Twenty-five years ago, Sherwin Nuland’s How We Die: Reflections on Life’s Final Chapter spent more than 30 weeks on The New York Times bestseller list, was a finalist for the Pulitzer Prize, and won a National Book Award. It’s remarkable that a nonfiction book about disease and death, written by a surgeon and med school professor, would enjoy this sort of commercial success. In another way it makes perfect sense. Nuland recognized that a huge population was dying from the same handful of causes and in remarkably similar ways, but with little knowledge of what to expect or how to prepare.
Reading Kathryn Butler’s Between Life and Death: A Gospel-Centered Guide to End-of-Life Medical Care, I often thought of Nuland’s How We Die. This is high praise, and well-deserved.
Like Nuland, Butler is a well-trained and practiced physician writing with expert knowledge and rich experience. Like Nuland, Butler has a remarkable ability to describe modern medicine in plain language. And like Nuland, Butler is tapping into a world of experience most of us will encounter and few of us feel prepared to deal with.
But there are also crucial differences between these books, differences that take us to the heart of what Butler is doing and why. Nuland focuses on the most common causes of death; Butler focuses on the most common treatments used to hold off death. Where Nuland has chapters on heart disease, Alzheimer’s, and cancer, Butler has chapters on mechanical ventilation, dialysis, and the ICU.
The reason for this focus is clear and compelling. She writes not just to teach us what to expect, but to help us make wise decisions in some of the worst moments we’ll ever face.
Saving Life or Prolonging Death?
The technologies available in a modern ICU have tremendous power to preserve life. They can buy precious time for doctors to figure out what’s going on and work to resolve the problem. But these technologies also have the power to blur the line between life and death:
From the doorway of a hospital room, a patient who will recover may appear identical to one fighting for his life. In both scenarios, we may require a mechanical ventilator to breathe, and sedating medications may plunge us into unconsciousness. An array of poles with intravenous (IV) bags and pumps will surround us. Wires from monitors may coil from our chest and scalp. For the aggrieved spouse at the bedside, such foreign trappings render looming death indistinguishable from steady recovery. (27)
To the untrained eye, clouded by fear and grief, it can be nearly impossible to tell whether these aggressive interventions are saving life or prolonging death. Everything about the setting is disorienting. And so patients and their families are forced into agonizing choices that would have been unthinkable 100 years ago.
Should we try resuscitation again? Do we intubate? If we turn off life support, are we killing our loved one? And if it’s right to withdraw support in some cases, how do we know when it’s time?
Modern medical advances save countless lives. But for all their merits, sophisticated technologies have created a daunting new challenge, namely a blurring of the expanse between life and death. This book offers a distinctly Christian guide to end-of-life care. It equips readers by explaining common medical jargon, exploring biblical principles that connect to common medical situations, and offering guidance for making critical decisions. In these pages, readers will find the medical knowledge and scriptural wisdom they need to navigate this painful and confusing process with clarity, peace, and discernment.
To face questions like this we need wisdom. And this brings me to the primary difference between Butler’s book and a book like Nuland’s. Butler knows that wisdom begins with fear of the Lord. That’s why she leads with a chapter on four biblical principles that should affect our end-of-life decision making.
Four Biblical Principles
First, the sanctity of life. Because every human life is made by God in his image, every life is precious and worth saving. If an intervention buys time for a cure, we ought to intervene.
But, on its own, commitment to the sanctity of life can do more harm than good. Butler cites research showing that patients with high “religious coping” are more likely to pursue aggressive end-of-life care at any cost (34). Perhaps that comes from a belief that faithfulness requires doing everything we can. Perhaps it’s about buying time for God to work a miracle. But the Bible gives us a second principle, beside the sanctity of life—only God has authority over life, and in our fallen world every life ends in death. It’s no failure of faith to acknowledge that no medical intervention can give our bodies eternal life. And though God can work any miracle, “he does not need our help, nor does he call us to pursue futile interventions to give him time” (37).
This balance sets up a third principle. If preserving life is good, but ultimately impossible, how do we decide what interventions are worth pursuing? Mercy and compassion. We should avoid measures that increase suffering where there’s little hope for a cure.
Finally, the freedom we need to act out of mercy rather than life-at-all-costs desperation comes from hope in Christ, Butler’s fourth principle. We don’t have to throw everything we have against an unbeatable enemy because Christ has thrown himself at our enemy, and conquered. “Since we believe that Jesus died and rose again, even so, through Jesus, God will bring with him those who have fallen asleep” (1 Thess. 4:14).
These principles frame up the central work of Between Life and Death, which shines most in its chapters on specific life-sustaining interventions commonly used in the ICU. Butler’s descriptions are consistently clear and concrete. There are stories that make the descriptions more relatable. There’s a glossary of common medical terms for easy reference.
And throughout these chapters, among the greatest strengths of the book, there is humility. As I’ve said, Butler writes to orient our thinking about a foreign world, and to give us tools to work through crucial questions. But she knows better than to answer those questions for us. Every situation is unique. That means we need good doctors to explain what’s going on with our bodies. We need family and friends paying close attention. We need faithful pastors to help us apply the wisdom of the Word. This book is meant to feed into all of these conversations, not to settle them.
Whatever your position in what you’re facing—patient, friend, or pastor—Butler has given you a wonderfully useful gift.