I SHOULD like to make four comments related to the theme of this conference bearing on the inter-relationship of medical and religious ministries to the dying patient. I assume we have in mind not only the person whose death is imminent, but also the patient whose prognosis is apparently hopeless but who has a more or less extended period of time in which reflection and communication are possible.
What About Death?
Our relationships with the dying patient are inevitably influenced by our personal thoughts and feelings about death.
In an article "The Experience of Dying," Dr, E. Mansell Pattison, psychiatrist, writes:
Death is not the primary problem, but rather how one faces death and goes about the process of dying. Although we cannot deal with the ultimate problem of death, we can help the person to deal with the various parts of the process of dying. . . . Only when the clinician has come to face death within himself can he begin to practice the high therapeutic art of helping people to die.—American Journal of Psychotherapy, January, 1967. What Pattison says of the clinician might be said of the clergyman and all persons who are related to the dying.
In varying degrees we are all caught up in and reflect our death-denying, death-defying, death-distorting, death-evading culture. Pascal wrote: "Since men have not succeeded in eliminating death, they have decided not to think of it." Most of us have our own fears and hangups in relation to dying and death. It is so much easier to avoid the dying person, for in some ways he is a threat to us.
Thus, we who have special responsibilities for meaning something to the dying sometimes actually contribute to the dehumanization of the dying process. Too often we avoid the dying patient at the point of his greatest human need—to be related to as a thinking, feeling, hurting, hoping, communicating person.
Ethical Issues
There are ethical issues that attend our respective ministries to the dying patient. We need to be doing more about getting these into the open, sharing whatever wisdom and perspectives we may have. All of us who deal with the dying make decisions that implicitly or explicitly involve value judgments and issues of a philosophical character. Man is now called upon to make decisions related to life-and-death control that only a few years ago we thought were not in human hands.
What and how should a patient be told of his condition?
Given a patient who in the doctor's best medical judgment has no foreseeable chance of recovery, to what lengths ought he go to prolong the patient's life? How is the concern for life to be balanced with the concern to help the patient die with comfort and dignity?
If the life of a dying person might be prolonged by a transplanted or artificial organ, what advice should be given? In ministering to the dying patient, how are the respective concerns for patient, family, community to be related? At times decisions must be made in the light of priorities.
We are in a day when more attention needs to be given to ethical issues in patient care. It is interesting to know that the Kennedy Foundation is funding an institute for "the study of Human Reproduction and Bioethics."
Any extended physician-clergy dialog must sooner or later confront ethical issues in patient care. Hopefully in such discussion we could learn from one another.
Personal Concern
The dying patient is a human being. Like all human beings, he is not an island unto himself. He is sustained through personal relationships. It is essential that he be caringly attended on a person-to-person basis. Our professions share responsibilities in this matter.
Dr. Pattison, to whom reference has been made, holds that there is no experience of dying, but "rather many experiences of dying." Perhaps we could say that death is a moment when dying ends. Pattison analyzes the part-aspects of the experience of dying in terms of certain fears: fear of the unknown, of loneliness, fear of loss of family and friends, fear of loss of body, fear of loss of self-control, fear of loss of identity, fear of regression. To feel that one is meaningfully related in the midst of the experience of these fears, that one is not alone or abandoned, is terribly important. Only so can the experience of dying become a part of living.
In her book On Death and Dying (Macmillan, 1969) Dr. Elisabeth Kubler Ross, a psychiatrist, reports on an interdisciplinary seminar on death and dying that has now been going on for several years in Chicago. It includes interviews with dying patients. I think it is a book from which we can all learn something about our own difficulties in dealing with the dying per son, as well as learn about the dying per son's need to be attended, to be cared about as a person, and at times, to be heard. Dr. Ross writes:
There came a time when all of our patients had a need to share some of their concerns, to lift the mask, to face reality, and to take care of vital matters while there was still time. They welcomed a breakthrough in their defenses, they appreciated our willingness to talk to them about their impending death and unfinished tasks. They wished to share with an understanding person some of their feelings, especially the ones of anger, rage, envy, guilt and isolation. They clearly indicated that they used denial when the doctor or family member expected denial because of their dependency on them and their need to maintain a relationship. —Page 262.
While we may function somewhat differently, no one profession is exclusively responsible for being meaningfully present in the sense of which Dr. Ross writes.
The Clergyman's Role
If there is to be a "team approach" as today's program suggests, it would seem to be essential that we share with each other our own professional self-understandings— with special reference to our responsibilities in relation to the dying patient.
In 1967 four professors at the Columbia University College of Physicians and Surgeons established the Foundation of Thanatology. With a 112-member professional advisory board, this group now holds interdisciplinary workshops, seminars, and symposia, conducts research, and publishes three journals dealing with various aspects of death, dying, and human grief. Dr. Austin H. Kutscher, of Columbia, president of the foundation, writes: "Our purpose is to serve as a catalyst, bringing together the disciplines that deal with the problems of dying and grief."
In the spirit of that purpose and as a start on setting forth a point of view on the clergyman's role in dealing with the problems of death and dying, I would make the following observations.
Religion has a persistent function in all cultures: to help persons achieve a measure of hope in the face of situations that are potentially demoralizing and that are believed to be beyond one's control. Religion has other functions, as well, but this one is persistent. The distinguished cultural anthropologist Clyde Luckhohn wrote:
Every society desperately needs morality in the sense of common standards, and religion in the sense of orientations toward such inescapable problems as death, individual responsibility, and other ultimate value attitudes.—Mirror for Man, p. 215.
In similar vein Peter Berger says:
Every human society is, in the last resort, men banded together in the face of death. The power of religion depends, in the last resort, upon the credibility of the banners it puts in the hands of men as they stand before death, or more accurately, as they walk inevitably toward it.— The Sacred Canopy, p. 52.
Religious ministry to the dying patient begins, then, very early in life. It begins with models or identification figures who in the words of Erik Erikson "have integrity enough not to fear death" (Childhood and Society, p. 269). It involves a religious education and nurturing that helps persons to know God not simply as a God of life but a God who undergirds the life-death cycle.
What the minister does in attending the dying patient is an acting out of, or implementation of, or witness to, his philosophy or theology of the life-death cycle.
What's Involved?
Religious ministry involves a being present with the dying patient.
Religious ministry involves bringing the assurances of faith in personal presence, in word, in shared silence, in reading, in rite, in prayer—in the varied languages that say "that neither death nor life . . . shall be able to separate us from the love of God" (Rom. 8:38, 39).
Religious ministry involves listening— hearing the patient in his "plain English, symbolic nonverbal, and symbolic-verbal" languages. The ministry of listening is essential if we are to provide the supportive care and understanding needed and sought by the dying.
Religious ministry involves an enabling role—enabling the patient to draw on and express his own religious resources.
Religious ministry involves the sensitive attending, affirming listening, enabling presence which helps the dying patient through what Dr. Ross calls "defense or coping mechanisms" defined in terms of stages: "denial and isolation, anger, bargaining, depression, acceptance." Speaking from a theological perspective, it is a basic role of the clergyman to assist the dying patient in coming to what might be called "the peace of reconciliation."
Religious ministry is a communication of faith, hope, and love, grounded in the abiding presence, power, and love' of God.
Religious ministry to the dying includes ministry to the family. We are learning more about grief and the grieving processes. We need to know more than we presently do about the relation of the time and manner of a patient's dying to the grief experiences of the family. But hopefully through interdisciplinary work we will continue to learn more of the phenomenon of grief, and how we can relate meaning fully to the family of the dying patient.
In closing I should like to express appreciation to Porter Hospital for taking the initiative in planning this conference. Hopefully we are entering an era of increased communication, an era in which we see man not simply as a collection of parts, but as a whole creature—in whom body and spirit, life and death, are wondrously interrelated.
