Science at the End of Life: Contributions and Limitations
The determination of death can be highly ambiguous. Both scientific and theological contributions are important to understand what is happening.
by Allen Verhey
About the Author: Allen Verhey spent the better part of 30 years teaching at Hope College in Michigan, where for the last 10 years he was the Evert J. and Hattie E. Blekkink Professor of Religion. Verhey was also director of the Institute of Religion at the Texas Medical Center for 2 years. He joined the faculty of Duke Divinity School as Professor of Christian Ethics in 2004. Author of the acclaimed 2003 book Reading the Bible in the Strange World of Medicine, Verhey has published extensively. He has written, edited or co-edited 12 books, including Remembering Jesus: Christian Community, Scripture, and the Moral Life. A well-traveled academic, he has spoken across the country on topics such as stem cell research, spirituality and medicine and ethical issues in hospice care. He has long been at the forefront of issues such as understandings of Scripture and Christian life and Christian voices in medical ethics.
It is a great honor to be invited to give the Witherspoon lecture, to join a distinguished group of scholars who have brought to these lectures their enormous learning in science and in theology.
Given the reputation of the Witherspoon lectures and the reputations of the past Witherspoon lecturers, I feel it is wise to lower your expectations a little. I am not a scientist, and I claim no great learning in the sciences. I do claim to be a theologian, one of that strange breed of theologians known as moral theologians, a moral theologian interested in bioethics and lately in care at the end of life. Those interests have brought me into conversation from time to time with health care professionals and scientists, conversations that I have cherished, especially now since those conversations have brought me to this honored lectern.
Let me report just one of those conversations. I have a friend, a geneticist, who used to delight in telling me that knowledge in genetics doubled every six months or so and in asking me then whether knowledge in theology had doubled in the course of, say, two thousand years. I asked him once what he thought the appropriate attitude of theology to science was, and he replied, rather too quickly, “humility.” There was wisdom in his response, of course, but it was delivered with a tinge of the hubris that has always been a temptation to both scientists and theologians, not to mention humanity.
I invite your attention tonight to the end of life - and to the contributions and limitations of science at the end of life. I want to ask about the place of science at the end of life, its contributions to care at the end of life, and its limitations, and I want to suggest that when those limitations are not recognized, care at the end of life can be distorted.
Introduction: “Whither Thou Goest”
“‘Brain-dead,’ said the doctor.” It’s the first line of Richard Selzer’s story of Hannah in “Whither Thou Goest.”1 But this scientific judgment is hardly the last word.
Hannah and Sam, her husband, had celebrated his birthday by spending a weekend at the beach together. On the trip home Sam had stopped their pickup to help a stranded motorist. The Good Samaritan ended up the victim in this encounter, assaulted, robbed, and shot in the head. He was left in the road, “half-dead,” with a halo of blood, while the motorist raced off. Three weeks later, as preface to his request that Hannah donate her husband’s organs for transplantation, the doctor announced that Sam was brain-dead. It seemed reasonable enough, supported by an electroencephalogram that the doctor unrolled to display a tidy flat line. In an effort to reassure Hannah, however, the doctor added, “The only thing keeping him alive is the respirator.” That remark, hard on the heels of the doctor’s confident announcement that Sam was brain-dead confused Hannah - and revealed a messy ambiguity that no flat line on a graph could hide.
“Let him go,” the doctor said, evidently unable to comprehend the implication of his own diagnosis that he was already gone. The doctor pressed on toward the request. “We would like your permission to harvest Sam’s organs for transplantation,” he said. And, as if to make it easier for Hannah, he added, “that way your husband will live on. He will not really have died.…” This statement confused Hannah still more, and in an effort to restore some sense to this conversation she responded, “Dead is dead.”
In spite of her confusion - and Sam’s doctor’s - Hannah allowed the transplant. A week later she received a thank-you note from the doctor. It informed her that, thanks to her generous gift (and “to the miracles of modern science”), Sam’s organs were benefiting seven people. There was a little list of organs and unnamed recipients, including the information that Sam’s heart had been given to a man “about your husband’s age in a little town near Arkansas.” The note was nice, but Hannah was baffled. “‘Dead is dead,’ she had told that doctor. But now she was not so sure.” “Maybe, she thought, it was a matter of percentages - if more than 50 percent of your husband was dead, you were a widow.” She even stopped going to the Evangelical Baptist Church cemetery to visit Sam’s grave. “It wasn’t Sam in that cemetery, not by a long shot. It was only parts of Sam, the parts that nobody needed. The rest of him was scattered all over Texas. And, unless she had been misinformed, very much alive.”
There’s more to the story. I will not spoil it for you. But it invites consideration of two contributions of science to care at the end of life, the determination of death (“Brain-dead,” the doctor said) and the remarkable technologies medicine brings to care for those threatened by death (the “miracles of modern science”).
I. “‘Brain-dead,’ said the Doctor”: Science and the Determination of Death
Consider first the development of tidy and reasonable criteria for the determination of death. It was, of course, the ambiguities that attended the technologies of respirators and transplant that made it important and necessary to develop some tidy and reasonable criteria for the determination of death. Science surely contributed here, but its contribution could only be made in the context of non-scientific accounts of death, and its objectivity did not eliminate the ambiguity.
I am old enough to remember billboards urging motorists to drive safely by joining a picture of Dr. Christiaan Barnard in scrubs to the message, “Slow down! Dr. Barnard wants your heart!” When I saw that billboard (sometime close to 1968, I presume), I did slow down a little and, muttering something about the fact that I was still using mine, I wondered how Dr. Barnard could take a living heart from a person without killing that person. One wanted to assume, of course, that the person from whom the heart was taken was already dead, but how could you know that someone with a beating heart was dead? The question was unavoidable, and the first moral challenge for heart transplantation procedures was to answer that unavoidable question.
The challenge was met with the help of science. A remarkable consensus developed that one could determine death by the irreversible cessation of whole brain function, a determination that could be made independently of either cardiac or respiratory arrest. In 1968 a Harvard ad hoc committee recommended criteria by which such a determination of death could be made. In 1972 an influential study group from the Hastings Center endorsed these criteria, and in 1981 the Presidents’ Commission gave their approval and drafted a Uniform Determination of Death Act. That model law was endorsed by both the American Medical Association and the American Bar Association and eventually adopted by all fifty states (in some form).
The unavoidable question had an answer. There is a way to determine scientifically that someone with a beating heart is dead, a way to determine that a person is dead independently of heart and lung function in those cases where a person’s respiration and heart beat are mechanically supported, whether transplantation is an option or not. The answer, the consensus that supports it, and the legislation that gives it effect are a great accomplishment. The possibility of determining death in cases like these is surely a contribution of science at the end of life.
Still, this contribution could only be made in the context of non-scientific accounts of death, and its objectivity did not eliminate the ambiguity. Hannah’s confusion may help us to make both points. Consider, for example, Hannah’s comment (and the doctors suggestion) that Sam was not really dead, after all, that only those parts of him that nobody wanted were buried in that cemetery, and that the rest of him was scattered all over Texas, very much alive. It is obvious, I suppose, that the objectivity of the flat EEG did not eliminate the ambiguity. But we will return to that point. Consider, first, the dependence of the scientific contribution on non-scientific accounts of death. If we meant by death the death of all the parts of the organism, down to the organs and the cells, then Sam is alive, and so is Helen Lane, whose cancer cells are found in labs around the country. And then the place for the scientist to look to determine death would be the cells themselves. But, of course, that is not what we mean by death, and that is not where scientists should look. That may be enough to display the fact that the scientific contribution depends on the context of a non-scientific account of death.
But what do we mean by death? Suppose we mean the irreversible loss of the soul. In that case, at least if Descartes were right (not likely!), we might ask scientists to look in the pineal gland or, based on the correlation of breath and spirit in both pneuma and ruach, at the respiratory system. Leave aside the problems with anthropological dualism, the simple truth is that we cannot observe “the soul” as a separate entity in order to know its departure. So we locate the departure of the soul at the moment of death, but then we need some other place to look and some other non-scientific account of death that will guide the scientific search. Suppose we mean the irreversible loss of vital fluids, blood or breath, for example. Then we might look indeed at the pulse or at respiration. Like the scientist on Gunsmoke, Doc Holliday, we might hold a mirror under the body’s nostrils to see if it fogs up. And that is frequently a pretty good measure, but not always. We have learned to distinguish clinical death from real death because sometimes when the respiration and circulation have stopped, the person is not dead. But now let me suggest two other accounts, the two accounts which seem to me to be the contemporary contenders.
The first of these may be contrasted to Hannah’s suspicion that Sam was still alive because his organs were still alive. No, we are likely to say, we do not mean by “death” the death of the whole organism but rather the death of the organism as a whole. Death, then, is the irreversible loss of the integrated functioning of the organism as a whole. And the place to look then is the brain, including the brain stem, where the integrated functioning of the organism as a whole takes place. A flat EEG could serve to confirm the judgment that a person is dead. This is, I think, an essentially conservative account of death, even if the criteria for determining the death of the organism as a whole now include technical assessment of brainstem activity.
Some contend, however, for different accounts of death. On this account, the person is dead not at the death of the organism as a whole but at the irreversible loss of the capacity for consciousness or social interaction. Then the place to look is not the whole brain, including the brain stem, but the neo-cortex, that part of the brain that supports our capacities for consciousness and social interaction. Then a person is dead, “gone,” even if there is some electrical activity in the brain stem, when there is neocortical death.
These accounts of death are clearly correlated to different account of our humanity, of our “personhood.” But the point here is not to argue which account is better but simply to call attention to the point that the contribution of science to the determination of death depends on a context provided by a non-scientific account of death. Science cannot provide the anthropology that finally determines the determination of death.
Let me return briefly to the other point, that the development of tidy and reasonable criteria for the determination of death does not eliminate the ambiguity of death.
Hannah’s confusion is not difficult to understand - and it is evidently shared by at least some who work in transplantation.2 The “neomort” appears very much alive, and every reasonable effort is made to keep it “alive” for the sake of the transplant. Brain-dead and ready for surgery, the cadaver is warm, has a good color, and continues to digest and eliminate. Moreover, monitoring continues, along with interventions designed to preserve the cadaver’s “health.” Even our language, you see, almost inevitably expresses this confusing situation. A “healthy cadaver” is an oxymoron. But for the sake of it, we have “brain-dead” bodies on “life-support” systems. After the transplant, the “brain dead” are removed from the ventilator and “allowed to die” or “allowed to die all the way” or “really die.” The point is not to call into question the rightness of the criteria, but to suggest why they are insufficient.
Even without the complicating factor of organ transplantation, the tidy criteria are insufficient. Joseph Fins tells the story of a seventy-seven year old Chinese woman who was assessed for brain death.3 The patient, a widow with a history of poorly controlled hypertension, had come to New York to visit her youngest son and his wife. The daughter-in-law had begged the patient to see a physician, but the patient had refused. Then she suffered a severe anoxic brain injury after a large intracranial hemorrhage and subsequent cardiac arrest. The son and daughter-in-law were distraught, of course, and when told that the patient would be assessed for brain death, they objected. (Under New York law clinicians are required to make “reasonable accommodation” for religious and moral objections to brain-death criteria.)
The daughter-in-law was feeling guilty that she had not convinced the woman to have her blood pressure monitored, and she worried that the family in China might blame them for the woman’s death. The son felt “marooned between life and loss.” Because his mother was “alive,” he could not bring himself to grieve. For his sake, at least, a determination of death was evidently called for, but the tidy criteria for brain death were not what this family needed to clarify their situation and to recognize the death of their mother. The doctors withheld their determination of death while the daughter-in-law and son went through rituals appropriate to dying in their culture. The daughter-in-law read a large Chinese placard to the patient. With tears in her eyes, plaintively rocking back and forth in a trance-like state, she read the message dictated by relatives back home that was full of wishes and blessings, “saying goodbye and asking for forgiveness.”
After the rituals were complete and the family had left the room, the assessment for brain death was done. The neurologist who performed the test dismissed the concerns of the family about the application of a brain death criteria by saying, “You are your brain.” Others in the room, Fins reported,
were not so sure anymore. After the patient did not breathe on her own, the endotracheal tube was removed. She looked quite peaceful. Her coloring remained good. She remained in a normal sinus rhythm on the monitor. After about eight minutes she flexed her arms and brought them to the midline in what appeared to be a purposeful movement, only to let them fall slowly to her side.… After this, she became dusky. Though it was almost certainly a physiologic response, the change struck me as a profound moment of transition. One resident in the room commented that the patient now “looked dead.” One colleague later described it as the patient’s true passage. And that certainly was the intuitive sense that many of us had in spite of our training in biomedical science. Even as the neurologist reassured us that what we had witnessed was just a cervical reflex often described as a “Lazarus sign,” the intensivist quickly reached for his stethoscope to listen to the patient’s heart and lungs. Reflexively, he had to confirm that the patient was truly dead by conventional means, notwithstanding the declaration of brain death that had been make moments earlier. At that moment, science only took us so far.The story not only displays the insufficiency of the tidy brain-death criteria to eliminate the confusion about the determination of death; it also identifies why the criteria are insufficient: “science only took us so far.” Death is a human event. It may not simply be reduced to the objective criteria used to determine it or to a flat line on paper. When the criteria are not acknowledged as insufficient, we risk the sort of reductionism to which the neurologist gave voice.4 The tidy and eminently reasonable criteria for the determination of death do not quite fit with the messy and not altogether manageable experience of death.
Lest it be forgotten, let me repeat the observation that science, with its objectivity, has made an important contribution to the determination of death. Those who care for the dying deserve to be informed, against their fondest wishes sometimes, that the one they care for is no longer dying but dead. And those invited to consider donating a loved one’s organs need to be told about the criteria for brain death and why they justify treating a patient not just as dying but as dead. The scientific criteria are a significant contribution. Because we are dealing with death, however, it should not surprise us that these people need more than tidy and scientific criteria. Death involves us and repels us more deeply than that. It is not so easily managed and domesticated. Death is a human event, a religious, communal, and embodied event.
As a religious event, it always invokes consideration of - and attention to the powers that bear down on us and sustain us (or not).
As a communal event, it always involves the dis-member-ment of some social body, the dis-organ-ization of some relationships. When death is the context for transplantation, it is little wonder that the “soft words of husbandry and soil” associated with transplantation seem deceptive. The event of death is a dis-member-ment, and transplantation in the context of death can seem the epitome of this dis-member-ment. In this light, one can understand the reluctance of some to consent when a loved one has died - even if they have previously considered and approved of transplantation. If, for example, the potential donor is a suicide, the family will be understandably anxious about any action toward the mortal remains that could be interpreted as mistreatment of the person. If the potential donor is an accident victim, the family may desperately hold to the continuity between mortal remains and the person they have lost. And if the efforts to save a person’s life had justified treating him or her like manipulable nature, like an object, then it is not surprising if the family insist that the person’s death ought to put an end to such treatment, not justify continuing it by regarding the corpse as so many “spare parts.”
A dualism of body and soul is operative in the reduction of the body to “spare parts.” Surely doctors must sometimes “objectify” the body in an effort to heal a person’ surely sometimes they must treat the body as manipulable; but the risks are both familiar and great. Human beings are not to be reduced to their bodies, but neither are their bodies to be consigned to the realm of mere things. We are not in our bodies the way Descartes’s ghost was presumably in the machine. We are embodied selves, and communal selves as embodied. People do not live or die or suffer as ghostly minds nor as mere bodied but as embodied (and communal) selves.
Because persons may not be reduced to their bodies, there is a discontinuity between persons and their mortal remains. But because persons may not be reduced to minds or ghosts or disembodied souls, there is also continuity between persons and their mortal remains. The continuity helps us to understand why the first experience of medical students in the gross anatomy lab is frequently repulsive to them5 and why some family members are reticent to consider the dis-member-ing of their beloved son or daughter or parent. The discontinuity helps us to understand how medical students can settle down to the tasks of learning anatomical parts, their places, their relations, and their function, and also how family and friends experience in the presence of mortal remains that the one they loved is somehow gone.
A tidy definition and a scientific determination of death are not all that the grieving need. They need to acknowledge the reality and the sadness of death. They need people to stand with them in acknowledging the loss, the disorganization of their communal selves. They need people who will discipline the human tendencies to deny death and to flee from it, who will stand with the grieving, attentive to the mortal remains, once - and still - identified with the person who has died, once - and still - the medium by which family and friends displayed the affection and loyalty of various relationships. They need people who will respect not only their autonomy but their communal integrity, who will respect both the continuing connections of the mortal remains with the person and with the community and the hard reality of the discontinuity that death inevitably brings. They need something like a funeral. The person is dead; relationships are broken; communities are dismembered. Family and friends need to surrender the person and the mortal remains; they need to “let go.” But neither they nor doctors can by decree or by scientific fiat reduce the body to “spare parts.” It is appropriate to remind those sickened medical students of the discontinuity. However, students who treat their cadavers cavalierly need to be reminded of the continuity, need to be reminded that their cadavers remain the mortal remains of someone who experienced the sights and sounds and smells of the world in it, someone who loved and blushed in it. Similarly, it is appropriate to remind those who refuse to consider organ donation of the discontinuity. And it is necessary to remind all who reduce the newly dead to “manipulable nature” or to exchangeable parts of the continuity. While the discontinuity makes dissection morally possible, the continuity requires that the retrieval of organs be undertaken with all due respect not only for the recently deceased but also for those who are dis-membered by the loss and need to grieve.
II. “The miracle of modern science”: Science and Care at the End of Life
Hannah’s story acknowledges the contribution of science to the task of determining death, but it calls attention to an ambiguity no tidy flat line can hide and to a context for the contribution of science that science itself cannot provide. Hannah’s story also acknowledges the contribution of science to the vocation of health care. The “thank you” note from the hospital, after all, noted that because of her generosity and because of “the miracle of modern science” seven people were being helped.
“The miracle of modern science,” of course, includes more than transplant surgery. It includes penicillin and vaccination and chemotherapy and… the list goes on, but the list surely includes the heart transplant Hannah’s generosity and modern science made possible. These contributions of science to care at the end of life are obvious enough and worthy of celebration.
Still, these contributions of science require again some context, some non-scientific and human context. One context for the contributions of medicine to care at the end of life, as also seems obvious enough, is the practice of medicine. If the practice of medicine is distorted, then science not only contributes to care at the end of life but can also contribute to the distortion of care for the dying.
The practice of medicine, of course, can be distorted in a variety of ways. It is distorted when it is confused with the science it uses, when it is reduced to science. It is distorted when it (or the culture that supports it) entertains extravagant and idolatrous expectations of medicine. And it is distorted when its resistance to death is undertaken in the fear that death has the last word. I want to attend briefly to each of these.
a. The Distortion When Medicine is Confused with the Science It Uses
Consider Hannah’s complaint about doctors. “They haven’t the least idea about the human heart,” she said, “except to move it from place to place.” That complaint is not, I think, altogether fair, but it is surely familiar. The complaint that medicine has “depersonalized” the patient has been something of a refrain for almost as long as we have demanded of doctors that they provide the “miracle of modern science.”6 The complaint is not hard to understand. In diagnosis medicine fixes its objective gaze on the body, and sees the body as an object. In therapy medicine treats the body, and treats the body as manipulable nature. The “person” sometimes gets lost - and so does the body! At least the patient’s relationship to her body as “me” can be displaced by the physician’s diagnostic and therapeutic - and “scientific” - relationship to the body as “it.” The familiar complaint is that medicine treats “me” like an “it.”7
Foucault traced the beginnings of this “medical perception” or the “gaze” that reduces the body to an object to the development of “scientific” medicine in the eighteenth and nineteenth centuries - and especially to the position that the corpse assumed in such medicine. Science made an object of the body and when physicians turned their clinical gaze upon the body, they lost sight of the person and of the body as “me.”8 That’s not all bad, of course; when my wife’s doctor examines her, I am glad for my confidence in his “clinical gaze.” But the “clinical gaze” gave birth to a biomedical “view” of the body, a biomedical model for “knowing” the body scientifically, as object to be measured and calculated, managed and controlled, manipulated and corrected.9 And that’s not all bad, either, of course; it nurtured the development of the “miracles of science,” the contributions of science to care for people at the end of life. But such a relationship with a patient will hardly nurture attention to them as persons or to their suffering as embodied and communal and religious selves.
If “the clinical gaze” gave birth to this view of the body as object, one might still regard René Descartes, often called “the father of modern philosophy,” also as the father of this view of the body, at least as the philosophical midwife at its birth. Everything can be doubted, he famously insisted, but this is certain: cogito, ergo sum. I think; therefore I am. Because I think, I cannot doubt my existence as a thinking thing. This thinking thing, this res cogitans, this mind, was the essential self, the soul, in Descartes’ view, and it was immortal, rational, and free, quite independent of the body and its mortality, transcending any particular social location and its limits. Cartesian dualism assigned the body to the realm of matter, to res extensa, to be measured and mastered. The body was a fragile machine, an animated corpse, that the soul mysteriously inhabits for a time. As if to stake a claim to his paternity of the biomedical view of the body, Descartes concludes his Discourse on Method by calling for the development of a knowledge of nature, or the body, that would master nature and free human beings from disease and from the withering of old age. Cartesian dualism gave medicine permission to see and to treat the body as manipulable matter, as res extensa, and it would permit nothing else!10
Medicine, for its part, seems little interested in questions of the paternity and midwifery of its “view” of the body. It acknowledges, to be sure, that health care may have had its beginnings in religion and philosophy, but in the story it frequently tells of itself it has transcended that past, making “progress” by science. It prides itself on being a scientific discipline.11 When medicine and the culture celebrate medicine as “scientific,” however, the celebration itself is hardly a matter of “science.” The celebration puts medicine at risk of forgetting, of neglecting, and of distorting the human context of care for the suffering. There is always some context, of course, some narrative that orients and locates us, some mythos that shapes an ethos,12 even if the myth is that we can do without myth, the story that we have no story.13 In that context it is little wonder that we reduce health care to the science it uses - and little wonder then that we are at risk of one or another form of scientific reductionism.14
b. The Distortion When a Cultural Myth Prompts Extravagant Expectations
Even if we reject such reductionism, as we should, there is a mythos that provides an ethos for science and health care in our culture and that sponsors extravagant and idolatrous expectations of science. It is what has been aptly named “the Baconian project.”15
The Baconian project locates the study of nature as a “practical” science and orients it toward “the relief of human subjection to fate or necessity.”16 That sounds commendable enough, and it is surely commonplace enough in the modern world. But it invokes a myth that is ripe for doubt and distorts our care for the dying. It invites us to folly.
It is not folly to distinguish the “practical” from the “speculative” (or theoretical) sciences. Aquinas had done that. Aquinas, however, affirmed that all knowledge is “good.”17 Bacon, however, distinguished them in order to reject the “speculative” sciences as the mere “boyhood of knowledge” and as “barren of works.”18 Western culture has followed Bacon in exalting a particular form of knowledge, the knowledge for which it reserves the honorific term “science.” In the classical account, theory (or the speculative sciences) provided the wisdom to use the practical sciences appropriately. In Bacon’s account, where shall we look for wisdom?
The modern account may admit, as Bacon had, that for knowledge to be beneficial humanity must “perfect and govern it in charity,”19 but science is “not self-sufficiently the source of that human quality that makes it beneficial.”20 (The Human Genome Project has not found a marker for charity.) Moreover, the compassion or charity that responds viscerally to suffering will urge us to do something in response to suffering, but it will not tell us what thing to do. Given our Baconian confidence in the “practical” sciences, in technology, it is little wonder that the thing to do is to reach for the latest technique or the nearest tool in an effort to put an end to suffering. Our enthusiasm for science and technology as a response to suffering has blinded us to the limits of science in care at the end of life. The Baconian account of knowledge simply arms compassion with artifice, not with wisdom. It trains compassion to eliminate suffering, not to bear it, not to share it. For the knowledge to “perfect and govern” human powers and for the wisdom to guide charity, science must call upon something else. But upon what? And how, in Bacon’s account, can humanity have “knowledge” of it?21
The “practical” knowledge Bacon celebrated was sought in the confidence that it would render humanity “capable of overcoming the difficulties and obscurities of nature,”22 able to subdue and overcome the vexations and miseries that nature brings, and “to endow the human family with new mercies.”23 Knowledge, in Bacon’s view, is power over nature, and the myth is that mastery over nature inevitably brings human wellbeing in its train. That is a myth shared by much of Western culture. The myth of the Baconian project sets humanity not only over nature but against it. The natural order and natural processes have no dignity of their own; their value is reduced to their utility to humanity. And nature does not serve humanity “naturally.” Nature threatens to rule and to ruin humanity. The fault that runs through our world and through our lives must finally be located in nature. Nature may be - and must be - mastered.24 In this myth science and the technology it provides become the faithful savior. I do not claim that all physicians shared this vision or this project, but I do claim that the Baconian project shaped the practice of medicine and the cultural context within which science made its contributions to care at the end of life.25
The ambitions of the Baconian project extended to human finitude itself, to human nature, to our mortality and vulnerability to suffering. The Baconian project has provided the context for our health care at the end of life. Francis Bacon identified what he called a “third end” for medicine, the preservation of life, and he regarded that goal as the “most noble of all.” For two millennia physicians had defined their role in terms of restoring health and easing pain. They saw the good of health and their powerlessness against death. When patients were mortally ill, “overmastered by their diseases,”26 they refrained from efforts to cure them.27 Bacon rejected the traditional resignation in the face of those “overmastered by their disease”; he complained that “the pronouncing of these diseases incurable gives a legal sanction, as it were, to neglect and inattention and exempts ignorance from discredit.”28 Bacon’s recommendation was innovative for its time, and it came to shape the context for health care and the conduct and character of physicians as powerfully as the once innovative oath had. Physicians were enlisted on the side of life, fighting a messy but heroic battle against death. Their courage was their refusal to call any disease incurable. Their weapons were forged in scientific study and research. Their allies were the university and its laboratories.29
Among the effects of this shift, of course, was the ability to cure a number of diseases that once overwhelmed the sick. For that, of course, for “the miracle of modern science,” we must be thankful. But we may and must regret other ways this context has shaped care at the end of life. Ironically, Bacon’s complaint about the neglect and inattention and ignorance that were sanctioned by the former medicine have been turned against the medicine Bacon inspired.
Where neglect is identified with a decision no longer to attempt to cure, there medical care and the project of healing are reduced to cure. Where attention to patients is identified with the effort to cure them, there attentiveness to patients is reduced to attentiveness to their pathologies. Where “knowledge is power,” regarded as power over nature and celebrated as bringing human wellbeing in its train, there care for patients is reduced to treating their bodies as manipulable nature in an effort to cure them. The ironic result is that the medicine formed by such a mythos sanctions another kind of ignorance, ignorance of the identities of patients, of the particular stories they tell, the individual aims they cherish, and of their communities. And when such ignorance is sanctioned, the physician will be ill prepared to understand and respond to the particular ways in which patients suffer, to the particular ways in which patients experience their condition as a threat to their embodied integrity.30 The Baconian account of medicine had great success, but the limits of that success are told in sad stories of lingering dying, tragic stories of physicians who see only diseases and lose sight of the human realities of their patients, sad stories of patients suffering not only from certain pathologies but from the treatments for them. Care motivated the search for a cure, of course, but the search for a cure pushed care to the margins. “[Those doctors] haven’t the least idea about the human heart,” Hannah said, “except to move it from place to place.”
c. The Distortion of Resistance to Death in the Fear that Death has the Last Word
In spite of Bacon, however, people die. In spite of extravagant expectations of medicine, our lives end in death. Pascal said it well, “The last act is tragic, however happy the rest of the play is; at the end a little earth is thrown upon our head, and that is the end forever.”31 Peter DeVries may have said it even better, “We’re all like the cleaning woman. We come to dust.”32 But the Word of God may say it best, “You are dust, and to dust you shall return” (Gen 3:19). However many changes have taken place between the first century and the twenty-first, whatever differences mark human beings and cultures around the world, they are alike in this: people die. That seems scientific enough for most of us. That scientific prognosis puts the question to all of us whether an ultimate, if defiant, despair is the appropriate human disposition in the world.
The science that makes the prognosis, however, can not answer the question that it puts. It can say death is real, but it cannot say that it has the last word. It can say death is no illusion, but it cannot say that death is our ultimate destiny. Christians have no stake in denying the reality or the power of death in the world, for at the heart of its story is a narrative of the death of Jesus. Death is real - and it is a real evil! It is intimate with sickness and suffering. Death - and sickness and suffering33 - alienate people from their own flesh, from their communities, and from God.34 And if death is our ultimate destiny, then so is alienation. The same story, however, includes a resurrection and the triumph of God over death. The resurrection does not require - and will not permit - a denial of the reality of death, but it does give us quite a different sense of an ending. It has prompted Christians to the affirmation, “I believe in… the resurrection of the body, and the life everlasting,”35 and to dispositions of hope and joy in the world.
To its great credit, medicine resists death. But if medicine is undertaken in the context of the fear that death is finally the last word, in the context of that ultimate, if defiant, despair, with no other and no better sense of human destiny, then the resistance medicine offers grows sometimes presumptuous, sometimes desperate, and frequently (if ironically) alienating. It can and sometimes does prematurely alienate the dying from their bodies, from their communities, and from God. Then medicine becomes a strange world where a distorted care permits death premature triumphs in the very resistance to death.
1. Death and Our Flesh
Death threatens, first, to alienate us from our own flesh. The threat is real and terrible, for we are embodied selves, not ghosts. Sickness, that forerunner and messenger of death, reminds us that we are our bodies, that our “selves” depend on the integrity of the bodies we otherwise take for granted, that our health and our lives, our “selves,” are radically contingent.36 This reminder, however, does not come gently; it is not like listening to some friendly preacher read from the Psalms. In sickness this identification with the body is experienced at the same time as alienation from the body.37
Death makes its power felt in serious or chronic illness and in severe pain, when the body is experienced not only as “us,” but as “the enemy.”38 It makes its power felt in the weakness that robs the sick of the capacity to exercise responsible control of themselves and of their world. Death makes its power felt when the wonderful variety of God’s creation is reduced to something barren and sterile or to something putrid and foul. It makes its power felt when the body no longer opens up into a larger and sharable world, when the body - and the world - of the sick shrinks to that place “a bandage hides.”39 Death makes its power felt in the sense of a betrayal of that fundamental trust we have in our bodies. (And when such a fundamental trust is broken, all trust can become suspect - more important, to be sure, but more questionable, too.)
Medicine resists death - and its resistance is sometimes heroic.40 However, without some other and some better sense of an ending, its resistance is sometimes presumptuous, pretending to rescue human beings from their mortality and their vulnerability to suffering - and frequently desperate, laboring under the tyranny of survival or ease. And sometimes - ironically and tragically41 - death makes its power felt in a hospital and in the sort of medicine which is technologically oriented to biological survival. When the sick, at once identified with their bodies and alienated from them, seek medical care, they sometimes find this self understanding reinforced;42 they are sometimes reduced to their pathology, and the body is treated as “the enemy,” as that manipulable and untrustworthy “nature” which must, for the sake of my self, be overpowered, but which remains, willy-nilly, my self. Patients suffer then not only from the disease but also from the treatment of it - and death makes its power felt not only in sickness but also in the strange world of medicine.
2. Death and Our Communities
Death threatens also to separate people from their communities. The threat is real and horrible, for we are communal selves, not isolated individuals. Our lives are lives lived with others, and death threatens separation and removal, exclusion and abandonment.
Sickness comes as the forerunner and messenger of this alienation, too. Death makes its power felt when the sick or dying are removed and separated from those with whom they share a common life. It makes its power felt when their environment is inhospitable to family and friends. It makes its power felt when disease so monopolizes attention that there is no space for the tasks of reconciliation, forgiveness, and community. It makes its power felt when the fear of being abandoned is not met by the presence of others who care.
Sickness, with its pain and weakness, pushes people to the margins of public life, forces a withdrawal from the public activities of working and shopping, attending a concert or a ballgame.43 And those of us who are “well” provide some of the leverage that moves the sick to the margins, for we are not hospitable to reminders of our own vulnerability and contingency.44 We are autonomous, in control, in charge, productive; they are not. We have been successful against the powerful threats of nature; they have not. They have been captured by the power of death, by the forces of chaos, by the nature that threatens us all, by the nature against which our best hope is technology, the power knowledge gives, the knowledge most of us do not have. They belong, therefore, in a hospital and under the care of a physician, not in public spaces reserved for strength and beauty, for efficiency and productivity, for life. They belong - “elsewhere.”45
Even within their own spaces, moreover, those who suffer can be further isolated and alienated, for suffering can rob the sick of their voice. In W.H. Auden’s wonderful and painful line, “Truth in their sense is how much they can bear;/ It is not like ours, but groans they smother.”46 The point is not just that those who suffer are sometimes driven back to the sounds and cries human beings make before they learn a language. The point is rather that there are no words. The person in pain knows it, knows it with a certainty that Descartes might envy, but the one suffering it cannot make sense of it, cannot tell it, cannot communicate it or “share” it.47 And the silence of death makes its power felt in the lonely dumbness of the sick and the helpless deafness of those who would care!
Medicine resists death, and can sometimes identify the pain, can “objectify” it, make sense of it, and manage it by creating a language for it. But sometimes that language is not the language of the patient; and where that language is the “official” language, there patients find themselves aliens, not knowing the language, “speechless,” and with little hope for making their pain - or themselves - known.
Medicine resists death, but without another and better sense of an ending, sometimes - ironically and tragically - death makes its power felt, first when a community abandons the sick to medicine, and then, in a hospital when medicine neglects the community and the voice of the patient. It’s a strange world of medicine.
3. Death and God
Death threatens people, finally, in their relationship with God. The threat is real and terrible, for human beings are religious, in spite of the denials of secularism. Death threatens any sense that the One who bears down on us and sustains us is dependable and caring. It threatens abandonment by God and separation from God. It threatens human beings in their identity as cherished children of God. Death makes its power felt whenever the sick and dying, or those who would care for them, are not assured of the presence of a loving God who cares. Death makes its power felt not only in the sense of betrayal by our bodies, not only in the sense of betrayal by our communities, but also in the sense of betrayal by God.
Such at least was the experience of Stein, the character in The Blood of the Lamb who described his daughter’s leukemia as a “sluggishly multiplying anarchy… a souvenir from the primordial ooze. The original Chaos, without form and void. In de beginning was de void, and de void was vit God. Mustn’t say de naughty void.” “God,” Stein said, “is a word banging around in the human nervous system.” And when he was reminded of the martyrs and of their courage, he called it “Part of the horror. It’s all a fantasy. It’s all for nothing. A martyr giving his life, a criminal taking one. It’s all the same to the All.”49 Then medicine is just, as Stein said, “the art of prolonging disease… in order to postpone grief.”50
Medicine resists death, but with no other or better sense of human destiny, its resistance is undertaken under the power of death, under the tyranny of survival, and with the desperation of hopelessness. Then medicine becomes - ironically - a strange world where death makes its power felt, by alienating patients from their bodies, and from their communities, and from God - before the end of their lives and for the sake of their survival.
The last word, it seems, belongs to death, and the horror of it is not simply the termination of existence, but the unraveling of meaning, the destruction of relationships, the lordship of chaos. It is the light that seems ephemeral; it is the darkness that seems to surround and to “overcome” the light and life. Then we are right to be fearful of death, to tremble in the face of darkness and chaos.51
4. Resurrection and the Difference it Makes
Christians claim, however, that it is not so, that the last word is not death. They believe, as they say, “in the Holy Spirit, the Lord and Giver of life,”52 and they list among the works of the Spirit “the resurrection of the body and the life everlasting.”53 They have - and their creeds have - quite a different sense of an ending; they affirm that “we live by the Spirit.” Christians do not deny the reality of death - or the ways it threatens human beings in their relationships with their own bodies and with their communities and with God. Nevertheless, Christians make the audacious (and finally hilarious) claim that the last word belongs to God and to the life-giving and gracious Spirit of God. The last word, then, is not death but life, not suffering but shalom.
Two questions seem obvious. The first is whether there are any grounds for this affirmation, for this hope, for this confidence in a different and better destiny. Hope that has no basis is simply wishful thinking. And the second question is whether it makes any difference. Hope that has no consequence is simply sentimental optimism. The questions are related, of course, for in the grounds for hope we will also discover a direction. “If we live by the Spirit, let us also be guided by the Spirit.”
Permit me, first, to consider - very briefly and quite inadequately - the grounds for hope and then to suggest - also briefly and also inadequately - the difference a context of such hope would make to care at the end of life.
a. The Grounds for Hope
To consider the grounds of hope brings us squarely back into the conversation between theology and science. Science made the prognosis, you will remember, that our lives will end in death, and the prognosis for our world and for the cosmos is no different. And theology had better listen to science - and with something like the humility my geneticist friend recommended. If the world narrated in the Christian story is the same world that is investigated by the sciences, then there is both the possibility and the necessity of a genuine conversation between science and theology.54 Science calls attention to the absolute contingency of human life and of the cosmos.55 To listen to the sciences here is to learn that there is - and is to be - no denial of death.56 This is hardly shocking to Christians, I suggest, who have always acknowledged that the creation does not have its life the way God has God’s life.
The science that makes this prognosis, however, cannot answer the question that it puts to us. It can say death is real, but it cannot say that it has the last word. It can say death is no illusion, but it cannot say that death is our ultimate destiny. It can say that our lives and our universe - left to their own regularities - provide little hope for the triumph of life, but it cannot say that there are no other reasons for hope.57
Theology, frankly, is not much better off in this conversation. A sense of the reality and the finality of death can hardly be dispelled by an argument.58 Only God can raise the dead. Only God can secure a hope in the midst of death that is not illusion, evasion, or fantasy. Still, theology may bear witness to that God. The church tells a story that can make God and the power of God known, and it performs that story in practices and activities that display Christian hope and do so in a way that can be more convincing and moving than any theological argument. The hold that death has on our imagination may yield to the story and to Christian practices that include the sacraments and the forgiveness of sins and care for the dying.
In considering the grounds for hope, we must begin with the story, and the story begins with the creation. In that beginning God made all things out of nothing and made all things good. The Spirit was there, of course, “in the beginning,” the wind that swept across the waters of chaos to create a cosmos (Gen. 1:2), the breath of God that made of dust a living creature (Hb.: nephesh; Gen. 2:7).59 The story is not science, of course, but science simply traces the way God ordinarily worked and works. From that beginning it is clear that, if we live at all, we live by the Spirit. From that beginning it is clear that without the Spirit of God human weakness and mortality would make their inevitable way towards death, that without the Spirit of God great human powers would demonstrate their weakness, their “flesh,” by their inability to preserve the cosmos from tilting back to chaos. The grounds for hope in the Christian tradition are not found in some “soul” that has its immortality independently of God and finds liberation in the death of the body. The grounds for hope are not located in some romantic account of nature as bringing always the return of life and of spring. And the grounds of hope are not found in some Baconian account of technological mastery over nature as bringing always human flourishing in its train. The grounds for hope are these: the powerful and creative word of God and the life-giving Spirit of God that can call a cosmos out of chaos and give light to the darkness and life to the dust. The sense of an ending is given with the story - and with the faithfulness - of the triune God.
The creation, of course, is not the whole story. The narrative continues with the story of human sin and of a “curse” that rests on the whole creation and on all life. Sin brings death and alienation in its wake - not mortality, it should be said, which was and is a simple sign that we do not have life the way God has life. Sin left ugly marks on the world God made: the curse of patriarchy, the enmity and envy of brothers, the confusion of tongues at the Tower of Babel, and death as the alienation of human beings from their own bodies, from their communities, and from God.
The story might have ended there, the cosmos smashed back to chaos. But God did not abandon the world to sin or to death. Even under the burden of a “curse,” these are the grounds for hope: the faithfulness of God to what was the cause of God from the beginning, God’s refusal to let sin and death to have the last word in the world God made, God’s “maintaining his unconditional creative relationship to what he has created even beyond death.”60 The Spirit was still there, present now in the chaos human beings had wrought, brooding now on the waters of human tears, preserving, renewing, pledging now that death would not have the last word in the world God made.
So, “the fall” - or the flood - is not the end of the story either. God comes again to covenant and to bless. And the blessing with which God would visit the world is not a rescue from the world but a vocation within it, a vocation to be a blessing (e.g., Genesis 12:1 4), to restrain and to lift the power of the “curse” in the world God made and preserves and loves.
The center of the Christian story - and of the creed - is Jesus of Nazareth. He came announcing the good future of God, and he made its power felt in works of healing and in words of blessing. When the dead were raised, the good future of God was revealed. When the sick - those under the power of death - were healed, the good future of God was present. When demons were cast out and those afflicted returned to themselves and to their communities, the good future of God was made known and made real. And when the poor heard good news, the good future of God made its power felt.
This Jesus “suffered under Pontius Pilate, was crucified, dead, and buried.” He had not chosen suffering; he had not chosen death; but he endured both for the sake of God’s cause in the world and his own integrity. In contrast to the sublime tranquility with which Socrates drank the hemlock, confident that the death of his body would free his immortal soul, Jesus wept and cried at the prospect of alienation from his flesh, from his friends, and from God (Mark 14:33, Hebrews 5:7).61 And his death was real and horrible (in contrast to the beautiful death of Socrates); he made the human cry of lament in the face of death his own cry, “My God, My God, why have you forsaken me?” (Psalm 22:1, Mark 16:34).
But God raised this Jesus up, “the first fruits of those who have died” (1 Corinthians 15:20).62 The power of God and the love of God reached into death to raise this Jesus up, vindicating both Jesus and God’s own faithfulness. The powers of death and doom had done their damnedest, but God would have the last word. God raised this Jesus up - and established once and for all the good future, the destiny, of which he spoke.
This is the reason for the hope that is in us (1 Peter 3:15): Jesus was raised in this world and in this history, and this world and this history have - happily - no escape. Because of that resurrection of Jesus of Nazareth, God’s victory over the powers of death and sin, Christians say, “Therefore, I hope. Therefore, ‘I believe… in the resurrection of the body; and the life everlasting’.” The New Testament fairly thunders with that sense of victory and expectation.
Because Jesus has been raised, the Spirit has been poured out, “the first fruits” (Romans 8:23) and the “guarantee” of God’s good future (2 Corinthians 1:22, 5:5; Ephesians 1:13), and the Spirit is included in the creed and in the grounds for Christian hope.
The Spirit, as Paul says, “helps us in our weakness” (Romans 8:26). While we “groan inwardly” (Romans 8:23), when there are no words, while we wait for “the redemption of our bodies” (Romans 8:23), the Spirit gives us words, “Abba! Father!” (Romans 8:15) and makes us “heirs,” “joint heirs” (Romans 8:17), of God’s good future. The Spirit is at work where the groaning find words and where God’s future still makes its power felt: when the sick are healed, when the grieving are comforted, when (like Pentecost and unlike the tower of Babel) people understand each other, and when the threat of death is met with confidence in God, and with care for persons as embodied and communal selves.
The Spirit is at work in the Church, in that community where the resurrection is celebrated and where the good future of God is anticipated in practices of friendship and forgiveness, or as the Creed says, “the communion of saints, [and] the forgiveness of sins.”
Christians hope because they know the faithfulness of the One who made all things, because they know the story of one who was raised from the dead, and because they know a life giving Spirit. They cannot but claim to know something of the end of the story. They cannot but say, “I believe… In the resurrection of the body; and the life everlasting.” The Christian Church owns a story in canon and in creed that ends with talk of God’s good future - and our own. It is not yet that good future, of course, still sadly not yet that future. The creation and the Christian still “wait” and “watch” and pray for it (Romans 8:19 23).
b. The Difference It Makes
We began by acknowledging the reality and the power of death, but we have seen that - in spite of appearances - there are grounds for believing that death is not the last word, that human destiny is life and light. But if this is true, if death is not the last word, if our destiny is life, what would our dying and our care for the dying look like?
The short answer to that question, I think, is “watchfulness.” That is to say, our dying and our care for the dying should display and confirm our hope. But then, what does “watchfulness” look like? Here we might take a cue from Mark’s gospel and its call to heroic discipleship. Watchfulness takes the shape of courage. Or we might take a cue from Revelation; watchfulness takes the shape of patience. Or we might consult the letters of Paul and their invitation to “rejoice (and to grieve) in hope.”63 But let it suffice to take a cue from the Gospel of Matthew, where the call to “watch” becomes a call to care for those who are pressed down and crushed by hurt and harm.
Matthew brings his account of watchfulness to a climactic conclusion with a story about the last judgment (Matthew 25:31 46).64 When the Son of Man comes in his glory, he invites some to enter the kingdom - because, as he said, “I was hungry and you gave me food, I was thirsty and you gave me something to drink, I was a stranger and you welcomed me,… I was sick and you took care of me….” Those who heard him were surprised, shocked, by the words. “When?” they asked, “We were watching for you, waiting for you, but when, Lord, did we care for you?” And the Son of Man answered them, “Inasmuch as you cared for one of the least of these, you cared for me.”
The parable is eloquent testimony that watchfulness takes the shape of care. And it is an elegant reminder to caregivers that the presence of God is mediated to them through their patients, that patients - in their very weakness and vulnerability, in their hurt and loneliness - (re)present Christ to the care giver.
Caregivers may still stand there stuttering and sputtering, “Do you mean to say that that was you, Lord? That that fat old fart was you, Lord? That that irritating gomer was you, Lord? She certainly had a rough life, and she was you, even so? Do you really mean to say that that broken body was your spiritual presence?” And the answer is always “yes,” and the answer calls for a kind of reverence in response.
This reverence requires care for patients as embodied and communal selves. It does not just insist in Cartesian fashion that the patient is also an agent; it does not set the mind (or the will) over and over against the body; it does not simply demand respect for a patient’s autonomy while the body remains manipulable nature. A watchful medicine, formed to care with reverence, is more apt to attend to suffering than either the technical expert who reduces the sick to manipulable nature or the moral expert who reduces the patient to capacities for choice, for patients suffer neither as ghostly minds nor as biological organisms but as whole persons.65
The parable is eloquent testimony that watchfulness calls for care, and it is an elegant witness to the humility appropriate to caregivers. There is no place here for Messianic pretension. If anyone is Messiah in this parable, the patient is. The caregiver is not Messiah. A watchful medicine will not deny the not yet character of our existence or of our medicine, not to itself and not to patients. On the contrary, a watchful medicine will sustain and nurture truthfulness about our finitude, about our limits. Humility, after all, finds its twin in truthfulness.
And if medicine is not Messiah, it is freed by watchfulness and its humility for a more carefree care. A watchful medicine need not bear that finally intolerable burden of being Messiah; they need not substitute anxiously for a finally powerless God. Watchful medicine needs not panic in the presence of suffering and dying. In a watchful medicine caregivers can simply “be there” with and for patients, present to the suffering and the dying.66 When there are no words, when the suffering is mute, a watchful care giver can “be there” with a silent readiness to listen - and that silent presence can help a patient to find words to express the hurt. And when the patient finds those words, a watchful care giver can “be there,” ready to join her voice to his in com-plaintive lament - and that “expressive compassion” can help a patient to find meaning and to begin to construct the next chapter of a life, even if it will be the last chapter.67 Watchfulness can nurture and sustain a more carefree care, and bring calm to chaos.
Death, we said, threatens alienation from our bodies. A watchful medicine will care - and meet the threat by attention to embodied selves, relieving pain and nurturing the strength of patients to exercise self control and responsibility, by attention, yes, to the delights of the flesh, to the music patients like and to the flowers they love, to their environment and to their dining (no less than to their diet), and by the human touch that signals compassion.
Death, we said, threatens alienation from our communities. A watchful medicine will care - and meet the threat by hospitality not only to patients but to those whom patients love and by whom they are loved, by making those visiting the sick and dying comfortable and welcome, by ministering to those who can only stand and wait, for in such hospitality medicine cares for the patient, too. A watchful medicine will care - and help the patient recover her voice, even if only in lament.
And death, we said, threatens alienation from God. A watchful medicine will care - but not by trying to dispense God, not by trying to provide God in pleasant little doses, convenient tablets, say, designed to make God easier to swallow. A watchful medicine is not undertaken as though God were not present to those threatened by death unless someone produces God; a watchful medicine is undertaken as a sign of a divine love which is always present and as a signal of a human hope which is already real.
A watchful medicine, it needs finally to be said, requires a watchful community.68 A watchful community will not abandon the sick or the suffering to medicine, nor will it abandon caregivers to their technology. A watchful community will call the sick and suffering to courage and patience, will comfort them in their lament, and encourage them to heroic discipleship and patient endurance. A watchful community will call care givers to understand their work as a calling, indeed as a “holy calling,”69 as a form of discipleship of the suffering and saving Christ, a vocation in which and through which they can serve the cause of God, rejoicing sometimes in some little token of God’s good future they are able to bring, lamenting sometimes with a patient that it is still not yet God’s good future.
A watchful community and a watchful medicine will not disown science. On the contrary, it will nurture and sustain and honor science, setting it in the context of our delight and wonder at the ways God ordinarily works, in the context of a “dominion” that serves the cause of God, and in the context of care for embodied and communal creatures of God. In that context we may celebrate science and its contribution to care for the dying. We may be glad, that is, for the contributions of science to care at the end of life, to intervene sometimes against premature death and to relieve pain even when it cannot cure, but we will not indulge in extravagant and idolatrous expectations of medicine as though it were the faithful savior. It is not that such a medicine has a smaller place for science but that it sets science in a different context.
Then we may signal together another and a better destiny, that death is not the last word, and that God’s good future makes its power felt not where the dying cling desperately to life, nor where the dying are deliberately killed, but where the dying is faced with courage and accompanied by care. It may be that our dying and our caring for the dying may be the most compelling evidence to be offered, short of eschatological vindication, for the claim Christians often make, “I believe in… the resurrection of the dead, and the life everlasting.”
Endnotes
1 Richard Selzer, Imagine a Woman and Other Tales (New York: Random House, 1990), pp. 3-28.
2 See S. J. Youngner, S. Landefeld, C. J. Coulton et al., “‘Brain Death’ and Organ Retrieval: a Cross-sectional Survey of Knowledge and Concepts among Health Professionals,” (Journal of the American Medical Association 261 (21) April 1989) 2205-2210. In this fascinating survey of nearly two hundred physicians and nurses involved in organ procurement Stuart Youngner and his colleagues demonstrated the dissonance between the intellectual understanding of criteria for the determination of brain death and the experience of those who care for brain-dead organ donors. In one part of their study, the doctors and nurses were presented with two cases and asked both whether the patients were legally dead and whether, aside from legalities, they themselves regarded the patients as really dead and why. Only about a third of the total number of respondents and about two-thirds of the physicians were able to identify the criteria for determining death correctly and “the personal concepts of death varied widely.” The study did not suggest that death was being misdiagnosed or that patients were being prematurely declared dead for the sake of access to their organs, but it did suggest a “conceptual disarray”; it did suggest that Hannah’s confusion is not unusual. And if professionals sometimes find this experience confusing and sometimes disconcerting, then one can image how much more difficult it must be for families. For families, of course, the “neomort” is not just a cadaver, but Mom or Son or Sam.
3 Joseph Fins, “When Brain Death Pulls at the Heart Stings,” in Personal Narratives on Caring for the Dying (2nd edition; American Board of Internal Medicine, 2000), pp. 21-22.
4 See Hans Jonas, “Against the Stream: Comments on the Definition and Redefinition of Death,” in Philosophical Essays: From Ancient Creed to Technological Man (Englewood Cliffs, N.J. Prentice-Hall, 1974). In one of the initial challenges to the drain-death criteria, and in spite of the developing consensus, Jonas criticized the Harvard ad hoc committee for attempting to provide a sharp line between life and death when, in fact, according to Jonas, life often shades imperceptibly into death. “Giving intrinsic vagueness its due is not being vague,” he said.
Aristotle observed that it is the mark of a well-educated man not to insist on greater precision in knowledge than the subject admits…. Reality of certain kinds - of which the life-death spectrum is perhaps one - may be imprecise in itself, or the knowledge obtainable of it may be. To acknowledge such a state of affairs is more adequate to it than a precise definition, which does violence to it.Even if we admit the necessity of some precise and objective criteria, Jonas reminds us of the inevitable ambiguity and warns us against pretending that any tidy criteria can eliminate that ambiguity. Such pretense violates the human experience of both caregivers and survivors.
5 Leon Kass, Toward a More Natural Science (New York: Free Press, 1985), pp. 277-278.
6 One may plausibly date the “birth of bioethics” to this complaint. If one does, then bioethics was born around 1936 and may have hospital chaplaincy as a sibling. In 1936 Richard Cabot, a physician at Massachusetts General Hospital, and Russell Dicks, a minister who served as chaplain there, published The Art of Ministering to the Sick (New York: Macmillan Co., 1936). In it they called attention to the “whole person” and insisted that healing is not simply a matter of curing the body by scientific medicine; they called for cooperation between the physician and the minister. By 1940 the American Protestant Hospital Association adopted a set of standards for hospital chaplaincy. One might also mention the extraordinary Swiss physician, Paul Tournier, who called for a medicine attentive to the “whole person.” See Paul Tournier, A Doctor’s Casebook in the Light of the Bible (trans., Edwin Hudson; London: SCM Press Ltd, 1954).
7 It’s a strange world of medicine when it loses sight of both the person and of my body as “me.” The irony is captured nicely in the story of the physician carefully listening to a patient’s chest with his stethoscope. The patient tried to ask the physician a question, but the physician said, “Quiet. I can’t hear you while I’m listening.” (Richard Baron, “An Introduction to Medical Phenomenology: I Can’t Hear You While I’m Listening,” [Annals of Internal Medicine 103 (1985): 606-611, p. 606], cited by Warren Thomas Reich, “A New Era for Bioethics: The Search for Meaning in Moral Experience,” in Allen Verhey, ed., Religion and Medical Ethics: Looking Back, Looking Forward [Grand Rapids: Eerdmans, 1996], 96-119, p. 97).
8 Very much like a corpse; see Michel Foucault, The Birth of the Clinic: An Archaeology of Medical Perception (trans., A. M. Sheridan Smith; New York: Vintage Books, 1994.) The French original was first published in 1963, and although Foucault denied writing the book “against medicine” (p. xix), it provided an historical explanation of the sort of medicine against which complaints were made at the beginning of bioethics.
9 See, for example, Peter E. S. Freund and Meredith B. McGuire, Health, Illness, and the Social Body: A Critical Sociology (Englewood Cliffs, N.J.: Prentice-Hall, 1991. They identify five assumptions in the biomedical model for knowing the human body scientifically: a dualism of mind and body, the reduction of the body to the material, the doctrine of specific etiology (i.e., that each disease is caused by a specific and identifiable agent), the metaphor of the machine, and the assumption that the body is an object subject to rational regimen and control.
10 More than one account of medicine has traced its problematic way of regarding the body to Cartesian dualism. See especially Drew Leder, The Absent Body (Chicago: University of Chicago Press, 1960). Richard Zaner, Ethics and the Clinical Encounter (Englewood Cliffs, N.J.: Prentice-Hall, 1988), also traces the biomedical view of the body to Descartes, but he focuses on Descartes’ medical writings. He finds there not the famous dualism of the Discourse on Method but a dualism between nature, or body, as understood in ordinary experience and nature, or body, as an object understood in science. Moreover, Descartes’ medical advice would seem to suggest that proper treatment of patients may not be reduced to the treatment of objects. See further the thoughtful account of Leder, Zaner, and Foucault in Gerald P. McKenny, To Relieve the Human Condition: Bioethics, Technology, and the Body (Albany: State University of New York Press, 1997), pp. 184-210.
11 The story medicine tells of itself and of its “science” has its own lineage, but the family resemblance to the positivism of August Comte is hard to miss. Comte’s story of “progress” in human knowledge is a triumphalist tale of science. Progress in the quest for human knowledge has proceeded, Comte said, through three stages, and progress requires that each stage leave behind the previous stage as ignorance. The first stage, the most primitive stage, Comte called “theological.” That was superstition, and humanity, at least the enlightened ones, have transcended it, leaving it behind as myth and legend. The second stage Comte named “metaphysical.” It was progress, to be sure, but not yet real knowledge, more like guesswork. And it is left behind as ignorance in the final stage, the “scientific.” Finally human beings truly know, and this knowledge gives them great power to make further progress. The story is a familiar one. See Joel Shuman, The Body of Compassion: Ethics, Medicine, and the Church (Boulder, Colorado: Westview Press, 1999), pp. 11-12.
12 Aristotle’s claim (Poetics 1450a.15-1450b.4) that character development (or ethos) requires a plot (or mythos) is extended here to suggest that human responsibility requires a myth. It is important, of course, to explain the use of the term myth. It is used popularly and pejoratively to refer to a story that is not true, a story that can be refuted by science. Myth may better be regarded as
characterized by the fact that it sees the empirical world and its happening, and above all, man and his action, in the light of the reality that constitutes them, and makes them a unity, and at the same time transcends them.… It is mostly in narrative form, a story which is “sacred word”… as word about true being and the all-sustaining event, not merely in the causal sense, but in the sense that it gave meaning and purpose to all actual being and happenings.(H. Fries, “Myth,” in Encyclopedia of Theology: The Concise Sacramentum Mundi, ed. K. Rahner [New York: Seabury Press, 1975], pp. 1011-1012; cited by Daniel P. Sulmasy, “Every Ethos Implies a Mythos: Faith and Bioethics,” in Notes from a Narrow Ridge: Religion and Bioethics, eds. Dena S. Davis and Laurie Zoloth [Hagerstown, Maryland: University Publishing Group, 1999], p. 230.) Myths help us to map our world and our place in it. They serve to orient us, to locate us, to enable us to interpret and to see the significance of the things and events around us. Without some such map we are lost. Without some such story or drama we do not know what role we are to play.
13 Some narrative context seems inescapable, however, even for science, even for those who would use science to debunk myths. We have already identified Comte’s narrative (see note 9), but consider also the case of Jacques Monod. In Chance and Necessity (trans. Austryn Wainhouse; London and Glasgow: Collins, Fount, 1977) he wants to convince us that nature is “objective,” by which he means that it has no values or purposes, no narrative. Everything in it, he says, is “contingent,” by which he means that all the items in it are unconnected except by “chance,” not by any narrative coherence. Leave aside for a moment that this way of picturing the universe relies on the (once popular) myth of separate and impenetrable atoms. Leave aside the fact that relations are much more interesting and much more complex, even scientifically. Leave aside the fact that order is not an illusion, and if it were (or if the order were not somehow knowable), science could not be undertaken. Monod is interested in contingency and chance as an alternative to a story of God and the purposes of God. To explain things as “by chance” means that God and purpose can be - and must be - excluded from a scientific attitude. But Monod does not escape myth! Instead he adopts the myth of the casino: deep down the world is as it is as a result of a Monte Carlo game (p. 137). This would not be quite as dangerous, perhaps, if science were just about establishing “facts” not about explaining them, as Monod sometimes humbly claims, but he also claims that scientific knowledge provides the only source of value in a world otherwise “chillingly value free.” (The quote is from Mary Midgley, Science as Salvation: A Modern Myth and its Meaning [London and New York: Routledge, 1992], p. 38. Midgley observes, furthermore, that casinos are “not chancy things at all but highly purposive human artifacts, devices to produce a peculiar arrangement that is never normally found in nature -namely a calculated disorder which can baffle prediction” [p. 42]. For Monod’s claims about science as moral guide see Chance and Necessity, pp. 164-165.) Monod may serve as an illustration not only of the fact that myth is inescapable but also of the fact that some myths are better than others. Myths, of course, are frequently unexamined and unquestioned. Indeed, they so order our thought that they seem unquestionable. Still, there are good reasons to question Monod’s myth of the casino. And there are surely good reasons - both reasons of science and reasons of humanity - to doubt the Nazi myth or the Communist account of “dialectical materialism.” Some stories finally will not wash. An alternative story of science might be that it considers how God ordinarily works to order the world, sometimes in wonder, echoing the Creator’s line, “God, that’s good,” and sometimes in service to what we know of the purposes of God.
14 We have already heard one example of scientific reductionism in the neurologist’s remark, “You are your brain.” The current favorite form of reductionism, however, is surely genetic reductionism: “It’s all in the genes.” A moment’s reflection may be sufficient to identify and dismiss this “gene myth” as another form of reductionism. (See Ted Peters, Playing God? Genetic Determinism and Human Freedom [New York: Routledge, 1997], pp. xiii, 5, and Ruth Hubbard and Elijah Wald, Exploding the Gene Myth [Boston: Beacon Press, 1993]). Myths, however, frequently go unexamined, and especially when the myth is that we can do without them.
Consider Walter Gilbert, a Nobel laureate in genetics, who made the plausible prediction that we will each one day have a CD containing a map of our individual genetic code. But he went on to make the foolish suggestion that we could hold up that CD and say, “This is me” (Walter Gilbert, “A Vision of the Grail,” in Daniel Kevles and Leroy Hood, eds., The Code of Codes [Cambridge: Harvard University Press, 199], p. 96). Such a future (along with such rhetoric) we must resist and reject. The human person may not be reduced to her genes. The ability to map and sequence the genes does not give us what Gilbert hoped for, “the ultimate answer to the [ancient] commandment ‘know thyself’” (Jean Bethke Elshtain, Who Are We?: Critical Reflections and Hopeful Possibilities [Grand Rapids: Eerdmans, 2000], p. 90, citing Gilbert). Indeed, not even the body may be reduced to genes; a genotype is not to be confused with a phenotype. (See James F. Keenan, S.J., “Genetic Research and the Elusive Body,” in Lisa Sowle Cahill and Margaret A. Farley, eds., Embodiment, Morality, and Medicine [Dordrecht: Kluwer Academic Publishers, 1995], pp. 59-73, p. 63.) Persons and bodies have histories, not just genetic fates.
Or consider what it is that the Human Genome Project maps. Not the human person. Not the human body. Not even that thing called “the human genome.” There is no such thing as “the human genome.” The Human Genome Project itself reminded us that genes differ from person to person. The aim of the project was to publish the average or ‘consensus’ sequence of 200 different people. But that provides a map neither of everyone nor of anyone. Does “the human genome” have blood group A? or B? or AB? or O? We know where to look on chromosome 9 for a marker for blood type, but if we look carefully, we will not see the blood type of “the human genome.” We will see that “Variation is an inherent and integral part of the human - or indeed any - genome” (Ridley, The Genome, p. 145). It is easy to get the impression that what it really locates are diseases. Open a catalogue on the human genome and you are confronted with a list of diseases. Open a newspaper and you are confronted with a series of headlines: “New gene for mental illness.” “Gene for kidney cancer isolated.” “A new Alzheimer’s gene.” “Yet,” as Matt Ridley says (Ridley, pp. 54-55),
to define genes by the diseases they cause is about as absurd as defining organs of the body by the diseases they get; livers are there to cause cirrhosis, hearts to cause heart attacks and brains to cause strokes. It is a measure, not of our knowledge but of our ignorance that this is the way the genome catalogues read. It is literally true that the only thing we know about some genes is that their malfunction causes a particular disease. This is a pitifully small thing to know about a gene, and a terribly misleading one.Or consider, finally, Francis Crick’s rhetoric when he and James Watson had discovered the structure of DNA, the now familiar “double helix,” in 1953. They celebrated their discovery in a pub near their lab, where Crick announced to those gathered that they had just discovered “the secret of life.” (James D. Watson, The Double Helix [New York: Athenaeum, 1968], p. 126.) That sort of rhetoric is commonplace in pubs, I suppose, but it was to grow commonplace also in the descriptions of the genome. It was the “Bible” for life, the “Book of Man,” “the Holy Grail.” (See Dorothy Nelkin and M. Susan Lindee, The DNA Mystique: The Gene as a Cultural Icon [New York: W.H. Freeman, 1995]).
We should reject genetic reductionism. The gene myth may pretend to wisdom, as if the human genome were the “secret of life” or the “code of codes” or the “map of human life,” but we should reject this way of thinking about and talking about nature and human nature and the genome. It is the way of folly, not wisdom. When we reject scientific reductionism, we do not reject the sciences; and when we reject genetic reductionism, we do not reject the study of genetics. We reject the claim that the map of the human genome is sufficient to locate its own significance. We acknowledge, that is, the necessity of some other map or maps of nature and human nature, some other ways to locate and to orient ourselves with respect to the knowledge and power that the sciences provide, some other myth. There is no great wisdom in rejecting the gene myth, but there is no hope for wisdom unless we do.
15 On the Baconian project see Gerald McKenny, To Relief the Human Condition: Bioethics, Technology and the Body (Albany: State University of New York Press, 1997). Francis Bacon himself, to be sure, intended his “great instauration” to be a form of obedience to God, as a restoration of humanity to the mastery of nature that was given with the creation but lost through the fall. Indeed, he prays “that things human may not interfere with things divine, and that … there may arise in our minds no incredulity or darkness with regard to the divine mysteries” (Francis Bacon, The New Organon and Other Writings, ed. R.H. Anderson [Indianapolis: Bobbs Merrill Co., 1960 (1620), pp. 14-15].) Bacon provided, however, no place on his map of knowledge for the knowledge of such mysteries.
16 McKenny, p. 22.
17 Aquinas, Commentary on Aristotle’s On the Soul 1.3; cited in Hans Jonas, The Phenomenon of Life: Toward a Philosophical Biology (Boston: Beacon Press, 1966), p. 188.
18 Bacon, The New Organon and Other Writings, p. 8.
19 Bacon, The New Organon and Other Writings, p. 15
20 Jonas, The Phenomenon of Life, p. 195
21 The irony, of course, is that science does not tell us what to do with the great power it gives. It does not tell us what ends to seek or what limits to observe. It cannot tell us how to use these great powers without violating the human material upon which they are used. At the end of the story, even as we continue to tell it, we know better. Human progress cannot be reduced to scientific progress. Knowing a patient cannot be reduced to scientific knowing. Indeed, the scientific “view,” if the complaints are to be credited, can distort our vision and blind us to persons and to the body as “me.” Knowledge of that which transcends “use” has no place in Bacon’s account.
22 Bacon, The New Organon and Other Writings,/em>, p. 19
23 Bacon, The New Organon and Other Writings, p. 29
24 Jonas, p. 192.
25 It must be admitted that the Baconian vision of science and medicine was shared and nurtured by Puritan scientists and physicians. See Charles Webster, The Great Instauration: Science, Medicine and Reform, 1626-1660 (New York: Holmes & Meier, 1976), pp. 246-92. The optimistic - indeed millennial - expectations of Bacon and the Puritans turned triumphalist with their success. Bacon’s call for knowledge to be practical, tested by experience and experiment, and apt for the restoration of dominion over nature to human hands and, so, for progress toward human well-being, was heard as a religious vocation by the Puritans, but ironically it led to a different conception of God, a designer God who, having fashioned a world, politely withdrew, leaving the world to the hands of human freedom and reason. The different conception of God led inevitably to a certain indifference to the God so conceived.
26 As the Hippocratic treatise “The Art” put it; in Stanley Reiser, Arthur Dyck, and William Curran, eds., Ethics and Medicine: Historical Perspectives and Contemporary Concerns (Cambridge, Mass.: MIT Press, 1977) p. 6.
27 Indeed, to relieve the suffering of dying patients ancient Greek physicians counted among the tools of their trade poisons and other techniques to produce a painless death; they sometimes killed them. The famous Hippocratic oath, of course, stood against such practice: “I will neither give a deadly drug to anybody if asked for it, nor will I make a suggestion to this effect” (Ludwig Edelstein’s translation, in Charles Burns, ed. Legacies in Ethics and Medicine [New York: Science History Publications, 1977], p. 14). The oath was a minority report, but this effort to reform the practice of medicine was remarkably successful. It shaped the context for - and the conduct and character of - medicine for centuries. Because the goods intrinsic to medicine were to heal the sick, to protect and nurture health, to relieve pain, limits could be imposed on the use of skills within the practice. The skills were not to be used to serve alien ends, and the destruction of human life was regarded as an alien and conflicting end. But while they would not kill, there was not yet any sense of an obligation to prolong the life of those overcome by their illness. On the Hippocratic oath see Nigel M. de S. Cameron, The New Medicine (Wheaton, IL: Crossway Books, 1991); Leon Kass, Toward a More Natural Science: Biology and Human Affairs. (New York: Free Press, 1985), pp. 224-26; and Allen Verhey, “The Doctor’s Oath and a Christian’s Swearing It,” in Stephen Lammers and Allen Verhey, eds. On Moral Medicine: Theological Perspectives in Medical Ethics, second edition (Grand Rapids: Eerdmans, 1998), pp. 108-119.
28 Francis Bacon, De Augmentis Scientiarum: The Philosophical Works of Francis Bacon, ed., J. M. Robertson (New York: Books for Libraries Press, 1970), pp. 487-89.
29 See William F. May’s accounts of the “fighter” and the “technician” in his The Physician’s Covenant: Images of the Healer in Medical Ethics (Philadelphia: Westminster Press, 1983), pp. 63-106.
30 See Eric Cassell’s lament about the inattentiveness of medicine to suffering; Eric J. Cassell, “Recognizing Suffering,” Hastings Center Report 21 (May-June, 1991), 24-31.
31 Blaise Pascal, Pascal’s Pensees, 210 (New York: E.P. Dutton & Co., 1958), p. 61.
32 Peter DeVries, Slouching Towards Kalamazoo (New York: Little, Brown and Company, 1983), p. 23.
33 Karl Barth, Church Dogmatics III/4 (trans., A.T. Mackay, T.H.L. Parker, Harold Knight, Henry A. Kennedy, John Marks; London: T.& T. Clark, 1961), p. 366.
34 See William F. May, “The Sacral Power of Death in Contemporary Experience,” in Stephen E. Lammers and Allen Verhey, eds., On Moral Medicine: Theological Perspectives in Medical Ethics, second edition (Grand Rapids: Eerdmans, 1998), pp. 197-208, especially pp. 181-184; and William F. May, The Patient’s Ordeal (Bloomington: Indiana University Press, 1991), pp. 9-14, 200-206.
35 The Apostles’ Creed, in John Leith, Creeds of the Churches (Third Edition; Atlanta: John Knox Press, 1982), pp. 24-25. Although the Apostles’ Creed was not written by the apostles, it is an ancient confession and the most widely used creed in the western church; its predecessors may be traced to the Interrogatory Creed of Hippolytus (c. 215; Leith, p. 23). The Nicene Creed, which was accepted in Nicea in 325 and revised at Constantinople in 381, ends similarly: “We look forward to the resurrection of the dead and the life of the world to come. Amen” (Leith, p. 33).
36 Arthur Kleinman, The Illness Narratives: Suffering, Healing and the Human Condition (New York: Basic Books, 1988), p. 45.
37 Kleinman, The Illness Narratives, p. 45.
38 Kleinman, p. 45; Elaine Scarry, The Body in Pain: The Making and Unmaking of the World (New York: Oxford University Press, 1985), p. 47; M. Therese Lysaught, “Suffering, Ethics, and the Body of Christ: Anointing as a Strategic Alternative Practice,” Christian Bioethics, Vol. 2, No. 2 (1996), pp. 172 201, p. 177.
39 W.H. Auden, “Surgical Ward,” Selected Poems of W.H. Auden (New York: Random House, Modern Library, 1958), pp. 45 46.
40 Hessel Bouma III, Douglas Diekema, Edward Langerak, Theodore Rottmann, and Allen Verhey, Christian Faith, Health, and Medical Practice (Grand Rapids: Eerdmans, 1989), pp. 123 143.
41 On tragedy see further Hessel Bouma III et al., pp. 123-143.
42 Lysaught, “Suffering, Ethics, and the Body of Christ”, p. 177.
43 Kleinman, The Illness Narratives, p. 44; Bradley Hanson, “School of Suffering,” in Stephen Lammers and Allen Verhey, eds., On Moral Medicine, pp. 249 255; Lysaught, p. 176.
44 Lysaught, “Suffering, Ethics, and the Body of Christ”, pp. 176 177.
45 Auden, “Surgical Ward.”
46 Auden, “Surgical Ward.”
47 This loss of voice is confirmed by the words of a patient (Kleinman, The Illness Narratives, p. 68): “That’s the worst thing about pain. You can’t see it. You can’t know what it’s like unless, God help you, you suffer from it.”
48 Peter DeVries, The Blood of the Lamb (New York: Little, Brown and Company, Popular Library Edition, 1961), p.177.
49 DeVries, The Blood of the Lamb, p. 178.
50 DeVries, The Blood of the Lamb, p. 179.
51 Nicholas Lash, Theology on the Way to Emmaus (London: SCM Press Ltd., 1986), p. 174.
52 The Nicene Creed
53 The Apostles’ Creed
54 Kant divided the world into a phenomenal realm ruled by necessity and investigated by science and a noumenal realm marked by freedom and home to morality and religion. But neither science nor theology should be satisfied with such a division. It invites the Church to withdraw to some other world, some private world where it meets esoteric religious needs and props up morality, and it nurtures Christians of divided minds and compartmentalized lives.
55 The prognosis for our planet is no better than the prognosis for individual lives. Indeed, the scientific prognosis for the universe is also death; the cosmos will come to an end, whether in ice or in fire, whether in a cosmic expansion that freezes or in a cosmic fiery collapse. For a readable account of the scientific predictions of these catastrophes see William R. Stoeger, S.J., “Scientific Accounts of Untimate Catastrophes in Our Life-Bearing Universe,” in John Polkinghorne and Michael Welker, eds., The End of the World and the Ends of God: Science and Theology on Eschatology (Harrisburg, PA: Tinity press International, 2000), pp. 19-28.
56 This is not to deny, of course, that there are scientists who regard the death of individuals as a biomedical problem awaiting a biomedical solution and the death of the planet or of the cosmos as a problem awaiting a technological solution. J. D. Bernal, The World, the Flesh, and the Devil (London: Cape, 1929), first proposed colonizing space in 1929 when science gave its prognosis for the planet. Freeman Dyson, Infinite in All Directions (New York: Harper and Row, 1988), and Frank Tipler, The Physics of Immortality: Modern Cosmology and the Resurrection of the Dead (New York: Doubleday, 1997), envision some disembodied immortal intelligence in the context of an expanding (Dyson) or collapsing (Tipler) universe. I am not qualified to judge the quality of the science in these books. (John Polkinghorne, “Eschatology: Some Questions and Insights from Science” in J. Polkinghorne and Michael Welker, eds., The End of The World and the Ends of God, p. 33, regards these ideas as “excessively speculative.” Polkinghorne also calls these ideas “chillingly reductionistic.” It looks not so much like good science as a rather frantic and desperate attempt to deny death, like the Baconian project run amuck. See further Mary Midgley, Science as Salvation: a Modern Myth and Its Meaning, passim but especially pp. 17-31.
57 Hans Weder, “Hope and Creation,” in J. Polkinghorne and Michael Welker, eds., The End of The World and the Ends of God, p. 193:
The scientific view of finitude is ambivalent: it can serve as an argument for the nothing, as an argument for the annihilation of the finite being beyond its end, but it can serve as well as an argument for creativity, as an argument for the re-creation of the creature beyond its end. This ambivalence is essential for scientific descriptions, unless they have become reductionist. In interpreting the limited being as a creature, theology does not contradict natural science, but rather enriches it by disclosing a deeper dimension of being finite.
58 Don Juel, “Christian Hope and the Denial of Death: Encountering New Testament Eschatology,” in J. Polkinghorne and Michael Welker, eds., The End of The World and the Ends of God, p. 174. See also Christoph Schwobel, “The Church as a Cultural Space: Eschatology and Ecclesiology,” ibid., pp 121-122.
59 The “living being” (Hb. nephesh) was and remained “flesh” (Hb. basar); that is, whole selves were and are “flesh” in their creatureliness, in their contrast to God and in their dependence upon God, in their weakness and mortality. To be sure, the nephesh is basar; but the basar is nephesh, too. The “flesh” is not without God. The flesh, too, is from God. Whole selves - embodied selves, mortal and dependent, creative and powerfully gifted - are “flesh,” and it is good (but not without God).
60 Schwobel, p. 122.
61 See Oscar Cullmann, “Immortality of the Soul or Resurrection of the Dead,” in Krister Stendahl, ed., Immortality and Resurrection (New York: Macmillan Co.,1965), pp. 9 53, esp. pp. 12 20.
62 It was a curious body, to be sure, but it was recognizable as Jesus’ body - as the body of the one who preached and healed and suffered. His wounds were raised with him. It was no mere “spirit” (Luke 24:40); this embodied person was identifiable - had an identity - in ways no mere “spirit” could. “It is I myself,” he said (Luke 24:40), “handle me, and see.”
63 I tried to follow these cues in Remembering Jesus.
64 Matthew adopts Mark’s chapter about watchfulness (cf. Mark 13:1-37 and Matthew 25:1-44), but he adds to it a collection of parables about watchfulness (Matthew 25:45-26:46), a collection which climaxes in the parable of the last judgment (26:31-46).
65 Eric J. Cassell, “Recognizing Suffering,” Hastings Center Report, Vol. 21, No. 3 (May June, 1991), pp. 24-31.
66 William F. May, The Physician’s Covenant: Images of the Healer in Medical Ethics (Philadelphia: Westminster Press, 1983), p. 60.
67 Warren Reich, “Speaking of Suffering: A Moral Account of Compassion,” Soundings, Vol. 72, No. 1 (Spring, 1989), pp. 83-108, pp. 93-97; Margaret E. Mohrmann, Medicine as Ministry. Reflections on Suffering, Ethics, and Hope (Cleveland: Pilgrim Press,1995), pp. 75-88.
68 Stanley Hauerwas, Suffering Presence: Theological Reflections on Medicine, the Mentally Handicapped, and the Church (Notre Dame: University of Notre Dame Press, 1986), pp. 63-83.
69 Walter Rauschenbusch, “For Doctors and Nurses” (1909), in Stephen E. Lammers and Allen Verhey, eds., On Moral Medicine, p. 5.
