Here is another really good article for Orthodox who are in the medical industry...
Health Care and Theosis
by Fr. Philip LeMasters
...Orthodox Christianity envisions the salvation of the whole person - body, soul, and spirit -in the Kingdom of God. No bit of human existence, or of the creation as a whole, is by nature isolated from our Lord’s salvation. The incarnation of Jesus Christ is Good News for every dimension of us, especially when we are sick and in need of physical healing.
That is why the concept of theosis shapes our understanding of the practice of medicine. Theosis refers to the Orthodox understanding of salvation. Namely, humans find eternal life as they grow in holiness and union with the Trinity. Salvation is a dynamic process of fulfilling our true nature as those created in the image of and according to the likeness of God. Even as the divine and human natures are united in the one person of Jesus Christ, theosis refers to the fulfillment of our humanity through deification. As the Lord was raised from the dead as a complete, embodied person, the Christian hope is for the resurrection of the entire person - including the body — in the coming Kingdom of God. In all dimensions of our humanity, we are to become by grace what God is by nature, to share in the eternal life of the Trinity.
It might be tempting to dismiss the practical relevance of such a seemingly abstract spiritual vision for the practice of medicine. Nonetheless, we must remember that the Orthodox understanding of salvation focuses on victory over death. As we sing throughout the Paschal season, “Christ is risen from the dead, trampling down death by death, and upon those in the tombs bestowing life.”
Not envisioning a disembodied or purely spiritual life, Orthodoxy teaches that “the problem of sickness and death and Christ’s victory over death is at the center of what we say about salvation.” Western Christianity is dominated by Anselm’s theory of the substitutionary atonement, with its view of God as the vengeful Father Who demands His pound of flesh from the Son for our salvation. In contrast, the Christian East understands humans to be sickly, weak creatures in need of healing from the corrupting consequences of sin, not fundamentally as violators of a law who are in need of someone to appease God’s wrath on their behalf. “In the East, the sin of Adam is primarily understood not as disobedience to the Law but as a willful disruption of the communion between God and man. As a result, a distortion of man’s whole being, body and soul,entered in, as man is only healthy when rightly related to God.” St. Ignatius of Antioch referred to the Holy Eucharist as “the medicine of immortality, and the sovereign remedy by which we escape death and live in Jesus Christ for ever more.” The Church ministers to the healing of the whole person in the Holy Mysteries. Baptism, Chrismation, Eucharist, Confession, Holy Matrimony, Holy Orders, and Holy Unction all seek the healing of our corrupt nature, body, soul, and spirit.
When we remember our Lord’s healing ministry, it should not be surprising that Orthodoxy gives such a prominent place to the healing of the body in our salvation. To provide bodily care to the sick is a means of participating with Christ in the life of the Kingdom. The purpose of such care, however, is not simply tofacilitate the functioning of a biological organism. Fr. John Breck notes that it should also “strive to provide optimal conditions for the patient’s spiritual growth at every stage of the life cycle.” It is often beyond our capability to cure a particular patient; indeed, all patients — including ourselves - will eventually die. In terminal cases, the most appropriate care will ease pain and “allow the patient, through prayer, confession and communion, to surrender him/herself into the hands of God.” Medical care should be used to serve our growth in holiness, to provide the kind of bodily care that helps us fallen creatures find holistic, eschatological healing in God. Consequently, medical technology should not become an idol of worldly self-preservation at all costs.
H. Tristram Engelhardt, Jr., quotes St. Basil the Great’s admonition that we eschew “Whatever requires an undue amount of thought or trouble or involves a large expenditure of effort and causes our whole life to revolve, as it were, around solicitude of the flesh.” Engelhardt observes that such spiritually burdensome measures “should be withdrawn or withheld. The postponement of death, the avoidance of suffering, and the correction of disabilities should not become all-consuming projects.” Instead, the overriding consideration is that Christians “remain on target,” using therapies that preserve and enhance life in ways that are consonant with growing in God’s holiness. Even as Orthodox asceticism calls for self-restraint in the consumption and enjoyment of the bounties of God’s good creation, we should make health care decisions in an ascetic way which refuses to make physical well-functioning the highest good of human life.
For the Orthodox, the highest good of our existence is our salvation, our holistic healing as those created in the image of and according to the likeness of God. Every Christian is the priest of his own life, and has the vocation to offer the entirety of his existence to the Father Eucharistically. In other words, our body and blood - together with the rest of the creation - are intended for restoration and communion with the Holy Trinity. Jesus Christ’s incarnate life, death, resurrection, and ascension are glimpses of the destiny of whole human beings, and of the creation itself, for eschatological fulfillment. We are to live Eucharistically by offering ourselves, in union with Christ, for the healing of the Kingdom. Our self-offering includes our bodies, and we have an obligation to seek physical healing in ways that facilitate our growth in holiness. We are to be stewards and priests of our lives, and to resist the temptation of making bodily health a false god. Even as Adam’s sin was to offer the world to himself, and not to the Lord, we must resist the temptation to value physical wellbeing as anything but God’s gift which we are to use in accordance with His gracious purposes for our salvation. As Fr. Alexander Schmemann observes, “The only real fall of man is his non-Eucharistic life in a non-Eucharistic world.”
In this context we must consider how to distinguish between health care that amounts to idolatry and that which helps us to share more fully in the life of God. Like any part of creation, medicine may be used for the glory of the Lord or to serve human pride. There is no doubt that certain forms of plastic surgery and weight-loss therapy, for example, exist primarily to promote vanity. Even medically indicated life-preserving measures may be sought as a desperate means to preserve one’s biological existence at all costs. No measure of clinical competence makes irrelevant the spiritual questions at stake in healthcare.
Since our experiences of health and illness occur in the world we have corrupted by our own sin, it makes sense to begin our discussion with the relationship between illness and the Fall. Jean-Claude Larchet shows that Orthodoxy views illness as a consequence of the Fall, and not the work of God. “When God specifies to our first parents the evils that will result from their transgression (Gen. 3:16-19), He does not produce those evils; He merely predicts and describes them.” A particular person’s sins should not be seen as the direct cause of his illness, but as signs that he shares in the consequences of humankind’s estrangement from God. Because of the Incarnation we may, through theosisy participate in Christ’s gracious restoration and fulfillment of all dimensions of human nature through ascetic struggle and the strengthening provided by the Holy Mysteries or Sacraments. Even those far advanced in theosis, such as the saints, are not immune from bodily infirmities. They may suffer more than others when God allows them to become ill, perhaps due to demonic attacks, for the sake of their own spiritual growth and that of those close to them. If disease may be a vehicle for growth in holiness, it may not be condemned simply as evil. As St. Gregory of Nazianzus remarked, “Do not admire every form of health, and do not condemn every illness.” Sickness may be placed in a deep spiritual context which we use to grow in our knowledge of the human condition before God. When approached in this way, illness destroys our pride and worldliness, directing us to the true life in God." In the mortification of the flesh and “destruction of passions” worked by illness, we find a form of asceticism which teaches us patience and humility.
Nonetheless, we are not to seek illnesses for the sake of spiritual growth, as they sap much energy for the care of the body that could be used more profitably for the journey of theosis. The mystery of Holy Unction is administered with prayers for healing so that the sick person will glorify, thank, and praise God, and be restored “to your Church... able tofulfill your calling.” Even as Christ has conquered death, deliverance from the disease of the body is an epiphany of the Lord’s ongoing victory over the powers of evil. It is not by accident that the Lord and His apostles and saints healed sick bodies as a sign of the Kingdom. The Church uses prayer, Holy Unction, holy water, the sign of the Cross, and exorcism to heal the sick. From St. Luke to the present, there have been Christian physicians who use conventional medical treatments to care for their patients. Indeed, the origins of the hospital are in fourth-century Byzantium under the tutelage of Saints Basil the Great and John Chrysostom.
A “dubious rigorism” led some in the early Church to condemn recourse to secular therapies, and monastic communities have at times made use only of prayer and other spiritual remedies. Nonetheless, it is clearly not characteristic of Orthodoxy to condemn conventional medical care. All of the remedies and therapies of healing are viewed as God’s creation, given to us for our health. “A physician, through his art as well as through the medicine he prescribes, is merely implementing the divine energies that were generously poured out by the Creator.” Saint Diadochos of Photiki states that “There is nothing to prevent us from calling a doctor when we are ill. Since Providence has implanted remedies in nature, it has been possible for human experimentation to develop the art of medicine.” The Orthodox vision is that of Sirach 38:1-8:
Honor the physician with the honor due him, according to your need of him, for the Lord created him; for healing comes from the Most High, and he will receive a gift from the king...The Lord created medicines from the earth, and a sensible man will not despise them...And he gave skill to men that he might be glorified in his marvelous works. By them he heals and takes away pain; the pharmacist makes of them a compound. His works will never be finished; and from him health is upon the face of the earth.
The healings of the body and of the soul, then, are not necessarily in competition, for they are both created dimensions of the human person in need of restored health. Those who pursue bodily healing as the highest good in and of itself err, for the healing of our bodies is a visible sign of the salvation of our complete personhood in Christ. The work of the Christian physician points to and participates in the eschatological fulfillment of the human being in God. “They make of their practice...a means for conveying the grace that is manifested in the miracles they perform as these become signs, tokens of a deeper and fuller healing brought about by Christ.” The icons of “holy physicians” include the instruments of their medical practice, which are “washed in the uncreated Light (of divine energies) that radiates from their faces.” The practice of the Christian physician is a kind of enacted icon in which the healing of the body points toward the healing of the soul. This kind of healing ministry is a Eucharistic endeavor in which the physical realities of medicine become a means of participation in a healing that finds its fulfillment in the Kingdom.
In this light, Breck asks, “How can we make biomedical decisions that will fully respect the fundamental analogy that exists between the offering of the person and the offering of the Holy Eucharist: ‘Thine own of Thine own, we offer unto Thee, on behalf of all and for all?”’ Even as bread and wine may be used for luxury while thousands starve or as Holy Communion, physical health may become a false god or a foretaste of Heaven. As Jeffrey Carpenter notes,
I have often told my patients that I can treat them, but only God can heal them. Jesus joins himself with the clay of His creation to heal the blind man. Can you see here an icon of the sacramental nature of healing and how it participates in the larger proclamation of the Kingdom? God Himself takes the ordinary clay of material life and sanctifies it, transforms it, injects Himself into it to restore what is imperfect to health. Isn’t this the manifestation of the Kingdom of God on earth which we proclaim in the Eucharist, where ordinary bread and wine are transformed into the medicine of immortality? Isn’t the whole story of our salvation represented in this icon of God’s humility and love?
Since so much is at stake in how we approach the care of the body, we need to think clearly about the kind of bioethical guidance which directs medicine toward the ultimate end of theosis. Most contemporary accounts of bioethics will be of limited help in this endeavor because they fail to conceive of morality within the larger context of the human vocation to growth in holiness. Many instructive insights on moral reasoning and humane medical care may be gleaned from secular and other types of religious biomedical ethics. For those insights to be of use in directing us to salvation, however, they must be interpreted tofit coherently in the drama of human sickness and health before God. Engelhardt observes that:
Moral concerns with rights, values, and virtues are transformed and relocated in terms of the pursuit of holiness, union with God. Acting rightly and justly is not enough for salvation and can only be coherently pursued when oriented to holiness. The focus is not primarily on who has a right to do what, but on what aids in the pursuit of the Kingdom of God.
Orthodoxy is not concerned fundamentally with getting people to obey bioethical rules or embody laudable virtues. Instead, the focus is “on changing oneself so as to turn from oneself to God.” In pursuit of that goal, Orthodox bioethics may seem both perfectionist and lax. The first trait is seen in the goal to which it seeks to direct us: sharing in the life of the Holy Trinity. “You shall be perfect, even as your Father who is in heaven is perfect” (Matt. 5:48). The latter is evident in the recognition that everyone sins, falling short of the mark set by God. The Church’s canons and rules are applied pastorally in ways that direct us to greater holiness, given our particular amount of progress on the journey to the Kingdom. The Church exercises economia, which may seem like laxity, in cases where insisting on the letter of the law would hinder one’s journey to salvation. Engelhardt stresses the centrality of helping persons grow in holiness as opposed to the strict application of law for its own sake.
Moral principles are at best chapter headings and rules of thumb. Too much attention to general principles can even divert attention from the personal character of the communion with God to which all theology and all bioethics should lead. This is not to deny a place in Christian bioethics for moral rules, commandments, or precepts: properly understood, they indicate real boundaries beyond which one will go very wrong rather than enter into union with God. But they cannot be systematized in terms of conceptual foundations... [T]he Church will not always necessarily require applying the canons strictly. The appropriate response will not be found in a casuistic literature, or at least in a formalized casuistic approach. In each particular case, the appropriate response must be drawn from prayer and grace. A formal casuistry that provided recipes for responses to particular cases would confront the Spirit with our dead letters.
An Orthodox ethic is different from that of traditional Roman Catholicism in that medical morality is not governed by “casuistry,” the application of a natural law known by all through discursive reason. While Catholic teaching on contraception, for example, is driven by a biological account of the nature of intercourse, Orthodox teaching addresses the issue within the context of a particular couple’s growth in holiness. Bearing additional children may present profound challenges to the spiritual, physical, or emotional strength of particular couples. Perpetual abstinence, or regulating their sexual life by the dictates of “the rhythm method,” may be destructive of their marriage. Such circumstances raise deep spiritual issues for persons created in God’s image, not simply matters of biological function.
Likewise, Catholic teaching employs the law of double-effect to assess the moral ramifications of actions with varying repercussions. For example, a medically necessary hysterectomy on a pregnant woman will have the unintended effect of abortion, though the intended effect was to remove a cancerous uterus, not to abort an unborn child. Catholic moral theology thereby removes completely the gravity of causing an abortion. In contrast, Orthodoxy focuses on the comprehensive spiritual impact on those involved of the action in question. Logical distinctions do not remove the spiritual gravity of the acts of persons which direct them either closer to or further away from the life of the Holy Trinity. The taking of human life, whether voluntary or involuntary and done with knowledge or ignorance, has an impact on the soul for which we need healing. Rational arguments alone do not overcome the gravity of our actions in a fallen world.
The key point is that a sound knowledge of our nature as human beings is not available immediately to all through biology or moral philosophy in our corrupt state. Instead, natural law is a matter of noetic knowledge, of personal spiritual experience with God. As we grow in holiness and in union with the Holy Trinity, we will increase in our participation in eternal life; we will know and experience God more fully; and we will then have a better knowledge of ourselves and how we are to live in this world. The life of theosis should be a life of growing in the fulfillment of our nature and in our understanding of what it means to be a human being before the Lord. Our true nature is not that which we encounter immediately in ourselves after the fall; it is that of humankind growing in the likeness of God as Adam and Eve would have, had they not sinned. The restoration and transformation of our fallen nature is found in Jesus Christ, and we will know the law of nature ever more fully as we share in His life.
Essential to our growth in the knowledge of what God intends for us is our ongoing progress in holiness. Our knowledge of God’s purposes for us is dynamic and a function of our personal communion with the Lord. To quote Engelhardt:
Natural law is not first discovered or primarily disclosed discursively...Though this experience of the moral law can be strengthened by instruction, it grows principally through prayer, virtuous action, and love of God. It is in particular nurtured by a worshipful relationship with God...Natural law in this sense is not a set of moral obligations that can be appreciated in purely secular terms as the basis for a bioethics open to all. Natural law or the moral law, as well as Christian bioethics, are therapeutic. They bring us away from ourselves to God our Creator.
This view of bioethics will appear strange to many people in contemporary western culture. Our society typically relegates religion to the private sphere, denying its relevance to public endeavors like medicine as anything more than light-weight psychotherapy. We often assume that religion is a matter of emotion, useful only to individuals who are not engaged in matters as weighty as bodily life and death. When religion is used in support of a moral appeal, it is often employed in support of an agenda which stands on secular grounds, such as that of an American political party of whatever ideological stripe. Consequently, it would be hard to overestimate how much at odds with our culture a substantive Orthodox bioethics would be. Rather than an enterprise controlled by secular norms of rights, duties, and virtues, it stands as part of a Eucharistic life directed toward the Kingdom of Heaven. Its constituency is comprised of members of Christ’s Body, not litigious individuals whose horizons extend nofurther than their own biological integrity.
Consequently, we may be tempted to withdraw from American society and establish our own Orthodox cultural world, pretending that we live several hundred years ago in Antioch, Constantinople, or Kiev. Some may resolve the tension between Orthodox and secular bioethics by sectarian withdrawal from participation in medical institutions and professions which do not aspire to this spiritual ethos. Complete withdrawal, however, would not be in keeping with the historical vision of symphonia or harmony between the Church and the world. It would also amount to a repudiation of the Eucharistic vision of offering the entire creation to the Father in union with the sacrifice of the Son by the power of the Holy Spirit. If Christians were to abandon all fallen dimensions of the creation, we would have to abandon ourselves along with the rest of God’s good, but now corrupt, world. Clearly, that would be a contemporary form of Manichean dualism, and would amount to a denial of God’s lordship and power. Moreover, to pretend that we live in another time and place is to engage in fantasy and to deny reality. Like it or not, our present world is the only one we have this side of the Kingdom.
Acknowledging the tension between Orthodox and secular bioethics, Engelhardt suggests that the Church work toward the creation of health care institutions which provide “basic adequate medical care...special opportunities for prayer, access to the Mysteries, anointing with oil from the vigil lamps of wonder-working icons, and blessings with the relics of saints.” The primary responsibility of the staff in such an institution would be to ensure that “the medical care was compatible with the care of the soul...The pursuit of physical health and the postponement of death would have their place in terms of the struggle to salvation.”
The examples of Roman Catholic hospitals and of the hospice movement may be instructive as healthcare institutions which care for patients in accord with definite sets of spiritual or humane values. While noting that “a monastic community can be an ideal setting in which to end one’s earthly existence,” Breck concludes that “a new form of philanthropic organization” may be necessary for the Church to provide “a genuine alternative to physicianassisted suicide.” It is certainly possible for a monastery, a parish, or another group of believers to receive a blessing to provide care for the sick or aged in a fashion that embodies the Orthodox ethos. For example, Constantinople’s Pantokrator monastery in the twelfth century provided “drugs, physical therapy, special diets, surgery, and emergency care.”
Outside areas of large Orthodox populations, it is unlikely that the Church will establish healthcare institutions of any size. Nonetheless, Orthodox physicians and other healthcare professionals may practice in ways that are conducive to the embodiment of this spiritual ethos to the best of their ability. A clear example of such a medical practice was that of Saint Luke of Simferopol, a renowned surgeon in the Soviet Union who was also an Orthodox archbishop and political prisoner. Despite undergoing terrible persecution for decades at the hands of the Communists, Saint Luke insisted that there be an icon in the operating room when he performed surgery. Despite the great hardship which resulted from his practice of the faith, he was a chief surgeon for Soviet soldiers during World War II and a pioneer in a variety of lifesaving surgeries. This saint manifested God’s great mercy to the sick within the context of an atheistic social order that persecuted and murdered millions of Orthodox believers. As his biographer notes,
Bishop Luke imparted his knowledge, skill, and experience to all doctors who asked him. He simultaneously tried to inspire another ethos in them. He usually stressed that the doctor must love the sick person, sacrifice himself for the patient, and do everything in order to save his life. The bishop-doctor would be disappointed when he saw doctors who were money lovers or who were more interested in the “case,” in the illness, than in how the sick person was feeling and how much he was suffering.
Medical care in the United States is increasingly regulated by the federal government and controlled by large insurance corporations. Far too many men, women, and children do not have health insurance or access to quality medical care. These developments have often resulted in a reduction in the freedom of physicians to treat patients as they see fit. The American healthcare professional, however, faces nothing like the deadly persecution of the Soviets. Ample opportunities exist for physicians, nurses, and therapists to embody Christlike concern for their patients, treating them as suffering persons instead of as scientific experiments or bureaucratic cases. Especially in primary care, opportunities exist to build ongoing relationships in which it is possible to invite patients to place their bodily health within the context of transcendent concerns, including religious commitments. Though the Orthodox healthcare professional would never coerce a patient to embrace the faith, it is certainly possible that one’s relationship with a patient may draw that person to greater holiness. The potential spiritual impact of a patient’s relationship with a humble, caring physician or nurse should not be underestimated.
The cultivation of a genuine spiritual ethos is not, however, the unique responsibility of healthcare providers. Breck comments that:
Medical treatment is an aspect of the priestly ministry common to every member of the Church. The question the physician must answer is therefore the question every member of the ecclesial body must deal with: How can we exercise an authentic synergy or cooperation between man and God, such that our choices and decisions concerning life and death conform thoroughly and faithfully to the divine will?
Orthodox patients and families must take an active role in seeking the kinds of care that are consonant with their convictions. All competent adults are free to refuse forms of medical care which would hinder their spiritual growth. Physicians may not coerce us to accept care to which we have not consented, whether for religious or secular reasons. Through advance directives, informed consent requirements, and the hospice movement, a patient may avoid forms of treatment that he or she judges to be undesirable for spiritual reasons.
These considerations are relevant to all forms of medical care, not simply those at the end of life. Some may discern that they are called toforego expensive, risky treatment of non-terminal diseases, instead enduring patiently a level of chronic pain or disability as a form of asceticism. To refuse a means of treatment for valid spiritual reasons is neither suicide nor masochism; instead, it reflects a realistic awareness of the limits of medical care and of our bodies in the fallen world. The dying or debilitated body may be offered to God for the eschatological healing that transcends the world as know it, even as we refuse forms of treatment that seem pointless or counterproductive for our growth in holiness.
A key characteristic of healthcare in an Orthodox context will be a focus on the personhood of the sick and weak, extending from conception to death. Orthodox anthropology is Trinitarian in the sense that every human being is considered a person created in God’s image and destined for communion with the three Persons of the Trinity. Breck distinguishes the individualism of modern western culture from true personhood. Instead of viewing humankind as a collection of isolated individuals whose integrity is dependent upon autonomy from others, “authentic personhood unites us in a bond of communion with each other and with God.” In Christian terms, personhood is not equated with criteria such as selfconsciousness, autonomy, and rationality. By definition, those in need of healthcare are in some respects weak and dependent. Many have profound constraints on their freedom to live as they wish, and the human life-cycle includes periods of complete dependence and lack of rational self-awareness. Nonetheless, all human beings bear the image of God and are persons because they are created and redeemed for communion with the Persons who are the Holy Trinity. “[P]ersonhood is conferred bj God and not by physiological development, medical analysis or social convention.” As Carpenter puts it,
Marginalized persons — the mentally ill, the disabled, the elderly, the unborn - derive their humanity not from their physical state but from their inherent God-relatedness. They, just as much as we, are created in the image of God and as such are fully human. No life, therefore, is unworthy of care and no life is to be abandoned.
It is sometimes wrongly assumed that such an unequivocal stance on the sacredness of human life requires us to preserve biological existence at all costs. Breck notes that the Orthodox pray regularly for “a Christian ending to our life, painless, blameless, and peaceful.” More important than exhausting every possibility for prolonged biological function is spiritual preparation for death, including “reconciliation with God through confession, and time for a final communion in the life-giving Body and Blood of Christ.” Rather than insisting on pointless heroics or eliminating the patient through euthanasia, the Church should “exercise its priestly function by offering the dying person to God in prayer, through gestures of love, compassion and intercession on his or her behalf.” A more effective use of painkilling medication in the U.S. would be a sign of God’s great mercy for many dying patients, and help them to prepare in relative peace for the end of their life on earth. By contrast, “The prospect of spending weeks, months or years attached to a ventilator, fed intravenously, and slowly expiring in a hospital ward is demeaning and depressing.” Pointless treatments, including life-support and artificial means of nutrition and hydration for terminal patients in some cases, may be refused or stopped in accordance with the desires of the patient or family. As persons destined for the eternal life of the Trinity, our hope extends beyond the biological integrity of our bodies in this life. “The life freely bestowed by God must one day be freely and willingly surrendered to him, in order that he remain Lord over both the living and the dead.”
As noted earlier, Engelhardt follows St. Basil the Great in recognizing the spiritual limits placed on medical care: “Whatever requires an undue amount of thought or trouble or involves a large expenditure of effort and causes our whole life to revolve, as it were, around the solicitude of the flesh...” must be avoided. To use medicine in a way that “significantly distracts from our life of prayer or brings us to being obsessed with preserving this life” is idolatrous. “It is not just that such treatments may be withdrawn or withheld. They should be withdrawn or withheld. The postponement of death, the avoidance of suffering, and the correction of disabilities should not become all-consuming projects.”
On the controversial question of withholding or withdrawing artificial means of nutrition and hydration, Breck teaches that such actions “may be morally permissible even obligatory...” when a patient is irreversibly dying. “Where further medical intervention is futile, and merely hinders the person in his or her struggle to die, then such intervention should be judged to be abusive rather than beneficial. Medical heroics in such a case are morally inappropriate.” The possibility of refusing life-sustaining treatment must not be abused, however. This warning is needed especially for those who presume that we should withdraw feeding and hydration tubes from all victims of brain damage or patients who are otherwise seriously debilitated. Such patients are by definition weak, vulnerable to abuse, and require substantial care which is often costly and in other ways inconvenient for family members and health-care providers. Breck maintains that “any patient, terminally ill or not, should be provided with adequate food and water if they are conscious and request it...”
Actually removing or foregoing artificial means of nutrition and hydration may be morally acceptable for an “irreversibly comatose” patient who had previously clearly expressed through a living will or durable power of attorney a definite and “un-coerced desire toforgo such procedures.” Breck also allows that it is moral to comply with the wishes of a patient “in the last stages of the dying process” who clearly indicates a desire for nutrition and hydration to be withheld or withdrawn. In such cases of imminent death, the use of a feeding tube serves no medical purpose and may only hinder the process of dying. Breck notes that, though in the past he opposed the removal of tubes for nutrition and hydration in all cases, he now views the “use of hydration, nasal-gastric and gastrointestinal tubes” as “extraordinary measures that can be morally refused by the terminally ill or their proxies.”
Engelhardt also lists “long-term artificial hydration and ventilation” as the kinds of treatments that may be “so encompassing or burdensome as to harm the spiritual life of the patient.” The distinguishing feature of treatments that should be refused is not, however, defined technologically, but by their spiritual impact on a particular person. Indeed, “a hermit’s traveling to a dialysis center to treat renal failure could be an example of treatment that should be avoided,” as it would be contrary to the fulfillment of the hermit’s vocation in offering his or her life to God. “At the end of life, even normal eating may become too burdensome for a particular patient,” as in the case of dying monks on Mount Athos who have devoted all their remaining energy to prayer and repentance. “The issue turns on discerning when attempts to postpone death or bring health distract from preparation for eternal life with God.” He teaches that Orthodox believers “should use advance directives not only to avoid medical indications likely to be useless or spiritually burdensome, but also positively to ensure appropriate spiritual guidance as death approaches.” They should empower “a proxy decision-maker” and their spiritual father to make choices on the course of further treatment with a view toward “one’s pursuit of the kingdom of heaven.”
No legal issues would have arisen in the Terri Schiavo case had Ms. Schiavo left a living will or designated her parents as decision-makers through a durable power of attorney. But regardless of such legal and procedural matters, Breck insists that it is morally obligatory for Christians to provide, and presumably to accept, life support “where life can be preserved without rapid and painful deterioration.” Presumably, such deterioration would be contrary to ending one’s life in proper states of prayer and repentance. There may, at times, be a fine line between life-sustaining care that is obligatory and that which is not. Breck describes the issues at stake poignantly.
As bearers of God’s image, we are called to cherish and preserve our entire life, including our physical existence, as fully and faithfully as we can. This means that we, as Christian people, may at certain times and in certain circumstances accept levels of ongoing suffering that many in our society would reject on principle. We may do so, however, as long as that suffering is not accepted or sought out for its own sake, as a kind of prideful, self-serving martyrdom. Suffering, especially in terminal cases, can indeed be redemptive. But suffering can also become so burdensome that the person can concentrate on nothing else. In extreme cases it can become impossible to pray or even to relate in any meaningful way to those around us. Pain and anguish can become so all-consuming that physical life itself becomes an intolerable burden. When such levels of suffering occur in clearly terminal cases, then it is not only futile but cruel and unreasonable to maintain the dying patient on lifesupport. An acceptable protocol would instead include appropriate pain management and measures to assure as much comfort as possible. As anyone who has accompanied the dying knows, it is far better to die in hospice than in an ICU.
We should not subject ourselves or others tofutile treatments which serve only to prolong suffering and to inhibit prayer and repentance. On the other hand, we should not throw away our lives or those of others in order to avoid all suffering. Instead, we must make our living and dying an offering to the Father, following in the way of Christ to the cross and the empty tomb. Pride may manifest itself in the insistence to preserve our biological existence at all costs or in a desire to embrace death rather than to suffer at all. As Christians, we do not live and die on our own terms: “Seek first the Kingdom of God.”
Our response to disease, suffering, and death is part of our journey to theosis, which is a matter of personal healing and transformation in Christ. We truly share in the life of the Holy Trinity by grace when we offer these profound dimensions of life to the Lord. The gravity of these matters extends far beyond mere ethics or legality; rational application of abstract standards does not even scratch the surface of the profundity of our call to grow in the likeness of God, even as we suffer and die. To answer that call, we need a life of prayer, repentance, asceticism, participation in the Holy Mysteries, and guidance by a spiritual father. Such a life makes us receptive to the Divine Energies which cleanse the eye of the soul. And when the soul is cleansed, we will know how to respond faithfully to terminal illness and the available treatments in ways that are pleasing to God. Rather than relying on the rigid imposition of rules, Orthodoxy places these matters in the context of the healing of the soul, and calls us to embrace or refuse medical care on the basis of whether it will help us share more fully in the life of the Holy Trinity.
To many in our culture, it would seem strange to relate spiritual discernment so closely to questions of health care. Is not religion, some would say, about feelings, emotions, or at least a disembodied spirit? And does not medicine rely on scientific fact? The problem is that neither assumption is accurate. Orthodox Christianity believes in the God who created reality itself, all things visible and invisible, and Who became incarnate for our salvation. All dimensions of truth, including the physical reality of our bodies, stand before God, and may not be separated from Him. Though scientific fact is a crucial part of medicine, there is no un-interpreted fact; we make sense of facts in a larger context. And all truth, all reality, is God’s and should be used in accordance with His purposes for us. To claim that scientific facts have complete autonomy from the Lord’s purposes for creation is to commit idolatry. Instead, we are to offer every dimension of ourselves and our world to the Father for blessing, healing, and transformation. If the care which we give our bodies is left out of this offering, we are not living Eucharistically.
The Orthodox vision of theosis shapes the Church’s view of healthcare in many ways. In particular, we have seen that the healing of the body serves as a sign of the eternal healing of the whole person in the Kingdom of God. We are to grow in union with the Holy Trinity in every dimension of our personhood, offering our bodies to the Father Eucharistically. Orthodox bioethics will not draw primarily on rules known by discursive reason, but will be oriented toward helping particular people grow in holiness as both healthcare professionals and patients. The physical realities of disease will be placed within the narrative of Jesus Christ’s healing of the corruption of human nature through His birth, death, resurrection, and ascension. For Orthodox Christianity, the treatment of the body does not become an end in itself, but a means of fulfilling our vocation as those created in and according to the likeness of the Holy Trinity.
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From: Fr. Philip LeMasters, "Chapter 3: Health Care and Theosis" in "The Goodness of God’s Creation: How to Live as an Orthodox Christian (A Guide to Orthodox Ethics)" (Salisbury: Regina Orthodox Press, 2008) 47-67.
http://www.amazon.com/Goodness-Gods-Creation-Orthodox-Christian/dp/1928653359/
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