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

I. Making Decisions at the End of Life 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.1 Contemporary man finds himself bereft of such orientation. Both his life and his death tend to be trivialized, 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 the 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 be stated adequately in secular terms.

II. Against the Grain of 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. More and more, this world accepts not only active euthanasia (for example, the use of analgesics to hasten death), but also physician-assisted suicide and blatant voluntary active euthanasia. All of this is exactly what a bad death is about: it is focused on the willful con­trol of the end of one’s own life, rather than on humility and repentance. Orthodox Christianity brings a quite different message. Orthodox Chris­tianity teaches repentance, conversion, and the importance of 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; indeed, it knows that in the end the world will be made better after Christ comes in judgment (Revelation 21). In the meantime, the Orthodox Church must remind the world that the fi rst 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. Literally at the end, however, he turned to holi­ness, which holiness is personal: the triune God. Orthodox Christians, too, realize that truth is not propositional, but personal. Because of his con­version, the thief on the cross had a good death. Orthodox Christianity has to teach first and fore­most that we should turn to that Truth and, in so turning, we will come to know holiness. This fact of the matter, 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.

The personal character of the truth is 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. Yet they had noetically experienced God. They had come to know God.2 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 it is central 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 understood adequately 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-and­death 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 refl ection will never be enough.3 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 decision-making at the end of life, 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 (329–379) therefore notes with approval that “with mandrake doctors give us sleep; with opium they lull violent pain.”4 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.”5 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 decision-making at the end of life, 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 fi nite 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 decision-making at the end of life 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 signifi cance of death and the nature of the truth. As to the latter, Orthodoxy 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 signifi ­cance of death, and the goal to which one should direct one’s decisions at the end of life.

Rt. Rev. THOMAS Joseph Bishop of Charleston, Oakland and the Mid-Atlantic


1 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).

2 “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, Washing­ton: Uncut Mountain Press, 2008], p. 50).

3 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 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, his first Homily on the Gospel of Saint Matthew and his second Homily on the Gospel of Saint John.

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

5 The Liturgikon (Englewood, New Jersey: Antakya Press, 1989), pp. 281, 299.