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November 13, 2009

Part I

One of the great accomplishments of modern medicine is arguably the gains that have been made in extending longevity. Throughout the twentieth century, average life expectancy increased dramatically across the globe, a trend being continued in the twenty-first century with the notable exceptions of sub-Saharan Africa and Russia. For the first time in history it now seems “normal” that a person should live a long, healthy, and active life. Although the trend line is still moving up, it has started to plateau. The steep increase in longevity was achieved initially through relatively simple things such as improved nutrition and sanitation, declining infant mortality through better prenatal and postnatal care, and the development of inoculations and antibiotics. More modest gains have been achieved with the use of new diagnostic techniques and therapies for treating such life-threatening conditions as cancer and heart disease.

But the momentum in extending longevity is slowing, and many scientists believe that 120–125 years is the outside boundary that cannot be crossed. The Hayflick limit is evidently ironclad and absolute. Medical advances may be able to bring more individuals closer to this boundary, but few, if any, will cross over. Regardless of how proficient physicians may become in extending the lives of their patients, biology insists that death will still have the final word. There are some dissident scientists, however, who believe this boundary can be pushed farther out. With the advent of stem cell research and regenerative medicine, and with anticipated developments in biotechnology, nanotechnology, and bionics, there is talk of extending human life spans to perhaps 150 years, or even 175 or 200 years.[1] The more optimistic voices speak in terms of millennia rather than decades or centuries. The most adventurous prognosticators boldly assert that, contrary to Leonard Hayflick, the biological boundary is not absolute and can be crossed; immortality is within our grasp once we develop the appropriate technologies.[2]

It is tempting to dismiss these predictions as little more than wishful thinking. After all, despite the billons of dollars invested in life prolongation research, no significant advances have yet been made—except for some lucky mice and nematodes who lived three times as long as their less fortunate peers. The prospect of living longer seems at best a distant dream, and at worst an idle fantasy. It would be a mistake, however, to curtly dismiss the possibility of extreme longevity as little more than science fiction masquerading as science. In the first place, although research to date has been disappointing, this does not eliminate the possibility of dramatic breakthroughs in the future. I remember reading an article shortly before the announcement of Dolly in which the author confidently informed his readers that the technology for cloning a mammal (other than a rodent) was at least a century away if it could be developed at all. If anticipated breakthroughs are forthcoming, then it behooves us to start thinking about the subsequent moral, social, economic, and political implications—if you believe that Social Security and Medicare are in a mess now, just imagine a world populated by sesquicentennials.

Secondly, and more importantly, the rhetoric surrounding life extension research is prompting us to regard and treat aging as if it were a disease. With the development of more effective therapies and preventive measures we are enabling many people to live longer and more active lives. The image of a pensioner dozing in a rocking chair is not the poster child of AARP. Rather it promotes and supports cheerful and energetic seniors spending their lengthening golden years endlessly playing golf in Florida. Although some of the more immodest predictions regarding life prolongation may never prove true, the research is nonetheless enabling more people to live independent and active lives as they grow older. The trick is not only to live longer, but to maintain youthful strength and vigor. Now it may be asked: what is wrong with living a long, healthy, and active life? The short answer is: nothing at all. Contrary to Leon Kass’ objection that extended longevity would result inevitably in tedious boredom,[3] I think I could find plenty of worthwhile things to do if I could live to be 120 or more. The issue at hand is not living longer per se, but rather, what sense are we to make of this puzzling perception of aging as a disease that can be treated and perhaps even cured?

Fearing Mortality

Many of the champions of regenerative medicine and life prolongation research refer to aging and death with such words as “annoyance,” “irrational encumbrance,” and “tragedy.” But how has it come to be that morbidity and mortality are somehow inimical to human flourishing when they have been very much a normal part of our history as a species? Many people have grown old, and as far as we know no one has ever lived forever. It would appear that a natural and healthy fear of death has been malformed and personified into a foe that must be vanquished. But what would waging a war against aging and death entail? What would ultimate victory mean for both medicine and its patients? And even if we fail (which I think likely) how would such an unremitting struggle shape healthcare, and how would we come to regard ourselves both as finite creatures and what we aspire to become?

Hannah Arendt can help us think about these questions. She asserts that natality and mortality—birth and death—are the defining features of the human condition.[4] They are the brackets or bookends, so to speak, between which we shape and live out our lives. Our work, hopes, and aspirations only have meaning within a temporal structure that has a beginning and an end. Indeed, without a beginning and end the word life has no real meaning.[5] In confronting death we encounter mortality as the “only reliable law of life” that inevitably carries “everything human to ruin and destruction.”[6] According to Arendt, in death we face the prospect of our disappearance from the earth and its history; our permanent separation from the families, friends, and communities which have shaped and sustained us.[7] In death we face the prospect of the utter and complete annihilation of who we are and what we aspire to become.

When we become fixated on mortality, is not a natural reaction to find some way to fight against, overcome, or otherwise cheat this cruel fate? And is not some type of quest for immortality a rational strategy in this respect?[8] That we try to achieve a kind of immortal presence among subsequent generations through things we produce or legacies we leave? Through offspring we pass on a genetic inheritance to future generations that was bequeathed to us from our ancestors. The ancient Romans tried to build an immortal empire,[9] while late moderns attempt to construct an everlasting history.[10] Although individuals grow old and die, empires and histories purportedly live on forever. May we not say that our current fascination with employing medicine to extend longevity reflects a similar obsession with mortality? That ironically, our success in extending longevity has fixed our attention more relentlessly upon death? The principle difference is that now our gaze is cast simultaneously toward both individuals and larger corporate structures. We not only want to establish our immortal legacy through lineage, empire, or history, but to live our individual lives for as long as possible, even striving to achieve personal immortality. Pursuing this two-fold strategy requires a triumph of the will in which we construct our world and ourselves in the image of what we want it and ourselves to be. And the power to achieve these goals is seen most vividly in our growing use of various technologies. Consequently, we construct our children, political communities, and histories as artifacts of a corporate will, and we turn to medicine to construct ourselves individually as self-made artifacts.

This twofold strategy for conquering death, however, is comprised of diametrically opposite goals, leading to inevitable tensions, conflicts, and contradictions. If, on the one hand, individuals are dedicated to reengineering themselves to live as long as possible, perhaps even achieving personal immortality, there is no compelling reason why they should invest their time and energy to projects that are designed to outlive them. Why should individuals invest themselves in building an immortal lineage, empire, or history if the goal is to live forever? Such tasks simply detract attention away from achieving the objective of personal survival. The more time and money I spend on my daughter, for instance, means I have less to spend on myself. This is especially a waste of time and money if the goal is to develop medical care that wards off the ravages of aging so that I can remain independent rather than depending on my daughter (or anyone else for that matter) to care for me as I grow older. On the other hand, if we are dedicated to constructing lineages, empires, and histories that are intended to outlive us, extending the survival of most individuals, much less achieving personal immortality, is irrelevant and may even prove inimical. Individuals are expected to sacrifice their interests for the sake of the future. Investing in personal longevity wastes resources that could be better applied to these more expansive tasks. If, for example, I invest heavily in improving my cardio-vascular system but contract Alzheimer’s disease and linger on for decades, I no longer contribute to but detract from the task of building the very corporate future in which I am supposed to be immortalized. It would be better for all concerned if I would go sooner with heart disease than later with dementia.

This conflict I have sketched out between what may be characterized, respectively, as selfishness and altruism is admittedly little more than a caricature of the more complex relationship between these seemingly contradictory behaviors. A key tenet of evolutionary psychology, for instance, contends that the two are intricately related; indeed, that altruism presupposes and is dependent upon selfishness. The reason I am inclined to sacrifice my own desires and spend my limited financial resources on my daughter is that she carries my genes. Through her I will live on after I die. In this respect, it is in my self-interest to be altruistic. It is only in my fear of death that I am motivated to invest in my daughter’s future. Although proponents of evolutionary psychology overstate their case (not all of our behavior can be reduced to selfish genes), they nonetheless offer the salient insight that morality cannot be casually separated from biology. If in fact evolutionary psychology is correct in this regard, might our medical war against aging and death create some unwanted and troubling consequences? Again risking oversimplification the dilemma can be stated as follows: if I am dedicated to living for as long as possible, and perhaps forever, will I not lose my motivation to invest in my daughter’s future, or even produce and raise offspring? Conversely, if altruistic behavior is grounded in selfishness, should we take the risk of waging a war against aging and death if it lessens, or even removes, the fear of death as an underlying motivation?

Some of the more pronounced implications of this dilemma can be seen with greater clarity by focusing on some of the ethical issues at the beginning and end of life. At the beginning of life, great advances have been made in prenatal and neonatal care. Many infants who would ordinarily not have survived or would have suffered chronic conditions due to poor prenatal care or premature birth are now able to live happy and productive lives. With the assistance of various reproductive technologies, many infertile couples are able to have children. To the casual observer, it would appear that we are a very child-friendly, even pro-natalist, culture. Appearances, however, can be deceiving. An increasing number of individuals are choosing to remain childless, a goal that is assisted by various contraceptive techniques and easy access to abortion. More effective screening and testing (e.g., amniocentesis and preimplantation genetic diagnosis) is enabling parents to prevent the birth of children with deleterious conditions or other unwanted characteristics, select desirable traits (e.g., sex), and perhaps in the future to produce so-called designer babies. Not only have these techniques resulted in the destruction of many fetuses and embryos, but with the prospect of embryonic stem cell research and therapeutic cloning, prenatal life may come to be perceived as a biological resource or commodity that can be exploited in developing better healthcare, especially in respect to treating aging as a disease. Again, to the casual observer, it would appear that we are a culture that is at best indifferent to children, and at worst hostile.

These contradictions are played-out with an alarming symmetry at the end of life. Tremendous strides have been made in treating, and in some cases curing, a growing range of diseases which a few decades ago were tantamount to a death sentence. We now, for example, talk about surviving cancer as a possibility rather than a desperate hope. By in large we assume that with a combination of healthy lifestyles and proper medical care, virtually anyone can live a long and active life. Moreover, improved pain medication and palliative care has made the prospect of an “easy passing” more readily available. To the casual observer, it would appear that we are a culture that cherishes life and have developed a healthcare system that is devoted to its prolongation. Yet again, appearances can be deceiving. Under the banner of “quality of life” we also promote death as a means of exercising the right to control one’s fate. When an individual has determined that the quality of her life has reached such a low ebb that continued existence is no longer desirable, then she should be able to control the time and means of her death. Hence the growing public tolerance, if not acceptance, of euthanasia and assisted suicide. Moreover, exercising this personal choice to “die with dignity” has also created a subtle expectation that the dying should not be assisted in lingering too long and become a burden on others. Again, to the casual observer, it would appear that we are a culture with little tolerance for morbidity and little patience for the care of the dying.

How may we account for these apparent contradictions at the beginning and end of life? The strategies I have summarized are, I think, quite rational within the following scheme: although we have launched some initial forays in a war against aging and death, we are not placing all our eggs in this basket but hedging our bets. Declining birth rates tacitly acknowledge that in striving to live long and active lives, children are both an encumbrance upon one’s lifestyle and a drain on financial resources. Offspring are now more an option than a necessity, as reflected in the growing and puzzling perception of children as a means of their parents’ self-fulfillment. Hence the growing recourse to and anticipation of “quality control” techniques that help parents obtain the kind of children they want.

Yet there is also a grudging admission that offspring remain a necessity should the war against aging go badly. As people grow older they may still need their children, not to care for them directly but to be productive taxpayers. The late modern phenomenon of lengthy retirements coupled with declining birth rates is a recipe for long term financial disaster. A shrinking cohort of young workers simply cannot support an expanding collection of unproductive pensioners. Consequently, some European countries are now paying women or providing other economic incentives to have children, and even China has admitted that around 2050 a shrinking population will displace overpopulation as its principal social and political problem. In short, children are becoming both an artifact of their parents’ will and an insurance policy for the future.

A similar hedging strategy is also at play at the end of life. We are investing heavily in medical treatments and technologies which are designed to extend life for as long as possible while also maximizing certain values such as mobility and independence. But if medicine should fail to deliver the proffered goods, then we want to exercise the options of euthanasia or suicide should the quality of our lives become burdensome or undesirable. Even if we lose the war against aging and death, we can at least have a final, defiant gesture by choosing when and how we die. In this respect, our deaths are also artifacts of our will.

The seemingly contradictory strategies we are employing at the beginning and end of life become more explicable when the war against aging and death that we are undertaking is placed within the larger late modern project of asserting greater mastery over nature and human nature.[11] As late moderns we have come believe that we must construct our world and ourselves in an image of what we want to become in order to be more human and humane; our lives and our future are largely what we make of them. To be human has become virtually synonymous with being the masters of our own destiny. We assert this mastery through technology in general and medicine in particular. To assert ever greater control over the beginning and end of life is to exert greater mastery over our lives. In this respect, death remains the final, and most elusive, object of our mastery.

If I were to end on this note, I think we might be rather despondent, for the world I have described is the one envisioned by that troubled and troubling philosopher Friedrich Nietzsche; a world of restless and anxious nihilists. But fortunately I have concentrated on only half of Arendt’s depiction of the human condition, that of mortality. To complete the picture we need turn our attention to her account of natality.

Empowering Natality

Arendt insists that if we fixate on death, then anything which may be said to be genuinely human ends in ruin and destruction. We become locked into Nietzsche’s eternal recurrence of the same, for there is no purpose or direction to human life over time.[12] Some kind of principle is needed to disrupt this deadly pattern, and Arendt proposes natality as a promising candidate. By “natality,” she means something more than physical birth although this act symbolizes the disruptive power to break the pattern of mortality. Each new baby embodies a hope of new possibilities; something new is started, and is thereby also renewing. More broadly, natality entails the acknowledgment that there are fundamental limits inherent to what it means to be human. In other words, to be human is necessarily to be finite and temporal. It is only within the imposition of given limits that we are liberated to break the pattern of death and be genuinely creative, or better procreative in the sense that we create social and political structures that are greater than ourselves and enable human generations to flourish over time. Yet it must be stressed that we can only embrace natality by accepting, while also refusing to fixate on mortality. The creative and renewing potential of birth can only be effective by consenting to the inevitability and necessity of death. Withholding such consent in favor of a longing for personal immortality distorts the moral ordering of human life, because it removes the limits which give morality its meaning and purpose. This is the trap, Arendt notes, that the immortals or gods of ancient Greek mythology fell into. The pantheon of the gods was populated by beings that could point to their birth but did not face an impending death; they lived deathless lives of endless time. And in the absence of death the ensuing void was filled with an insatiable appetite for power and mastery. The immortals were objects of fear, but certainly not models to be emulated. More often than not they were vain, capricious, and cruel. The gods magnified every conceivable human vice while belittling virtue. The quest for immortality, Arendt suggests, leads inevitably to moral decay, for what is lacking is any “rule of an eternal God.”[13]

To consent to, rather than warring against, the inevitability and necessity of mortality redirects our attention back to natality, and in redirecting our gaze we discover the common life that binds us together over time. The renewal which natality offers provides the social and political bonds that embody, in Arendt’s words, “what we have in common not only with those who live with us, but also with those who were here before us and with those who will come after us.”[14] It is also through the possibilities engendered by natality that we preserve the moral precepts and virtues (such as self-denial and regard for others) which enable us to live together peaceably, especially across generation divides.[15] Consequently, natality, rather than mortality—birth instead of death—should provide the principle metaphor for ordering our common life.[16]

Theological Groundwork

I find Arendt’s argument to be highly suggestive, and below I want to explore some avenues for revitalizing medicine by turning our attention away from mortality and toward natality. We must first, however, take a preliminary step of preparing some theological soil in which her philosophical argument may be planted. This is needed, for although Arendt has correctly identified the fateful late modern fascination with death, she cannot quite bring herself to identify an eternal good or God which would help redirect our attention toward birth. The best she can offer is a politics based on justice that endures and improves over time as the highest good that humans can attain. This is a noble and worthwhile goal that should not be easily dismissed or despised, but it can neither be attained nor sustained. Her project depends upon a strength of will which all too often is too weak to stay the course. The temptation to become fixated on mortality is too compelling to be resisted on our own accord. Rather, those of us who are Christians believe that the highest good is fellowship with God through one’s life in Christ, which is in turn a life of grace instead of one’s will to power.

In preparing this theological soil it should be admitted upfront that although the medical war against aging is motivated by the fear of death, this fear is not irrational or cowardly. As St. Paul reminds us, death is the final enemy,[17] and when confronting any formidable enemy fear is a normal and healthy response. It should also be admitted that the desire to live a long and active life is neither wicked nor perverse. Again as Scripture reminds us, a long life is a blessing from God evoking praise and thanksgiving. The issue at hand is how we should confront the old enemy of death, and how we should fulfill the desire of living long and active lives. For those of us who are Christians, thinking about this “how” may start with the Incarnation. In Jesus Christ God became a human being; the Word was made flesh.[18] The Creator became one with his creatures, complete with their temporality and finitude. As attested in Scripture and affirmed by the creeds, Jesus was born of Mary and died on the cross. In these acts we may say there is an affirmation of both natality and mortality. The gospel, however, does not end with Good Friday. Death does not have the final word, for in resurrecting Jesus Christ from the dead life is renewed within the eternal life of the triune God. Easter Sunday is the ultimate act of natality. We face death, then, as a powerful but already defeated enemy. Like all such enemies it should be respected while not granting it finality, for in death we are raised with Christ into the eternal life of God. This is not an easy moral and religious stance to take, for make no mistake, death is real and cannot be cheated. Jesus did not avoid death, and neither will we. Death remains an enemy that should never be warmly embraced, but it should be struggled against on God’s terms and not our own. This is why regarding aging as a disease that can be treated, and perhaps cured, is not only futile but also misdirected. Waging a war against aging and death is misguided because there is nothing inherently unnatural, irrational, inconvenient, tragic, or unjust in the reality that we grow old and die; indeed the wellbeing of our descendants requires that we do so. Aging is not a disease, but a sign of our status as temporal and finite creatures. Christ did not come into the world to rescue us from finitude, but to welcome us to eternal fellowship with our Creator.

In treating aging as if it were a disease we make a fateful mistake in confusing immortality and eternity, for the two are not synonymous. In brief, immortality entails a beginning but no end, whereas eternity has no beginning or end. I am not invoking a fine semantic distinction so that over-educated people such as myself can remain gainfully employed. The difference is important and has grave practical implications. The quest for immortality requires a world of endless time. Is this a bad world? Yes! It is a world of frenetic and constant work without rest, because there is no end to or purpose of our labor. It is world of ceaseless and often pointless construction, deconstruction, and reconstruction. A world in which our births, our deaths, our very lives are reduced to artifacts of frenzied willing. It is world devoid of the good and the true, and filled with values of our own making. It is a world populated by frustrated souls in search of a perfection that will always elude them, for the goal is a projected fabrication that is itself always changing and moving, somewhat like Alice’s wonderland in which you can have jam yesterday or tomorrow but never today. In short, it is Nietzsche’s world of the will to power that has gone beyond good or evil, and therefore, a world predicated on raw power rather than love.

What a quest for endless time fails to recognize is that temporal and finite creatures, such as ourselves, require a beginning and an end if their lives are to have meaning, direction, and purpose. The realms of natural necessity and human history are bracketed by eternity; the eternal serves as bookends to the story of human existence. Christ is the alpha and omega of creation and its creatures precisely because he is also the eternal Word of God. It is also the eternal which is the source of the true and the good which are revealed in the Incarnation, and it is in Christ that we gain inklings of what is good and true entails, and we should conform our lives accordingly. Ironically, to strive relentlessly after more and ultimately endless time is to become fixated upon death, for to paraphrase Simone Weil’s beguiling observation, the realm of necessity—the realm of finitude and mortality—may be beautiful, but it can never be good.[19]

As St. Augustine reminds us, a properly ordered life is one that desires to know and be embraced by the good and the true; a life that seeks fellowship with the eternal God. He likens this fellowship to the eighth day of creation; an eternal Sabbath rest.[20] Any other desire can only frustrate and disappoint, for our hearts remain restless until they find their rest in God.[21] It is properly God alone that should be the object and goal of what we ultimately love and desire. To reemphasize once again, the desire to live a long and active life is not an evil or wicked desire, but if it is pursued for the sole purpose of extending longevity within a quest for endless time, it corrupts this otherwise good desire. Again as St. Augustine reminds us, the problem of sin, more often than not, is not that we desire bad things but that we love good things badly.[22] May we not say, then, that trying to live for as long as possible by any available means is a disordered desire because it means we desire our own survival more than we desire God? Moreover, does it not also mean that we fear our own deaths more than we fear or love God? If true, then a promising possibility presents itself: what would medical care look like if rather than seeing it as a means of prolonging life we perceived it as a means of preparing ourselves for eternity? Or to use Arendt’s metaphors, how would medicine be practiced if our fixation upon mortality were displaced by attending to natality, particularly at the beginning and end of life? In the first place, we would be better enabled to resist the temptation of regarding birth and death as artifacts of our own creation. Rather, we would see life as a gift that properly is not subject to our mastery and control. The concept of life as a gift has been developed in some detail by such theologians as Karl Barth,[23] Gilbert Meilaender,[24] and John Kilner,[25] and I can only summarize briefly the more salient features of their portrayals

Starkly put: our lives are not our own; they belong to God. Life is not a product we produce or own, but a gift that is entrusted to us, and we are to care for and use this gift in accordance with God’s expectations and commands. This sentiment is captured most vividly in the sacrament of baptism.[26] When parents present their child to be baptized, they simultaneously accept the divine charge to love, cherish, and protect this life that has been entrusted to their care, and they in turn commend their child back to the love, grace, and care of God in Christ as the origin and end of life itself. The child is not, in Meilaender’s apt but chilling phrase, the outcome of a reproductive project, but the beneficiary and recipient of their fellowship as wife and husband. In this respect, parents are not so much producers or creators of new life as they are trusted stewards or custodians. Consequently, an orientation toward natality as opposed to mortality will reject the notion of children as artifacts. On the one hand, although being a parent may prove rewarding, a child is not properly a means of parental self-fulfillment. If this were the case, then a child could not embody the kind of hope and possibility that Arendt envisions. It is precisely because a child is both like and unlike her parents that genuine fellowship between generations is established and honored. If she is merely an avenue of personal fulfillment, then she is like any other instrument that is used in constructing one’s lifestyle; an object exhibiting the will of its creator. It is only in recognizing the similarity and otherness of a child that mortal bonds are forged while the fateful drift into mortality is broken.

On the other hand, although children should care for their parents as they grow older, they are not properly insurance policies. Placing one’s hope for the future upon any child (save one) is to impose a burden no child can bear. Again if this were the case then a child would be little more than the sum total of parental aspirations. Such a prospect is bound to prove barren for both child and parent, for the latter is not the slave of the former. Particularly those of us who are Christians know that God, and God alone, is the only proper object of our hope. It is in placing our hope in God that we are freed to consent to our death, and in such freedom our children are empowered to pass on to a new generation the gift of life. Counter intuitively, is in consenting to the necessity and inevitability of death that each generation is free to turn its attention toward natality and away from mortality.

Medical Appropriations

What would it mean for healthcare at the beginning of life to be oriented toward promoting natality? Three suggestions: first and foremost, providing easily accessible prenatal, neonatal, and pediatric healthcare. It makes little sense to affirm procreation but remain indifferent to the health of children.

Second, policies should be strengthened or enacted which support parents in fulfilling their duties and obligations. It makes little sense to perceive children as embodying future possibilities if they are not given the resources to fulfill this potential. Having said this, however, it must be stressed that this responsibility is properly lodged with parents instead of the state or other social service agencies which should play a supportive rather than leading role. In this respect, tax and legal codes, as well as other economic incentives and support mechanisms that protect and empower marriage, family, and educational choice should be regarded as public health issues.

Third, greater respect for prenatal life needs to be exhibited. I am aware that many (including myself) have grown weary over the endless and acrimonious debates over abortion, embryonic stem cell research, and so-called therapeutic cloning. I do not believe that an adequate political consensus exists to offer anything approaching a definitive resolution. Nonetheless, I think it is incumbent, particularly upon Christians, to keep pressing these issues, if for no other reason than raising public awareness. How we treat the most vulnerable members of the human community tells us a lot about our moral convictions as a society and where we are placing our hope and confidence for the future. Casually destroying and exploiting prenatal life for either the sake of convenience or their potential to develop medical treatments should, at the very least, give the public some pause. If we are to be genuinely oriented toward natality, can we continue to neglect and prey upon the future?

An orientation toward natality as opposed to mortality will also reject any notion of death as an artifact. Life is a gift that is entrusted to our care, but not our keeping. The gift is also a loan with a foreclosure date; the life given by God also returns to God. Surrendering this gift and loan back to its rightful owner does not diminish St. Paul’s teaching that death remains the final enemy. But in our current crusade against aging, we often fail to resist this enemy properly. To use a crude analogy, we are tempted to either wage a fruitless struggle, to grasp tightly to the loan for too long, or to capitulate too early, surrendering the loan before it is due.

A long and bitter, though ultimately fruitless, struggle against death has been made possible by recent medical advances in prolonging life. This blessing, however, is also a curse. The modern image of death is a patient lingering in a hospital attached to various tubes and monitors. A death at home in the company of friends and family has been exchanged for a sterile room surrounded by machines and healthcare professionals. This is the kind death we wish to avoid, for it seemingly strips us of our dignity. We cannot recite with much enthusiasm a petition from the Great Litany which reads, “from dying suddenly and unprepared, good Lord deliver us,” for we rightfully fear the prospect of dying in pieces.[27] What this failed strategy of prolonging life at any cost fails to recognize is that there is a subtle, yet profound difference between extending life and delaying death.

Given this prospect the second temptation of succumbing too early is understandable and perhaps more prevalent today. When the quality of one’s life has deteriorated to an unacceptable level, one should be allowed and assisted to relieve the burden or put an end to the lingering life of an unconscious person. Is this not a preferable option to dying in pieces; an act of mercy in the face of prolonged pain and suffering? What this seemingly compassionate strategy fails to recognize, however, is that there is a subtle, yet profound difference between allowing a person to die and hastening death.

In waging a war against aging, both of these acts are defiant gestures against an adversary that cannot yet be vanquished. We can either wage a desperate but heroic struggle to the bitter end or end it on our own terms at a time of our choosing. Both options purportedly provide the satisfaction of somehow cheating death, but in fact they cheat life. In attempting to dictate how and when we die, we implicitly deny the sovereignty of God who is the Lord of life. But let us also admit that, given our present circumstances, these options are not irrational or perverse. Once again it is a case of disordered desire. There is nothing wrong in desiring a good death (which is the literal meaning of “euthanasia”), but how that good end is achieved is what is at stake. Since our lives are not our own, then neither are our deaths. Rather, we are called to be stewards of life, ordering our lives in obedience to God’s will and commands. Exercising such stewardship is a challenging and perilous enterprise, for as sinners we more often than not fail to discern correctly what the obedient ordering of our lives means and requires of us, particularly when our lives are coming to an end.

An admittedly imperfect principle which can guide our deliberation is that we seek to prolong life in ways which do not merely delay death, and allow death to occur while not hastening its arrival. Consequently, Christians must steadfastly resist policies which allow or promote assisted suicide and euthanasia. Although these are certainly lively options, they are not acts that affirm life. Yet our resistance must always be tempered with humility and compassion, avoiding the acrimony and recriminations that often characterize the state of contemporary moral debate. Barth’s teaching on suicide is helpful in this regard. He insists that although suicide is wrong, the person committing it should not be condemned, for we can never know what God’s final command might have been, and neither are we in a position to dictate the limits of God’s mercy and forgiveness.[28] In resisting assisted suicide and euthanasia we encounter the perennial task of hating the sin while loving sinners. In this respect, those of us who are Christians should spend far more time bearing witness to what a genuinely good death means and entails, rather than denouncing what we oppose.

Modeling what we believe a good death to be is an urgent task: how do we allow death to occur without either hastening or delaying it? How should we die in ways that are life affirming? In this respect, Paul Ramsey’s observation is apt that the problem at hand is not the fear of death, but the fear of dying alone and abandoned.[29] Christians should take the lead in promoting and assisting greater access to advance directives and durable power of attorney, improved palliative care and hospice services. Most importantly, we should strive to maintain and strengthen the bonds of fellowship with the dying to insure that they are not abandoned. Especially within the church, greater attention needs to be directed toward how the dying are included within the life and ministry of the community which gathers in Christ’s name.


Once again I must stress that there is nothing wrong with living a long and active life (a belief I hold more strongly with each passing year); indeed it is a blessing that should inspire praise and thanksgiving. But it is not surviving—living a long life per se—that makes this blessing a good gift. It is rather the extended opportunity to worship and serve Christ, to love God and neighbor that makes this gift good. Our attempt to wage a medical war against aging and death, however, is tantamount to refusing this gift, for in our fixation on avoiding death we are forgetting how to affirm life. Ironically, medicine is being used increasingly to promote a culture of death rather than life. I have suggested that Arendt’s emphasis on natality offers a potentially helpful metaphor for revitalizing medicine and redirecting its underlying culture. Yet those of us who are Christians can make a stronger claim: we need not use medicine to wage a war against death, for in the fullness of time it has already been defeated. We may affirm along with St. Paul: “O death where is your victory? O death where is your sting.”[30] This is not merely a pious platitude, but an assurance and starting point for being good stewards of the gift of life that has been entrusted to our care.


[1] For an overview see Stephen S. Hall, Merchants of Immortality: Chasing the Dream of Human Life Extension (Boston, MA and New York: Houghton Mifflin, 2003).

[2] See Immortality Institute, The Scientific Conquest of Death: Essays on Infinite Lifespans (Buenos Aires: LibrosEnRed, 2004).

[3] See Leon R. Kass, Toward a More Natural Science: Biology and Human Affairs (New York and London: Free Press, 1985), 299-317, and Life, Liberty and the Defense of Dignity: The Challenge for Bioethics (San Francisco, CA: Encounter Books, 2002), 257–274.

[4] See Hannah Arendt, The Human Condition (Chicago and London: University of Chicago Press, 1998), 8–9.

[5] See ibid., 97.

[6] Ibid., 246.

[7] See ibid., 96–97.

[8] See ibid., 19–20.

[9] See Charles Norris Cochrane, Christianity and Classical Culture: A Study of Thought and Action from Augustus to Augustine (Indianapolis, IN: Amagi Books, 2003).

[10] See George Grant, Time as History (Toronto and London: University of Toronto Press, 1995).

[11] See, e.g., George Grant’s essay, “Thinking about Technology,” in Technology and Justice (Notre Dame, IN: University of Notre Dame Press, 1986).

[12] See The Human Condition, 84–85.

[13] Ibid., 18.

[14] Ibid., 50.

[15] See ibid., 221.

[16] See ibid., 10–11.

[17] See 1 Corinthians 15:26.

[18] See John 1:1–4; see also Philippians 2:5–11.

[19] See Eric O. Springsted, ed. Simone Weil (Maryknoll, NY: Orbis, 1998), 73.

[20] See St. Augustine, City of God, XXII/30.

[21] See St. Augustine, Confessions, I/1.

[22] See St. Augustine, City of God, XIV.

[23] See Karl Barth, Church Dogmatics, III/4.55.

[24] See Gilbert Meilaender, Bioethics: A Primer for Christians (Grand Rapids, MI: Eerdmans, 1996), 24–25.

[25] See John F. Kilner, Life on the Line: Ethics, Aging. Ending Patients’ Lives, and Allocating Vital Resources (Grand Rapids, MI: Eerdmans, 1992), 65–69.

[26] See Brent Waters, “Welcoming Children into our Homes: A Theological Reflection on Adoption,” Scottish Journal of Theology, (55:4) 2002.

[27] See David C. Thomasma and Glenn C. Graeber, Euthanasia: Toward an Ethical Social Policy (New York: Continuum, 1991), 85–86.

[28] See Barth, Church Dogmatics, III/4, 400–409.

[29] See Paul Ramsey, The Patient as Person: (New Haven, CT and London: Yale University Press, 1970), 134.

[30] 1 Corinthians 15:55.

This article is adapted from a Combined Institutes Lecture given at the conference, Bioethics Nexus: The Future of Healthcare, Science, and Humanity, held at Trinity International University, Deerfield, Illinois, 10 July 2007. The article originally appeared in Ethics & Medicine: An International Journal of Bioethics 25, no. 2 (2009) and is used by permission.