Medical Assistance in Dying: Is Cheating Death Worth It?
“For a Christian end to our lives, painless, blameless, peaceful, and of good defence before the fearful Judgement Seat of Christ, let us ask of the Lord.”
This petition, from the Divine Liturgy of St. John Chrysostom, shows how important a role our death plays in preparing us for eternity. Leo Tolstoy illustrates this in two great works. In The Death of Ivan Ilyich, he devotes an entire novella to the main character’s escalating spiritual battle within himself, which he only begins to understand as he lies dying. In War and Peace, Tolstoy’s Prince Andrei is only able to overcome his hatred of a rival as he watches that man die.
Yet, if Prince Andrei and Ivan Ilyich were real people in this day and age, both might have been deprived of these blessings by Medical Assistance in Dying (MAID). In Canada today, a person may access medical assistance in dying if they satisfy all the following criteria including but not limited to:
- Having a serious and incurable illness, disease or disability
- Being in an advanced state of irreversible decline in capability
- Experiencing enduring and intolerable suffering as a result of their medical condition
- Being on a course toward the end of life. Death would have to be reasonably foreseeable in all the circumstances of a person’s health, but there would not have to be a specific prognosis or prospected time period before death
The Criminal Code of Canada currently prohibits MAID from being administered to patients solely on the basis of a mental illness. However, the federal government plans to revisit this exclusion by 2023, making it possible for mentally ill people to choose MAID instead of suicide by that time.
Once all the criteria are satisfied, MAID becomes as easy as one simple (and expensive) injection to induce a sleep from which one never awakens. It is felt to give the already dying a more dignified exit, by avoiding the final ravages of their illness. By expediting their death, the dying can take more control over it. There is also some added convenience. The dying can choose to bring their loved ones together at a pre-arranged date and time for their death, instead of burdening people with unexpected, last-minute preparations for travel, funeral arrangements and so on. One can even, if still able, dress oneself in one’s funeral attire before receiving the lethal injection. In the case of the Brickendens, the ageing couple was even able to arrange to die together while their children watched from the foot of their bed.[i] To a suffering individual or a scared individual or a proud individual, MAID can be attractive on many levels.
Does MAID really cheat death, though? Or does it cheat us? It may feel empowering to think that we are cheating death somehow by circumventing the agony of dying, but modern medicine with its palliative care options, has made it possible to eliminate physical pain, or to at least diminish it to a significant degree. If there is psychological or spiritual pain, this is what the Church calls a lack of peace. This type of agony sometimes pushes to the surface of one’s consciousness, the ugly parts of one’s life—the parts one would otherwise ignore and forget—forcing one to reconcile with them and with God in the form of repentance.
In War and Peace, Prince Andrei Bolkonsky was a bitter and angry man when he became mortally wounded in 1812, fighting Napoleon on the field of Borodino. He ardently hated the man who had seduced his fiancée into an elopement, but he hated her even more for her childish infatuation with Anatole and her betrayal of Prince Andrei’s own honourable love for her. Although the elopement had been discovered and intercepted, and Natasha suffered tremendous shame and remorse afterwards, Prince Andrei could not forgive her. He broke off their engagement and his promises to her, and in so doing, became a disenchanted and broken man. Such was the condition of his heart when he was wounded in battle. His doctor, knowing there was no hope for his survival, felt regret when the prince partially recovered, “for if he did not die now, he would do so a little later with greater suffering.”[ii] Prince Andrei’s sufferings, however, become a transformative blessing.
After he was carried off the battlefield, Prince Andrei was set on a table in a dressing station to have his wound examined and dressed. On the table next to him, another wounded soldier was undergoing a horrifying leg amputation. “In the miserable, sobbing, shattered creature whose leg had just been amputated, he [Prince Andrei] recognized Anatole Kuragin, ”the man who had seduced Natasha.2
Suddenly, “his soul awoke to a love and tenderness for her which were stronger and more pulsing with life than they had ever been … [He] remembered everything and a passionate pity and love for this man welled up in his happy heart. [He] could no longer restrain himself and wept tender compassionate tears for his fellow-men, for himself and for their errors and his own.”
The dying prince thought to himself, “‘Sympathy, love for our brothers, for those who love us and for those who hate us, love of our enemies—yes, the love that God preached on earth, that Princess Maria [his sister] tried to teach me and I did not understand …
… Yes—love. But not that love which loves for something, to gain something or because of something, but the love I knew for the first time when, dying, I saw my enemy and yet loved him. I experienced the love which is the very essence of the soul, the love which requires no object. And I feel that blessed feeling now too. To love one’s neighbours, to love one’s enemies, to love everything—to love God in all His manifestations. Human love serves to love those dear to us but to love one’s enemies we need divine love. And that is why I knew such joy when I felt I loved that man. What became of him? Is he alive? … Human love may turn to hatred but divine love cannot change. Nothing, not even death can destroy it. It is the very nature of the soul. Yet how many people have I hated in my life? And of them all, none did I love and hate as much as her.’ And he vividly pictured Natasha to himself, not as he had pictured her in the past with her charms only, which gave him such delight, but for the first time imagining her soul. And he understood her feelings, her suffering, her shame and remorse. Now, for the first time, he realized all the cruelty of his rejection of her, the cruelty of breaking with her. ‘If only I might see her once more. Just once to look into those eyes and say’ …
… When he came to himself Natasha, the veritable living Natasha, whom of all people he most longed to love with the new, pure, divine love that had been revealed to him, was on her knees before him…[She] knelt … gazing at him with frightened eyes and restraining her sobs … Prince Andrei fetched a sigh of relief, smiled and held out his hand … ”
It seems providential that Prince Andrei survived a shell blast that should have instantly killed him, and then witnessed the brutal amputation of his sworn enemy, Anatole. Instead of feeling vindicated, the synchronous experience of his own suffering and dying engendered compassion for his enemy and turned his hatred into love. The good doctor, drenched in the blood of the wounded while immersed in saving their lives, could not know any of this. Naturally, he wished Prince Andrei a quick death to spare him more physical suffering. Tolstoy, however, who knew the back story (because he wrote it) also knew that a quick death would have cheated Prince Andrei from a good death, a death that would teach the prince (and the reader) the power of forgiveness and the beauty of divine love.
This was also the case in The Death of Ivan Ilyich. According to Tolstoy, “the past history of Ivan Ilyich’s life was most simple and ordinary and most terrible.”[iii] It was most terrible, not because of the way he died (which up until the very end was also terrible) but because of the way he lived, which was how most people lived within his social circle. And yet, Ivan Ilyich was not a bad person.
He “was an intelligent, lively, pleasant, and decent man … educated in law school … [and] strict in fulfilling what he considered his duty [which was] all that was so considered by highly placed people. He was not ingratiating … but from the earliest age he [was] drawn … to the most highly placed people in society … adopting their manners, their views of life, and … establishing friendly relations with them …”
Ivan Ilyich had opportunities to repent of his sins early in his life, but he did not.
“In law school he had committed acts which had formerly seemed to him of great vileness and had inspired a feeling of self-loathing … but subsequently, seeing that such acts were also committed by highly placed people and were not considered bad, he, without really thinking them good, forgot all about them and was not troubled in the least by the memory of them …”
Even after law school, “… he had been given to sensuality and vanity … there was a liaison in the provinces with one of the ladies … there was also a milliner [hat maker]; there were drinking parties … and little trips to a remote back street after supper; there was also subservience to his superior and even to his superior’s wife; but it all bore such a lofty tone of propriety that it could not be called by any bad words … It was all done with clean hands, in clean shirts, with French words, and above all in the highest society … with the approval of highly placed people …”
And so, Ivan Ilyich never felt the need to trouble himself with change or repentance, something which his social circle did not practice or even think about. Although he never abused his power as an examining magistrate, Ivan Ilyich continued making an idol of himself and of the high society whose approval he always sought, devoting his life to every elegance and pleasure he could afford and consciously putting on those airs he felt suited his station in life.
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He sought only to pass his life easily and pleasantly. For a while, this worked out well. Even his marriage was very pleasant at first, until his wife began experiencing the discomforts of pregnancy and new motherhood which revealed to her, her husband’s self-absorbed selfishness. The more she tried to solicit his support and assistance with her difficulties, the more he felt this disrupted “the pleasantness and decency of life” and the more he ignored her. He spent less and less time with his family, devoting himself to his work and to his friends more and more. Soon, he and his wife were developing an ever-deepening animosity for one another. Even this did not bother him, however, provided there was no quarreling and he always had something pleasant with which to occupy himself.
After 17 years of a troubled marriage that he did his best to ignore, Ivan Ilyich was still relatively young at 45 when he developed an ache in his side. At first, he ignored it, just as he had ignored his wife, but this ache kept growing, forcing him to experience increasing unpleasantness, which progressively disrupted his chosen lifestyle whether he liked it or not. First, he had to seek out doctors and take medications. Then, the pain interfered with his ability to work, ultimately forcing him to stop work altogether. Card games, which he loved, initially distracted him from the pain, but eventually, he could not enjoy those either. Eating also became problematic followed by sitting with company, and he began needing to leave the room to lie down in private.
This gradual withdrawal peeved his family, particularly his wife who had grown so accustomed to his passive-aggressiveness, that she believed him to be purposely behaving this way, just to spite her. Instead of giving her husband the sympathy he craved, she even blamed him for his illness. Unfortunately, Ivan Ilyich could not see that he had brought this treatment from her upon himself because he had treated her the same way.
While the pleasantries of life for his family went on without him, Ivan Ilyich experienced more frequent visits to more doctors, increasing doses of opium and morphine, and a heightened realization that he might actually be dying. After eight weeks of decline, he became bed ridden, while bearing the humiliation of being changed, dressed and carried by a male servant. By the time his doctors and his family had all realized that he was, indeed, dying, Ivan Ilyich’s main torment changed. It was no longer the physical pain and the resentment he felt towards others for living life without him; it was now everyone’s “lie” that he was merely ill and not dying. Many times, he was a hair’s breadth away from shouting, “stop lying! … but he never had the courage to do it. The dreadful, terrible act of his dying … was reduced by all those around him to the level of an accidental unpleasantness, partly an indecency … in the name of that very “decency” he had served all his life …”
Ten weeks into his illness, everything became too much for him to bear. He “stopped holding himself back and wept like a child … over his helplessness, over his terrible loneliness, over the cruelty of people, over the cruelty of God, over the absence of God.”
Finally, Ivan Ilyich prayed: “Why have You done all this? Why have You brought me here? Why, why do you torment me so terribly?”
“What do you want?” was the first clear idea that he heard.
“What? Not to suffer. To live,” he replied.
“To live? To live how?” asked the voice of his soul.
“Yes, to live as I lived before: nicely, pleasantly.”
“As you lived before, nicely and pleasantly?” asked the voice. He started to remember the best moments of his pleasant life, but strangely, all that had seemed like joys dissolved away, turning into something worthless and vile. Only his childhood seemed right to him. The further away from childhood he remembered, the more worthless and dubious were his joys. His climb in public opinion was proportional to the downhill decline of the remainder of his life. Then, the thought “Maybe I did not live as I should have” suddenly came into his head, but this made no sense to him at first because he had done “everything one ought to,” according to social expectations.
“What do you want now then?” his soul challenged. “To live? To live how? To live as you live in court, when the usher proclaims: ‘Court is in session!’ Court is in session, court is in session … Here is the court!”
“But I’m not guilty!” Ivan Ilyich shouted angrily. Again, he recalled all the correctness of his life and drove away the strange thought.
Another two weeks of agony went by before Ivan Ilyich reconsidered that perhaps he had, in fact, not lived rightly and this time he was able to see that this was so, both in himself and in his social circle. He saw “a terrible, vast deception concealing both life and death. This consciousness increased his physical sufferings tenfold.” He felt desperate. It made him hate both his family and everyone in his social class. When his wife called a priest for communion, this eased him only momentarily. For the next three days, Ivan Ilyich howled horrifically and spent every ounce of energy he had left thrashing from side to side, as though he were physically trying to push away all the horror of his life that had been revealed to him. By the end of the third day, he calmed down and said to himself, “Yes, it was all not right … but never mind. I can, I can do ‘right.’ But what is ‘right’?”
Just then, his young son entered the room, grabbed his father’s hand and weeping, kissed it. His wife also came in, her face tear stained and desperate. For the first time, Ivan Ilyich realized he had been tormenting them and he felt sorry for them. For the first time, he asked them to forgive him, and suddenly his torment resolved. “’How good and how simple,’ he thought … ‘And death? Where is it?’… There was no more fear because there was no more death. Instead of death there was light. ‘So that’s it!’ he suddenly said aloud. ‘What joy!’” For those around him, his apparent physical agony went on for two more hours, but for Ivan Ilyich, whose sufferings had ceased the moment he experienced Truth, the time passed in an instant.
“’It’s finished!’ someone said over him.”
“’Death is finished,’ he said to himself. ‘It is no more,’” and Ivan Ilyich took in his final breath but his first eternally happy and peaceful one.
Most of us can probably relate to Ivan Ilyich, who devoted his entire life to making an idol of himself and his lifestyle. We can also relate to at least some of his sins which seduced and deluded him under the guise of “decency”—his vanity, posturing, selfishness, shallowness, pride, worldliness, sensuality, hypocrisy, enmity, and idolatry to name a few. Because he wasn’t as bad as some and kept himself within the law, Ivan Ilyich had successfully deluded himself about the “decency” of his life to the degree of spiritual blindness, much like the Pharisees at the time of Christ. And yet, God did not give up on Ivan Ilyich. Knowing how far gone he was but not hopelessly so, He blessed Ivan Ilyich with as much suffering as he needed to open the eyes of this blind man to the truth of his terrible life, leading him to repentance, salvation and joy. When the fruit of Ivan Ilyich’s soul finally became ripe and ready to be transplanted into the eternal garden of paradise, only then did our loving God take it there.
Tolstoy’s world (and ours as well) was filled with “decent” Ivan Ilyiches whose main goal in life was the pursuit of pleasure and ease, even amongst those who practised a form of Christianity. This story, therefore, explains the purpose behind the torment of forgotten or unrecognized sin. This type of torment becomes a blessing when it leads to repentance.
A classic real-life example is the death of the penitent thief on the cross next to Christ. His death was not “painless, blameless or peaceful,” but because the Lord knew the condition of his heart, this man was blessed with the experience of crucifixion next to Christ as a final but most profound opportunity to confess his sins. Doing so became the salvific “Christian end” to the life of the thief when Christ said to him, “Today, you shall be with Me in Paradise.” (Luke 23:43)
On the other hand, Prince Andrei’s story successfully drives home the extremes of hatred, love, repentance and forgiveness which often battle it out in the hearts and minds of those who strive for spiritual growth and righteousness. It took a mortal wound to help Prince Andrei reach this spiritually salvific level.
Leo Tolstoy understood the purpose of suffering, the mystery of death, and the nature of God’s divine love. Tolstoy believed that since Christ condescended to death on the cross, He will also do whatever else it takes to save us, individualizing our dying experience according to the spiritual needs of each one of us. “O Death, where is thy sting? O Hades, where is thy victory?” (1 Corinthians 15:55) does not only refer to Christ’s one-time destruction of Hades, but also to His Life-offering presence as each of us dies. He persistently and tirelessly knocks on the door of our hearts, even to the very end of our earthly lives, if we have not “lived as [we] should have.” Had Tolstoy’s characters not died the way they did, they would have been deprived of the most profound experiences of their lives (their salvation); and we would have been deprived of the priceless lessons they learned.
We all hope for a “painless, blameless and peaceful ending,” but if we do not live as we should, God, in His unfathomable lovingkindness may grant us enough difficulty in dying to teach us the lessons we resisted learning while alive and well. This is not by way of punishment, but by way of lovingly helping us truly repent, to ensure that our own unique experience of death transforms us and transports us from the land of the dying to the realm of the living.
There are many examples of difficult deaths which opened the gates of paradise. The holy martyrs who lived for Christ, often suffered, some by way of physical torture, others through spiritual battles, and still others by rejecting the pleasures of this world, to name a few examples. What would have happened to them if they took the easy way out—if MAID had intercepted their physical and spiritual struggles? What can happen to us if we allow MAID to intercept our own dying process? For many, as in the case of the pleasure-seeking Ivan Ilyiches of the world, death becomes the final opportunity for repentance and salvation.
For love of neighbour, we should do all we can to alleviate the suffering of any human condition; but playing god by hastening death through MAID in the name of human dignity and ease, which Ivan Ilyich called “decency” does not cheat death. It only cheats the dying out of eternal life.
[i] “Medically assisted death allows couple married almost 73 years to die together,” The Globe and Mail, April 1, 2018.
[ii] All quotations from War and Peace are taken from Rosemary Edmunds’s translation, Penguin, 2009.
[iii] All quotations from The Death of Ivan Ilyich & Other Stories are taken from Richard Pevear and Larissa Volokhonsky’s translation, Knopf, 2009.
Irene Polidoulis MD, CCFP, FCFP – an Orthodox Christian in Canada
thanks to:
https://orthodoxreflections.com/medical-assistance-in-dying-is-cheating-death-worth-it/
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