It is easy for me to imagine what I did not see with my own eyes: that my grandmother, not known for her acquiescence in living, displayed no tranquility in dying; that though she was baptized and had received the Eucharist throughout her life, those lifelong graces apparently did not comfort her as death approached. When it became clear to all around her hospital bed that death was coming, that her insistent protestations she would soon return home were illusory and nonsensical, my father said, “Mom, this is the end. Can we spend these moments reaffirming our love for each other and looking forward to a happy reunion in the future?” She refused. She was going home, she said—not to some celestial city but to the suburbs of Philadelphia. There was no commending her spirit into the hands of God or anyone else. Stubborn in life, she was intransigent in death. Death was indifferent to her stubbornness, of course, and took her anyway.
There have always been many ways of dying badly. In the late eighteenth century, the devout English writer Samuel Johnson struggled furiously and profanely against his own demise, ordering his surgeon, beyond all hope and reason, to delve deeper with a scalpel to force more senseless bleeding. That was then. Surely things are better now? Not according to theologian and ethicist Travis Pickell, who argues in his new book that the vast array of modern end-of-life technologies have only ended up providing us with even more ways of shuffling off this mortal coil. What Pickell calls “burdened agency” is a particularly modern condition arising from a combination of two factors. First, because we are presented with more choices than ever before, we are obliged to choose more than ever before. Only a century ago, for example, an ailing person simply met death when it came. Now the ailing person must choose whether to undergo exceedingly invasive medical operations, or perhaps hasten death through physician-assisted suicide. Even if one were to reject both of these routes, that itself is a choice with consequences and moral meanings. Where once an elderly person dwindling slowly to death may have stood as an example of resolution and quiet dignity unto the last, now that person is stubbornly choosing to drain the healthcare coffers and drive up insurance premiums for the rest of us, when they could instead have disqualified themselves from life and saved society the burden.
The second feature of burdened agency is the declining authority of traditions that once helped guide our choices. This is a lament we have heard before. In his The Troubled Dream of Life (1993), Daniel Callahan observed that “modern medicine increasingly forces us to make choices,” even while the society in which we make those choices is one in which there is “no common response to death, no shared ritual, no clear conventions of succor, sorrow, and grief.” Callahan argued that modern society therefore needs a “shared communal meaning” of death, which meaning cannot be secured by “membership in a religious or ethnic group that itself offers an interpretation of death and a way of understanding it.”
Although religious traditions have lost much of their cultural authority in late modernity, we might still recover their fragments, to paraphrase T.S. Eliot, to shore them against our ruins. Pickell does not attempt here to recover or articulate a common response to death that is plausible to a pluralist society. Instead, he looks to the theology and practices of one religious tradition. From the work of Dominican moral theologian Servais Pinckaers, who studied the figure of the martyr in biblical texts as well as patristic and medieval writings, Pickell recovers the “spirituality of martyrdom.” Because the martyr neither hastens death through suicide nor flees from it in fear, the spirituality of martyrdom confounds the modern dichotomy between active and passive responses to death, persisting as “faithful witness” to the end. As a subject of religious persecution, the martyr is an extreme example, to be sure. But as Augustine of Hippo argued, the stories of the martyrs can serve as guides for those facing more mundane circumstances. The Christian “can be a martyr in his bed,” writes Pinckaers, “if he remains faithful to Christ in the face of disease and death, refusing the amulets and superstitions that some hold out to him.”
Pickell likewise commends the work of Swiss Reformed theologian Karl Barth, who sought to answer age-old questions of theodicy within the shifting intellectual landscape of the twentieth century. Like Athanasius of Alexandria in the fourth century, who claimed that humanity’s creation from nothing caused it to have a proclivity toward returning to nothingness, Karl Barth’s account of “creaturely finitude” affirms that death is a natural entailment of human finitude, even as sinful human creatures experience death as the place where they meet God’s judgment and God’s grace. So the human should learn “to see death as a God-given boundary—while simultaneously affirming life as a God-given gift.”
Pickell traces these Catholic and Barthian strands of thought in the work of Stanley Hauerwas, a theologian who spent much of his career thinking about the church as a community of moral formation. At its best, such a community forms its members according to what Hauerwas calls the “ethic of dispossession,” an ethic shaped, on the one hand, by the acceptance of creaturely limits and, on the other, by the sacrifice and victory represented by the prototypical martyr, Jesus of Nazareth. This ethic encourages a dispossession not only of “things,” writes Pickell, but also of “our compulsive need to be in control.”
Here we encounter Pickell’s critique not just of modern medicine but of modernity itself, a civilizational project of expanding mastery and control to every sphere of life. That distortion—that inordinate desire to be in control—is rendered all the more acute at the end of a life, an experience that is dreaded not primarily because of the anticipation of pain and suffering but because of the fear of the loss of control.
The Christian church, according to Pickell, can offer an alternative way of approaching this ultimate dispossession by means of those ancient practices of prayer, baptism, and Eucharist. Each of these disciplines resists the ethic of “mastery and control” by cultivating “receptive agency.” The promise that Pickell envisions for those who follow such ecclesial practices is a lovely one: “Drawing closer and closer to death—a process, we would do well to remember, that occurs throughout our lives—those shaped by these Christian practices will be accustomed to giving over their life to God. They did so in their baptism. They were formed into the broken body of Jesus, the one who gave himself for all humanity, through the Eucharist. They witnessed the encounter of the gospel with death through the proclamation of the word of life.”
Yet there are empirical reasons to doubt the plausibility of this promise. Pickell claims that “a people shaped by the Eucharist cannot long deny their mortality and vulnerability.” But it seems, in fact, the opposite is true. It is perhaps an inconvenient fact that religious people make more use of intrusive, invasive, and ultimately futile forms of medical care at the end of their lives. One study published by JAMA Internal Medicine found that “patients reporting high spiritual support from religious communities…were less likely to receive hospice…, more likely to receive aggressive [end-of-life] measures…, and more likely to die in an ICU.” Another Journal of American Medicine study of advanced cancer patients found that “greater use of positive religious coping was associated with increased preference for heroic measures…, and lower rates of [do not resuscitate] order completion…, living will completion…, and designation of a healthcare proxy.” And a meta-study published in the journal Palliative & Supportive Care found that Christians in the Netherlands were “less likely to refuse resuscitation at [end of life], compared to the less religious groups,” and that in Wisconsin “fundamentalist Catholics and Protestants were more likely to advocate life-prolonging treatment in terminal illness, compared to their non-fundamentalist counterparts.”
These are overmedicalized bad deaths, undergone by people who seem to be formed by many of the practices that Pickell recommends for dying well. Pickell laments that “when the avoidance of death and suffering takes on paramount importance, for example, every technological advantage must be employed in the fight against disease and death.” He attributes this to “modern identity.” But many Christians who make use of these technological advantages say they believe that God does miracles in response to faith and that refusing aggressive end-of-life treatment would be a manifestation of a lack of faith in God. It appears, then, that the imperative to do all that we can to extend life—allegedly a distinctive of modern mastery and control—has been retrofitted with Christian theological justification. This suggests that “modern” identity and “Christian” formation are mutually interpenetrating, rather than opposed wholes. In short, there is no unstained community of formation to be found. Perhaps we should give up looking for one.
Indeed, guides to dying well can be found both inside and outside the church. For all his criticisms of Rome, Augustine, that great skeptic of pagan virtue, told his readers to “carefully and soberly contemplate the Roman examples.” Foremost among them he placed Marcus Regulus, the Roman general who kept his word to his Carthaginian captors to return to them and face execution at their hands. By neither killing himself nor violating his word by staying with the Romans, “he went back undaunted to his terrible end.” It was because of his virtuous acceptance of death—neither hastening toward it by his own hands nor fleeing from it through vice—that Augustine claimed “among all their praiseworthy men, renowned for their outstanding virtue, the Romans offer none better than Regulus.”
Looking for guides and allies beyond the confines of the church is also a necessity of democratic politics, which is inherently coalitional. It is not Christians alone, after all, who have stood up against the expanded legalization of physician-assisted suicide in Europe and North America but a coalition of disability rights groups, pro-life groups, and others, many of them on the political left. Whatever one’s theological or political commitments, it is possible to see how such public policies create a perverse incentive structure that would nudge vulnerable people to an unjust and tragic end. This suggests, among other things, that our society is strongest when religious communities, strengthened by the sort of moral formation that Pickell writes about so eloquently, join with others to protect and care for the most vulnerable.