What is Death Exactly? And What’s It Like?
“A User’s Guide to Death and Dying” — Part 1 of 2
It’s still October, Respect Life month, and so we’re naturally focused on the gift of life. But it’s also the threshold of November, the month of All Souls, prayers for the dead, and the liturgy getting all dark and apocalyptic – an annual reminder that the world will end and that each of us faces his own mortal end as well.
But we Catholics hear about death all the time. It’s right there in our liturgy, our creed, and even our routine devotional prayer – like the Hail Mary: “…now and at the hour of our death.” It even came up pretty early in our catechetical formation when we learned about the Four Last Things: judgment, heaven or hell, but first death – for everyone, regardless of where we end up for eternity. Death is the great leveler, the one thing that all of us, unquestionably and without exception, have in common.
And yet we still studiously avoid thinking about our mortality – an attitude on display in Roz Chast’s book about her parents’ final years, Can’t We Talk About Something More Pleasant? Death is so dark and mysterious – the great unknown. “It is in regard to death that man's condition is most shrouded in doubt,” reads the Catechism (§1006). But we’re Christians, and so we know the end of the story. “I came that they may have life, and have it abundantly,” Jesus tells us. It’s an assurance that leads St. Paul, quoting a pagan poet, to boast, “O death where is thy victory? O death, where is thy sting?” Following Paul’s example, we too can laugh at death, make fun of it, because it is beaten – we’ve already won! Indeed, according to Ven. Solanus Casey, it can even be a celebration. He wrote that death “can be very beautiful – like a wedding – if we make it so.”
So, how do we make it so?
What is it?
First things first: What is death exactly? It depends on whom you ask. Medically, we think of death as the end of physical life. Traditionally, it was defined by common sense observations: We know that we need air to breathe and blood to circulate to live, so people naturally interpreted a lack of breath and a lack of a heart beat as signs that life has ended – or what one standard medical reference defines as “the permanent cessation of all vital functions” (Taber). In simple terms, it’s the absence vital signs – no heart beat or blood pressure, and no spontaneous breathing, which means that body tissues can’t get the oxygen required for cellular function.
Since the 1960s, we’ve also come to accept lack of brain function as a sign of death, even when the heart continues beating and the lungs continue processing oxygen delivered through artificial ventilation. It’s still controversial and hotly debated, especially with reference to vital organ transplantation that brain death makes possible, but it’s a definition largely accepted in clinical practice.
What the two medical definitions of death have in common is an assumption that death is somehow natural, that it’s somehow “a part of life,” but it only seems that way and we know better. “Even though man's nature is mortal, God had destined him not to die” (CCC 1008). Thus, the Church’s definition of death makes it plain that it’s not natural at all. It’s a “departure” when the “soul is separated from the body” (CCC 1005). In fact, it’s a punishment, and it’s what God warned our first parents would result from their disobedience and sin—original sin, that is.
They chose sin anyway, resulting in the Fall, and since we’re all sons of Adam and daughters of Eve (as they’d say in C.S. Lewis’s Narnia), we all inherit that same condition and its ultimate consequence.
Consequently, death is truly a foe, having entered the world in the first place due to man’s disobedience, but also our ongoing disobedience. “Bodily death, from which man would have been immune had he not sinned” is “the last enemy” of man left to be conquered (CCC 1008).
What’s it like?
So, what do we know about this enemy? Medically speaking, it’s manageable failure under the best circumstances. Regardless of what precipitates the dying process – trauma, disease, or just things wearing out – the body systems shut down one by one. It’s a domino effect that culminates in heart and respiratory collapse, and since it’s ultimately unstoppable, we care for those in the last stages of life by focusing on managing symptoms – optimizing comfort, that is, instead of seeking a cure.
Physical comfort takes precedence here, particularly aggressive pain control, but we’re also attentive to breathing, the skin, digestion and elimination, and other body systems. At the same time, we also strive to meet the dying individual’s psychosocial needs, addressing their fears and anxieties, helping them make satisfying final connections with loved ones, and generally fostering what we call a “good death” – that is, a comfortable leave-taking that includes making peace with God and man.
For Christians, that final peacemaking with God points to a more theologically nuanced understanding of the dying process, for we are confident that “Jesus has transformed the curse of death into a blessing” (CCC 1009). In fact, the baptized have already experienced a sacramental death, and our physical death ought to be its ratification. “If we die in Christ's grace, physical death completes this ‘dying with Christ’ and so completes our incorporation into him in his redeeming act” (CCC 1010). This is so much the case that we shouldn’t be surprised when we read of the saints (or hear our dying loved ones) express a yearning for physical death. “[T]he Christian can experience a desire for death like St. Paul's: ‘My desire is to depart and be with Christ’” (CCC 1011).
What can we do about it?
Here’s the nub: We know we’re going to die, so what’s to be done about it? Let’s consider this question from three different angles – that is, what we can’t do, what we must do, and what we ought to do.
What we can’t do
The Church provides us with all kinds of specific guidelines in this regard, but the bottom line is this: First, do no harm – the axiomatic healthcare principle of primum non nocere. It’s a principle that accords with the Fifth Commandment: Thou shalt not kill – thou shalt not murder, that is, thou shalt not intend another’s death. That seems pretty straightforward, but as we all know our culture in general, and our healthcare culture in particular, has lost sight of this – or has at least twisted and obscured it to the point that it has little meaning any more.
The most obvious example is the broader healthcare industry’s insistence on framing elective abortion as a “medical intervention” – a preposterous notion. Equally preposterous is attempting to frame intentional killing at the end of life as medical treatment. No appeal to “mercy” or “futile care” can disguise an intentional, willful act directed toward hastening the dying process as legitimate medicine. This includes physician assisted suicide, for we are “stewards, not owners, of the life God has entrusted to us,” the Catechism teaches us. “It is not ours to dispose of” (CCC 2280), and we cannot cooperate with anyone’s designs along those lines.
Neither can we practice “euthanasia” (ERD 60) – a funny word that literally means “good death.” On the one hand, we do want to foster good deaths for those we care for, but euthanasia, in practice, is never truly a good death because it is always homicide, and therefore absolutely contrary to the Fifth Commandment.
We tend to think of euthanasia as any medical intervention that directly leads to death – usually an injection of some kind, generally some kind of overdose. These are acts of commission, or examples of what we call active euthanasia, but euthanasia can be practiced by omission as well – that is, by willfully leaving off doing something that should be done. The withholding of what is considered ordinary care and the ordinary means of preserving life, with the intent of bringing about death, would be considered an passive euthanasia.
Active euthanasia is still outlawed in this country, but passive euthanasia happens all the time, although it is not often identified as such. The reason for this is that the healthcare industry has re-defined any kind of assisted eating and drinking as medical intervention, and thus something that can be discontinued by a physician once it is determined to be superfluous.
However, providing food and water, no matter how delivered, should always be seen as part of ordinary care for those at the end of life. It’s a default requirement, even for those who require tube feedings, as long as the gastrointestinal tract is functional (ERD 58). Starvation and dehydration should never be the cause of anyone’s death.
Here the ethical principle of proportionality comes into play. If someone’s GI system can no longer absorb food and fluids, especially when their continued provision becomes excessively burdensome to the individual, then they may be legitimate reason to withhold them – especially in the final hours and days of a terminal illness. The benefit of continuing such feedings, in other words, could be viewed as no longer providing proportionate benefit since they can’t accomplish what they’re intended to do – namely, the nourishing of the person.
In most cases, however, assisted nutrition and hydration, including tube feedings, are pretty low-maintenance and not excessively burdensome. It’s simply using readily available medical technology to deliver essential food and fluids to someone who can’t get it otherwise – like when we feed a toddler and help him to take a drink. Even a baby bottle is technological and “assisted,” in a sense, and we’d never consider withholding that.
To be continued…