Thereupon he advanced even as far as death itself.
—Irenaeus
Abstract
Developing the ethics of palliative sedation, particularly in contrast to terminal sedation, requires consideration of the relation between body and soul and of the nature of death and dying. Christianly considered, it also requires attention to the human vocation to immortality and hence to the relation between medicine (as aid for the body) and discipline (as aid to the soul). Leaning on Augustine’s rendering of the latter, this paper provides a larger anthropological and soteriological frame of reference for the ethics of palliative sedation, organized by way of nine briefly expounded theses. It argues that palliative sedation, like other elements of medicine, is appropriate where, and only where, it properly orders care for the body to the requirements of care for the soul.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
Notes
Cf. Cur Deus homo, 2.2–4, in [3].
This work, with an introduction, can be found at https://thainsbook.wordpress.com.
To make good on this point for today’s man or woman of science, steeped in evolutionary thinking, I would have to talk at some length about the Christian understanding of human origins and show where that understanding does and does not embrace evolutionary thinking; but I will not attempt such a discussion here.
As William Carroll puts it: “Each natural substance has an actualizing principle that makes it be the substance that it is. Such a principle, known in the Aristotelian tradition as a form, is the source of the actuality and unity of what exists” [5]. Viewed thus, the human soul is the life-giving form of the body, not an independent substance that may or may not be encumbered by a body.
One might turn for help with all of this to Saint Irenaeus, who is brilliant on the subject of limits and the overcoming of limits, including death. See further my Ascension Theology [6, p. 130f.].
Kass’s comment could be redeemed if it were made to refer only to the present life, as per Irenaeus at Haer. 5.36.1, or Tolkien’s Athrabeth—which is to say: our present life is not the proper measure of what it is to be human.
Essa ha dato senso e valore alle sofferenze, alla malattia, al dolore [11].
I mean, of course, in his manner of life and death, as well as in what he wrote and said on the subject. Weigel [9, p. 188], reports the following remark made to him by the Cardinal: “Do you realize that we are going to spend the rest of our lives trying to convince people that suffering and death are good for you?”
Cf. De civitate Dei 19.14.
Following Romans 13:10, while expounding (see Mor. Ecc. 13ff.) the remarks of Jesus in Matthew 22:37ff.
When I say “more broadly,” I mean that works of charity (such as giving to the poor) qualify for Augustine as “medicine.” But he is also using the term more narrowly, since he does not apply it to healing of the mind, as does, for example, the American Heritage Dictionary, which defines medicine as “the science of diagnosing, treating, or preventing disease and other damage to the body or mind” [14]. In the present frame of reference, that would be both medicine and discipline.
Oliver and Joan O’Donovan [15] have reordered the text for rhetorical purposes, placing at the head of this passage the definition of peace as tranquilitas ordinis.
Augustine does not directly consider the situation under discussion, but remarks rather on that in which some peace “still subsists to the extent that their suffering is not all-engulfing, and their bodily constitution is not torn apart by it” (in qua nec dolor urit nec compago ipsa dissoluitur, Civ. Dei 19.13). Even in the situation being considered, however, so long as the soul struggles to preserve and quicken the body, there is still a residual form of peace inasmuch as this very struggle and the intense pain it entails witness to the unity of body and soul (Civ. Dei 19.12).
As Augustine says: “If we were irrational animals, we would seek nothing but the ordered functioning of our bodily organs and the satisfaction of our appetites … [but] ‘ordered coherence of thought and action’ is how we described the peace of the rational soul. The purpose, then, for which we humans avoid the attacks of pain, the agitations of passion, and the dissolution of death, should be to acquire useful knowledge and shape our lives and habits accordingly” (Civ. Dei 19.14, in [15, p. 157]).
The same would be the case should the brain, as the locus of rational thought, have deteriorated to the point that it is no fit instrument to the soul, though still capable of registering pain.
The morality of an act depends upon its immediate object (which determines its nature), but also on the accompanying intentions, circumstances, and foreseeable consequences. The principle of double effect distinguishes consequences foreseen and intended from consequences foreseen but unintended. It acknowledges that a good act may, under certain circumstances, remain good, even though bad consequences are among those foreseen but unintended. See further John Paul II, Veritatis splendor [17, §71ff.].
This must be without demands for so-called effective referral, which—lobbyists in the legislatures and uncomprehending judges on the bench notwithstanding—already infringe on the conscience rights of physicians, as in, e.g., Christian Medical and Dental Society of Canada v. College of Physicians and Surgeons of Ontario, 2018 ONSC 579.
I am not saying that the patient who is unwilling to share in Christian discipline should have it forced upon him—how could it be? I am saying that neither the patient, nor the state or professional association on behalf of the patient, can justly attempt to force upon the caregiver a course of action the latter regards as unethical. Nor, indeed, when unjust force is applied, can the latter justly capitulate. No doubt there is a price to be paid for refusing to capitulate, but it must be borne in mind that violations of conscience cannot be coerced. They remain free—and wrong—choices (see Anselm, De libertate arbitrii, 5ff. [18]).
Cf. Augustine, Civ. Dei 1.17–27 and 19.4, in [19].
The “and” here is crucial. Many today are questioning or defending patient autonomy without adequate attention to the complexities of the matter, while courts and legislatures are deploying the concept to override the rights of caregivers. Very briefly on the complexities, see, e.g., [20].
See Michael Banner’s important essay, “Christian anthropology at the beginning and end of life” [21].
See further Chapter 7 in my Theological Negotiations: Proposals in Soteriology and Anthropology [22].
See further [23].
If drugs are permissible, then in principle so are other methods of depriving someone of consciousness.
I do not think Gilbert Meilaender right, then, to draw the line between CDS with nutrition and hydration and CDS without nutrition and hydration, as if the former were morally acceptable—unless and until it is clear, medically speaking, that the patient has already passed beyond any meaningful consideration of the priority of discipline over medicine. See the section “Harder Cases” in his contribution to the present volume [25].
Cf. Luke 22:39–46.
See again Augustine, Civ. Dei 19.4.
References
Weigel, George. 2016. Catholicism’s empty quarter. First Things, September 7. http://www.firstthings.com/web-exclusives/2016/09/catholicisms-empty-quarter.
Anselm of Canterbury. 1998. Monologion. In Anselm of Canterbury: The major works, ed. Brian Davies and G.R. Evans, 5–81. New York: Oxford University Press.
Anselm of Canterbury. 1998. Why God became man. In Anselm of Canterbury: The major works, ed. Brian Davies and G.R. Evans, 260–356. New York: Oxford University Press.
Tolkien, J.R.R. 1993. Athrabeth Finrod ah Andreth. In Morgoth’s ring, ed. Christopher Tolkien, 303–366. Boston: Houghton Mifflin.
Carroll, William. 2015. Souls matter. Public Discourse, March 11. http://www.thepublicdiscourse.com/2015/03/14534.
Farrow, Douglas. 2011. Ascension theology. London: T&T Clark.
Kass, Leon R. 2001. L’Chaim and its limits: Why not immortality? First Things 113: 17–24.
John Paul II. 1995. Evangelium vitae, Encyclical letter, March 25. Vatican City: Libreria Editrice Vaticana. http://w2.vatican.va/content/john-paul-ii/en/encyclicals/documents/hf_jp-ii_enc_25031995_evangelium-vitae.html.
Weigel, George. 2015. Letters to a young Catholic. New York: Basic Books.
Augustine of Hippo. 1872. Of the morals of the Catholic church. Trans. Richard Stothert. In The works of Aurelius Augustine, Vol. 5: Writings in connection with the Manichaean heresy, ed. Marcus Dods, 7–50. Edinburgh: T&T Clark.
John Paul II. 1993. Cerimonia di congedo, Lithuania, September 8. https://w2.vatican.va/content/john-paul-ii/it/speeches/1993/september/documents/hf_jp-ii_spe_19930908_congedo-lituania.html.
Tertullian. 1903. On the resurrection of the flesh. Trans. Peter Holmes. In The Ante-Nicene fathers: The writings of the fathers down to A.D. 325, Vol. 3; Latin Christianity: Its founder Tertullian, ed. Alexander Roberts and James Donaldson, 545–595. New York: Charles Scribner.
Farrow, Douglas. 2007. Resurrection and immortality. In Oxford handbook of systematic theology, ed. John Webster, Kathryn Tanner, and Iain Torrance, 212–235. New York: Oxford University Press.
Medicine. 1994. In American heritage dictionary of the English language, 3rd ed, ed. Anne H. Soukhanov. Boston: Houghton Mifflin.
O’Donovan, Oliver, and Joan Lockwood O’Donovan (eds.). 1999. From Irenaeus to Grotius: A sourcebook in Christian political thought. Grand Rapids: Eerdmans.
Lee, Gregory W. 2011. Republics and their loves: Rereading City of God 19. Modern Theology 27: 553–581.
John Paul II. 1993. Veritatis splendor, Encyclical letter, June 8. http://w2.vatican.va/content/john-paul-ii/en/encyclicals/documents/hf_jp-ii_enc_06081993_veritatis-splendor.html.
Anselm of Canterbury. 1998. On free will. In Anselm of Canterbury: The major works, ed. Brian Davies and G.R. Evans, 175–192. New York: Oxford University Press.
Augustine of Hippo. 1881. The works of Aurelius Augustine, Vol. 2: The city of God, ed. Marcus Dods. Edinburgh: T&T Clark.
Baumgarten, Elias. 1999. The concept of patient autonomy. Medical Updates 2: 1–6.
Banner, Michael. 1999. Christian anthropology at the beginning and end of life. In Christian ethics and contemporary moral problems, 47–85. Cambridge: Cambridge University Press.
Farrow, Douglas. 2018. Theological negotiations: Proposals in soteriology and anthropology. Grand Rapids: Baker.
Farrow, Douglas. 2015. Desiring a better country: Forays in political theology. Montreal: McGill-Queen’s University Press.
Farrow, Douglas. 2016. The acid of autonomy. Convivium, June 1, 13–18. https://convivium.ca/articles/the-acid-of-autonomy.
Meilaender, Gilbert. 2018. Comforting when we cannot heal: The ethics of palliative sedation. Theoretical Medicine and Bioethics. https://doi.org/10.1007/s11017-018-9445-0.
Irenaeus. 1905. Against heresies. Trans. Marcus Dods. In The Ante-Nicene fathers: The writings of the Fathers down to A.D. 325, Vol. 1; The apostolic fathers with Justin Martyr and Irenaeus, ed. Alexander Roberts and James Donaldson, 309–567. New York: Charles Scribner.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Farrow, D. Reckoning with the last enemy. Theor Med Bioeth 39, 181–195 (2018). https://doi.org/10.1007/s11017-018-9437-0
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11017-018-9437-0