Planning for Death? Or Living Towards Death?
Death poses many paradoxes. Is it a purely natural event, or in some sense unnatural? An end, or also a beginning? What is the state of our soul after our passing? How should we understand what death is? And why is it that we die the death we die?
These questions have occupied theologians since the Fathers. Augustine wired into Christian theology the notion of death as both intrinsically bad and punishment for sin. His mentor Ambrose was more positive, holding that “death must be active within us if life is also to be active within us.”[1] Down the centuries, pious faithful have striven to keep these two views in tension: mourning death as an evil that robs us of earthly life while simultaneously greeting it as the entryway to life eternal.
Today, these questions take on a different urgency. We are frequently admonished to “plan” for our last days by completing legal forms stating what we would like done and who should make decisions for us in the event we lose capacity. Too often, this urge to “plan” plays upon our anxieties and fears: That absent a “plan,” we may suffer needlessly, lose our dignity, and have our “autonomy” stripped away. Care of the dying risks being reduced to a transaction: If you want good care at the end of life, first tell us what you want done. But as Daniel Sulmasy reminds us, “death is not a clinical problem like [elevated potassium levels]. Death is an insurmountable ontological condition of being human.”[2]
For Christians, the transactional approach should not do. Like Sulmasy, we confront the mystery of death from a different worldview, one that lives in that tension between mourning and hope. Maintaining that tension in an age of divisive bioethical debates over the very definition of death, the role of physicians in “aiding” death (euthanasia), and related matters compels us to consider ever more deeply our own “theology of death”—revisiting, in a contemporary idiom, the questions addressed by Ambrose, Augustine, and their successors.
Seven decades ago, the eminent German theologian Karl Rahner, S.J., published On the Theology of Death, a monograph that became a touchstone of Christian reflection on these questions. Rahner provocatively asserted that death is not merely suffered passively but “must also be understood as a human act, as a deed of man, originating within.”[3] Death is an act, in which (due to its veiled nature) man must surrender himself fully and with unconditional openness to the disposal of the incomprehensible decision of God.”[4] As such, death is “the simultaneity of fulfillment and emptiness, of actively achieved and passively suffered end, of full self-possession and complete dispossession of self.” In short, death is both a “thief in the night” and the “fulfillment of [man’s] personal reality.”[5]
Rahner’s account of death as a “human act” is accessible to human reason and theologically verifiable in light of revelation. On the side of reason, Rahner gives the example of martyrdom, the Christian death “par excellence”[6]—an act that defined the completeness and perfection of the martyrs’ lives. From the standpoint of revelation, Rahner stresses that death constitutes an event of salvation or damnation “according to whether it is encountered in faith or godlessness.”[7] If death were exclusively imposed from without, it would be difficult to speak of judgment as intrinsic, as a manifestation of our own life decisions. Rather, judgment would be seen as a pure imposition of divine will, as opposed to an illumination of the soul as to its own guilt or innocence, leading it to either glory, purification,[8] or perdition. Since judgment is both intrinsic to death and an act of the soul itself, death too should be seen as both a divine and human act.
Rahner thus reminds us that we die as we do because of a loss of natural justice, the ultimate demonstration of our estrangement from God brought about by the Fall. The loss of Grace caused death of the body to become a natural event, one fitting to man’s state as a sinner. Nonetheless, death retains an unnatural aspect: The soul exists, literally, to animate the body, and thus the body’s death[9] runs counter to the nature of the soul. What distinguishes our death from the consummation that would have occurred to humans absent the Fall? Rahner’s answer: “the veiledness of death”: A mystery we cannot fully comprehend, but, in the parlance of our day, one we must “lean into.”[10]
Thus, death is axiologically present—present as a value.[11] While the moments surrounding death are privileged, death is not an event isolated from the actions of the living. Rather, it is “an active consummation, worked out through the whole of life”—an act of man, therefore, reflecting a lifetime’s exercise of deliberation and will. Lest any doubt remain, consider that precisely due to the uniqueness of each human life, no person’s death is identical to any other’s: “Beneath the veil of darkness and, indeed, precisely because of its darkness, the very essence of the death-phenomenon can and will differ profoundly from case to case.”[12]
If one accepts this axiological presence of death, we can see that human will and deliberation—the attributes defining a genuinely “human act”[13]—will inform and infuse the event of death, however it occurs. This insight illuminates the “optimism”—or more accurately, “hope”—found in Rahner’s approach. For Rahner does not deny the reality of death—it is, he affirmed, the end of the embodied human person.[14] Rather, hope is grounded precisely in the act of surrender that also constitutes a person’s highest act of self-possession:
Whoever fears death as an animal, with only dumb life-instinct and tries to hide from it, or whoever connects the immediate meaning of death only with the biological anguish of the suffering and has not the heart to practice the abandonment of the last surrender, is in fact not the man he ought to be. His attitude suppresses that which primarily makes him different from animals, that is, the knowledge of the transcendent . . . . Wherever there is free liberty, there is love for death and there is courage to face death.[15]
These words should resonate with all Christian pastors, hospital and hospice chaplains, and clinicians, for they set forth a challenge even more relevant today than when written in 1958. The practical question is how, amidst the contemporary agon regarding care of the terminally ill, and controversies such as physician-assisted suicide, euthanasia, brain death, and organ donation, can this challenge be met?
The “Dignity of Death” vs. “Death with Dignity”
The “veiledness” of death enshrouds a mystery, one that too induces confusion. Instead of confusion, the mystery should induce recognition that death possesses a dignity commensurate with its status as the ultimate human act—the fulfillment, as Rahner writes, of our “personal reality.” By acknowledging this dignity, we give death its inherent “due.”[16] This is a far cry from the common agitation for “death with dignity”—a phenomenon driven by the twin factors identified above: the quasi-animalistic fear of death and the reduction of death’s meaning to the physical anguish of suffering that must, by any means available, be relieved. The ethos of “control” over one’s death negates the theology of surrender illumined by Rahner.[17]
Consistent with this ethos of control is an ascendant Cartesian dualism, reflected in the recent comment by one influential ethicist that “if we could only choose our heads or our hearts as the locus of personhood, we—and many other Westerners—would choose our heads.”[18] He may well be correct. But the dualist ethic he espouses strips away the “embodiedness” of the human person, the fundamental human reality defended by Sulmasy,[19] O. Carter Snead,[20] Oliver O’Donovan,[21] Leon Kass,[22] and others. As Rahner, following Aquinas, points out, the soul (form) when united to the living body (matter) is closer to the Divine than when it is separated from the body at death.[23] Rigid “soul-body” or “brain-body” dualism also contravenes the account of man’s creation in Genesis.
Rejecting this ethic of dualism and control requires asserting—through preaching, catechesis, and care of patients and loved ones—two truths: that of our embodied personhood and that of the reality of death as the ultimate fulfillment of our personhood, to which we must surrender in faith. As death approaches or is “planned for” through instruments such as advance directives, we ought not permit a “functional” or “transactional” approach to cloud those realities. How well we guide our family members, friends, congregants, and patients in these matters will influence whether they face their deaths with the liberty, love, and courage Rahner’s theology of death calls for. That call for guidance may arise at two key junctures: when a person considers making an advance directive, and when a clinician and family face a dilemma over continuation of life-sustaining care to the terminally ill.
Every state allows appointment of a surrogate to make healthcare decisions in the event of incapacity and for the specification, in that event, of treatment preferences. Yet the option of making such an advance directive has morphed into an expectation. Thus, the first step in counseling someone on these matters is to set that expectation aside in favor of more fundamental issues: our understandings of death and of our Christian obligation to live towards death as a reality axiologically present through our lives. Once that process is underway, discussions about care at the end of life can ensue. No one contemplating an advance directive should fail to recognize that what they think now about such matters may change as the years pass. Appointing a trusted surrogate with a commensurate Christian understanding of death’s reality is thus a preferred alternative to listing specific treatment directives that may or may not be clinically relevant. But even here, a trap awaits, one rooted in the ascendance of “autonomy” in contemporary medical ethics. The decisions of a surrogate, like that of a competent patient, should not be executed in isolation, but in relation: to clinicians and other caregivers, to other loved ones of the patient, and to the best interests of the patient himself or herself. The legal authority given to a surrogate by an advance directive does not diminish the responsibility that others have in making decisions on the patient’s behalf, a responsibility that extends to care of the surrogate, who may be undergoing great stress and grief.[24] Thus, counseling of a person being appointed as a surrogate may be just as important as counseling the person who appoints. Since most state advance directive forms reflect a purely transactional approach, Christians may eschew those forms—which is their right to do—in favor of written statements that better reflect the relational realities and responsibilities that should attend to the deathbed.
Whatever advance directives are (or are not) written, there will come a time when patients and/or their family members will have to make decisions regarding the initiation or continuation of life-sustaining medical treatment. Here, it is sometimes necessary to address another impulse that stands in the way of giving death the dignity that it is due: reluctance to “let go.” Preparing family members in advance to accept their loved one’s death as an act of fulfillment and surrender may prevent the undue prolongation of life by means that provide diminished benefit and no comfort. But even when this has been done, the tension between mourning and hope that characterizes the Christian attitude toward death can snap. Christian families, shaken by the impending death of a loved one and distrustful of physicians or other hospital staff, sometimes insist on invasive treatments that offer no hope of cure. Navigating such cases requires the building (or re-establishment) of trust. Doing so will require recognition by all parties that, as Sulmasy stated, death is not a clinical problem but an ontological reality of human life. This demands courage on the part of patients and families and clinical humility on the part of healthcare professionals. The “dignity of death” deserves nothing less.
Conclusion
Rahner’s theology of death might seem at first of little practical import. But in an age where death is often preceded by complex medical interventions, the reality of death as an act of human fulfillment is often obscured. Re-centering that reality can counter the transactional approaches to medical decision-making that characterize much so-called “planning” for death. In truth, we live toward our death, no matter how our human nature impels us to flee from it. Rahner’s fundamental proposition that death is both a human act and the ultimate fulfillment of our humanity is a powerful antidote to attitudes that either cower in fear of death or seek mastery over death in negation of its inherent dignity.[25]
References
[1] See David Albert Jones, Approaching the End: A Theological Exploration of Death and Dying (Oxford University Press, 2007), 29–30; Ambrose, “Treatise on Death as a Blessing,” Second Reading for Office of Readings, Saturday of Thirty-First Week of Ordinary Time, The Liturgy of the Hours (Catholic Book Publishing), 497–98.
[2] Daniel Sulmasy, “Advance Care Planning and ‘The Love Song of J. Alfred Prufrock,’” JAMA Internal Medicine 180, no. 6 (2020): 813–14, https://doi.org/10.1001/jamainternmed.2020.0796.
[3] Karl Rahner, On the Theology of Death, trans. Charles H. Henkey (Herder and Herder, 1961), 38; Zur Theologie des Todes. Mit einem Exkusus über das Martyrium (Herder, 1958). The primary text was published under the same title in Zeitschrift Für Katholische Theologie 79, no. 1 (1957): 1–44, http://www.jstor.org/stable/24174397. Unfortunately, the English text is out of print. It is the author’s intention to facilitate a retranslation and republication.
[4] Rahner, On the Theology of Death, 52.
[5] Rahner, On the Theology of Death, 38.
[6] Rahner, On the Theology of Death, 109.
[7] Rahner, On the Theology of Death, 46.
[8] On the question of purification, Rahner strongly critiqued the fantastical depictions of Purgatory present in some Roman Catholic piety, reminding readers that there is no earthly temporality in the realm of eternal life. Pope Benedict XVI also moved Catholic teaching away from reliance on mythical depictions of Purgatory. Benedict XVI, Encyclical Letter Spe Salvi, The Holy See, November 30, 2007, 47, http://www.vatican.va/content/benedict-xvi/en/encyclicals/documents/hf_ben-xvi_enc_20071130_spe-salvi.html (noting favorably the view of some theologians that the “fire that burns and saves is Christ himself”).
[9] Rahner, On the Theology of Death, 27–28, 43; Joseph Pieper, Death and Immortality, tr. Richard and Clara Winston (St. Augustine’s Press, 1999), 25–26; Thomas Aquinas, Summa theologiae, II.II, q. 164, a. 1, ad. 1.
[10] Rahner, On the Theology of Death, 44.
[11] Rahner, On the Theology of Death, 51–52.
[12] Rahner, On the Theology of Death, 58.
[13] Aristotle, Nicomachean Ethics, III.2, 1112b (“We deliberate about things that are in our power and can be done”).
[14] Moreover, the soul, while immortal and awaiting the Final Judgment and Resurrection, does not carry on its existence in any temporal or spatial realm. Thus, we must reject both temporal spiritism and the Feuerbachian notion of immortality as a mere essence subsumed into a common, infinite, and ever-progressing “Spirit.”
[15] Rahner, On the Theology of Death, 94–95.
[16] See Letter Samaritanus Bonus: On the Care of Persons in the Critical and Terminal Phases of Life, Congregation for the Doctrine of the Faith (CDF), June 25, 2020, https://www.vatican.va/roman_curia/congregations/cfaith/documents/rc_con_cfaith_doc_20200714_samaritanus-bonus_en.html.
[17] Daniel Sulmasy, “‘The Syringe Belongs in the Hand of the Physician’: Power, Authority, Control, Death, and the Physician-Patient Relationship,” in Physician-Assisted Suicide and Euthanasia: Before During, and After the Holocaust, ed. Sheldon Rubenfeld and Daniel P. Sulmasy (Lexington Books, 2020).
[18] Brendan Parent, Carrie Thiessen, Anji Wall, Macey Levan, and Elisa J Gordon, “A Clarified Interpretation of Permanence Justifies Death Determination in NRP Protocols,” American Journal of Bioethics 24 no. 6 (2024): 46–48, https://doi.org/10.1080/15265161.2024.2337402.
[19] Daniel P. Sulmasy, A Balm for Gilead: Meditations on Spirituality and the Healing Arts (Georgetown University Press, 2006).
[20] O. Carter Snead, What It Means to Be Human: The Case for the Body in Public Bioethics (Harvard University Press, 2020).
[21] Oliver O’Donovan, The Disappearance of Ethics: The Gifford Lectures (Eerdmans, 2024).
[22] Leon Kass, Life, Liberty and the Defense of Dignity: The Challenge for Bioethics (Encounter Books, 2002).
[23] Rahner, On the Theology of Death, 26; Thomas Aquinas, Quaest. disp. de potentia Dei 5, 10, cited in Joseph Pieper, Death and Immortality, trans. Richard and Clara Winston (St. Augustine’s Press, 1999), 32.
[24] Daniel P. Sulmasy & Lois Snyder, “Substituted Interests and Best Judgments: An Integrated Model of Surrogate Decision Making,” JAMA 304, no. 17 (2010): 1946–47, https://doi.org/10.1001/jama.2010.1595.
[25] For further reflection, the author recommends: Lydia S. Dugdale, The Lost Art of Dying: Reviving Forgotten Wisdom (Harper Collins, 2020); and Matthew Levering, Dying and the Virtues (Eerdmans, 2018).