Reckoning with the Last Enemy

Theoretical Medicine and Bioethics https://doi.org/10.1007/s11017-018-9437-0 © Springer Nature B.V. 2018 Reckoning with the last enemy Douglas Farrow Abstract: Developing the ethics of palliative sedation, particularly in contrast to terminal sedation, requires consideration of the relation between body and soul and of the nature of death and dying. Christianly considered, it also requires attention to the human vocation to immortality and hence to the relation between medicine (as aid for the body) and discipline (as aid to the soul). Leaning on Augustine’s rendering of the latter, this paper provides a larger anthropological and soteriological frame of reference for the ethics of palliative sedation, organized by way of nine briefly expounded theses. It argues that palliative sedation, like other elements of medicine, is appropriate where, and only where, it properly orders care for the body to the requirements of care for the soul. Read: https://rdcu.be/4jj7 Reckoning with the Last Enemy Douglas Farrow* Thereupon he advanced even as far as death itself. – Irenaeus Dying a Christian death in the twenty-first century: I expect this will mean for many, as it did in the twentieth century, dying a martyr’s death; but already it means, for more than a few, facing down a doctor or nurse or insurance agent who is nudging them towards that most un-Christian of deaths, namely, state-assisted suicide or euthanasia. My friend, George Weigel, remarked not long ago at First Things that when my summer neighbors here in Québec were growing up, their parents sought the intercession of ‘Brother André’ for their sick. Today, three members of my summer parish were each asked, on being given a diagnosis of cancer, whether they wished to be euthanized—and that was the first question put to them… [Quebec] is about to become this continent’s premier state-sponsored killing ground of the inconveniently ill and elderly; and it seems likely that the severely disabled won’t be far behind.1 When we keep this in view, our own question about the moral licitness of palliative sedation (as opposed to terminal sedation or euthanasia) seems somewhat overscrupulous, but of course one thing leads to another unless we are scrupulous. We ought indeed to ask ourselves about the precise role, as well as the particular measures, of pain relief and sedation, and to ask this as a moral and not merely a medical question. It is the supposition that medicine can somehow be amoral without being immoral that leads, as it has in Canada, to so-called medical aid in dying (MAiD) – a cleverly crafted * Professor of Theology and Christian Thought at McGill University in Montreal 1 “Catholicism’s Empty Quarter,” 7 September 2016 (www.firstthings.com). 2 euphemism, not for anything properly medical, but for state-assisted suicide and indeed state-sponsored killing.2 I have not been asked to address this directly, however, but rather to address theological issues that arise at the intersection between suffering and death and the mandate to heal, or at least to comfort, in the face of suffering and death. I have even been asked to bring to bear consideration of the afterlife, or as I would prefer to say, of the human vocation to immortality. I am very glad to do so, for without this larger frame of reference it is not possible to do the job properly. Now of course dying a Christian death is one thing from the standpoint of the dying person and another from the standpoint of one charged with his or her care. The former will want to die Christianly whether or not attended by Christians. The latter will want to be Christian in the caring, whether or not the dying person is a Christian; though if he is not, or if he is an ill-formed Christian, then significant differences may arise in regard to the care, just as significant differences may arise between carers when one is thinking Christianly and the other not. So we will have to return to that in due course, albeit briefly. What I want to do first is to make several points about what it means to think Christianly on the subject of suffering and death, and to apply these to the question before us. 1) Suffering and death are neither good nor natural. I think we’d better begin here, for this is the Christian place to begin. The world has not always been. It had a beginning and, as we know it, it will have an end. But the human creature was made for fellowship with the living God. God is man’s end. It does not belong to man qua man to die, but rather to live. Death is the consequence of sin and of the judgment passed upon the sinner; only as a consequence of sin is it “natural.” Likewise, it does not belong to man to be unhappy, but to be happy. Happiness is what all men want, and happiness is certainly possible. Only as a consequence of sin does man become unhappy, though as a consequence of being but a creature he is at first only imperfectly happy. See further my web-page chronicling these affairs in Canada (www.mcgill.ca/prpp/euthanasia), where attempts are being made in policy and law to coerce doctors and other health-care workers into some form of participation. 2 3 St Anselm rightly insists in his Monologion that “the human soul was created to love the supreme essence,” and that it is not possible to think coherently about this highest of all vocations without thinking at the same time of immortality. Not just any kind of immortality, however, such as the kind our bio-technology experts have in mind in the so-called immortality project or in its transhumanist offshoots; for that is just perpetual life, not the good life or the happy life. Listen to Anselm: The human soul that always strives to love the supreme life never loses its life. But what sort of life? Long life on its own, after all, is no great thing, not without real immunity from adversity. What is life lived in fear, suffering, or in the illusion of security, but life lived in unhappiness? The happy life is the life that is free of all this. And will the nature that always loves the supremely good and omnipotent, always live an unhappy life? Quite absurd! Clearly, therefore, this is the sort of life that belongs to the human soul: provided that it keeps to the purpose for which it exists, it will, at some time, live the happy life, the life truly immune from death and all distress.3 If it does not keep to its purpose, however, the human soul does not simply disappear, for its vocation is irrevocable. Rather, it has an endlessly unhappy life, shut out from the presence of its Maker, as Jesus himself taught. If we grasp this starting point – man is made to live, because he is made for the living God – we already have everything we need. But this starting point is both attacked by those who reject Christianity and undermined by many who accept it. The latter will normally claim that death is natural, but that we now experience it unnaturally as a result of the fear that accompanies sin. I recommend to you, in answer to that beguiling view, a fascinating fictional work by J. R. R. Tolkien, Athrabeth Finrod ah Andreth. In this discourse about death and destiny, Andreth responds to Finrod just as Anselm would have: “We knew that in our beginning we had been born never to die. And by that, my lord, we meant: born to life everlasting, without any shadow of any end.”4 A disclaimer: To make good on this first point for today’s man or woman of science, steeped in evolutionary thinking, I would have to talk at some length about the Monologion 69 (trans. Simon Harrison, in Anselm of Canterbury: The Major Works, ed. Brian Davies and G. R. Evans, New York: Oxford University Press, 1998). Cf. Cur deus homo 2.2–4. 3 This work, with an introduction, can be found at https://thainsbook.wordpress.com. It is published in J. R. R. Tolkien, Morgoth's Ring, ed. Christopher Tolkien (Boston: Houghton Mifflin, 1993). 4 4 Christian understanding of human origins and show where that understanding does and does not embrace evolutionary thinking; but I will not attempt that here. My point is simply that man qua man – meaning man, not only as an intelligent animal, but as supernaturally gifted with and for the imago dei – was not made to die. 2) Death is no friend. Death is an enemy, the last enemy, of man. Death is not a friend, even where it comes to him as a friend, or is earnestly desired. My father died not long ago, shortly after his 95 birthday. My sister took him to th his doctor, and he told the doctor not to bother with him. He’d had enough and was at an end. He was ready to go and fully expected to go. At that point he regarded death as a kind of friend, because it put an end to that which he by no means desired to go on indefinitely, that which was no longer life as it was meant to be lived. A day or so later, he died at home, in my sister’s presence, of a pneumonia the doctor (perhaps taking his instructions at face value) had missed. Death did come as a friend. A fortiori, it comes as a friend to the man being tortured by man or devoured by disease, or perchance, like Job, by perplexity and grief. That is why people sometimes take their own lives, or why they demand euthanasia. Once they desired that some or even all limits be removed from them; now they desire that there be a limit, a final limit. Yet I repeat: Death is not a friend of man, for death is the dissolution of the unity between the soul and the body that a man is. The soul cannot wish the death of the body, of which it is, by divine design, the life-giving form, without in some way contradicting itself. 5 For the creature it is good that there be limits. The creature is that which has a beginning, and in having a beginning requires other kinds of limits, which serve it as guides to its ends, to the fulfillment of its nature. Moreover, it is good, given the fall, that there be limits to sin and limits to suffering, where sin has corrupted a nature and consigned it suffering. In the mercy of God, death provides such a limit. But As William Carroll puts it in “Souls Matter” (11 March 2015, www.thepublicdiscourse.com): “Each natural substance has an actualizing principle that makes it be the substance that it is. Such a principle, known in the Aristotelian tradition as a form, is the source of the actuality and unity of what exists.” Viewed thus, the human soul is the life-giving form of the body, not an independent substance that may or may not be encumbered by a body. 5 5 death remains a judgment, not a solution. It remains an enemy, even where it is a friend. Death is not salvation! Death is dissolution. Death is defeat. Death is the Last Enemy. 6 3) Suffering may nevertheless be good for us. We ought to agree with Paul and to disagree with Leon Kass, for example, who claims that “to argue that human life would be better without death is … to argue that human life would be better off being something other than human.”7 We may agree with Kass, however, that what we are really longing for when we resent, rather than welcome, death is not mere continuance but “wholeness, wisdom, goodness, and godliness.” And for the pursuit of that – given the fact of our fall – suffering, even the suffering of death, can indeed be good for us, when rightly undertaken. The martyrs are already sufficient proof of that. They remind us that suffering itself is not the last enemy, but an instrument for defeating the last enemy. For that is what God himself, in the person of Jesus Christ, has made of suffering. He who knew no sin was made sin for us. He who was subject neither to suffering nor to death, bore our sorrows and suffered our death, “and by his stripes we are healed.”8 We all know that suffering can have a remedial function, both for the body (as in athletic training, say, or confinement to a cast) and for the soul, which also needs training and restraining. Suffering can and should contribute to the wholeness, wisdom, goodness, and godliness of the soul. Alas, it often doesn’t. It is an urgent theological, pastoral, and medical task, particularly at the present time, to explain that avoiding or resenting suffering may prove an evil rather than a good; to explain the goodness of suffering for remedial purposes. Listen to St John Paul II in Evangelium vitae: The only goal which counts [today] is the pursuit of one's own material well-being. The so-called “quality of life” is interpreted primarily or exclusively as economic efficiency, inordinate consumerism, physical beauty and pleasure, to the neglect of the more 1 Cor. 15:26. One might turn for help with all of this to St Irenaeus, who is brilliant on the subject. See further my Ascension Theology (London: T&T Clark, 2011), 127ff. 6 “L’Chaim and its Limits: Why not immortality?” (First Things, May 2001). Kass’s comment could be redeemed if it were made to refer only to the present life, as per Irenaeus at Haer. 5.36.1, or Tolkien’s Athrabeth. Which is to say: our present life is not the proper measure of what is to be human. 7 8 Isa. 53:5 6 profound dimensions – interpersonal, spiritual and religious – of existence. In such a context suffering, an inescapable burden of human existence but also a factor of possible personal growth, is “censored,” rejected as useless, indeed opposed as an evil, always and in every way to be avoided. When it cannot be avoided and the prospect of even some future well-being vanishes, then life appears to have lost all meaning and the temptation grows in man to claim the right to suppress it. Within this same cultural climate, the body is no longer perceived as a properly personal reality, a sign and place of relations with others, with God and with the world. It is reduced to pure materiality: it is simply a complex of organs, functions and energies to be used according to the sole criteria of pleasure and efficiency.9 As John Paul said elsewhere, in his homily on Lithuania’s Hill of Crosses, the cross of Jesus Christ “has given meaning and value to suffering, to illness, to sorrow.”10 It is well known that his own very public suffering from Parkinson’s was something he offered up with a view to teaching this lesson. Here in Chicago, Francis Cardinal George was also eloquent in this respect.11 4) After the dissolution that is death, there is still a future for body and soul. If the cross gives meaning and value to suffering, the resurrection and bodily ascension of Jesus guarantee that there is still a future for body and soul. The resurrection of Jesus, together with the cross, is the central fact of the Christian faith, its sine qua non. It guarantees this future. But what future? There will be a judgment, not only for the soul at death, but for body and soul at the parousia of Jesus Christ and the general resurrection of the dead. There will be a future in happiness or a future in unhappiness. To remind people of that is a still more urgent task than to explain the goodness of suffering for remedial purposes. The latter cannot be done effectively without the former. §23 (http://w2.vatican.va/content/john-paul-ii/en/encyclicals/documents/hf_jp-ii_enc_25031995_evangeliumvitae.html) 9 Essa ha dato senso e valore alle sofferenze, alla malattia, al dolore (http://w2.vatican.va/content/john-paulii/it/homilies/1993/documents/hf_jp-ii_hom_19930907_siauliai.html); cf. George Weigel, Letters to a Young Catholic, rev. ed. (New York: Basic Books, 2015), 201. 10 I mean, of course, in his manner of life and death, as well as in what he wrote and said on the subject. Weigel (ibid. 188) reports the following remark made to him by the Cardinal: “Do you realize that we are going to spend the rest of our lives trying to convince people that suffering and death are good for you?” 11 7 The way we live in the body, and the way we die in the body, is the determining element as regards our future. Which means, of course, that death may or may not mean the cessation of suffering. It is the cessation of suffering for those perfected in righteousness, for the saint or the martyr. Not so for the wicked, which is why men fear death. For those who have not and will not have their salvation in Christ, death is not the terminus of suffering but the threshold of an untreatable suffering, a suffering that has no remedy and is not itself remedial. Death is not the cessation of suffering even for those who are made beneficiaries of Christ, if their justification through faith in him is deficient in the sanctification that it requires. For no one can enter into the glory of Christ or into the bliss of his kingdom without justice of soul. No one can be happy without justice of soul. And the letting-go of injustice in the soul – purgation, to use the classical term – is also a kind of suffering, albeit a joyful suffering, a suffering that heals. It must be remarked here that it has always been urgent, Christianly speaking, to remind people that there is a future in happiness and a future in unhappiness. But it is especially urgent today, as assisted suicide and euthanasia become normalized. For such acts, deliberately and competently undertaken, determine us for unhappiness. Christians ask the blessed virgin Mary, Mother of God, to pray “for us sinners, now and at the hour of our death.” We know that divine grace is still open to us at that hour, that even where repentance and faith have been lacking, they may yet be possible. But if we ourselves determine the hour of our death, thereby asserting that our lives belong to us and not to God, that we are free to dispose of them as we will, though they were given to us without our will, what then? Does grace still remain? Can we still pray the Hail Mary? Have we not turned at the last away from repentance and faith, and so from grace? Is it not the doors of Hell on which we are pushing, rather than the gates of Glory? If that is so, and the Church has always insisted that it is so, it can never be just or compassionate to obscure it from people. That some people take their own lives without full moral competence, and that we may in these cases still hope and pray for their salvation, does not relieve us of the obligation to tell those who are more or less of sound mind that suicide and euthanasia is a self-determination for Hell rather than Heaven. 8 5) The medical practitioner, as neighbour to the dying, must be concerned with the good both of body and of soul. The point has already been made that the soul is not merely incidentally or accidentally related to the body. It is not something that exists prior to the body or that belongs to the body only temporarily. The human being is, as Augustine says, “a rational soul with a mortal and earthly body in its service.” 12 As such it is divisible, or rather dissoluble. But the rational soul of a human being, as distinct from the rational soul of an angel, is for the body, just as the body is for the soul. “Man is as much body as he is soul.”13 The perfection of the human being entails the perfection of the body, too, through the proper submission of body to soul, and of both to the Spirit of God, who gives to body and soul the freedom and glory proper to each. If these things are so, we must follow Augustine when he observes in De Moribus Ecclesiae that doing good to the neighbour, in fulfillment of the second great commandment, can only mean doing good to both body and soul. First, do no ill? Yes. “The love of neighbour works no ill.” 14 Then, do good to the neighbour; love the neighbour as you love yourself, which means helping him or her also towards God, who is man’s chief good. To do good to the body is called medicine, though of course he is using that term more broadly than we do, to refer to anything that benefits the body, guarding it “against injuries and mishaps from without as well as from within.” To do good to the soul is called discipline. It is discipline “by which the health of the mind is restored, without which bodily health avails nothing for security against misery.” 15 This, he rightly remarks, is a subject of great difficulty. For “these things require more than mere good-will, and can be done only by a high degree of thoughtfulness and prudence, which belongs only to those to whom it is given by God, the source of all 12 Mor. Ecc. 52; cf. Civ. Dei 19.14. Tertullian, Res. 32; cf. e.g. Augustine, CD 22. See further my “Resurrection and Immortality,” in The Oxford Handbook of Systematic Theology, ed. J. Webster et al. (New York: Oxford University Press, 2007), 216ff. 13 14 Mor. Ecc. 50, following Rom. 13:10, while expounding (see Mor. Ecc. 13ff.) the remarks of Jesus in Matt. 22:37ff. Mor. Ecc. 55. When I say “more broadly,” I mean that works of charity (such as giving to the poor) qualify for Augustine as “medicine.” But he is also using the term more narrowly, since he does not apply it to healing of the mind, as does, for example, the American Heritage Dictionary (Houghton Mifflin, 1970), which defines medicine as “the science of diagnosing, treating, or preventing disease and other damage to the body or mind.” In the present frame of reference, that would be both medicine and discipline. 15 9 good.” 16 Since it is God “who gives to all things their being and their well-being,” 17 it is to God that we must look for the kind of prudence that is necessary here. If we will not look to God, we will not develop the requisite prudence no matter how thoughtful we are. Now, with respect to the body, “those who seasonably and wisely supply all the things required for warding off … evils and distresses are called compassionate” – although, if they are wise, “no painful feeling disturb[s] their mind in the exercise of compassion.” 18 That is to say, they do not respond to bodily needs or to suffering out of agitation at the sight of them. They are not governed by perturbation, but guided by virtue. “There is no harm in the word compassionate,” he adds, “when there is no passion in the case.” With respect to the soul, that is, to the discipline of the mind without which bodily health “avails nothing” against the threat of misery, this “includes two things, restraint and instruction.” The neighbour must be turned back from that which endangers his soul and directed towards that which will heal it. “Restraint implies fear” on the part of the one being helped, as in the saying, “Fear God.” Instruction implies love, on the part of both the helper and the helped. One loves the neighbour by helping him to learn to love God above all things, and the neighbour loves in return by receptivity to what is being taught. Augustine sums up thus: “He, then, who loves his neighbor endeavors all he can to procure his safety in body and in soul, making the health of the mind the standard in his treatment of the body. And as regards the mind, his endeavors are in this order, that he should first fear and then love God.” 19 6) The good of the soul is paramount. From this we may draw a conclusion that bears directly on our concern with palliative sedation: Medicine that renders discipline impossible is anthropologically disordered. If, in treating the suffering of the body, we so incapacitate the mind that it can no longer 16 ibid. 51 17 ibid. 55 18 ibid. 53 19 ibid. 56 10 receive either restraint or instruction – that it can no longer experience godly fear or love of God – we put the needs of the body ahead of the needs of the soul. Which is morally backwards. The body is the servant of the soul, not the soul of the body. Expressed otherwise, we put the lower interests of the soul, which involve care of the body, above the higher interests, which involve care of the mind and concern for its contemplation of things eternal. Which is morally upside down. Augustine, if we may appeal to the City of God, where he takes up these ideas again, is working with the following definitions: “The peace of any and every thing is the tranquility of order. The peace of the body is the ordered functioning of its organs... The peace of the rational soul is the ordered coherence of thought and action. The peace of the body-soul union is the ordered life and health of animal existence. The peace of man and God is the ordered obedience of faith governed by the eternal law.” 20 And order itself? As Gregory Lee notes, Augustine defines order as “the arrangement of things equal and unequal in a pattern which assigns to each its proper position (parium dispariumque rerum sua cuique loca tribuens dispositio).” Order demands the subordination of lower things to higher things, and for humans, this means the submission of the body to the soul, and the submission of the whole person to God. The righteous person “views all peace, of body or of soul, or of both, in relation to that peace which exists between mortal man and immortal God, so that he may exhibit an ordered obedience in faith in subjection to the everlasting Law.”21 It follows that a patient is not “at peace” just because the brain is no longer registering pain. To act on that assumption would be a grave error. But what happens when the brain is registering pain, severe and intolerable pain? When the body is thus disordered, the mind suffers with and because of the body, and may do so to such a degree that it is completely distracted from its other tasks. The will becomes incapable of forcing the mind to attend to those tasks. Ordered coherence of thought and action, to use Augustine’s expression, becomes impossible when suffering CD 19.13 (trans. Oliver and Joan O’Donovan, From Irenaeus to Grotius: A Sourcebook in Christian Political Thought, Grand Rapids: Eerdmans, 1999; they have reordered the text for rhetorical purposes, placing at the head of this passage the definition of peace as tranquilitas ordinis). 20 Gregory W. Lee, “Republics and their Loves: Rereading City of God 19,” Modern Theology 27.4 (2011), 569; quoting CD 19.13 and 19.14. 21 11 is all-consuming. 22 This may on occasion render it necessary to treat the body with such heavy dosages of pain-killers and/or sedatives that neither the mind nor the will are capable (as far as we know) of doing anything at all. But if medicine is properly subordinated to discipline, this course of action will be aimed at restoration of proper function to the mind and will. It will be for their benefit. The goal of restoring the body as far as possible to tranquility of order, so that it is not a debilitating source of agitation to the soul by reason of its pain, is a good goal, but its greatest good lies in seeking to reestablish the conditions of possibility for tranquility of mind.23 So what happens if there is no reasonable prospect of such a reestablishment? Is continuous deep sedation (CDS) until death a morally sound alternative? This question is distinct from the question as to whether CDS is morally acceptable in situations where it is likely to hasten death – a question that need not be posed if CDS until death is deemed immoral in and of itself. I do not think that it follows from Augustine’s principle that it is necessarily immoral. If it is reasonably certain that levels of pain are so high that the mind cannot function in any meaningful way, and that in consequence the will cannot do its task either, since it requires direction from the intellect, and if it is further reasonably certain that the cause of pain cannot be treated in any sufficiently ameliorating fashion as to hope for the mind to resume its proper function, at a minimally adequate level for the purposes of discipline, then it may be asserted coherently that CDS does not interfere with discipline, since the condition of possibility for discipline is lacking.24 Whether such reasonable certainty is attainable, and under what circumstances, I am not Augustine does not directly consider the situation that we are considering, but remarks rather on that in which some peace “still subsists to the extent that their suffering is not all-engulfing, and their bodily constitution is not torn apart by it” (in qua nec dolor urit nec compago ipsa dissoluitur, CD 19.13). Even in the situation we are considering, however, so long as the soul struggles to preserve and quicken the body there is still a residual form of peace inasmuch as this very struggle and the intense pain it entails witness to the unity of body and soul (19.12). 22 As he says: “If we were irrational animals, we would seek nothing but the ordered functioning of our bodily organs and the satisfaction of our appetites… [But] ‘ordered coherence of thought and action’ is how we described the peace of the rational soul. The purpose, then, for which we humans avoid the attacks of pain, the agitations of passion, and the dissolution of death, should be to acquire useful knowledge and shape our lives and habits accordingly” (CD 19.14, O’Donovan translation). 23 The same would be the case should the brain, as the locus of rational thought, have deteriorated to the point that it is no fit instrument to the soul, though still capable of registering pain. 24 12 qualified to say. Thankfully, the relevant cases appear to be quite rare, and in them death is usually imminent, rendering all but moot the next question, the question about hastening death. All but moot, yet not quite moot. If the drugs are intentionally chosen and applied in such a way as to minimize the level of pain to the point that the mind can properly function, if it can function at all, rather than for the purpose of permanently preventing the conscious functioning of the mind and/or hastening death, then – even if failure to regain useful consciousness and the shortening of life are foreseeable consequences – there is no moral error. Where these consequences are unintended, appeal can safely be made to the principle of double effect. If, however, one or both of these consequences is the goal of the action, that principle does not come into play and there is moral error. For it is never right either to effect the death of the innocent or to subordinate discipline to medicine rather than medicine to discipline. It must be added, for greater certainty as the lawyers say, that it could never be right to apply CDS to one whose body is not, or is not any longer, preventing the mind from its proper functioning, as if the fact that death is neither imminent nor intended, nor likely to be much hastened, were somehow to relieve us of the responsibility to subordinate medicine to discipline. That someone prefers lack of consciousness to painful discipline does not qualify him for CDS. Like the rest of us, though his trial be ever so much greater, he needs to be restrained by the counsel to fear God, rather than to fear pain and death, and to love God with the remaining strength that God supplies. Since CDS deprives him of his capacity for that, it is not justified.25 7) The patient autonomy principle should not prevail. Here we may run afoul of the patient autonomy principle, to which recourse is often made in order to accommodate demands for deep sedation until death, for assisted suicide, and for active euthanasia. The Christian can only respond that the principle is a relative one, for autonomy is not the soul’s highest good. God is the soul’s highest 25 I find myself in disagreement here with what I understand Prof. Meilaender to be saying. 13 good.26 Obviously this calls for self-discipline on the part of the Christian physician or healthcare worker, who cannot recognize these “rights” or dispense these “mercies,” no matter how much implored. Assisted suicide and euthanasia are by nature closed to the good of the soul and intrinsically evil. 27 They are neither rights nor mercies. All they accomplish is to send a soul to God in a state of mortal sin. That is what comes of regarding suffering rather than death as the last enemy. The autonomy principle must also be curtailed in the matter of demands for desperate measures to prolong life. If the demands just noted concede too much to suffering, these concede too much to death. Either way a false fear rules, and a false compassion is sought in response. The best antidote is found in the words of Jesus: “Fear not, I am the first and the last, and the living one. I died, and behold I am alive for evermore, and I have the keys of Death and Hades.” 28 These words shows the limits of the autonomy principle, which has its proper place in medical ethics but, pressed too far, is a dangerous illusion. What the person at the point of death needs to hear is the wonderful truth that he or she is not autonomous. 8) Medicine, as a natural good worked by general graces, is impossible to sustain without the supernatural good to which it is subordinate. Now, some are sure to say, in response to all this, that it may be well and good for Christians who find themselves working in a Christian jurisdiction under basically Christian rules. Otherwise it is utopian and not at all realistic; not merely because it begs many practical question, but because medicine is no longer organized or practiced in such a way as to leave much room for an explicitly Christian approach to death and dying – or to much else, for that matter. Secular hospitals and professional associations To respond thus is not to suggest that the patient who is unwilling to receive the discipline we are talking about should have it forced upon him – how indeed could it be? But neither can the patient, or the state or professional association on behalf of the patient, justly force upon the physician a course of action the physician regards as unethical. Nor indeed, when unjust force is applied, can the physician justly capitulate. No doubt there is a price to be paid for refusing to capitulate, but it must be borne in mind that violations of conscience cannot be coerced. They remain free – and wrong – choices. See Anselm, De libertate arbitrii, 5ff. 26 27 On suicide, see Augustine, CD 1.17–27; cf. 19.4. Rev. 1:17f. (RSV). See Michael Banner’s important essay, “Christian Anthropology at the Beginning and End of Life,” in his Christian Ethics and Contemporary Moral Problems (Cambridge University Press, 1999), at 68ff. 28 14 and ethics boards positively frown on specifically Christian principles and often forbid the choices or procedures that rest upon them. Governments in the West are actively seeking to suppress those principles and to promote what is contrary to them. Having spent a good part of my career chronicling the ill effects of militant secularism, I appreciate the force of this criticism. But I reply: Medicine itself is at stake here, along with actual human souls and destinies. Medicine is a natural good. Properly practiced, it is open to supernatural good, worked by the special graces of the Great Physician himself, but in itself it is a natural good, accomplished by general graces. What happens to it if it is deliberately closed off from supernatural good? I will tell you what happens: It becomes mere technology, pure instrumentality. In the end, it becomes as open to mutilation and even to killing as to healing. We are witnessing this in our time. We are witnessing the destruction of medicine as medicine, just as we are witnessing the destruction of democracy and of human rights, by the insistence that medicine and government be God-free zones – as if there were, or could be, such a thing! 29 I don’t profess to know how exactly to recover medicine, or the sense of medicine as a natural good subordinate to supernatural goods. Many more conferences like the present one would help, but of course what we are really talking about is the recovery of an entire culture. Meanwhile there will have to be brave acts of dissent from the culture in which we currently find ourselves. In my own country I have called for the establishment of more Christian hospitals and for civil disobedience in the matter of abortion, mutilation, and the wickedness called MAiD.30 I am well aware that there are costs, enormous costs, involved; and that acting on Christian convictions may very well make one a martyr in the sense that one is then deprived of gainful employment and fruitful medical service. In an age of martyrdom, or indeed in any age, that ought not to be decisive. One must take the long view. “Blessed are you,” says Jesus, “when men revile you and persecute you and utter all kinds of evil against you falsely on my account. Rejoice and be glad, for great is your reward in heaven.” 31 29 See further Farrow, Desiring a Better Country (Montreal: McGill-Queen’s University Press, 2015). 30 See, e.g., “The Acid of Autonomy,” Convivium (June/July 2016), 13–18. 31 Matt. 5:11f. 15 9) Palliative care, where it really means to be Christian, will be an evangelical mercy, to which rendering a patient unconscious will always be foreign, though not absolutely forbidden. Palliative care is medicine in its mode of relieving and comforting rather than curing. But medicine, we have learned from Augustine, should be subordinate to discipline, just as the body should be subordinate to the soul. When the body refuses to be subordinate, not as regards the lusts of the flesh but as regards pain receptors in the brain, medicine may on rare occasions be forced to foreclose on discipline through the use of drugs or some other device, 32 but only reluctantly (by permission of undesired side-effects rather than by direct intention) or provisionally (with intention to restore what has temporarily been taken away for the good of both body and soul). If more is permitted to medicine, if medicine is allowed to trump discipline, its comfort is, Christianly speaking, a false comfort – a comfort that puts in doubt its own evangelical character. We can drive this point home by observing that medicine that trumps discipline calls into question the coherence of martyrdom, the highest form of evangelical witness. Who is the martyr but the one who chooses, for Christ’s sake, discipline over medicine? We should not be too quick to retort that palliative care is not designed to make martyrs of those who receive it! For palliative care is, in its origins, a Christian witness both to the dignity of man, body and soul, and to the destiny of man, as one beloved by God and called to communion with God. Palliative care is not just about the relief of suffering. It is about helping people to die properly. And how does one do that without encouraging fear of God, who alone gives to all things their being and their well-being, and love of God, who has first loved us, and on our behalf faced spiritual and physical suffering and death, making himself an example as well as a saviour? As Irenaeus puts it, in a wonderful passage, the Lord Jesus Christ made himself a Master for us in everything pertaining to the human condition, not despising or evading any condition of humanity, nor setting aside in himself that law which He had appointed for the human race, but sanctifying every age, by that period corresponding to it which belonged to himself. For He came to save all through means of 32 If drugs are permissible, so also in principle are other methods of depriving someone of consciousness. 16 himself – all, I say, who through him are born again to God – infants, and children, and boys, and youths, and older people. He therefore passed through every age, becoming an infant for infants, thus sanctifying infants; a child for children, thus sanctifying those who are of this age, being at the same time made to them an example of piety, righteousness, and submission; a youth for youths, becoming an example to youths, and thus sanctifying them for the Lord. So likewise He was an old man for old men, that He might be a perfect master for all, not merely as respects the setting forth of the truth, but also as regards age, sanctifying at the same time the aged also, and becoming an example to them likewise. Then, at last, He advanced even as far as death itself, that He might be “the first-born from the dead, that in all things He might have the preeminence” – the Prince of life, existing before all, and going before all. 33 Those care-givers who have faith in this Master, when accompanying as far as possible those who are themselves advancing, in his train, to meet the last enemy, will ask themselves whether the good they are still seeking to do to the body, even at this late hour, is also a good being done to the soul, or is at least open to that good – that much higher good. If it is not, they will discard it in favour of that which is open. For they know, as Irenaeus, Augustine, and Anselm knew, that “the supreme good and evil” are not to be found in this life, but in what follows this life,34 and they act accordingly. My prediction is that palliative care, as something distinct from the kind of “care” that includes terminal sedation or euthanasia, will become the exclusive preserve of those who do know this. Haer. 2.22.4 (emphasis added; trans. adapted from The Ante-Nicene Fathers, ed. A. Roberts, J. Donaldson, A. C. Coxe [Grand Rapids: Eerdmans, 1987], vol. 1). Cf. Luke 22:39–46. 33 34 See again Augustine, CD 19.4.