Introduction

Pinki Virani thought that she was committing a charitable act by filing a plea in the Supreme Court of India (1) to end the life of Aruna Shanbaug, in a comatose state for 43 years at the KEM Hospital, Mumbai, following a sexual assault while on duty, on November 27, 1973. The Supreme Court turned down Pinki Virani’s plea on March 7, 2011. On another occasion, the Supreme Court upheld religious freedom through a judgment on September 1, 2015 (2), in the context of a fast unto death. It stated that the traditional Jain practice of Santhara or sallekhana was “simply a Jain way of mastering the art of dying, as much as the act of living”. Situations like these call for more urgent reflection than ever before on questions such as the fundamental value of human life and what alternatives we have to take care of dying persons when medical treatments become futile¹.

The term “palliative care” is spreading faster in the world of medicine than the names of medicinal drugs. Palliative care provides relief from pain, while affirming life and viewing death as a normal process. It is a system that provides special care and support to help not only dying patients, but also their families cope with the grim situation. This article focuses on the Christian perspective on the access of dying patients, especially those with incurable diseases, to palliative care. It has four parts, the first of which makes a brief attempt to understand human life and the concept of palliative care. Second, the article discusses the justification of the practice of palliative care within the Christian ethics tradition. Third, it considers the sacrament of anointing the sick in terms of a concrete application of palliative care. Finally, it discusses the magisterial teaching of the Catholic church, with a brief reference to the Protestant churches.

Human life in its totality and holistic palliative care

Christianity has always upheld the sacredness of human life. The dignity of life begins right at the time of conception. In all its teachings and doctrines, it emphasises that everyone has the basic right to have a decent and dignified life till the last breath. It has shown care and concern for even the last and the least valued in society. An outstanding example of a champion for the dignity of human life is Saint Mother Teresa of Kolkata, India. She is revered for her great zeal and commitment to upholding the dignity of life, whether at birth or death. She was deeply convinced that being unwanted, unloved, uncared for and ignored by everybody gives rise to a much greater hunger and poverty than does physical starvation.

“What is life?” is a million-dollar question. No one discipline seems to have a simple and straightforward answer to this question. Perhaps different disciplines – science, philosophy and religion – need to join forces and undertake this difficult task of exploring the meaning of life. Even then, however, a real grasp of the notion of life seems to be elusive. Dictionaries may roughly understand life as “the condition that distinguishes animals and plants from inorganic matter, including the capacity for growth, reproduction, functional activity, and continual change preceding death”. They may also refer to “the existence of an individual human being or animal” (3). Nevertheless, this still leaves us with several questions: Is life in our genes, or cells, or blood? When a person dies, what exactly happens? What exactly leaves him/her? The brain of a living person and that of the person who has just died will structurally look alike, but there is an enormous difference between those two brains.

The body is sacred and the life that activates it is sacred. “Therefore, the embryo, as well as the handicapped and patients in a comatose state, are all persons with dignity and any intervention on their body is to be in accordance with and respecting the dignity of the human person.” (4) Embryology, by and large, affirms that the beginning of a human being can be traced back to the time of fertilisation, when the male and female cells (sperm and egg) come together: “Fertilisation marks the beginning of the life of the new individual human being.” (5) Hurlbut says that “the act of fertilisation is a leap from zero to everything” (6). The new organism is complete from the moment of conception/fertilisation and nothing will be added to the existential and moral aspect of the embryo thereafter.²

Human beings are not just physical beings; their bodies are not merely “bodily”. The human body is not a machine made of different parts, but a colony of trillions of cells and about 250 trillion germs of all kinds. The human body is a living colony, all the members of which are interrelated with one another in a very fundamental way. Today, system biology has made it clearer than ever before that biology cannot be fully explained in terms of mechanical rules. Going against the tendency of reductionism, Emergentism advocates that complex systems and patterns are the emergent properties of simple interactions among their multiple parts (7). It argues that the emergent properties of complex systems show that they cannot be reduced to the parts, because complex systems are essentially irreducible and only a holistic approach will give us a real picture of these since the process of emergence results in something that is more than the sum of its parts. The tendency, therefore, to reduce all sciences to basic physics (“physicalism”); or to treat psychology as applied biology; or to treat biology as applied chemistry, is being seriously questioned today. According to holism, the complex systems are intrinsically irreducible and since the whole is more than the sum of its constituents, they can be understood properly only through a holistic approach. This outlook is also not new. Even Aristotle, in his Metaphysics (8), proposed that the whole is more than the sum of its parts. In biology, this approach could be interpreted to state that disease is more than the sum of the disordered parts and the interactions among them. Therefore, a patient is seen as a person, and the disease is viewed as a whole rather than being judged by the interactions between the cellular or molecular levels. Vitalism argues that the laws of physics and chemistry alone do not suffice to explain the processes of life, and that the life principle, rather than physical-chemical forces, is self-determining (9).

Palliative care ministers include physicians, nurses, social workers, psychologists, chaplains, pastoral workers and spiritual counsellors. In their own capacity as professionals all of them have to contribute to the total welfare of the patient being given palliative care. Physicians and nurses have to overcome the temptation to treat the patient only from the medical perspective; they must also take the patient’s spiritual and existential dimensions seriously. They do all that is possible to make patients in palliative care feel comfortable and confident about facing death, an undeniable reality of life. However, palliative care ministers need to be careful not to forget their own convictions and spiritual values while treating patients. They must not give up their own ethical and existential integrity and compromise just to make the patient feel comfortable.

The sacrament of Last Anointing: an actualisation of palliative care

Palliative care, as we know, has emerged as a specialty only about 15years ago. The basic conviction underlying it is that patients with incurable and terminal illnesses should be taken care of holistically. The goal of palliative care is to improve the quality of life both of the patient and the family. Thus, the idea of complete care encompasses care for the family too. The holistic approach of palliative care emphasises physical, emotional, spiritual, existential and social aspects. Palliative care does not serve only the dying. Instead, it focuses more broadly on improving life and providing comfort to people who may be of any age and have serious, chronic and life-threatening illnesses, such as cancer, cardiac disease (eg congestive heart failure), chronic obstructive pulmonary disease, kidney failure, Alzheimer’s, Parkinson’s and amyotrophic lateral sclerosis. The spiritual dimension of palliative care has specific goals: to comfort the grieving, break through their isolation, deliver them from fear, to help them deal with guilt, enhance their emotional stability, and encourage them to face the pain together (10). In Christianity, most of these elements are well taken care of in the sacrament of the Last Anointing (or Extreme Unction).

Christianity is convinced that patients at the very fag end of their lives, with all their ailments and agonies, are still people who have been created in the image and likeness of God. They cannot be dehumanised and reduced to bundles of corrupted and malfunctioning organs. This is one of the basic convictions that motivate Christians to take care of the sick and the dying. As Christians believe in life after death, the experience of death is not at all a frightening one. Since they believe in the resurrection of Jesus, everything does not end with death for them; death is not an end, but only a bend. Perhaps, from this end we do not clearly “see” what is waiting at the bend! This is what is reaffirmed in the sacrament of the Last Anointing.³ It must, however, be stated that the primary purpose of the minister is not to tend to his or her own beliefs, and not to impose an agenda, belief or values on patients and their families, but to serve them by heeding how they find meaning, and to respond to the needs both of the patients and their families in their concrete life situation. Though Christians believes that God has miraculous powers to cure illness, they are also convinced that such cures are only temporary because we all have to die one day. Therefore, the care of patients at an advanced stage of illness involves preparing them for a peaceful death. It helps them to become reconciled to the fact of life and not to be frightened of death because death, after all, is not the ultimate disaster; it is not the end of everything, but the beginning of a new life.

Patients in palliative care suffer not only physical pain, but also psychological suffering, besides experiencing a spiritual “vacuum”. With advanced medications, one may be able to reduce or even totally remove the physical pain, but not the patient’s “suffering”. The very thought of being forsaken by everyone and forced to resign oneself to death will create fears and a sense of “vacuum”. That is why palliative care treats patients in their “totality”. In the words of Bert Broeckaert, “Palliative patients can suffer terribly even when they have no severe physical symptoms or when their physical symptoms are well controlled. Coping with this existential suffering, with this ‘cry for meaning’ (Victor Frankl) may sometimes be more important than medical or technical solutions. Indeed, the existential or spiritual domain is an important determinant of quality of life for many patients.” (11)

Christianity firmly believes in the healing power of Jesus Christ. The sacraments of Christianity bestow upon the recipients the grace that they need for their daily life. The sacrament of reconciliation (or penance), as the Catholic Church teaches, heals those who are sincerely penitent of the effects of their sins. The sacrament of the Last Anointing completes and complements the sacrament of penance, by removing the state which might be an obstacle to the obtaining Resurrection. The sacrament of the Last Anointing is administered by the ordained priest at the time of death or danger to life. Earlier, it was given only to patients at the fag end of their life, but now it is administered to any seriously ill person, even if there is no danger to his/her life. The recipient becomes like the risen Christ during and through the last anointing. In this way, the sick are duly prepared for a happy journey to eternity.

By anointing the sick with olive oil and having them blessed by the Bishop during the Chrism Mass of the Holy Week every year, the Holy Spirit takes away their sins, removing the stains of their sins. Then it creates confidence in the eternal mercy of God. The sick are strengthened to face and bear the pain of illness. The anointment of the sick enables them to overcome the fear of death, which is instilled by the devil. As St Paul declares, Christ has overcome death: “Where, O death, is your victory? Where, O death, is your sting? The sting of death is sin, and the power of sin is the law. But thanks be to God! He gives us the victory through our Lord Jesus Christ” (1 Corinthians 15:55–57) (12). Thus, with the anointment of the holy oil, the sick participate in that victory and share in the resurrection of Christ.

Sacraments make the invisible God’s grace visible; the intangible power of divinity is made tangible in and through the sacraments. In the words of St Augustine, “A sacrament is the visible of invisible grace.” The teachings and explanations of the sacraments were set forth by Peter Lombard, further explicated by Thomas Aquinas, and clearly defined and promulgated by the Council of Trent (1545–1563) (13). “The special grace of the sacrament of the Anointing of the Sick has as its effects: the uniting of the sick person to the passion of Christ, for his own good and that of the whole Church; the strengthening, peace and courage to endure in a Christian manner the sufferings of illness or old age; the forgiveness of sins, if the sick person was not able to obtain it through the sacrament of Penance; the restoration of health, if it is conducive to the salvation of his soul; and the preparation for passing over to eternal life.” (Catechism of the Catholic Church, no. 1532) (14)

The Church bases itself on the Biblical text of James 5:14–15 (12): “Are any among you sick? They should call for the elders of the Church and have them pray over them, anointing them with oil in the name of the Lord. The prayerof faith will save the sick, and the Lord will raise them up; and anyone who has committed sins will be forgiven.” The other references supporting this aspect of the healing ministry of the Church are: “Cure the sick, raise the dead, cleanse the lepers, cast out demons. You received without payment; give without payment” (Mathew 10:8) (12); “Whenever you enter a town and its people welcome you, eat what is set before you; cure the sick who are there, and say to them, ‘The kingdom of God has come near to you'” (Luke 10:8–9) (12); and, “They cast out many devils, and anointed with oil many that were sick, and cured them” (Mark 6:13) (12).

Christian ethics and palliative care

Human life is very fragile during its beginning and its end. Vulnerable preborn human beings and aged people need care and protection. There are unending debates and ethical standpoints on the moral value and status of human embryos. On the basis of these arguments, philosophers, physicians and other scientists either accept or oppose abortion and other life-destroying techniques and technologies. Similarly, the question of euthanasia is being discussed and debated all over the world. There are people who argue that euthanasia is preferable to the prolongation of futile treatments, and there are others who oppose euthanasia. The Catholic Church and other agencies argue that nothing can justify ending, taking away or killing an innocent human life (15). All that we need is a consistent ethic that respects the fundamental right to life, whether at the initial or end stages of life.

Palliative care provides pain relief to terminally ill and dying patients. It accepts the withdrawal of futile treatments, while regarding death as inevitable and dying as a normal process. It is not aimed at hastening or postponing death. Palliative care helps to reduce the unbearable physical pain and affirms the aspect of human suffering. It helps the patient to cope with the pain and suffering positively. Can we justify palliative care within the tradition of Christian ethics? Is it right to increase the amount of morphine administered to the patient at the end of life to deal with pain, and thereby, indirectly hasten death, considering the effect of morphine on the respiratory system? This falls under the typical principle of double effect, developed by Thomas Aquinas in his work, Summa Theologica (16). According to the principle of double effect, it is morally permissible to perform an act that has double effects – good and bad – provided that the following conditions are met: (i) the act must not be intrinsically evil, but good or at least indifferent; (ii) the good effect must be the intended outcome and the evil effect the unintended outcome; (iii) the good effect must not be caused by the evil effect; and (iv) the unintended evil effect must not outweigh the good effect.

Bridget Campion, a Catholic bioethicist, has applied the principle of double effect to the issue of pain relief at the end of life. The intended good of pain relief is within the normal standards of medical practice. Pain relief is not intrinsically evil. Increasing the dose of morphine is associated with an unintended risk of hastening the patient’s death, which is possible but not sought.⁴ The intended good is not achieved by hastening the patient’s death; the latter is only a side-effect, unlike in the case of physician-assisted suicide, in which death is a means of putting an end to the patient’s suffering. By increasing the dose of morphine and thereby relieving the patient’s physical pain, the caretakers make it possible for the patient to attend to outstanding issues, such as spiritual matters or family reconciliation. The intended good is much greater in proportion than the unintended effect of hastening death. It is good both for the patient and the family if the patient is freed from physical suffering prior to death. The risk of hastening death might be tolerated in the process (17).

Palliative care is thus ethically justified and should be lawfully promoted. The Catholic tradition, which finds the principle of double effect perfectly valid and logically justifiable, not only accepts the hospice practice of palliative care, but would also promote it as a part of its proclamation regarding God’s love for the suffering and the sick. It falls within the manifesto of Jesus, who affirmed the life of all people, including sinners, and accepted the existential fact of suffering on a cross as a model for human beings.

Magisterial teaching on palliative care

In this final section, we would like to draw attention to the official teaching of the Church on palliative care. The purpose of this section is not to impose the views of the Church on medical professionals, but to show that the official Church has a positive view of palliative care.

While discussing the dignity of human life and the practice of euthanasia, which denies human dignity, the Catechism of the Catholic Church encourages caregivers and family members to treat sick or handicapped persons with “special respect” (Catechism of the Catholic Church, no. 2276) (14). “True ‘compassion’ leads to sharing another’s pain; it does not kill the person whose suffering we cannot bear” (Evangelium Vitae, no. 66) (18).

The doses of narcotics required to effect adequate pain management in the treatment of some serious illnesses, such as cancer and AIDS, are associated with a foreseeable risk of shortening the patient’s life. Pope Pius XII taught in a 1957 address that it is permissible to relieve pain with narcotics, even if it decreases the patient’s consciousness and shortens his/her life: “If no other means exist, and if, in the given circumstances, this does not prevent the carrying out of other religious and moral duties… death is no way intended or sought,… the intention is simply to relieve the pain effectively” (19).

The Church subsequently reaffirmed the morally licit nature of authentic palliative care, so long as the medicines are not taken or prescribed with the intention of bringing about the patient’s death. The Catechism describes palliative care as a special form of charity, which should be encouraged (Catechism of the Catholic Church, no. 2279) (14). The Church recognises the legitimacy of palliative care, which aims to make suffering more bearable in the final stage of illness and to ensure that patients are supported and accompanied throughout their ordeal (Evangelium Vitae, no. 65) (18).

The second issue that arises pertains to what measures must be taken to preserve life. Patients, family members and healthcare providers are not morally obligated to pursue every possible avenue of extending human life. Instead, “it needs to be determined whether the means of available treatment are objectively proportionate to the prospects for improvement” (Evangelium Vitae, no. 65) (18).

The Church has distinguished between “extraordinary” and “ordinary” care, with the latter being morally obligatory: “Discontinuing medical procedures that are burdensome, dangerous, extraordinary, or disproportionate to the expected outcome can be legitimate; it is the refusal of ‘over-zealous’ treatment. Here, one does not will to cause death; one’s inability to impede it is merely accepted” (Catechism of the Catholic Church, no. 2278) (14).

Even when death is considered imminent, patients, by virtue of their human dignity, should continue to receive “ordinary” care. Such care includes nursing care, hygiene and palliative care. It also involves nutrition and hydration, orally or with artificial assistance, if this helps to support the patient’s life without imposing serious burdens on him/her (20). Allowing the patient to die a natural death with dignity does not amount to euthanasia. While it is not permissible and is, indeed, reprehensible to cause the death of patients through starvation or dehydration, providing food or water to patients in the final stages of the dying process would cause greater hardship than relief, and those tending to these patients may forego such care (21).

In providing palliative care and foregoing “over-zealous” treatment, the goal is not to terminate the patient’s life, but on the contrary, to treat the patient with dignity and respect. The patient’s death is accepted without being willed or deliberately accelerated. In both cases, we see the principle of double effect in action. Some forms of treatment may have two effects – one good (for example, pain relief) and one evil (shortening of the patient’s life). In appropriate circumstances, the treatment may be provided because of the intended good effect, despite the possibility of the foreseeable but unintended bad effect (Catechism of the Catholic Church, no. 1737) (14). The pivotal issue is what one is trying to accomplish through a given medical decision. If the intention is to kill or shorten the patient’s life, then it is not morally justifiable.

In March 2015, while addressing the members of the Pontifical Academy for Life, Pope Francis spoke about the theme of the Assembly: “Assisting the elderly and palliative care.” Palliative care, he said, “is an expression of the properly human attitude of taking care of one another, especially of those who suffer. It bears witness that the human person is always precious, even if marked by age and sickness.” He said that palliative care recognises the value of the person at the end of life. He called on all those involved in palliative care to preserve this spirit of service, and to remember that “all medical knowledge is truly science, in its most noble sense” only if it has in view the true good of the human being, a good that can never be achieved when it acts contrary to human life and dignity. According to Pope Francis, “It is this capacity for service to the life and dignity of the sick, even when they are old, that is the measure of the true progress of medicine, and of all society” (22). When we care for the sick, the marginalised and the dying, we are truly caring for Him/God. As the late Mother Teresa would often say, she was serving the “hidden Jesus” in the poorest of the poor in Calcutta.

The Protestant churches do not have magisterial teaching. Even then, in many Protestant churches, bishops and their conferences affirm the importance of palliative care. For example, the community of Protestant churches in Europe came up with a well-studied document titled A Time to Live and a Time to Die, following thorough consultations between the 105 Community of Protestant Churches in Europe (CPCE) churches in 30 countries. The study emphasises the need to improve the social and medical conditions, as well as the conditions of care, for the patient to lead a worthwhile life and have a peaceful end. These include the extension and development of hospices, and the advancement of palliative care in theory and practice (23). This document found an echo in the voices of the Anglican bishops in the British Parliament on October 23, 2015, emphasisingas they did the need for palliative care. The House of Lords debated the Access to Palliative Care Bill, a private member’s Bill tabled by a cross-bench peer, Baroness Finlay of Llandaff. In her words, the Bill sought to “ensure that wherever a dying person is, whatever the time of day or night, whatever day of the week, they can receive high-standard care… It would do so by ensuring that commissioners commission a level of service for their populations to meet need… My Bill would ensure coordination so that help is accessible, efficient and can meet needs” (24).

Conclusion

The underlying conviction and faith of Christianity is that in spite of the seemingly hopeless situations faced by terminally ill patients, they have to be encouraged to retain a sense of meaning in life. Viktor Frankl was convinced that “human life, under any circumstance, never ceases to have a meaning, and that this infinite meaning of life included suffering and dying, privation and death” (25). When wealth is lost nothing is lost, as wealth can be regained; when health is lost something is lost, as one’s total health cannot be regained, but when meaning in life is lost everything is lost. The ability to see meaning in life gives rise to joy and reduces pain. Recalling an event, Viktor Frankl said, “One week later, she died. During the last week of her life, she was no longer depressed but on the contrary, proud and full of belief. Before that, she had lots of difficulties because she thought she was useless. Our talk made her aware that her life was meaningful and even her suffering made sense. The last words she spoke were: ‘My life was not meaningless. My life is a monument.'” (26)

With a strong spiritual tradition and firm faith in the God of life, love and laughter, Christians can always smile at life, in spite of the pain, suffering, agony and uncertainties it may bring. Life is beautiful and meaningful till its very end. These words of Jeff Stephenson are true and thought-provoking: “Working in palliative care can be challenging and demanding. People die only once, and as carers we only get one chance to get it right. But it is also tremendously rewarding and full of opportunity–Christians have a huge amount to contribute.” (27)

The Catholic tradition recommends palliative care for the terminally ill and the dying to help them cope with the realities of pain, suffering, life and death. Death is inevitable and imminent, but that does not mean it can be planned and imposed. Palliative care restores the whole person, giving the sufferer a sense of meaning that helps him/her cope with the life–death situation. We may not be able to save terminally ill patients, but we can help them have a joyful and meaningful death. While patients have a right to healing, they do not have an absolute right to live at all costs. The Catholic tradition accepts the withdrawal of futile medical treatments, and through the sacrament of the Anointing of the Sick, promotes the preparation of patients for restoration, reconciliation and a good death. Thus, palliative care is a great opportunity for Christians to manifest God’s unfailing love through the protection of human life, which has meaning beyond death.

Notes

¹ The first case implies the fact that Virani did not seek the consent of the patient and Virani was acting as a third person. The second case implies a personal voluntary commitment to faith. These two cases are used as stimuli and are not interrogated further in the article, since it focuses on the Christian perspectives of the healing ministry, issues concerning end-of-life care, and palliative care.

² Though the question of the origin of life may seem irrelevant here, the issue is raised only to show that human beings, from the Christian perspective, are considered sacred right from the moment of conception till death; and this, in turn, constitutes the rationale of the Christian commitment to palliative care.

³ The Catholic Church used the expression “Extreme Unction” in its early documents. However, from the early 1970s, it prefers to call it “The Last Anointing”.

⁴ Primafacie, there seems a hint of subjectivism as the decision hinges on the intention. This can be said of any moral theory that lays emphasis on the intention rather than the consequence. The assumption underlying this position is that human beings have the ability to know the difference between right and wrong, and in freedom, would choose right over wrong. This moral theory gives importance to the right reasoning of a human being. Thus with a clear conscience, we assume that a human being will not intend something wrong and justify his action on the ground of right intention.