Mortality and the Limits of Medicine

Why is the experiment of turning dying into a medical experience failing?
Appears in Fall 2015 Issue: Health Beyond The Hospital
September 1st, 2015
Being Mortalby Atul Gawande. Metropolitan Books, 2014. 304pp.


"Nothing is certain but death and taxes." Of course, that aphorism is only half true. Taxes can be evaded. But no amount of research, technology, and energy can bring under human control what we all must eventually face: death.

Three years ago, when I was thirty-nine, I was diagnosed with a terminal disease, and the reality of my mortality became more than an abstraction. Terminal. The word itself can hardly be spoken in our age of medical optimism. We expect a "medical miracle." Advances in medical technology and science have made us adept at denying our own mortality. We fool ourselves into thinking that our lives have no terminus. But we do have a terminus. The psalmist testifies to this fundamental reality, contrasting the everlasting Creator and his creatures.

Before the mountains were born
or you brought forth the whole world,
from everlasting to everlasting you are God. (Ps. 90:2)

Yet for human beings

Our days may come to seventy years,
or eighty, if our strength endures;
yet the best of them are but trouble and sorrow,
for they quickly pass, and we fly away. (Ps. 90:10)

Yet it's not only our age that struggles to live within the limits of creaturely life. In the sixteenth century, John Calvin commented on this very Psalm, saying that humans show their "great stupidity" when "bound fast to the present state of existence, [they] proceed in the affairs of life as if they were to live two thousand years." Death comes upon us unexpectedly— all too quickly—confounding our presumptuous expectations. "Before we discover that we are living, we have ceased to live," Luther says. Before "miracle drugs" and respirators, Calvin and Luther observed the denial of death, and they diagnosed it as idolatry— living as if we were God, from everlasting to everlasting, rather than as creature.

In our age, this self-deceptive tendency to obscure our mortality has been deepened and widened by a new cultural liturgy of death in which medical power and mythology have changed the way we die. Atul Gawande, a Harvard surgeon and a gifted writer, gives a compelling portrait of this change in Being Mortal: Medicine and What Matters in the End, a book that is in part a sociological portrait, but also a meditation on the gifts and profound limits of medicine.

There have been extraordinary advances in medicine in the last century. And yet mortality remains incurable. But that hasn't stopped us from trying to pretend otherwise. Sociologically, the trends for developed countries are quite clear: "As recently as 1945, most deaths occurred in the home. By the 1980s, just 17 percent did," Gawande points out. When death took place in the home, the dying were among family and their religious community. Now most deaths occur in institutions. There is a tremendous loss in this transition. Children do not observe the dying as persons living among them. The elderly enter institutions that are developed to meet not so much their own desires as much as those of their adult children ("keep them safe!"). "Our elderly are left with a controlled and supervised institutional existence, a medically designed answer to unfixable problems, a life designed to be safe but empty of anything they care about."

Many patients and some doctors act as if even preparing for death is an unforgiveable surrender, an unpardonable heresy.

Even more powerful than his sociological account, however, are the terrible consequences of failing to recognize the limits of medicine. Medicine is a valuable servant, but a tyrannical master. In his training as a surgeon, Gawande was taught to fix problems. But aging and mortality cannot be "fixed." "For a clinician, there is nothing more threatening to who you think you are than a patient with a problem you cannot solve." Rather than admit their defeat, however, many doctors— and even more patients—insist on trying every medical treatment imaginable to deny the inevitable. As a result the process of dying turns into a medical experience. "This experiment of making mortality a medical experience is just decades old. It is young. And the evidence is that it is failing."

Why is the experiment of turning dying into a medical experience failing? When medicine becomes the heroic master over human life rather than its servant, it crowds out the space otherwise filled by family and faith communities. Gawande contrasts our current practice of dying in institutions with the practices in India as his grandfather faced death. His grandfather displayed the characteristic Indian pattern of dying: he lived with his extended family as an elder—seen as a source of wisdom to the young—and as he gradually lost his bodily functions, the family stepped in and helped. Dying was a process observed by the whole family, who answered the call to be caretakers. In contrast, in the modern West today, usually "death comes only after long medical struggle with an ultimately unstoppable condition—advanced cancer, dementia," and so on. Rather than dying with the living in the home and sharing last words of wisdom and confession, most today die in a sterile hospital with highly trained strangers, "fighting" to delay the inevitable. With terminal illnesses today, "death is certain, but the timing isn't. So everyone struggles with this uncertainty— with how, and when, to accept that the battle is lost. As for last words, they hardly seem to exist anymore. Technology can sustain our organs until we are well past the point of awareness and coherence."

Gawande notes that this way of dying contrasts not only with his grandfather's context in India but with historic rituals that thrived in the West as well. "Dying used to be accompanied by a prescribed set of customs. Guides to ars moriendi, the art of dying, were extraordinarily popular." These guides "provided families with prayers and questions for the dying in order to put them in the right frame of mind during their final hours. Last words came to hold a particular place of relevance."

Make no mistake: the cultural liturgy has changed. As our master, medicine feeds our attempt to cling to life as if limits to our life are artificial or unreal. We've replaced final words with family members agonizing over when to shut off the ventilator. We've replaced the known pastor with the unknown ICU doctor. Rather than admitting that before God our life is "like a breath" and our "days are like a fleeting shadow" (Ps. 144:4) and thus putting our final hope in joining Christ in resurrection, we keep hoping for a quick medical "fix" around the corner. Many patients and some doctors act as if even preparing for death is an unforgiveable surrender, an unpardonable heresy.

Neither Gawande nor I are fundamentally critics of modern medicine. As I write this, I'm approaching the third-year anniversary of my diagnosis with an incurable cancer. Without the therapies developed over the last two decades, I would probably be dead now.

A few decades ago, the median lifespan for this disease was two to three years. It is now five to seven years. I am profoundly grateful for doctors, nurses, chaplains, and medical researchers. Indeed, I agree with Calvin that those who reject medicine reject the means through which God himself "provides us with the capacity to attend to our illnesses."

Yet we live in an age when good things have been turned into ultimate things, turned into idols. For those who make "medical optimism" their ultimate hope, dying does not follow the liturgy of ordering their life before God and others, passing on wisdom, confessing their sins, and putting their ultimate hope in Christ and his resurrection promise. Our new liturgy of death involves syncing to the disorder of desperate treatments, focusing our desires on the salvation of "a few more weeks" rather than the true Savior and Lord. While Gawande is not a Christian or a theologian, he reveals this new liturgy for what it is—hope in false promises. His analysis shows us how for many today, Christians included, "medical optimism" has become confused with true hope.

"I still hope in God," a family member of a cancer patient told me. "He's been getting so much bad news—the cancer is getting worse and worse. But I still hope in God, that God can turn it around." I have heard this sentiment from many Christians and their families struggling with terminal illness. For some, talk of dying and death is seen as a lack of faith. "Pray for a miracle—God can do it!"

Yes, the Almighty, who made our bodies, is free to heal them as he pleases.

But at what point do these sentiments reflect faith in God, and at what point do they collude with the cultural forces of death-denial? Billboards and cancer-center ads valorize the "fighter," those who never give up the "fight" with the disease, implying that those who prepare for death are weak.We've forgotten that talk of doctors "saving a life" is a euphemism: all that they can do is extend a life. Indeed, even when God heals in this life, it is life-extending, not "life-saving"—a foretaste of the final saving work that only the Creator can do. Healing in this life should never be the Christian's ultimate hope. The Heidelberg Catechism states this well in its exposition of the phrase "life everlasting" in the Apostles' Creed: "Even as I already now experience in my heart the beginning of eternal joy, so after this life I will have perfect blessedness such as no eye has seen, no ear has heard, no human heart has ever imagined: a blessedness in which to praise God eternally." Eternal life has begun now, by the Spirit. Because of Jesus Christ, death does not have the final word—and the joy of the present will be consummated in a great blessedness in praising the central actor in the story, the Triune God.

Mortals should rejoice in the gifts of medicine. And in our death-denying cultural moment, Christians in particular have a refreshing yet paradoxical word of witness to our fellow mortals: We need not deny our creaturely limits and bodily terminus. We can and should talk about these limits, and our dying, with openness. Why? For Christians, we do this because our messy, creaturely bodies are good—and also because death does not have the final word in Christ. We live and die in hope that our crucified and risen King, Jesus Christ, has the final word. Our call is to attend to the bodies and souls of the dying, knowing that our lives are short and brief, yet we belong to the God of new life, who is everlasting. As we walk with others who are dying—and as we ourselves die—we can express the countercultural freedom that we need not serve medicine as a master to try to "fix" unsolvable problems. Instead, in hope, in lament, and in joy, we trust that belonging to Jesus Christ, the true Lord, is enough. For the Christian's hope, as the Heidelberg Catechism puts its, is "that I am not my own, but belong—body and soul, in life and in death—to my faithful Savior Jesus Christ."

 

J. Todd Billings is Gordon H. Girod Research Professor of Reformed Theology at Western Theoligical Seminary in Holland, Michigan. Billings is also an ordained minister in the Reformed Church in America.

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