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Dying in America: “Everyday” Ethical Issues

Deaths of ancient humans were recorded with careful notation of each generation’s decreasing lifespan. Psalm 23, perhaps the most widely recited psalm, is a reflection on dying. Scripture, philosophy, legal codes and religious practices have variously described a “good death.”

Many ethical issues confront Americans as we approach death. In public conversation, “physician-assisted suicide” and “euthanasia” are legal and political flashpoints. This essay focuses on everyday practices that would bend care of the dying more toward ethical behavior.  <?xml:namespace prefix = o ns = “urn:schemas-microsoft-com:office:office” />
First, can medicine support a “good death”? When death appears the inevitable outcome of an illness, what should we expect of physicians, nurses and hospitals?  
1.       Dying is a messy business. It is messy because the dying person seldom conforms to our need for schedules. It is messy because the human body is not a machine and thus does not respond identically from one situation to the next. Peace and dignity are difficult to achieve in many death situations. We should expect health-care providers to prepare loved ones for the messiness and to accept the messiness themselves.
2.       Dying involves the whole person. We should expect health-care providers to focus on the patient’s whole situation, not a single problem. Health-care providers are oriented to rescue people from death. They are trained to act “heroically” within a special field. Each specialist may not be willing/able to see beyond a technical correction to the larger problem. We should expect them to act realistically, not heroically.
3.       Dying involves a person’s entire relational web. We should expect health-care providers to include that web in both care decisions and caring actions. Too many deaths occur in intensive care units where families have greatly restricted access. Most of those deaths could occur in more gentle surroundings, even if the institution is the best place to provide end-of-life care.
4.       Dying is sometimes physically painful. We should expect health-care providers to provide adequate pain control, as determined by the dying person’s values. Some will prefer to suffer increased pain in order to consciously relate to loved ones. Others will prefer to be sedated so as to not suffer pain, even if the sedated state removes them from relationships. 
Second, can congregations support a “good death”? The church has responsibility to bring the gospel into conversation with all realities of life, including death.
1.       Dying is a spiritual experience. We should expect churches to reclaim part of the responsibility for end-of-life care from the medical establishment. This will necessitate grappling with the facts of human finitude and mortality. Practices such as discussing living wills, durable powers of attorney for health care, and choices people face at the end of life will bridge part of the gap between medicine and church. More intensive use of rituals and family support are required.
2.       Dying is a hopeful business. Churches teach that the power of divine love exceeds all human limits. Churches can apply this to care of the dying by supporting people in ceasing to oppose death. “We do not live to ourselves, and we do not die to ourselves. If we live, we live to the Lord, and if we die, we die to the Lord” (Rom 14:7-8). Decisions are too often made that do nothing to further life, but only oppose death. The church can nurture people through ritual and presence to not oppose death.
3.       Dying is a redeemed experience. “I am sure that neither death, nor life … shall separate us from the love of God …” (Rom <?xml:namespace prefix = st1 ns = “urn:schemas-microsoft-com:office:smarttags” />8:38-39). The church needs to companion people as they approach death. If the church is indeed the body of Christ in today’s world, what better way to demonstrate the truth that nothing separates us from God’s love? It is true that many dying people draw smaller circles of relationship as they approach death. However, their loved ones require ongoing encouragement, support and love.
If “good death” is to become more common in America, both medicine and church must be transformed. That requires difficult and complex changes in the daily practices of medical and spiritual leaders. Should such everyday practices be nurtured, the problems encountered at the extremes will be much less frequent.
Steve Ivy is vice president for values, ethics, social responsibility, and pastoral services of Clarian Health Partners in Indianapolis, Ind.