ICU – At the Border between Life and Death [2]

C. Death- the rupture of the psychosomatic coalescence.

a. The notion of death

The notion of death, apart from its biological dimension, is also metaphysical. For Orthodox theology and tradition, death is the rupture of the coalescence of body and soul, the loosening of the bond, the separation [1].

But for the empirical sciences, this definition is without significance. The soul is not visible. Any attempt to approach death from the viewpoint of changes to the soul, particularly when we’re referring to what is happening to the body, runs the risk of scholasticism and arbitrariness. This is why it is safer to define death as necrosis of the body, subjection to the laws of nature, by which the soul, because of its own nature, remains unaffected. At the moment of death the soul doesn’t leave the body, so that the latter collapses- the soul isn’t something that goes in and out, but something that either co-exists or doesn’t; it’s the process of decay which makes the body unable to follow the course and to accept the life-giving energy of the soul [2], so that the totality of human nature is destroyed and the cohesion of the human person collapses.

In this sense, we might accept that the destruction either of the psychosomatic association or that of the functional cohesion of the body, which occurs with necrosis of the brain, marks the dissolution of the totality and integrity of human nature and this defines death.

The soul also has a causative, natural element and spiritual self-determination. The main organ of psychosomatic cohesion, the primary organ linking the body and soul from the point of view of physiology, is the brain. Therefore, we might define as “death” the final collapse of the body and the irrevocable cessation of manifestation of the psyche (self-determination, self-reliance, potential to express, receptivity, consciousness and so on), which, in reality, occurs with the cessation of brain functions.

b. The moment of biological death

The moment of death is the foremost moment that defines human value and is the time when God’s closeness to us is most keenly felt. This is why we regard it with awe, respect and a sense of mystery and humility.

We people are mortal beings and so death runs through our whole lives [3]. The count-down begins at birth. Death isn’t a single, simple moment. But when mortality becomes irreversible- not as a prognosis but as a procedure- then the person is biologically dead. The body ceases to exist as a living body the moment is ceases to support the person [4].

The Church, of course, regards death as a mystery [5]. And mysteries are not readily accessible, nor are they recognized, much less defined. For this reason, any attempt at the casuistic definition of details which, in the nature of things are not interpretable or accessible runs the risk of desecrating the sacred through incorrect knowledge and the audacity of certain definition, thus stripping it of its nature as a mystery.

The experience of Church life itself throws up difficult cases which prove that death is not a natural event that can be defined clearly, but rather a spiritual one which is approached with humility and fear. It’s an event which can be described, in general terms, but not precisely determined. This is also the reason why, in the Orthodox Church we avoid equating death with the cessation of brain, cardiac or other function.

c. The value of the last moments

The disposition to provide support and the effort to delay the moment of death for as long as possible are an expression of our natural struggle, as people, with the event of death as a concomitant of the Fall.  This least, last part of life may perhaps be of greater value than all that preceded it. And it is of greater value for the doctors and relatives protecting it than for the patient whose due it is [6]. Because the support, the hope and the desire for the life of the other person, central features of the spiritual life, are incomparably superior to the biological life of the patient.

The final moments of the life of a person, however, are of particular significance for that person, too. And may be of greater importance than any or all the other moments of their life [7]. Because the soul is judged in those moments, it may repent; it passes from the ephemeral to the eternal. Time is the guarantor of the connection between the soul and body. This is why death should not be actively hastened on any account.

Death is such a sacred event for each person that its purity must be retained at all cost. It’s the moment when the person deserves the greatest respect from society, which should no in any way demean this mystery by turning it into a cold, mechanical, temporal event. At the moment when the body is orphaned from the protection of the soul, it would be terrible if we were to strip it of its last vestige of dignity.

This is also the reason why the Church rejects euthanasia on any grounds whatsoever- especially assisted suicide- and why is it is troubled and wary in the face of what medical technology has created and what medical science calls “brain death”.

d. Life and survival

Quality of life must be compatible with survival. Nature accepts life only with particular specifications for its quality. Today we technologically impose survival on terms of unacceptable quality. Survival, maintaining breath, is one thing; life is another.

The many traffic accidents, the astonishing progress in pharmaceutical and medical technology have resulted in people being kept alive under extreme conditions. Thus, for example, in cases of cancer, invasive chemotherapy or radiotherapy does, indeed, grant an extension of life, but often leads to instances of multiple metastases which reduce the quality of life to unprecedently low levels. Nature itself, when life threatens to descend into mere survival, “protects” it with death. Modern technology, on the one hand, does away with death’s protection in these cases, and, on the other, has created forms and expressions of death unheard of in the complexity of their forms. To put it differently, but for the machines, we would die differently. The progress of technology has created people who either can’t die or can’t die naturally.

Another case is the use of a respirator, which, if, in the end, does not prove to be life-saving for the patient, brings us to the diagnosis of brain death, a state which is, perhaps more undesirable for the dilemmas it causes and certainly not desirable at all in terms of its therapeutic achievement. Medical intervention in cases such as this doesn’t provide treatment, opportunity or hope; it’s simply an impasse.

On the basis of this, if we agree that, for those who are brain dead, their condition is irreversible, loss of consciousness is final, and life is possible only with mechanical measures, then, in these cases, the respirator does not provide life, but mere survival; essentially it hinders the process of death without being able to provide any kind of treatment. Mechanical assistance has some point only when it grants relief, hope and the prospect of life; in cases when the patient can regain control and recover.

Efforts aimed at forcibly maintaining life “also have something of the nature of an arrogant attitude towards people, similar to that of bringing it to an end by force” [8]. Just as we have no right to hasten death, so we may not drag it out as a process. We need to accept it and respect it [9].

On the other hand, we only make an intervention in the body for therapeutic purposes. Any action which advocates and hastens its physiological decomposition affronts the soul, too. This is why the process of decay must be entirely natural and never forced.

e. Transcendence of life and transcendence of death

There is a case where respect for life means we have to fight with all our strength to keep someone alive, even with extensive bodily impairment. We supply what’s missing with our love, which is invaluable. In this case, the matter at issue is not whether the patient will live; nor is its success undermined by the possibility of bodily impairment. The expression of medical love, the common struggle by a group of doctors and nursing staff, the determination that evil (accident, criminal activity, carelessness etc.) shall not prevail are focused on keeping the person alive. This has greater value.

Then there’s another case where respect for the person means not simply that we allow but even make it easier for them to die. This doesn’t mean that we make them die, but that we pray for their death, rather than, as we usually do, for an extension of their life: out of love for them we’d prefer that they be deceased rather than tormented. The Church prays for the facilitation of the departure of the soul (the prayer for those close to death)[10], because for the Church, life is certainly a great gift, but it might be that death is a greater blessing.

Society respects the wishes of the dead even as regards the details of the post-mortem condition of their body: where it will be buried, whether wreaths will be accepted, whether coffee will be served and so on, provided these don’t clash with its centuries-old values and inviolable principles. Despite this, we would not be able to grant the wish of a patient who asks for help in hastening the moment of death. In cases such as those, our love is expressed more as respect for the gift of life, rather than for the wishes of the patient.

Notes:

1. Nemesios Περί φύσεως ανθρώπου, chap.2 Περί ψυχής, (PG 40.304 ff); essentially he quotes Chrysippus. Also James 2, 26, Gregory the Theologian, Ποιήματα ηθικά, 34, 25 (PG 37.947Α), Gregory of Nyssa (PG 45.1153D) et al.

2. This is obvious in the case of animals which lack an immortal and reasoning soul. So when we talk of biological death, we means the collapse of the bodily functions.

3. Archbishop Christodoulos of Athens and All Greece, Η Εκκλησία και το πρόβλημα της ευθανασίας, Thessaloniki, 2002, p. 21.

4. Protopresbyter Nik. Loudovikos Μεταφυσική και εσχατολογία του σώματος, Επιστημονική Επετηρίς της Θεολογικής Σχολής του ΑΠΘ, Τμήμα Θεολογίας, vol. 4, new series, pp. 113-137.

5. Nikolaos Vasileiadis, Το μυστήριον του θανάτου, Sotir, Athens, 1991, pp. 3-7. Death “the greatest mystery of the Wisdom of God” (John Chrysostom, Εις το κατά Ιωάννην, Ομιλία 83, 1, PG 59.447).

6. Inter-parliamentary Assembly on Orthodoxy, Euthanasia, General Principles, no. 8, Vilnius, Lithuania, 28 June 2003.

7. Hieromonk Cleopas Ilie, Πνευματικοί Λόγοι Orthodos Kypseli,, Thessaloniki, 1988, pp. 177-181.

8. Metropolitan Ioannis (Zizioulas) of Pergamon, Ευθανασία• Αποφάσεις κατά το τέλος της ζωής, Pandokheion, June 2002, vol. 6, p. 58.

9 Harakas, Stanley, Contemporary Moral Issues Facing the Orthodox Christian, Light & Life Publishing Co, Minneapolis, 1982, p. 176.

10. “Release your servant from this unbearable pain and from this continuing bitter sickness and give him/her rest with the spirits of the just” .