Vol. 46 No. 3 September 2013
Journal of Pain and Symptom Management
447
Humanities: Art, Language, and Spirituality in Health Care
Series Editors: Christina M. Puchalski, MD, MS, and Charles G. Sasser, MD
Ethos, Mythos, and Thanatos: Spirituality and
Ethics at the End of Life
Daniel P. Sulmasy, MD, PhD
MacLean Center for Clinical Medical Ethics and Program on Medicine and Religion, the Department
of Medicine and Divinity School, The University of Chicago, Chicago, Illinois, USA
Abstract
Every ethos implies a mythos in the sense that every systematic approach to ethics is inevitably
based on some fundamental religious or religion-like story that gives answers to questions
such as: Where did I come from? Where am I going? How am I to live? These narratives
generally lay hidden beneath the plane of the interpersonal interactions that characterize all
clinical encounters, but caring for patients who are approaching death brings them closer to
the surface. For many patients and practitioners, these narratives will be expressed in
explicitly religious language; others may invoke a sense of ‘‘immanent transcendence’’ that
affords a spiritual perspective without requiring theism or notions of eternity. In caring for
patients at the end of life, practitioners should strive to be more conscious of the narratives
that undergird their own spiritual and ethical positions as well as seek to understand those of
the patients they serve. J Pain Symptom Manage 2013;46:447e451. Ó 2013 U.S.
Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.
Key Words
Spirituality, ethics, religion, hospice, palliative care, physicians, nurses
Every ethos implies a mythos. Drawn from Aristotle’s Poetics (1450a.15-1450b.4), the original
meaning of this pithy aphorism was that in dramatic works, character development (ethos) requires a plot (mythos).1 The contemporary
English words ‘‘ethics’’ and ‘‘myth,’’ although
etymologically related to these ancient Greek
words, have been transmogrified in a way
that suits my purposes in this essay. My use of
this aphorism is intended to convey the thesis
that all ethics (ethos) depends on some sort
of underlying story that has a religious (or
Address correspondence to: Daniel P. Sulmasy, MD,
PhD, Department of Medicine, The University of
Chicago, MC 6098, 5841 S. Maryland Avenue, Chicago, IL 60637, USA. E-mail: [email protected]
Accepted for publication: March 29, 2013.
Ó 2013 U.S. Cancer Pain Relief Committee.
Published by Elsevier Inc. All rights reserved.
religion-like) nature (mythos).2 I am using
‘‘myth’’ in a technical sense as the term is
used in the study of religion. This technical
use of ‘‘myth’’ should not be mistaken for the
popular meaning of the word and interpreted
to suggest that I believe religions are false. To
the contrary, religions aim to tell us the most
fundamental truths about reality and human
experience. All that my use of the word
‘‘myth’’ should imply is that religions (and philosophies) express their most basic truths
through stories.
My thesis, then, is that every system of ethics
depends, either implicitly or explicitly, on
some very fundamental story about some very
basic questions such as the nature of the universe, the meaning of the human, the nature
of value, the purposes (or lack thereof) of human freedom, and others. The stories that
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http://dx.doi.org/10.1016/j.jpainsymman.2013.03.016
448
express these fundamental beliefs, even if not
religious, must be considered at least
religion-like in their character. The story of
Adam and Eve in the Garden of Eden, for instance, is one such story. Just so, however, is
the story of the ‘‘Original Position’’ as told by
the philosopher John Rawls, a story that is
full of assumptions about who the people are
in this mythical original position, standing behind the mythical ‘‘Veil of Ignorance,’’ and
choosing what their society will be like.3 Secular bioethics is full of such mythical stories, replete with built-in assumptions about the
answers to the most basic questions facing humankind, even before one begins to draw out
the bioethical implications of these stories.
For another example, think of the bioethics
of an author such as H. Tristram Engelhardt.
His libertarian bioethics is founded on some
very foundational commitments that find expression in stories. Sometimes, one must dig
deeply into what seem like purely rational philosophical musings to find the stories, but they
are there. I have called the myth that undergirds Engelhardt’s libertarian bioethics, with
its emphasis on individuals and their liberty,
‘‘The Myth of the American Frontier.’’2 As he
explains it in a footnote in one of his books:
This description somewhat foreshadows the
American frontiersmen who moved on further when the smoke from too many neighbors’ houses could be seen, or the old Texas
view that ‘‘your neighbors are too damn
close when you can’t shoot in all directions
without fear of hitting someone.’’4
The bioethics that flows from such a mythos
will be shaped by it.
Charles Taylor has written in secular
philosophical terms about the fundamental,
self-identifying, and morally originating commitments on which various systems of ethics
are based.5 He argues that each and every system of ethics requires answers to such questions before it can get off the ground. He
calls these ‘‘strong evaluations.’’ There is no
ethics from nowhere. Even if these selfidentifying and morally originating commitments are not religious, these comprehensive
sets of assumptions are really sets of religionlike beliefs. As the saying goes, it takes a lot
of faith to be an atheist. The answer to the
question of whether there is a deity will require
Sulmasy
Vol. 46 No. 3 September 2013
just as much or as little faith if one answers the
question in the negative as in the affirmative.
And it will require equal amounts of courage
to live one’s life in accordance with the fundamental moral commitments that flow from
one’s answers to such questions.
In thinking about the ethics of caring for patients at the end of life, then, it pays to attend
to the mythos that undergirds any ethical position that may be proposed, whether that mythos
is religious or secular. In thinking about addressing the spiritual and existential needs of
patients at the end of life, it pays to attend to
the mythos in which such needs are framed.
Every mythos about care at the end of life concerns itself, implicitly or explicitly, with an account of Thanatos (the Greek demiurge of
death). That is to say, there is no spirituality
of care at the end of life and no ethics of
care at the end of life that does not presuppose
some account of death that comes from a faithlike set of beliefs, often embodied in narrative,
beyond the reach of bare reason or brute fact.
Care at the End of Life and the Big
Questions
The profound questions that one confronts
in all of medicine are brought into sharp focus
when caring for patients at the end of life. Superficially, one faces questions such as whether
to use oxycodone or morphine to treat a patient’s pain; whether intravenous hydration
helps or hinders a patient’s quality of life in
the last hours or days. But underneath the clinical and scientific questions lurk the very deepest questions that religions and philosophers
have long sought to answer, questions about
the origin of life and of death; how to define
joy; whether physical suffering can have a purpose; about the scope of freedom and the
place of responsibility; about the power of
love, the necessity of contrition, and the role
of reconciliation; about the nature of good
and whether there is such a thing as evil; about
the relationship between the finite and the infinite; and many more. The answers we give to
these questionsdas practitioners, as patients,
and as a societydform the moral and spiritual
infrastructure on which hospice and palliative
medicine are founded. Because the clinical
practice of hospice and palliative care often
Vol. 46 No. 3 September 2013
Ethos, Mythos, and Thanatos
lays these very powerful questions bare, many
health care professionals shy away from this
area of medicine. This is understandable.
Most people do not want such questions thrust
in their faces on a daily basis. Thankfully, however, others are drawn to care for patients at
the end of life, whether consciously or unconsciously, precisely because this area of specialization forces them to confront these questions.
The Spiritual Roots of Palliative Care
Because of this, it should come as no surprise that the roots of contemporary hospice
and palliative care have been religious and
spiritual. Some of the earliest hospices in the
modern era, such as St. Vincent’s in Dublin
(1834), St. Rose’s (1899), and Calvary (1899)
in New York, were founded by religious sisters
specifically to provide comfort care for the dying indigent. It is well known that the deep Anglican faith of Dame Cicely Saunders was
instrumental in her founding of St. Christopher’s Hospice in London in 1967 and in
her shaping of the contemporary hospice
movement.6 More recent leaders in hospice
and palliative care such as Michael Kearney
continue to give voice to a profoundly, if
broadly conceived, spiritual inspiration for
the field.7 Although it is true that the field
has been in many ways secularized,8 it remains
the case nonetheless that many of those working in hospice and palliative care today are
drawn to that work for spiritual reasons.9,10
Belief and Medical Action
The central thesis of this essay is that our
fundamental self-identifying and morally originating commitments regarding the most profound questions that all human beings must
facedquestions that lurk always beneath the
surface of medical practicedinform our attitudes and shape our actions in the work we
do in caring for those who are dying. For instance, Curlin et al.11 have shown that while
69% of U.S. physicians are opposed to
physician-assisted suicide, 84% of highly religious physicians are opposed. Whether one acknowledges it or not, the big ethical questions
have a spiritual as well as a moral character. So,
for example, if the self-identifying and morally
449
originating mythos that informs one’s life is the
story of human progress, then death will remain a perpetual enemy and one will pursue
biomedical research with a spiritual zeal; regenerative medicine and transhumanist ambitions will be seen as instantiating human
excellence rather than as pursuits to be viewed
with caution or suspicion. If, in accord with the
tenets of one’s underlying mythos, death is utter
annihilation and physical suffering is pointless,
then it is difficult to see how one could be opposed to the legalization of euthanasia and assisted suicide on any grounds other than fear
that these practices will be abused.
Religion, Spirituality, and Ethics
Religions also have answers for these sorts of
questions and are often much more explicit
about the stories that express the fundamental
self-identifying and morally originating commitments of those that profess the religion. Religion and medicine meet at the same
junctures in human life, and both have a great
deal to say about the most significant aspects of
human existence, such as birth, sexuality, the
raising of children, sickness, suffering, and
death.
In caring for patients at the end of life, suffering and death are the main concerns. To illustrate how religious content can influence
the ethical decisions and the spiritual and religious concerns of dying patients, consider the
following two passages, one from Hinduism
and one from Christianity.
In the Bhagavad Gita (8.6), one reads the reply of the god Krishna to the inquiries of Arjuna who is facing the prospect of death on the
battlefield: ‘‘On whatever sphere of being the
mind of a man may be intent at the time of
death, thither will he go.’’12 Stories such as
this one have deep resonances for Hindus,
helping to explain, for instance, why a Hindu
might be reluctant to treat pain with opioids.
Consciousness at the time of death is of great
value, allowing preparation for one’s death
and, in part, determining one’s fate in the afterlife. Hindus typically also place great value
on dying at home, and may not wish to stay
in the hospital or a nursing home or even an
inpatient hospice as they approach death, because the familiarity of family and home also
can prepare them mentally for death.
450
Such stories can even resonate across religions. Buddhism, which owes a great debt to
Hinduism, has similar teachings about consciousness and death. And the great Christian
poet, T.S. Eliot, also approvingly incorporates
this verse from the Bhagavad Gita into his
poem, ‘‘Four Quartets.’’13
The Christian saint, Francis of Assisi, includes a verse praising God for death in his
poem called ‘‘The Canticle of Creatures,’’ in
which he praises God for the wonder of the
created world, calling the sun, the moon,
fire, water, the wind, and plants his brothers
and sisters. Finishing this poem and adding
this final verse on his deathbed, Francis writes:
Praise be You, my Lord, through our Sister
Bodily Death,
From whom no mortal being can escape.
Blessed are those whom death will find in
Your most holy will,
For the second death shall do them no
harm.14
This poem suggests that death is not an enemy and would fortify a believer to face death
as inevitable. Like the Bhagavad Gita, it also
speaks of the afterlife but emphasizes having
lived a life in accordance with God’s will rather
than emphasizing consciousness at the moment of death. Thus, for a Christian, the risk
of diminished consciousness should not be
an absolute barrier to taking opioid analgesics
or other potentially sedating drugs at the end
of life. Catholic Christians, like Francis of Assisi, also would want to be sure they stood in
right relationship with God before death and
would seek the Sacraments of the Sick, Reconciliation, and Communion before death. To try
to escape from the inevitability of death by
means of euthanasia or assisted suicide would
be considered ironic attempts to assert control
in the face of what ‘‘no mortal being can escape’’ and would be considered practices outside the ‘‘most holy will’’ of God.
Conclusion
From these arguments and brief examples, it
should be clear that the underlying mythos of
a person says a great deal about his or her ethos
in the face of death, partly determining that
Sulmasy
Vol. 46 No. 3 September 2013
person’s spiritual and existential needs and
partly determining his or her moral acts.
Conversely, I have argued that every person’s
spiritual and existential needs and moral convictions surrounding death depend on some
sort of story that embodies the person’s needs
and convictions and partly determines them,
whether that story is explicit or not. These
stories need not be religious, nor does a person’s spirituality need to be religious. Whereas
spirituality invokes the transcendent, Charles
Taylor has described a common contemporary
Western belief that he calls ‘‘immanent transcendence’’da belief in something that transcends the person and his or her needs and
preferences but is circumscribed by the
bounds of society or humankind or the world
or the universe and is not ‘‘supernatural’’ in
the sense of being beyond nature.15 Death becomes, in this secular spiritual view, ‘‘the paradigm gathering point for life.’’ Fundamental
self-identifying and moral commitments based
on some version of ‘‘immanent transcendence’’ can (and often do) undergird the spirituality of patients and practitioners.
Every ethos implies a mythos. Where did I
come from? Where am I going? How am I to
live? Every physician, nurse, and patient,
whether consciously or not, is committed to
some sort of story that answers these questions,
whether expressed in the language of the Big
Bang or of the Exodus of Israel from Egypt.
Careful, mindful practitioners will understand
this and will reflect on their own deepest selfidentifying and morally formative convictions
and work to understand, as best they can, those
of the patients they serve. The implication,
frightening as it may be, is that the work of
health care is itself more profound (perhaps
even sacred) than we usually recognize, an
awareness that the approach of death will often
make manifest in mysterious and myriad ways.
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