The Yale Journal for Humanities in Medicine

Spirituality, Religious Wisdom, and the Care of the Patient

Reconciliation at the End of Life

David Novak, Ph.D.
david.novak@utoronto.ca

David Novak holds the J. Richard and Dorothy Schiff Chair of Jewish Studies at the University of Toronto. He is a founder of the Institute for Traditional Judaism and serves as secretary-treasurer for the Institute on Religion and Public Life. He is the author of eleven books, most recently Covenantal Rights, which won the 2000 American Academy of Religion Award for best book in constructive religious thought. He has also served as a pulpit rabbi in several American communities and as Jewish Chaplain to St. Elizabeth's Hospital, National Institute of Mental Health.

One of the great decisions to be made by both patients and their health care providers is whether their current medical treatment is to prepare them for further life or for imminent death. The question is: What do both patients and their health care providers have to look forward to in the foreseeable future? Both the content and the method of one's current medical treatment in any particular case are very much determined by the answer to this most basic question.

In most cases of medical treatment, both the patient and the health care providers look forward to further life. Indeed, the success of the medical treatment requires this type of optimism on the part of all those participating in the treatment process. Even though the risks involved in this process, especially the fatal risks, should not be denied or ignored, the optimism called for by treatment for the sake of further life would seem to require that no one dwell upon these risks, let alone brood over them. Surely, a positive attitude is called for on the part of the patient whose own further life is being sought, and on the part of those seeking that further life for their patient.

But how are we to act when the prospect of further life is minimal or nil? And, even more basic is the moral question of whether patients and their health care providers may ever give up on their efforts to prolong a patient's life into an open-ended future.

In the case of health care providers, there is the problem of what might be termed the "success model" of medical treatment. Here the purpose of medical treatment is to prolong life; hence anything that would even call into question the ubiquity of that purpose is taken to be morbid pessimism. For those who base all medical treatment on this model, to acknowledge the inevitability of imminent death is to accept the shame of failure. Nothing should in any way impede or even call into question life-prolonging treatment, no matter how minimal the chances for success might be, and no matter how impaired the quality of the life of the patient whose life is being so prolonged will surely be, that is, even if he or she does survive the treatment. The reaction to this unrealistic medical optimism, which some regard as medical hubris, is to deny that the death of a patient ipso facto indicts their health care providers as shameful failures. And, this reaction also denies that preparing a patient for his or her imminent death involves pessimism, which is the exact opposite of the optimism required when we act for the sake of the furtherance of life. Some recent results of this reaction to the ubiquity of medical optimism have been the new emphasis on pain management in lieu of aggressive cure tactics in the case of terminal patients, and the hospice movement.

Pain management frequently means that our medical efforts are directed towards immediate care rather than ultimate cure. As for the hospice movement, some have called it "God's waiting room," namely, those who believe death will be God's taking our life away from us just as birth was God's giving our life to us, neither of which should be resisted or denied. In fact, the one time I visited a patient in a hospice, I was struck by the atmosphere of eerie calm and resolution resulting from the explicit waiting for death that is surely the raison d'etre of the hospice itself. That atmosphere is certainly an alternative to the usual medical optimism and self-confidence, yet it was not pessimism or despair either. Hence the hospice is not the exact opposite of the hospital. Perhaps the hospital in a place of one kind of hope and the hospice is a place of another kind of hope. Understood this way, there is far less hubris in hope than there is in the usual optimism of the hospital, and there is far less despair in hope than there is in what some think is the pessimism of the hospice. In both situations, patients and their health care providers are better able to face the truth.

The Jewish tradition is certainly life-oriented. Human life is to be conceived, birthed, nurtured, and prolonged. However, there are times when the tradition also recognizes that the prolongation of human life is not an absolute imperative. At times, we should be preparing for a noble death rather than a protracted dying. That does not mean, of course, that we are ever justified in deliberately terminating innocent human life. Even the life of the terminally ill requires our care until the end, not our efficiency in removing what has become a burden to everyone involved in that life, especially the person still living that life. Only the giver of life has the right to take it away at will. Nevertheless, we are permitted, perhaps even obligated, to inform patients of their imminent death when that death seems most likely to us, that is, when we can neither prolong the patient's life at all nor prolong it without causing profound and hopeless suffering to all concerned. Such information is a necessary part of our preparation for a patient's imminent death along with him or her.

Jewish tradition recognizes two states of imminent death. The person whose death is most imminent is called a goses: one who is in what used to be called the "throes of death." Today, especially when many persons in the throes of death are on life support systems, most of them are also comatose or only semi-conscious. As such, there is nothing they can do for themselves any longer; they cannot even make rational decisions, let alone communicate them to other humans. It is only a question of what we can do for them. So, for the most part, we are not to disturb the process of death by any interruptions, except doing what must be done to minimize the suffering of the patient. In fact, this means "letting the patient die." Some have even called this "passive euthanasia." But I think this term is confusing inasmuch as "letting the patient die" often means that we have to actively remove obstacles to death, obstacles that can only prolong the agony of dying. Accordingly, here only the patient is passive, almost always being incapable of any action at all.

However, before one becomes a goses, that is, when the imminence of one's own death is an urgent probability, yet one is still capable of rational decision-making, one is called a shekhiv me-ra, literally, one "lying down due to harm," what we would call being "on the critical list." Or, we often call such a person "dangerously ill," one with little chance of survival for very long. It is assumed that such a person is conscious and capable of the activity of rational decision-making. In fact, the tradition is so concerned with the decision-making capacity of this dangerously ill person that it allows us to consider important decisions made in this state to be fully effective immediately upon being made, "signed, sealed, and delivered," as it were. In more normal situations, on the other hand, many decisions are not fully effective until various procedures are followed in the interim - which may be long or short - between the original decision and its intended final result.

The reason for this dispensation from the normal procedures of implementation is because this dangerously or critically ill patient will probably be dead before being able to know that the result of his or her decision has been implemented. By dispensing with the normal, time-consuming procedures, we allow the critical patient the satisfaction of completing important unfinished business in his or her life. In fact, the Talmud presents the opinion that if we did not do so for this critically ill person, he or she might become deranged. This opinion seems to assume that we should do everything possible to enable a person to face his or her own death in a rational frame of mind, which means that he or she needs to be convinced he or she is still able to do something effectively with whatever little time he or she still has left. Clearly, all of this is a mutually active process between a patient and all those concerned with his or her care. Part of that care is leaving as little unfinished business as possible in this world.

Very often, though, patients in this end of life state, have unfinished business with significant other persons. How are health care providers to deal with this type of issue in the ebbing life of their patient? These significant other persons are either human or divine.

When it comes to the patient's relationship with God, be it the positive relationship of religious people or the negative relationship of nonreligious people (and I don't believe anyone is neutral, that is, neither positive nor negative, on the question of God), many would deny the right, let alone the duty, of any health care provider to get involved in the religious life of a patient at all. Most of us would regard health care providers who do get involved in the religious decisions of their patients to be engaging in impermissible proselytizing. (And this impermissible proselytizing could be done just as easily by an atheistic health care provider, trying to convince a patient of the futility of seeking God at the end of life, as it could be done by a religious health care provider, who is trying to "save the soul" of a patient in his or her care.) The most that a health care provider can do for such a critically ill patient is to ask him or her whether they would like to see a clergyperson (often a chaplain on the hospital staff), either of the patient's present faith, or of a faith the patient would like to accept before his or her death. Indeed, the only time a health care provider could do more than that with moral integrity is when the patient has actually chosen that health care provider because of the faith they both share in common.

However, when it comes to unfinished business with other significant humans, then a health care provider can take a more active role with moral integrity, that is, without fear of engaging in proselytizing. That is because there is more of a moral consensus in our multi-culture about what constitutes proper interpersonal relations between humans than what constitutes proper interpersonal relations between humans and their God.

For example, let us say you are a health care provider - usually a physician or a nurse - whose patient is a dying woman who for years has been estranged from her daughter. You know this because the patient herself has told you so. It is also safe to assume that the patient feels bad about this and wants some reconciliation with her daughter before it is too late. That is probably why she told you about her estranged daughter in the first place. She is asking for your help, even if the request is only implicit in the story she has told you. If she is a religious person, it is quite likely she doesn't want to face God's judgment at her death with the sin of indifference to her daughter weighing on her conscience. And, in the Jewish tradition, one is required to seek reconciliation from estranged significant human others before one can seek reconciliation with God at the time of ultimate judgment. But, even if this patient does not consider herself to be a religious person, or even if her religious beliefs do not include the idea of a final judgment by God, nonetheless she does not want to depart this life estranged from her daughter.

Under such circumstances, I think it is appropriate, maybe even moral obligatory, for the health care provider, who has been made privy to this agonizing situation in the life of his or her patient, to try to contact the estranged daughter. If contact can be made, either because the daughter can be found or because the daughter wants to be contacted, then the mother's need to be reconciled with her daughter should be emphasized to the daughter. Nevertheless, I do not think that the daughter's possible reconciliation with her dying mother should presented to the daughter as a matter of either charity or justice. The daughter should not be told to have pity on her poor dying mother. After all, maybe it is the daughter who deserves pity for what he mother may have done to drive her away. As for justice, for all we know the daughter might very well have the right to be estranged from her mother. The Jewish tradition recognizes that some parents are so wicked as to forfeit their right to honour from their children. (Honour, as in "honour thy father and thy mother," is taken to mean personal attention to them.) Instead, it should be emphasized that the daughter could accept her mother's desire for final reconciliation - irrespective of what actually happened between mother and daughter in the past - so that the daughter might not lose her mother with unfulfilled regrets over what might have been. It is in the daughter's best interest, emotionally speaking, to accept her mother's love now, even if she couldn't accept it in the past, or it wasn't there in the past to be accepted.

In my own experience as a hospital chaplain many years ago, having been part of a team of health care providers, I was able to persuade the estranged father of a dying son that their reconciliation would have to be now or never. In so doing, I believe a small contribution was made to the son's being able to depart this world in greater peace, and to his father's being able to say good-bye to his son in peace. I believe that this was morally required of me as a health care provider, whether I was a rabbi or not.

Christina M. Puchalski, "Forgiveness: Spiritual and Medical Implications"
Forgiveness: Introduction
Table of Contents

Published: December 16, 2002