I. Introduction: Illness, Suffering, and the Work of Perfection
The contemporary debate concerning physician-assisted suicide is predicated, from the traditional Christian standpoint, first, on a belief that illness and suffering have no particular value or purpose and, second, that there is no life after death or, if there is, earthly life is not a necessary preparation or determinative for that life. Traditional Christianity, articulated in some detail by H. Tristam Englehardt in his article, “Physician-assisted suicide reconsidered: Dying as a Christian in a post- Christian age,” can also be summarized in the following statement by St. John of Kronstadt:
In our eyes, illnesses appear only as painful, unpleasant, indeed terrible … but in God's all-wise and most merciful providence, not a single illness remains without some profit to our soul... Not a single sickness sent to us shall return void... For man the earthly life, life in the body, serves only to prepare us for life eternal... Therefore we must, without delay, make use of this present life to prepare ourselves for that other life to come.
A latter-day father of the Church, St. Ignatius Brianchaninov, further explained that “earthly life—this brief period—is given to man by the mercy of the Creator in order that man may use it for his salvation, that is, for the restoration of himself from death to life” (emphasis added). This means that the focus of one's life is not primarily here, and therefore not political or sociological, but there, in the next world, in the Kingdom of Heaven. This is vividly illustrated by the final words of the righteous monk, Theodore of Svir (+1822) who, on his deathbed, said: “God be blessed! God be blessed! I have crossed the stormy sea of life and endured many troubles, but now the coast is in view.”
Given this otherworldly viewpoint, it then follows that “how long we live, what disease or illness accompanies our death—such things are not the proper concern of [traditional] Christians.” Afflictions of all kinds, illness, and death came into the world by God's permission in order to frequently, if not constantly, remind us that we are only creatures and in need of spiritual refinement and purification before we can enter the Kingdom of Heaven. This great mystery of suffering applies even to seemingly “innocent” children who sicken and, sometimes, die. The great Optina Elder, St. Ambrose, explained it thus:
We should not forget that in our age of “sophistication” even little children are spiritually harmed by what they see and hear. As a result, purification is required, and this is only accomplished through bodily suffering... You must understand that Paradisal bliss is granted to no one without suffering.
The process by which bodily afflictions act upon the soul is explained by St. John Chrysostom:
But if the body suffers only a little, we make every effort to be free of the illness and its pain. Therefore, God corrects the body for the sins of the soul, so that by chastising the body, the soul might also receive some healing... Christ did this with the Paralytic when He said: Behold, thou art made whole; sin no more… (Chrysostom, 1975, p. 205).
Orthodox Christians, on the other hand, have always believed, and still do, that the highest way to serve God is not out of expectation of any kind of reward but simply out of love. The act of loving God is thus seen as a reward and a goal in itself. This does not mean that one cannot ask God for bodily (as well as mental and spiritual) health—Orthodox Christians, for instance, constantly pray for “health, salvation, and welfare” in our Divine services—but such well-being is not seen as an end in itself, nor is a lack of health seen as “bad” or a sign of spiritual weakness (unless, of course, one has ruined one’s own health through poor stewardship of the body).
This reflects still another ancient Christian idea, preserved today primarily by Orthodox Christians: that suffering and sorrows, when carried in the shadow of the Cross, have value:
Church tradition relates that St. John the Merciful, after completing a Divine service, once noticed that a woman was crying bitterly in a corner of the church. He told his deacon: “Go and bring that woman, so that we can find out why she is so grieved: whether her husband has died, or her children are sick, or God has sent her some other misfortune.”
The deacon brought the woman to the saint. When St. John asked her why she was crying so inconsolably, she said: “How can I not cry, holy father! Three years have passed, and no sorrow has come to us. It seems that God has forgotten us completely. There is no sickness in the home, no ox has been lost, nor has a sheep died, and my family has begun to live carelessly. I am afraid that we will perish because of our easy life, and that is why I am crying.” The bishop-saint marveled at that answer and praised God.
“In such a way the Christians of the past have considered sufferings to be sent from God and have grieved when they did not have sorrows...”
Similarly, St. Ignatius Brianchaninov explains: “A sorrowless earthly life is a true sign that the Lord has turned His face from a man, and that he is displeasing to God, even though outwardly he may seem reverent and virtuous.”
In this context one can already see that any attempt to induce or hasten death for the primary purpose of ending pain and suffering (as distinct from the possible requirements of war or capital punishment) by any outside or artificial means, such as physician-assisted suicide, is not grounded in the traditional and ancient Christian way of seeing meaning and value in life’s afflictions. In fact, suicide (whether physician-assisted or not) is considered a symptom of despair—a deadly and soul-destroying sin—for such an act incorrectly assumes that joy or happiness are primarily the absence of suffering, and stands in stark contrast to St. Paul’s statement that we can be sorrowful, yet always rejoicing (2 Cor. 6: 10) and all who will live godly in Christ Jesus shall suffer (2 Tim. 3:12). However, in our secular culture the idea of joy or contentment in the midst of sorrow and affliction is becoming increasingly politically incorrect. The traditional Christian sees that if the dying process were without pain and discomfort, very few would opt for suicide or physician-assisted suicide. It is the avoidance of pain which has become the imperative today, even though a good deal of life and living is naturally accompanied by afflictions and suffering of all kinds, and cannot be avoided—and not just bodily pain, but emotional, mental, and spiritual, as well.
Although the word euthanasia means “good death,” traditional Christians see this as a misnomer, for they have always defined death—when it is sought as an end in itself—as evil. According to Orthodox theology, man was originally created in order to live forever, and death, which came into the world by sin, is a violation of God's plan for man. Therefore, although one need not—as we see in the lives of the saints below—artificially attempt to extend the dying process, we may not ourselves hasten the cessation of life, either. “This holds equally true whether the decision for death is made by the person concerned or by his caregivers.” In the case of those confessors who actually sought martyrdom, their death, like that of the soldier fighting to stop the spread of Nazism or Communism, is not an end in itself, but in order to achieve a greater good—i.e., the spread of the faith, the end of tyranny, etc. The voluntary martyr, therefore, far from opening even a tentative door to physician-assisted suicide (even as the lesser of two evils, as some suggest it may actually be), presents us with someone quite different from the person who seeks death only in order to stop his own personal physical and mental suffering, and who may thereby be rejecting the providence of God in his life, a providence that encompasses many things, including purification and refinement of soul which, experience shows, comes to those who accept the suffering of their final illness.
II. The Saints Show Us How to Die
Orthodox Christianity not only possesses a body of abstract theology and doctrine but also contains what could be called living theology or “theology in action”—which is the lives of the saints. Thus, “the Christian experience is the same across generations. From the inside, one will experience this unity as a bond to God across the generations of Christians. Dogmas are not simply to be known but experienced and lived.”
This is where the saints can be of help, for their lives are not intellectual arguments but actual experience. Such a traditional and rich Christian theology reflects and describes the process of sanctification and transfiguration rather than being reduced either to theological theories or twentieth century political-sociological principles. Therefore the saints—that is, those who have been specially chosen by the Holy Spirit and revealed to the Church for special honor and emulation by the faithful—are actually “theology incarnate.” This gives them practical power in the day-to-day lives of the faithful, for they often provide better and more accessible models for how to live and die than could many learned volumes by the fathers of the Church. Thus, St. John of Kronstadt exhorts his readers:
Call upon the saints, so that seeing every virtue realized in them, you may yourself imitate every virtue... When your faith in the Lord, whether in health or in sickness, in prosperity or poverty, whether at any time during this life, or at the moment of leaving it, grows dim from worldly vanity or from illness and the terrors and darkness of death, then look with the eyes of your heart and mind upon the companies of the saints... These living examples, so numerous, can strengthen the wavering faith in the Lord and the future life of each and every Christian.... Those Christian communities who do not venerate the saints... lose much in devotion and in Christian hope. They deprive themselves of the great strengthening of the faith by the examples of men like unto themselves.
Accordingly, if we look at the various ways in which traditional Christian saints arrive at the moment of death—almost always through the pain and suffering of a “final illness,” just like everyone else—we can see healthy and congruent models not only of what is called a “holy death” but vivid descriptions of how traditional Christians in fact die. To illustrate this I have chosen deaths from the lives of nine saints—seven men and two women—of comparatively recent times. After giving excerpts from their lives, usually written by direct disciples who were eyewitnesses of these events, we will look at similarities and dissimilarities in terms of how each one approached his end, and how he viewed pain and the use of medicine and physicians, etc. The first six examples were elders or “startsi” in the world of pre-Revolutionary Russian Orthodox spirituality. That is, they were spiritual directors thoroughly imbued with a certain Russo-Byzantine legacy of spiritual formation which permitted no innovation and left only very little room for personal “style” regarding how that Tradition was to be lived and then passed down. These elders—all of them were glorified by the Russian Church Abroad in 1990—were also, successively, spiritual fathers in a particular place, the great Optina Hermitage; they were also conscious bearers of a worldview and exemplars of a way of life which they both taught and modeled for their spiritual children in the monastic community, as well as laymen who came to them from the society at large for direction.
The author of Elder Leonid's life tells us that when the elder's final illness (of only five weeks duration) came, in 1841, he experienced sharp pain on his right side as well as lung congestion and constipation. “The people who surrounded the elder wanted to summon a physician but he would not agree and did not want to take any medication.” He also refused food, accepting only a little water and Holy Communion. After the first two weeks of suffering he “began to prepare intently for death:” 
Lying on his death bed he would call out in a compunctionate voice, “O Ruler of All Things! О Redeemer! О All-Merciful Lord! Thou seest my illness; I can endure no longer. Receive my spirit in peace”... He told the fathers and brothers who came, “Pray that the Lord shorten my sufferings.” But then once again, submitting to God's will and entrusting himself to His Providence, he called out, “Lord, Thy will be done! Do what is pleasing in Thy sight.”
The Elder Macarius, who died in 1860 after an illness of only two weeks, had himself been greatly influenced by the traditional Christian death of one of his own spiritual children, a layman from the nobility and mother of one of his disciples. “The Elder, with tears in his eyes, called this death ‘holy’ [and added] ‘I count myself fortunate that God has allowed me to see a righteous death.’”
Two days later his own death agony began. Although he was given various medicines, he experienced no relief. He went to Confession and received both Holy Communion and Holy Unction (Anointing of the Sick).
He was surprisingly peaceful, and with a clear mind and firm will he gave the necessary orders in preparation for his coming death, down to the smallest details… When his disciples asked, “What shall we do without you, Father?” He said: “You have seen the way I have acted in your presence. If you desire to imitate me, follow God's commandments, and God will send you His Grace.”
Although by now Elder Macarius was tormented by shortness of breath, he “strengthened himself with the Sign of the Cross, took the most bitter medicine, and suffered in silence, only gently moaning and praying.”
[He] often gazed with tears and reverence at the icon of our Savior wearing the crown of thorns, exclaiming: “Glory to Thee, my King and my God!”... yet his spirit was completely peaceful and quiet, like a child, and sometimes by a fatherly look, sometimes by squeezing their hands and weeping, he thanked the brethren surrounding him for their care.
The following year (1862) saw the death of Elder Moses at the Optina Hermitage. His disciples described his three week long illness in these words: “At last the time came for the Elder to be released from this life like a ripened fruit from the tree.”
We are told that he suffered from a large swelling, perhaps a tumor, in his back, which caused intense and growing pain. The doctors operated, providing some relief, but an abscess grew to the size of a bowl and his condition was “unexpectedly complicated by an acute abdominal edema ... which redoubled the patient's sufferings.” When asked how he was feeling, the elder murmured: “Well, God continues to be long-suffering with me.” And to another he said, quoting from Psalm 50: A sacrifice unto God is a broken spirit; a heart that is broken and humbled God will not despise. Those who saw him at the very end said that he lay “upon his bed of sickness ... radiant amid grievous sufferings.” “He showed the same magnanimity and the same spiritual fortitude with which throughout his long life he had endured the greatest privations, sorrows and cares...”
In 1864 Elder Anthony foretold his own death, which came the following year. At the onset of his illness (typhoid fever), which lasted about one month, he instructed one of his spiritual children to write with large letters on a poster: “‘Don't waste time!’ and fasten it over his bed of illness as a steady reminder for others ... as well as for a reminder to himself ... His physical sufferings were very severe... Amidst his fatal sufferings he took more care for others than for himself.”
The elder paid no attention to his doctor's order to rest and cease from his labors and, “conquered by love which he was unable to contain, did not care to suppress or conceal” the spiritual gifts God had given him in abundance. Near the end he remarked: “‘Other people are afraid and fear death, but I, a sinful man, have no fear, nor am I at all afraid; on the contrary, I feel a kind of joy and peace, and I await my death like a great feast’... One could not notice in him any trace of impatience or any similar thing.”
Although he tended to ignore his physician's insistence that he rest, Elder Anthony did not refuse other kinds of medical assistance but at the same time he told his disciples that he hoped he was not being helped by either the doctors or their medicines! For “having surrendered completely to the will of God, he had, since the very beginning of his illness, not desire to prolong his lif.”
Elder Ambrose came to his deathbed in 1891, suffering from extremely painful abscesses in his ear. This condition lasted about three weeks, towards the end of which, greatly weakened, he slipped into a twilight state of semi-consciousness as the infection spread throughout his body. His followers believed that during the dying process he was given a profound if disturbing sense of spiritual desolation: “He probably was allowed providentially to experience for a short time an abandonment by God, as it were, in order to give him a complete understanding of the poverty and weakness of human nature.” At the end, “he raised his right hand, joined his fingers together and made the Sign of the Cross... Then he took a … last breath.”
Next in this spiritual dynasty, we have the death of Elder Joseph in 1911. Unlike his predecessors, he was in failing health for a very long time—six years—but it was only near the end that he developed a high fever and his condition became suddenly critical.
Diagnosed with malaria,
he lay almost without moving and with eyes closed; only his lips whispered the prayer unceasingly... He clearly foresaw his approaching departure from this life, and he prepared for this hour quietly and joyfully, by immersing himself completely in prayer and pious reflection. [At death an] angelic smile irradiated and rested upon his noble countenance.
St. John of Kronstadt, a renowned miracle-worker and a married parish priest rather than a monastic, died in a manner quite similar to that of the elders—i.e., although in extreme pain from “an illness which he meekly and patiently endured, never complaining to anyone,” he predicted the exact day of his death and resolutely rejected the orders of the doctors who treated him, saying “I thank my Lord for granting me suffering for the purification of my sinful soul.”
The last two examples are nuns, neither of them yet canonized but both greatly venerated as righteous women. Abbess Thaisia, a spiritual daughter of St. John of Kronstadt, was seventy-five when she died in 1915. For the last two months of her life she was bedridden, suffering from a kind of paralysis, swelling of the legs, and shortness of breath. In order to breathe she had to lie in bed sitting, alternately dozing and alert. Her last words and conversations are apparently not recorded although we are told that “when she would wake, she would demonstrate flashes of thought, but then would fall into a semi-coma.” When well, she had been a vigorous organizer and founder of convents and a copious writer and memoirist, but on her death bed all seemed to be peaceful silence; the details of her death agony were so unremarkable yet evidently serene that no one thought to record them.
She would answer in the words of the Psalms, “O sister, do you not know that God is the fortress of our heart?” and it therefore became clear to us that the Lord sent her such a serious illness that she might be given greater glory in Heaven... She said, “The Lord knows how much one can endure, and allows just so much for our testing. Since you cannot bear the lesser trials, the Lord does not send you great ones. The Lord promises us a great reward for endurance.”
In the cases of saints it would be ludicrous to expect to find any examples of physician-assisted suicide or any other kind of suicide for that matter.
Such a death was and is viewed with horror by traditional Christians. One might suppose that in today's Western culture these same monks and nuns might approach death differently, but in fact there are monastics in the Orthodox Christian tradition spread all throughout today's world (including the United States), and among them is never found a suggestion that death should be hastened by the hand of man. This is true even in very pluralistic and technologically advanced societies such as our own. How to account for this? It seems that traditional Christians today still know their spiritual heritage, and still value and abide by it, following the examples of their fathers and mothers in the faith and being relatively unimpressed by the “new thinking” of our technological age. Their experience affirms that the “old way” (patience with the circumstances God sends or allows at the time of one's end) brings more peace and fulfillment than any other way. This is related to an old-world, almost tribal, ability on the part of many of our ancestors (including non-Christians) actually to sense that the span of life has reached its natural conclusion and the end is near. To interfere with or suppress this inherent sense of things (which modern medicine and technology can easily do if we are not careful) would be to cease being a child of God, fully human, fully aware.
We can look for other distinctive patterns in the deaths of the righteous men and women I have cited above. The first thing we notice is that none of them died suddenly and without warning, say, from a fatal stroke or heart attack. This may have had more to do with lifestyle and diet, which were naturally much different from (and apparently healthier than) ours today. Although the medicine of that time was primitive and unsophisticated, we do have some medical diagnoses to help us grasp what was happening on these particular deathbeds. We note that one of these monastics died from malaria, another from diabetes, and still another from cancer. The rest may well have suffered from congestive heart failure, together with other undiagnosed and poorly understood ailments. In all of these cases, however, there was considerable physical discomfort and sometimes actual agony. In one case the pain was sufficient to cause the patient to beg God to shorten his sufferings. In almost all of these examples we also see a deterioration and failing of body functions that would cause most men and women (both the patients and their caregivers), distress and even repulsion (such as oozing sores, etc.).
In the midst of all this physical messiness and pain, however, what do we find? A profound acceptance of God’s will and even, in a few cases, a fear that taking medicine might actually interfere with Divine Providence. This is not to say that the taking of medicine, even painkillers, is forbidden to Orthodox Christians (some took medicines, including pain killers, without protest, others did not)—but the Church Fathers teach that although knowledge of medicines is given by God, one should be very careful and aware at all times of the impact such drugs have, even in extremis, on one's mind and soul as well as on one's body. About this, St. Basil the Great wrote, “Whether or not we make use of the medical art, we should hold to our objective of pleasing God and helping the soul, fulfilling this precept: Whether you eat or drink or whatsoever you do, do all to the glory of God (I Cor. 10:31).
We also notice that in all of these cases there was no impropriety, rudeness, or misbehavior of any kind, such as is sometimes the case with the dying when they have no larger context in which to understand their suffering. Among Orthodox Christians, as exemplified by the saints discussed above, illness is never an excuse for resting from the labor of cooperating with God's Grace and doing spiritual work on oneself. In fact, even if we are bedridden, we are to continue the struggle against the passions [vices], producing fruits worthy of repentance. This work of perfection perfection demands that we acquire patience and long-suffering. What better way to do this than when we lie on a bed of infirmity? St. Tikhon of Zadonsk says that in suffering we can find out whether our faith is living or just “theoretical.” The test of true faith is patience in the midst of sufferings, for “patience is the Christian's coat of arms... Many wish to be glorified with Christ, but few seek to remain with the suffering Christ. Yet not merely by tribulation, but even in much tribulation does one enter the Kingdom of God.”
It appears, then, that physician-assisted suicide, aside from being a violation of both Christian law and Christian simplicity, should be absolutely avoided in order not to deprive the terminally ill of the full human and spiritual experience of dying, an experience which, within the context of a traditional Christian way of thinking, living, and acting is far from intolerable or negative; rather, it is exceedingly enriching and valuable, offering another way of knowledge—that of experience informed by theology—a way of knowing of which modern man, in his race to avoid all that is uncomfortable or unpleasant, has almost no understanding.
Reprinted with permission from “Christian Bioethics, Non-Ecumenical Studies in Medical Morality,” 1998, vol. 4, No. 2