritual Beliefs and End-of-Life Care Preferences among People Receiving Dialysis,” JAMA Network Open 4, no. 8 (2021): e2119355, https://doi.org/10.1001/jamanetworkopen.2021.19355.
[26] Melissa M. Garrido et al., “Pathways from Religion to Advance Care Planning: Beliefs about Control over Length of Life and End-of-Life Values,” The Gerontologist 53, no. 5 (2012): 801–16, https://doi.org/10.1093%2Fgeront%2Fgns128.
[27] Sharp, Carr, and MacDonald, “Religion and End-of-Life Treatment Preferences,” 275.
[28] Sean O’Mahony et al., “Association of Race with End-of-Life Treatment Preferences in Older Adults with Cancer Receiving Outpatient Palliative Care,” Journal of Palliative Medicine 24, no. 8 (2021): 1174–83, https://doi.org/10.1089/jpm.2020.0542.
[29] Osmer, Practical Theology, 82–83.
[30] Balboni, et al., “A Scale to Assess Religious Beliefs.”
[31] Kenneth Pargament, The Psychology of Religion and Coping (New York: Guilford, 1997); cf. Thomas Merluzzi and Errol Philip, “‘Letting Go’”: From Ancient to Modern Perspectives on Relinquishing Personal Control—A Theoretical Perspective on Religion and Coping with Cancer,” Journal of Religion and Health 56, no. 6 (2017): 2039–52, https://doi.org/10.1007/s10943-017-0366-4.
[32] I do not claim the Biblical passages I cite, properly interpreted, actually support the belief in question; I simply indicate the kind of verses that might be thought relevant.
[33] David Cutler states that high medical costs combined with stagnant incomes for a large share of the population and the inability of government to raise tax dollars leads to increased health and economic disparities: fewer people covered by private insurance, the rationing of care in public health programs, and the lack of funds for other social programs. “What is the US Health Spending Problem?” Health Affairs 37, no. 3 (2018): 493–7, https://doi.org/10.1377/hlthaff.2017.1626. Medicare spends one-fifth of its budget on people’s last year of life; costs increase sharply in the last days of life. Critical care costs exceed $82 billion annually, and thirty percent of expenditures have little meaningful medical impact. See Ian Duncan et al., “Medicare Cost at End of Life,” American Journal of Hospice and Palliative Medicine 36, no. 8 (2019): 705–10, https://doi.org/10.1177%2F1049909119836204; Nita Khandelwal et al, “Patterns of Cost for Patients Dying in the Intensive Care Unit and Implications for Cost Savings of Palliative Care Interventions,” Journal of Palliative Medicine 19, no. 11 (2016): 1171–78, https://doi.org/10.1089/jpm.2016.0133). At the same time, 26 million Americans—eight percent—lack healthcare insurance and access to medical services. “New HHS Report Shows National Uninsured Rate Reached All-Time Low in 2022,” Department of Health and Human Services, August 2, 2022, https://www.hhs.gov/about/news/2022/08/02/new-hhs-report-shows-national-uninsured-rate-reached-all-time-low-in-2022.html.
[34] Vitalism is not the only way to understand the sanctity of life. A willingness to forgo futile treatment but a refusal to use active life-ending measures also protects life’s value.
[35] Govert den Hartogh, “Suffering and Dying Well: On the Proper Aim of Palliative Care,” Medicine, Healthcare and Philosophy 20, no. 3 (2017): 413, https://doi.org/10.1007/s11019-017-9764-3.
[36] Pope John Paul II, Salvifici Doloris [On the Christian Meaning of Human Suffering], The Holy See, February 11, 1984, https://www.vatican.va/content/john-paul-ii/en/apost_letters/1984/documents/hf_jp-ii_apl_11021984_salvifici-doloris.html.
[37] Myrick C. Shinall, Jr., “Fighting for Dear Life: Christians and Aggressive End-of-Life Care,” Perspectives in Biology and Medicine 57, no. 3 (2014): 329–40, https://doi.org/10.1353/pbm.2014.0028.
[38] Amy Peterman, “Religious Beliefs Influencing Aggressive End-of-Life Care Preferences: A Measurement Advance and Continued Challenges,” Cancer 125, no. 9 (2019): 1415, https://doi.org/10.1002/cncr.31945.
[39] Osmer, Practical Theology, 135.
[40] Hessel Bouma et al., Christian Faith, Health and Medical Practice (Grand Rapids, MI: Eerdmans, 1989), 134.
[41] Dietrich Bonhoeffer, Ethics (Minneapolis: Fortress Press, 2009), 91–92.
[42] Sondra Wheeler, Stewards of Life: Bioethics and Pastoral Care (Nashville: Abingdon Press, 1996), 75–76.
[43] Robert Wennberg, Terminal Choices: Euthanasia, Suicide, and the Right to Die (Grand Rapids, MI: Eerdmans, 1989), 151.
[44] John Hardwig, “Is There a Duty to Die?” Hastings Center Report 27, no. 2 (1997): 34–42, https://doi.org/10.2307/3527626.
[45] Bouma et al., Christian Faith, 278. For a fuller discussion of this, see footnote 33.
[46] Richard M. Gula, What Are They Saying About Euthanasia? (Mahwah, NJ: Paulist Press, 1986), 137.
[47] Christopher P. Vogt, “Practicing Patience, Compassion and Hope at the End-of-Life: Mining the Passion of Jesus in Luke for a Christian Model of Dying Well,” Journal of the Society of Christian Ethics 23, no. 1 (2003): 135–58, https://www.jstor.org/stable/23561590.
[48] Osmer, Practical Theology, 175.
[49] Bruce Morrill, “Pursuing the Intrinsic Relationship between Liturgy and Ethics: Practical Theological Promise in Poverty of Spirit,” Theologica 10, no. 1 (2020): 77–98, https://doi.org/10.14712/23363398.2020.45.
[50] John Witvliet, “How Common Worship Forms Us for Our Encounter with Death,” in Worship Seeking Understanding, ed. John Witvliet (Grand Rapids, MI: Baker, 2003), 296.
[51] Vigen Guroian, Life’s Living Toward Dying: A Theological and Medical-Ethical Study (Grand Rapids, MI: Eerdmans, 1996), 35.
[52] Episcopal Church, Book of Common Prayer (New York: Seabury, 1979).
[53] Bryan Jeffrey Leech, “We are God’s People,” Evangelical Covenant Church, The Covenant Hymnal (Chicago: Covenant Publications, 1996), 600; Richard Gillard, “The Servant Song,” The Covenant Hymnal, 617.
[54] St. Francis of Assisi, “All Creatures of Our God and King,” Episcopal Church, The Hymnal (New York: Church Publishing, 1982), 400. Edward Plumptre, “Rejoice Ye Pure in Heart,” The Hymnal, 556.
[55] William Williams, “Guide Me O Thou Great Jehovah,” The Hymnal, 690; John Rippon, “How Firm a Foundation,” The Hymnal, 636.
[56] Verhey, Christian Art of Dying, 299.
[57] Holly Nelson-Becker et al., “Spirituality and Religion in End-of-Life Care Ethics: The Challenge of Inter-Faith and Cross-Generational Matters,” British Journal of Social Work 45, no. 1 (2015): 104–19, http://dx.doi.org/10.1093/bjsw/bct110; Aurelie Lucette et al., “Spirituality and Religiousness are Associated with Fewer Depressive Symptoms in Individuals with Medical Conditions,” Psychosomatics 57, no. 5 (2016): 505–13, https://doi.org/10.1016/j.psym.2016.03.005; Teresa Velosa et al., “Depression and Spiritual Distress in Adult Palliative Patients: A Cross-Sectional Study,” Religions 8, no. 8 (2017): 156, http://dx.doi.org/10.3390/rel8080156.
[58] Natalie C. Ernecoff et al., “Healthcare Professionals’ Responses to Religious or Spiritual Statements by Surrogate Decision-makers during Goals-of-Care Discussions,” JAMA Internal Medicine 175, no. 10 (2015): 1662–69, https://doi.org/10.1001/jamainternmed.2015.4124.
[59] Craddock, Speaking of Dying, 43.
James Gould, "Worship, Ars Moriendi, and End-of-Life Ethical Decisions," Dignitas 30, no. 4 (2023): 10–16, www.cbhd.org/dignitas-articles/worship-ars-moriendi-and-end-of-life-ethical-decisions.
