What matters in the end

OPINION | Michael Jensen
Eternity #67 March 2016

Through a friend, I had been put in contact with David, who lives in my parish, and who has terminal cancer.

I went to visit him. He was pale, but not yet in an advanced state of illness. As we sat drinking a cup of tea and gazing out towards the heads of Sydney Harbour on a clear sunny day, he turned to me and said, “Well, don’t worry: we are all in the queue.”

Dying seems to make people wise. I was struck at that moment that this man was not in a different category to me, as if somehow the dying and the living are made of different stuff.

To come face to face with his mortality was to come face to face with my own inevitable terminus. I am dying no less than he is.

Quite the opposite. To come face to face with his mortality was to come face to face with my own inevitable terminus. I am dying no less than he is. He just has more information about when it will be, and what it will be like.

And yet, we have an extremely uneasy relationship with our mortality and with the mortality of others – more so than other cultures, and more so than our own culture in times gone by. I have been reading a truly excellent book by Atul Gawande, called Being Mortal: Illness, Medicine, and What Matters in the End. Gawande is a surgeon, and also a son. In both of these roles he has been brought face to face with the end of life, and the tragic decisions we are compelled to make as our health is taken from us, either by disease or by old age.

Our medical technology, Gawande notes, has given us a much greater life expectancy, and also an optimism that medical intervention will work, if not to cure disease outright, then at least to prolong life.

But the lack of an open discussion about what life is actually about has, according to Gawande, meant that the purpose of intervening to keep someone alive is often unclear. At the end of life, people are often confronted by a multitude of medical issues, and doctors wrestle with the tricky balance of figuring out whether their remedies will cause more harm and pain than they will prevent. Patients are given choices that they cannot fathom – in Gawande’s account, more often than not, false hope is offered by doctors who (who can blame them?) don’t want to deliver the worst possible news to a patient. As Gawande writes:

“Being mortal is about the struggle to cope with the constraints of our biology, with the limits set by genes and cells and flesh and bone. Medical science has given us remarkable power to push against these limits, and the potential value of this power was a central reason I became a doctor. But again and again, I have seen the damage we in medicine do when we fail to acknowledge that such power is finite, and always will be.”

As a culture we need to help each other to practise the art of dying well.

He later writes:

“Over and over, we in medicine inflict deep gouges at the end of people’s lives, and then stand oblivious to the harm done.”

So what to do, then? Gawande offers the fascinating observation that we have a “remembering self” and an “experiencing self”. Our brains help us to evaluate our experiences not simply by calculating an average of pain and pleasure over time. We tend to remember when pain was at its worst, and then the pain we last experienced. It doesn’t matter how long pain lasted for: it is the end experience that counts. Gawande reminds us of what it is like to watch a football match in which your team leads until the final whistle, when it suddenly loses. You may have enjoyed the whole experience at the time, but your evaluation of the experience overall will be very negative.

Where are we going with this? Gawande writes: “People don’t view their life as merely the average of all of its moments – which, after all, is mostly nothing much plus some sleep. For human beings, life is meaningful because it is a story. A story has a sense of a whole, and its arc is determined by the significant moments, the ones where something happens …”

How does this observation affect our decision-making as we approach death, or how might it help us?

“When our time is limited and we are uncertain about how best to serve our priorities, we are forced to deal with the fact that both the experiencing self and the remembering self matter. We do not want to endure long pain and short pleasure. Yet certain pleasures can make enduring suffering worthwhile. The peaks are important, and so is the ending.”

What this means is that patients will often accept very risky medical procedures if the faint hope of enjoying one of their life’s great pleasures is offered out to them. And yet, the surgery or chemotherapy administered will take away whatever moments of pleasure and happiness they have left to them.

Gawande argues, very powerfully, that as a culture we need to help each other to practise the art of dying well. This may not mean “pain free”, though pain alleviation will be part of it. But in particular, it means dying, as much as we can, meaningfully – and giving each other the opportunity to do so.

But the Christian perspective gives an added dimension here which is extremely useful. And that is: Gawande is absolutely right about our storied existence. But for the Christian, life is not framed by death. Death is not the end of the story, but merely a phase we are passing through.

The end of the story matters, but death is not the end.

I think we need to realise that, because of the age we live in, most of us will die slowly rather than quickly or suddenly. Without becoming morbid, I think we need to admit this to ourselves and not be caught unawares by it. We will be given, probably, options for surgery, chemotherapy, radiation treatment, experimental drugs and the like. We will have to consider what we would endure suffering for.

It is interesting how often the Bible treats suffering this way. In Romans 8:18, Paul writes, “I consider that our present sufferings are not worth comparing with the glory that will be revealed in us.” Suffering, for the Christian, is actually a sign of hope, because it produces the endurance that will bear fruit beyond the moment of pain. As he says in 2 Corinthians 4:17: “For our light and momentary troubles are achieving for us an eternal glory that far outweighs them all.”

This is not saying that God has afflicted us with suffering in order to make us better for it. Rather, it is telling us that even meaningless and pointless suffering is woven by God into his plan for those who love him.

As for death itself: in 1 Thessalonians 4 Paul urges Christians “not to grieve as those who have no hope.” Notice that he doesn’t tell us not to grieve. It is a different kind of grief – one that acknowledges the profound awfulness of dying and death, and which sheds many tears. And yet: those who have died in the Lord have just “fallen asleep”. When Christ comes, with the sound of the trumpet, he will bring with him all of those who have fallen asleep in him. Death is not, in the Bible, denied. But it is confronted, and defeated.

What does this mean for us all, since we are “all in the queue”?

I think we need to realise that, because of the age we live in, most of us will die slowly rather than quickly or suddenly. Without becoming morbid, I think we need to admit this to ourselves and not be caught unawares by it. We will be given, probably, options for surgery, chemotherapy, radiation treatment, experimental drugs and the like. We will have to consider what we would endure suffering for.

And if this is not our experience, it is likely that we will stand with someone we love as they go through it.

I think Christians can thank God for modern medicine, but realise with Gawande that it has very often become a deep distraction from what matters in the end. Technological and scientific knowledge is not the same as wisdom to know what matters. As Christians, we have an added reason to know that preparing for the end of one’s mortal life involves seeking to make peace with our families, with our friends, with those we have wronged, and most of all with God. We have been given the wisdom that it is relationships that matter more than anything else, and that the time we have on earth, however long, is for these most of all.

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