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Care at the End of Life: What Orthodox Christianity has to Teach

by the Rt. Rev. Thomas Joseph, Bishop of Charleston West Virginia

2 December 2008

I. End-of-Life Decision-Making in a Post-Traditional Culture: Finding One’s Way to God

Orthodox Christianity offers orientation in the cosmos. More precisely, it leads us away from our passions and purifies our hearts so that we can be illumined by the uncreated energies of God and come into union with Him.[i] Contemporary man finds himself bereft of such orientation. Both his life and his death tend to be trivialized by being reduced to what can make sense without any recognition, much less experience, of transcendent meaning, purpose, and obligation. As a consequence, much reflection on end-of-life decision-making gives priority if not exclusive attention to comfort care, death with dignity, and preservation of personal autonomy until death. All of this is done without ever asking the foundational question, What was life really all about, much less the foundational spiritual question of how I should and can repent from a life that was poorly lived so as finally to turn in repentance to God. Properly directed care at the end of life is care that focuses on repentance. To talk about end-of-life decision-making and not to place centrally the urgent issue of repentance is to miss the target completely. Care at the end of life should offer a final opportunity to the dying person to find orientation. That is, end-of-life care must bring the dying person to repentance through a recognition of how the holy, indeed God, defines the meaning of the right, the good, and the virtuous. Good end-of-life care cannot be the product of a secular or philosophical bioethics. It must be the proclamation of a living theology. Orthodox Christianity teaches how to become oriented in life and to achieve a good death. What is important to be said cannot adequately be stated in secular terms.

II. Against the Grain of the Secular Culture: Remembering that One’s Religion is not a Personal Matter

We live in a world that increasingly accepts passive euthanasia in the sense of withdrawing or withholding treatment with the intention to bring about an earlier death. This world increasingly accepts not only active euthanasia in the sense of the use of analgesics with the intention to effect an earlier death, but it also views ever more positively physician-assisted suicide and blatant undertakings in voluntary active euthanasia. All of this is exactly what a bad death is about: it is focused on the willful control of one’s own death rather than on humility and repentance. Orthodox Christianity brings a quite different message. Orthodox Christianity teaches repentance, conversion, and the importance of all turning to God. It surely does have concerns with the good, with justice, and with protecting life. But these concerns are set within concerns for the holy. Orthodox Christianity is not against making the world better. It knows in the end that the world will be made better after Christ comes in judgment (Revelations 21). In the meantime, the Orthodox Church must remind the world that the first Orthodox Christian convert to enter heaven was the thief on the cross, who did no good thing save to repent and convert (Luke 23:39-43). The thief had no opportunity after his conversion to accomplish anything worthwhile. However, literally at the end, he turned to holiness, which holiness is personal, the triune God. Orthodox Christians realize that truth is not propositional, but personal: the Trinity. Because of his conversion, the thief on the cross had a good death. What Orthodox Christianity has to teach first and foremost is that we should turn to that Truth and in so turning we will come to know holiness. This fact of the matter, the circumstance that truth exists and is personal, should orient our lives and our deaths, and should direct all end-of-life decision-making. It should help us to see the death of the thief as the icon of a good death.

This personal character of the truth constitutes one of the central distinguishing marks of Orthodox Christian theology. To begin with, those who are theologians in the strict sense are not those who merely know about God, but those who know God: they are holy Fathers. At least half of the great Orthodox theologians of the twentieth century were not academicians, many never attended a university, but they had noetically experienced God. They had come to know God.[ii] This is why the Orthodox Church rarely, and only for rhetorical purposes, gives proofs for the existence of God. Otherwise, such endeavors would be something like a wife developing five proofs for the existence of her husband with whom she lives. Offering such proofs would be a hint that she is alienated from her husband, that she no longer experiences his presence. Because we experience God, we do not believe in His existence as one might believe in a philosophical proposition. His presence is realized in our lives and in our deaths. For this reason, instruction in how to die well is not derived from manuals and treatises, but from accounts of the lives and the deaths of saints. We look to the models of proven successful dying. This point of attention always directs us beyond the good towards the holy.

Because of the centrality of the need to understand the good, the right, and the virtuous only with reference to God, Orthodox Christianity refuses to accept the dilemma that Plato (428-348 B.C.) develops in his dialogue, Euthyphro. In response to the question as to whether the good is good because God approves of it, or whether God approves of it because it is good, Orthodox Christianity realizes that the good, including the good of a good death, can never be adequately understood apart from God. It is something like not being able to understand the orbits of the planets without reference to the sun. Orthodox Christianity refuses to reduce theology or moral issues to natural-law reflections or discursive philosophical analyses and arguments. It focuses instead on the kind of person we should be for eternity. It does this in the face of a Truth that it is absolute and enduring: the Persons of the Trinity.

In contrast, spiritual character-building in our contemporary culture is frequently regarded as a do-it-yourself task, like the assembly of a meal in a cafeteria. The result is that one examines various moral and religious positions as if they were dishes from which one could sample and choose on one’s own, composing in an aesthetic and willful fashion one’s own life and one’s own death. Orthodox Christianity, in contrast, reminds persons that they must rightly orient their life-and-death choices through ascetically directing their lives to the meaning of the universe, Who is God. Orthodox Christianity is thus not simply pro life, but pro life directed to God, which direction in our lives and deaths is only achieved through ascetic struggle. One can only have a rightly-ordered ethic of life through turning rightly to God. The good cannot be understood apart from the holy. A philosophical analysis and reflection will never be enough.[iii] Orthodox Christianity, as a consequence, does not offer an ethic of life, but a way of rightly and theologically living one’s life. There can be no adequate understanding of rightly-directed end-of-life decision-making, absent an adequate theological orientation.

Although life in general and dying in particular are ascetic struggles, one should note that Orthodox Christianity recognizes the importance of pain control and comfort care. In particular, Orthodox Christianity has from the beginning appreciated that pain and distress can bring the dying to temptation and despair, thus leading them away from a wholehearted pursuit of salvation, St. Basil the Great (A.D. 329-379) therefore notes with approval that “with mandrake doctors give us sleep; with opium they lull violent pain.”[iv] Indeed, twice in each Liturgy, the Church prays for “a Christian ending to our life, painless, blameless, peaceful and a good defense before the fearful judgment seat of Christ.”[v] This prayer emphasizes the goodness of a death that is painless and peaceful. In so doing, however, it does not lose sight of the great offering to God made by the death of martyrs. In all these cases, a blameless death is like the death of the thief, repentant and marked by confession of Christ. As a result, there is nothing more frightening than the prospect of dying peacefully in one’s sleep without warning, without a final opportunity for prayer and repentance. In summary, with regard to end-of-life decision-making, there must be a focus on God, and this can require withholding and withdrawing treatment when such would distract from turning wholeheartedly to God. The focus remains on wholeheartedly aiming at repentance.

III. Seeing the Big Picture

Life lived fully within the horizon of the finite and the immanent has a trivial character in contrast to a life lived in recognition of God. So, too, does end-of-life decision-making remain radically misdirected and incomplete, no matter how much it might be embedded within a concern for death with dignity or directed by an ethic of life. Set within the horizon of the finite and the immanent, reflections on one’s death and end-of-life decision-making highlight creature comforts for a creature who thinks of himself as about to go out of existence. One is blind to the earnestness of taking advantage of final opportunities rightly to orient one’s life towards the future beyond death, that is, to God. Orthodox Christianity has the task of pointing out this big picture: the significance of death and the nature of the truth. As to the latter, Orthodox Christianity reminds the world of Who this Truth is. Only oriented to the Triune God can one in the end understand the meaning of life, the significance of death, and the goal to which one should direct one’s end-of-life decisions.

[i] The final stage beyond illumination (theoria or union with God) is what is achieved by true theologians. “The mystical and perfecting stage is that of the perfected ones, who in fact become the theologians of the Church.” Hierotheos, Bishop of Nafpaktos, Orthodox Spirituality, trans. Effie Mavromichali (Levadia, Greece: Birth of the Theotokos Monastery, 1994), p. 50.

[ii] “The theologians of the Church are only those people who have arrived at a state of theoria, which consists in illumination and theosis. Illumination is an unceasing state, active day and night, even during sleep. Theosis is the state in which someone beholds the glory of God, and it lasts as long as God sees fit.” John S. Romanides, Patristic Theology, trans Hieromonk Alexis [Trader] (Goldendale, WA: Uncut Mountain Press, 2008), p. 50.

[iii] Orthodox Christianity has an attitude towards philosophical reflection like that of St. Paul’s.

Where is the wise? Where is the scribe? Where is the disputer of this age? Did not God make foolish the wisdom of this world? For since, in the wisdom of God, the world knew not God through its wisdom, it pleased God through the foolishness of the preaching to save those who believe. For indeed, Jews ask for a sign, and Greeks seek wisdom, but we proclaim Christ Who hath been crucified; to the Jews, on the one hand, a stumbling block, and to Greeks, on the other hand, foolishness (1 Cor 1:20-23).

This Pauline insight is one often reinforced by the Fathers. One might consider the rather critical things St. John Chrysostom has to say regarding secular Greek philosophy. See, for example, St. John Chrysostom’s first Homily on the Gospel of Saint Matthew and his second Homily on the Gospel of Saint John.

[iv] St. Basil the Great, “The Hexaemeron,” Homily 5, §4, in Nicene and Post-Nicene Fathers, Second Series, eds. Philip Schaff and Henry Wace (Peabody, MA: Hendrickson Publishers, 1994), vol. 8, p. 78.

[v] The Liturgikon (Englewood, NJ: Antakya Press, 1989), pp. 281, 299.