End of life care: What do religions say?

With figures showing that many people around the world die painfully due to scarce access to morphine, the World Health Organization is calling for improvements to end of life care.

But even when pain medication is available, the end of someone's life is often an immensely difficult moment for all concerned. So for those who believe, what guidance can religions offer in a person's last moments?

At first glance the words 'good' and 'death' might not seem compatible, yet most of us will have reflected on how we would like to depart this world, if given the opportunity to choose.

While the proverbial scenario 'at home, asleep' might unfortunately not be attainable for everyone, it does give a sense of what the 'ideal' death might look like: peaceful, pain-free and dignified.

Such themes occur in religious discourse around the end of life too. Although there can be variations in how branches of the same faith view specific situations, there is one common thread: that life is sacred and should be preserved.

Rabbi Yehuda Pink, convener of the West Midlands Jewish Medical Ethics Forum, says that traditional Judaism gives life infinite value, as humans are created in the image of God. Therefore, an hour, a day or a week of life has as much value as a year or ten years.

The challenge, says Rabbi Pink, comes when we need to determine whether we are preserving life or prolonging dying.

"There is no obligation to prolong the dying process, quite the opposite," he says. "We need to ensure that people don't suffer pain, so palliative care serves a very important role in Jewish beliefs."

Similarly, Christianity, Islam and Buddhism see looking after the ill as a core value. Dr Desmond Biddulph, president of the UK's Buddhist Society, says that Buddhism's First Noble Truth recognises that death is suffering but not unexpected. Buddhism teaches to accept death while still recognising that life is precious, but no particular advice is given in terms of end of life care.

Relieving pain

While healing miracles appear in the Abrahamic faiths, palliative care is generally not seen as giving up on God's powers. Rabbi Pink explains that Judaism views medicine as a partnership with God, who has hidden within nature the ability to do many things: "Unveiling and unleashing the potential of medicine is actually a declaration of faith in God," he says.

Faiths agree on the fact that a patient with an incurable illness does not have to undergo extensive suffering. Reverend Kevin Dunn, chaplain at the Christie NHS Foundation Trust, describes situations in which someone might negotiate the amount of pain relief they are administered, as they want to remain conscious and less sedated.

However, he says that pain does not have an intrinsic religious value in traditional Christianity: "Pain can be used by the person in a spiritual way, but pain does not equal close to God."

'Angels and prophecies'

The meaning attributed to suffering can differ from patient to patient. Dr Jonathan Koffman, lecturer in palliative care at King's College London's Cicely Saunders Institute, has researched the role of religion and spirituality at the end of life.

His observations of London's Afro-Carribean communities show how religions have developed a very strong framework for "making sense of the inexplicable".

Dr Koffman stresses the importance for doctors to communicate with their patients and to understand that a person's beliefs, levels of religiosity and ways to respond to illness can change. For example, some patients may have prophetic visions - such as an angel - which, despite evidence to the contrary, convince them their conditions will improve. These visions, which are deeply rooted in the patient's belief system, can affect their end of life medical decisions.

Moreover, some patients may interpret pain in a religious key: "Some may ascribe pain to being a test of their religious faith, or divine punishment," he says. "And in some instances they may refuse [pain relief], because they have to bear that suffering."

A similar view can be found among some Muslim faithful. Imam Yunus Dudhwala, head of chaplaincy at Barts Health NHS Trust, says this belief comes from a saying of the Prophet Mohammed which hints at difficulty and pain as a way to expiate sins. Hence, some patients may be reluctant to take pain relief.

Intentions and results

Another reason some might refuse strong pain medication, explains Imam Dudhwala, is that in some cases it may hasten death. This is one of the many ethical issues surrounding end of life: that medicines used for a positive purpose, relieving pain, might have a negative effect: the death of the patient. The doctrine of double effect is often cited in these cases to support one argument over another.

Rabbi Pink says in these cases effects and their likelihood should be looked at carefully: "If the administration of the pain relief would have such severe effect, like to almost certainly kill the person, that would clearly be forbidden. For example, euthanasia is certainly not allowed in Jewish terms."

Intentions have a very important role in the Buddhist approach too. Dr Biddulph explains that karma is created through selfish actions. Discussing hypothetical scenarios of individuals having to take medical decisions for a patient, he says not taking into account the best interest of everyone involved in the situation might affect karma.

Humane decisions

Withdrawing hydration and nutrition from a patient can be controversial. In general, religions agree that they do not constitute treatment, but basic human requirements. Rev Dunn says that in some particular cases they have been reduced or withdrawn because, as the body begins to close down, it stops processing food and fluids, and forced hydration and nutrition can be very painful.

So the focus is on a humane death and, perhaps, the opportunity to say the last goodbyes. While some families are reluctant to tell a loved one that they are dying, according to Imam Dudhwala, the patient has a right to know, because "it's their right to prepare for what is coming, whether it's writing a will, or preparing to meet their Creator."

Rather than prescriptive advice on medical treatment, faiths aim to offer a framework to approach and make sense of death. Rev Dunn suggests: "making a will, making sure your affairs are in order, making sure your relationships are reconciled, thinking about organ donation." To make sure that, in the darkest of days, some solace can be taken in knowing that nothing was left undone.