Foundations: No.75 Autumn 2018

Book Reviews

Departing in Peace: Biblical Decision-Making at the End of Life

Bill Davis, Presbyterian and Reformed, 2017, 300pp, £7.41 (Amazon)

Books dealing with end-of-life issues make me apprehensive. Why? Because their first few pages set out authors’ mindsets and I have already read too many ethically-flawed such books. Departing in Peace allayed most of my fears early on. In the Preface Bill Davis explains that, “…Bible-believing Christians are too often persuaded that the Bible requires us to use medical means to extend physical life as long as possible. I will be arguing against this supposed requirement”. And again on page 6, “This book is driven by the most common source of anxiety expressed by Christians as they have faced end-of-life decisions. They have often thought that they are obligated to do everything medically possible to extend earthly life as long as possible.” Phew! Yes indeed, Christians are not latter-day vitalists.

Chapter 2 – the flagship chapter

So intent is Davis to correct this apparent wayward thinking that he makes it the raison d’être of this book. In particular, Chapter 2 is his flagship chapter. It is entitled “Foundational Considerations” and consists of 45 pages of biblical exegesis starting with the threefold tasks of multiplying, stewarding and honouring derived from Genesis 1. Davis makes the latter task of honouring bear directly on end-of-life decision-making. The relationship between a suzerain king and his subjugated vassals is used as an analogy of our role as divine representatives or ambassadors of God to speak and act for him. Thus, “Killing a human is an act of treason against this Master because it deprives the Master of a member of his ambassadorial team” (27). Another grand theme is drawn from Matthew 25 where those who feed, water, welcome and visit “the least of these” are commended by Jesus, they are “blessed by my Father”. In other words, “The task of defending and protecting those without a champion is explicitly given to God’s people” (29).

The chapter continues with an examination of “choice”. As image-bearing stewards we have authority to choose not only for ourselves, but also for others, including children, the unconscious and the incapable. These choices are first to serve God’s purposes and second our own. No Christian will disagree with these august biblical principles. Less convincing, and more problematic, is their application to specific twenty-first century medical scenarios. Davis is a formidable advocate for the use of modern-day advance directives. Clearly the Bible has nothing explicit to say in this area, but Davis’ call to look ahead and anticipate such choices is based on Paul’s vague instructions in his letters, such as Col 4:10 (32). This is straining the book. Similarly, if no advance directive exists, others must step up. As Davis explains, “The legal hierarchy is clear – spouse, children, parents, siblings, etc.” (34). And Davis defends this order by reference to Genesis 2:24 and the Fifth Commandment, though he later sidesteps it, such as on page 245. There is a fretting trend throughout this book that everything must be adjudicated as “biblically permissible” and that every such ruling must be accompanied by a proof text. This is too affected, too artless. 

Which brings me to another of Davis’ idiosyncrasies – he refuses to use the word “patient”. He prefers “sick person” or “person in the bed”. Well, OK, I get his fear of dehumanising individuals, but even “patient” will usually be replaced by “Mr Smith” or “Tom” or “Mum” in the real world. That notwithstanding, Davis is happy to refer, somewhat abstrusely, to a patient’s decision-maker as the “agent” or “surrogate”.

Chapter 2 also further expands Davis’ fundamental theme of doing less than everything that is medically possible. Over the last sixty or so years, cardiopulmonary resuscitation (CPR) and ventilators have brought wonderful benefits and dreadful burdens into the medical mix. Previously if a person’s heart stopped beating, that was it, she died. Similarly, once his breathing ceased, he died too. Nowadays, both patients could be hooked up to life-sustaining equipment and their lives could be extended almost indefinitely. Such treatments can be curative life-savers when employed for short-term infections or injuries, but end-of-life maladies are not curable. Then the ethical dilemmas arise – should we switch on or switch off? Davis is clear: “…the principles taught by God’s Word… make it permissible in some cases to decline or discontinue life-sustaining treatments” (37). The Word has not changed but the range of medical options has. His “in some cases” is the glitch. Who decides? Davis answers with a biblical discourse on life and death. He concludes that “Human life is precious… Earthly life is not the highest good… There is a time to die… Death is defeated” (38-40). And there are treatments that are futile and burdensome – they will never produce a cure and they can cause extra suffering. And although the Christian life can be a pilgrimage of suffering we are not obligated to suffer merely to stay alive for as long as possible. When the benefit-burden balance is unattractive, it may be time to discuss a DNR (do-not-resuscitate order). Moreover, Davis insists that we also weigh up spiritual burdens and benefits. Are the ordinary means of grace – corporate worship, prayer, sacraments and fellowship – still being enjoyed? Are spiritual burdens creating additional hazards? While considering these matters will not necessarily resolve, or even soften, some of the knotty end-of-life dilemmas, they will invariably signpost what is right and wrong and hence the most appropriate, the most God-honouring path to take. 

Davis spends several pages considering the topic of suicide both from the Bible and the contemporary physician-assisted variety from the Western world. He, of course, rightly condemns both. This is followed by a section on pain, and particularly unmanageable pain and its relief. Davis’ scope here is too limited. While many dying people suffer from physical pain, many more suffer from other adverse symptoms, such as breathlessness, restlessness and depression. It is the wonder of palliative care that seeks to bring relief with not just analgesics, such as morphine, but also sedatives and other drugs to ensure that the dying patient is comfortable. And finally in this chapter, the role of prayer is discussed. Some pray for healing, some pray for a miracle, some use the latter as a tactic to delay facing reality, and some pray for the doctors and nursing staff. You know what is right and proper! But remember your loved one is dying, and death is crouching at the door. Above all, get real.

Some of the challenges

Chapter 3 is entitled “End-of-Life Treatment Decisions: Challenges”. This is based largely on US state-wide protocols and questionnaires that seek to determine what the patient wants in terms of restricting possible treatments. Four conditions of permanent unconsciousness, permanent confusion, terminal illness and dependence for daily living are discussed. Then four treatment options of CPR, life support, treatment of new conditions and artificial nutrition and hydration are considered. The text is rather pedestrian and its attempt to provide general answers from real-life cases mostly fail because the examples are inevitably too specific – they prompt minor questions rather than major answers. Nevertheless, all is not lost. One of the recurring treatment decision-making yardsticks used throughout the book is found, for instance, on page 85 in the case of Gloria, a wheelchair-bound, stroke victim. In discussing and then approving the use of kidney dialysis by Gloria, the author concludes, “The treatment would have the prospect of restoring and maintaining her ability to use her talents and other resources to serve God’s purposes”. That is a refreshingly proper aspect of decision making.

Chapter 4 consists of six real end-of-life situations together with several questions, each with three possible answers. Perhaps I have read and written too much in this area, but I found the “correct” answer always obvious. Chapter 5 is all about advance directives. It rather laboriously teaches you how to complete one, specifically, the Tennessee Advance Care Plan. This will not particularly appeal to non-US readers.

Nor will much of Chapter 6, which covers “Money and End-of-Life Decisions”. This is hardly an issue with the UK’s NHS system of “socialized medicine” where “decisions about end-of-life care are made by government agencies” (209). In the US, money and medicine are intimately intertwined. An example is that of 5-year-old Joel who needs expensive surgery for a brain tumour. Can the family afford to go ahead with it? They cannot pay immediately but,“…they can make the promise on his [Joel’s] behalf to pay for it with his [Joel’s] future earnings” (221). Yes, I was astounded too. And I was also surprised at the minimal role given to a patient’s pastor – he is rarely mentioned. Yet a pastor is beyond useful – he is typically younger, biblically-minded, generally accessible and largely responsible for his congregation’s well-being. And in Davis’ mind there is a seemingly uneasy separation between patient and church as exemplified by, “The church should not announce or publish that you need prayer for your medical condition without your agent’s permission” (186). Really? Would the congregation be unaware, or unwilling? Furthermore, organ donation is blithely accepted as, “…a great way to bless others, so we should look for a way to help by making our organs available” (181).

Chapters 7 and 8 deal with some realities for inside hospitals and some practical advice for outside. Let me endorse some of Davis’ wise suggestions. While in the hospital, try to get the big picture – ask, ask and ask again about current treatments and prognoses, and so on. If in doubt, ask for a second opinion. And pray. Outside the ward, talk about these issues with family and friends. Draft your own memorial service – choose the hymns and readings. Consider volunteering at a local hospice. Endeavour to connect with unbelieving neighbours. I have always thought how odd it must seem to them when us Christians have apparently nothing to say or offer to them in their times of perplexity and grief.

The US slant of the book

As already noted, unsurprisingly, the book is entirely US-oriented. High-priced, hi-tech medicine dominate the pages – there is little here for third-world Christians. Much is made of the 1988 PCA (Presbyterian Church in America) Report on Heroic Measures and the current Tennessee Advance Care Plan. Clinically-assisted nutrition and hydration (CANH) is discussed in the light of the US 2005 Terri Schiavo case, whereas the UK’s 1993 Tony Bland landmark judgment is overlooked. Nevertheless, fans of US hospital TV dramas will recognise Americanisms such as EMTs (emergency medical technicians), code blue (slang, typically for a cardiopulmonary arrest), and the roles of “hospitalists” and “intensivists”. And there are gaps. For example, there is no appreciation of the foundational roles that the historic doctrines of Christianity and the Hippocratic Oath have played in undergirding the ethics and practice of wholesome Western medicine. The story of modern palliative care is also nothing but inspiring, but it is missing here. The current and contentious issues of brain death and its diagnosis are also lacking. And while Davis is a strong advocate of advance directives he says nothing to encourage their revision in the light of either change of heart by the patient, or the introduction of novel and improved medical procedures. 

The author is a professor of philosophy at Covenant College, Georgia and an elder in the PCA. The structural comprehensiveness of his book is almost overwhelming. It consists of 8 chapters, each divided into about 4 subsections with some key terms, a dozen or so study and discussion questions, and a list of half a dozen or more articles and books for further reading. In addition, there are 3 appendices, a glossary, a bibliography, an index of Scripture and a general index. There are even complete lesson plans for accompanying four sessions of adult Sunday school classes that can be downloaded from the publisher’s website.

And finally

But my experience is that any book, conversation or sermon that discusses dying and death is invariably a tonic. Indeed, Davis opens the Preface with this sentence, “This book is for people who suspect that they may eventually die.” Yes, that’s me (and you). And this book’s overall message is undeniably crucial. There is a growing awareness within medicine that dying and death have become over-medicalised. For an alternative, albeit from a non-Christian perspective, let me suggest Atul Gawande’s splendid 2014 book Being Mortal – Illness, Medicine and What Matters in the End.

John Ling
Freelance speaker, writer and consultant bioethicist


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