The subject swept farthest under the rugs by Americans whose culture tells them that, in the end, they can overcome any obstacle, is death. Endless cartoons in the New Yorker show the Grim Reaper, forced to show up personally to “capture” the unwilling victim.
The medical establishment, whose burden and responsibility it often is to shepherd a patient toward an inevitable end, is often caught in the middle. Patients may know the truth, but maintain a posture of silence, as family members plead with doctors to get their loved ones well. And yet, even as they go through the motions, family members know that the end is near. But no one will say the word.
This American reality can put doctors in a difficult quandary, pushed to use technology to sustain life while at the same time being painfully aware that patients and families are not dealing with the reality of approaching death. According to Stanley Hauerwas, an often controversial theologian and professor of ethics at Duke Divinity School who has a joint appointment at the Duke University School of Law, the doctors’ predicament is that they are “practicing medicine in a morally anonymous context,” so they often get caught in the middle.
Hauerwas speaks on “Why the Avoidance of Death Dominates Our Healthcare System” on Wednesday, May 2, at 6:30 p.m. in the Cooper Conference Room in Erdman Hall at the Princeton Theological Seminary. Free, but prior registration is strongly encouraged. Call 609-921-8300.
From Hauerwas’s perspective, the unstated mandate to avoid the merest mention of death, and certainly its reality, forces choices that are perhaps unwise on the medical establishment.
“I think America is a culture that has a deep denial of death as a reality,” he says, “and that is exemplified in the practice of modern medicine in which we expect physicians to help us get out of life alive.” As a result, he continues, “we become subject to any technologies that promise us not to have to deal with death.”
Hauerwas says that when he asks lay people how they want to die, they usually respond, “‘quickly, painlessly, nicely — without being a burden.’” He adds that most people, near the end of their lives, “don’t trust their children.” He doesn’t pause to offer amplification during a brief interview, but perhaps he is suggesting that they know deep down that family members will not know how to deal with a more prolonged death.
Another result of Americans’ denial of death as an option, and one that affects doctors, is that patients and families “ask physicians to keep them alive until they don’t know they are dying.” Then Hauerwas adds, again somewhat cryptically, “so the family can blame the physicians.” Here his meaning is somewhat clearer — family and patients collude in the pretense that death will not happen, so that when it happens, the doctors are to blame.
Having stated the reality in starkest terms, Hauerwas poses the theological issues. “One of the difficulties of what it means to practice medicine in our society is: how do you practice medicine in a morally fragmented culture where we aren’t in agreement on what constitutes a good death? Then the only thing we share is the presumption that death is a bad thing, so we have to keep one another alive as much as possible.”
In our culture, he says, we are faced with situations we don’t have the vocabulary to handle. How do we talk about someone, near the end of life, who has pneumonia, but who does not want to take antibiotics? It is not something that family — or healthcare professionals — feel comfortable discussing.
Hauerwas received his doctorate from Yale University and a doctor of divinity degree from the University of Edinburgh. He has also taught at the University of Notre Dame.
His work draws from diverse disciplines, including systematic theology, philosophical theology and ethics, political theory, and the philosophy of social science and medical ethics. Hauerwas has been an outspoken Christian pacifist and has promoted nonviolence, and he has also been an opponent of nationalism, particularly American patriotism, arguing that it has no place in the church.
Hauerwas suggests two approaches that can help us all to better prepare for death. The first is to “know what a well-lived life looks like.” For this he urges people to turn to the resources in their own religion for the language to consider these matters, both the reality of death and what it means to die “in a manner in which we will be well remembered, that narrates our life for the upbuilding of that community.”
But perhaps more important is to talk about death before it happens. But sadly, he adds, “most people are not able to do that, because they don’t know what language they would have for doing so.