Between Life and Death - A Review

in ,
download (10).jpg

Every birthday I have to remind myself there are only two options: Getting old or dying. Each year my mortality becomes a little more real as the physical symptoms of age and decay overtake me and as more people that I know experience medical treatments for major trauma or age-related organ failure.

Other than the drama of television and movies, my first glimpse into the world of the ICU came as a young naval officer, when one of my sailors died due to complications from a surgery. He was in one of the top hospitals in the nation and they couldn’t prevent the problem. That forced me to realize there are limits to the ability of medical professions and available technology to preserve or repair life.

Seeing that formerly jovial, proud sailor wired and tubed in the hospital bed was jarring. I was certainly not prepared to see a 34-year-old (which seemed old at the time) inert and unconscious. Thankfully, I was not part of the decision about future medical intervention, because I was entirely unprepared.

I was, however, in the room when the ventilator was removed at the doctor’s recommendation and at the families’ request, which was supported by the documents he had left behind. He was functionally brain dead, so the only thing keeping him alive were the machines forcing his body to keep working. Once the ventilator was removed, the end came peacefully and swiftly. It seemed merciful, but at the same time left me with questions about whether removing organ supporting medical interventions was, indeed, moral.

Such end of life decisions are difficult for several reasons. First, we do not always understand what the function of specific medical interventions are. Which ones offer remedial help and which ones simply sustain animal functions so the body’s other processes can continue? Second, non-medical personnel have little frame of reference for whether a particular condition is likely to be recoverable. What are the odds that any intervention, no matter how expensive and traumatic, are going to be successful? Third, we often have little idea how damaging the attempt to fix one problem will be and what the likelihood of complications will be. Will a heroic attempt to fix one problem likely doom the patient to major problems later? Fourth, too often we have failed to consider end of life care, even for those who are reasonably approaching the end of life. It is understandable for a family to have no guidance for end of life medical care for a teen or someone in their twenties or thirties. However, by the eighth or ninth decade of life, there is little reason for the individual and their family not to have already discussed options and made some decisions.

Summary

Kathryn Butler’s book, Between Life and Death: A Gospel-Centered Guide to End-Of-Life Medical Care, is an extremely helpful volume in learning about various critical medical treatments, which can help make the cost/benefit analysis for choosing to continue with interventions. She also carefully sorts through the biblical data to consider whether an ethic of life, which is demanded by Scripture, entails pursuing every medical treatment possible no matter the cost, the low likelihood of success, or the trauma to the patient. Butler, a trauma and critical-care surgeon, has worked at several significant medical facilities and brings her experience and expertise to bear in a compassionate manner in this book.

The book begins by considering the place of death in the human experience. It is unnatural, in that it is a result of the fall, but it is a normal expectation for humans that walk the earth. She also roots her ethic in the authority of Scripture, which reassures the reader that she is beginning from Scripture and interpreting medical technology through that lens, rather than the reverse.

In the second section of the book, Butler offers chapters on resuscitation for cardiac arrest, and intensive care treatments such as mechanical ventilation, cardiovascular support, artificially administered nutrition, dialysis, and brain injury support. The key message here is that whether one of these treatments is warranted is really based on whether it is likely to be a temporary support while the body recuperates or whether it is merely prolonging the inevitable. The medically accurate data in these chapters helps inform the conversations that Butler outlines in the third section of the book.

In part three of the volume, Butler provides an outline of what is constituted by palliative care and hospice, how that is different from physician-assisted suicide, the importance of advance care planning, and the role of individuals designated to make proxy decisions. After the conclusion, Butler offers several appendices that include summaries of organ supporting measures, a sample advance directive, and some Scripture passages that offer comfort for those making these decisions.

Analysis

Between Life and Death is an important book. It was written at an accessible level both theologically and medically. It helpful translates some difficult medical terminology and sometimes confusing ethical language that can make an otherwise painful decision unbearable.

Butler does very well dealing with the difference between killing and letting die. There is a pervasive myth among many American Christians that unless we are doing absolutely everything to sustain life for as long as possible, we are “giving up on” or “killing” the patient. Butler shows that many of these support measures are bringing their own additional trauma, prolonging the inevitable for a short time, and actually increasing suffering. Ceasing supposedly heroic medical interventions is not killing an individual, it is merely allowing the process of dying to take its course. Butler’s book helps readers develop the wisdom to understand the counsel of physicians and make compassionate, Christ-honoring choices.

If this book is revised in the future, it would benefit from a deeper discussion on the nature of and purpose of suffering. The topic is explored somewhat, but Butler’s expertise is really on the technical side of the discussion, so the development of a theology of suffering (which is very important in making these decisions) is a bit thin.

Conclusion

Between Life and Death is the single best book on this topic that I have encountered. It is pastoral, technically accurate, and scripturally framed.

This is a book that belongs in the library of every pastor. Not only that, but it should be read, underlined, and outlined by elders and deacons as they prepare for making hospital visits, offering counsel, and seeking to comfort the sorrowful. This is the sort of book that a senior’s group at the local church would greatly benefit from discussing as they prepare for inevitable decisions. The time to read Butler’s book is not when the beeps and whistles of the ICU are surrounding a patient, but rather months or even years before any such condition is highly likely.

NOTE: I received a gratis copy of this volume from the publisher with no expectation of a positive review.

The Accidental Social Entrepreneur - A Review

in ,

Social entrepreneurship is the pursuit of business with social benefit as a primary concern rather than simply profit. In some cases, social entrepreneurship relies upon the intended social benefit as the chief marketing point. In the best cases, the entrepreneurs provide a good, needed service at a competitive price, but distribute profits with something other than the bottom line or shareholder value as the primary concern.

9781910012505.jpg

A reasonable profit is a good thing and necessary for a humane economy. Entrepreneurs generally risk their livelihood for their business. Profits allow business to continue, entrepreneurs to feed their families, companies to expand, and more people get jobs that support their families. Poverty will not be ended without business.

In The Accidental Social Entrepreneur, Grant Smith outlines his own life experience as a social entrepreneur. In a memoir-style book, he covers the successes, challenges, and failures he has experienced while running his Hand In Hand company with several faces and outlets. In one of its most significant aspects, Smith’s company became one of the largest home construction entities in Kenya.

Smith recognizes that business is a good thing. When run justly, companies provide opportunities for employees to feed their families. In Smith’s accounting, justice includes remunerating workers in proportion to the value they add to the company rather than as little as the market will allow. So, for example, although unskilled labor is paid near-starvation wages in Kenya, Smith’s construction company chooses to pay a significantly higher wage that ensures greater financial stability for those laborers. It works in this particular application because the profit margins for home construction in Kenya are very high. The difference between the market rate and the rate his company pays is found in the profit taken by the company itself.

For Smith, social entrepreneurship means building businesses that meet legitimate needs at a competitive price, providing a decent (though by no means extravagant) living for workers in proportion to the value they add (he is very big on merit based pay), and using a fair portion of remaining profits to invest in other charitable activities. Investors in Smith’s various schemes get a benefit, but that benefit is limited by other goals that the investors agree to in advance. Smith runs companies, but they are companies that take all stakeholders into account.

The Accidental Social Entrepreneur is an encouraging volume. It celebrates the good of business for creating wealth and freeing people from poverty. It also introduces a paradigm of valuing something besides maximizing profits to the discussion. Smith’s book strikes a healthy balance between recognizing the good of markets and considering the potential harms of markets.

Although he does not state it directly, Smith does seem to lean toward the moral superiority of his company’s practice of redistributing up to 85% of profits to more direct charitable causes. It is commendable that Smith decided to do so, but by no means morally obligatory. In some cases, by choosing to distribute profit rather than reinvest in other ventures, Smith may have made his company’s endeavors more difficult. This is by no means the major emphasis of the book, but more discussion would have been beneficial.

Another helpful aspect of this book is Smith’s honesty about times that his endeavors failed. In some cases, he even admits the mistakes that prevented entrepreneurial efforts from being successful. This adds value to the book, because it shows that the life of the entrepreneur is not necessarily a straight line toward success or failure. Rather, the entrepreneurs should expect ups and downs, successes and failures that hopefully contribute to the general good of society.

Hopefully, The Accidental Social Entrepreneur inspires some readers to take a step toward building a business with society in mind. Even if they take a more profit-oriented approach than Smith, the world will be a better place. Pastors and lay leaders in church would benefit from reading the book. It could shape social endeavors facilitated through the local church.

Note: I received a gratis copy of this volume from the publisher with no expectation of a positive review.

The Shallows - A Review

in ,

Recently several news outlets have reported that humans have begun to have skeletal adaptions based on our modern lives. Although the exact cause may not be clear, it appears the people that use smartphones and other digital devices regularly may begin to see biological changes due to looking down more than any previous generation. A humoristic vision of the human future might have people with extremely well-developed thumbs and hunched shoulders several hundred years in the future.

Whether our physical bodies are indeed changing will likely be explored more fully in the years to come, but it appears that the internet is indeed changing how people think, reason, and learn. That thesis is the subject of Nicholas Carr’s seminal book, The Shallows: What the Internet is Doing to Our Brains.

Published in 2010, Carr’s book has been oft cited, including in more recent books like Andy Crouch’s Techwise Family and Jacob Shatzer’s Transhumanism and the Image of God. At the time, Carr’s book sounded an alarm about the changes to the human mind caused by the easy access to information that was always available.

Though it has been nearly a decade since Carr wrote, his ideas have been proven to be more correct than he likely could have imagined. When his book was published, the iPhone was only a few years old and smartphones were just beginning to exist at the price point where the majority of the population in the developed world could have access to them. Now it is only the rare individual that does not have a smartphone.

As internet memes remind us, the smartphone would have ruined a large number of movie plots recorded through history. Is there a bomb in the building? No need to rush through traffic to warn those inside, simply text, call, or instant message those threatened by disaster. This wonder of technology in the form of a quarter pound of silicon and heavy metals promises a world where communication is easy and instantaneous. That sounded like a promise of lower stress and a simpler life.

The reality has not lived up to the promise. Surveys continue to indicate that people are more stressed now than in decades past. There seems to be good evidence that the internet, and particularly constant access to it, are increasing the feelings of stress and disconnection.

Additionally, human learning habits have changed. While I served on the administration of Oklahoma Baptist University, I would overhear students complaining about closed book exams. Their reasoning was that “in the real world” they would be able to do an internet search for all of the answers. They could see no need to know historical facts or even how to do mathematics. When the information or process was really needed, it would only be few keystrokes away. This was not a particular trait of students at my university, but a general trend in how the population values knowledge and skill. The pervasiveness of this attitude has been reinforced by the recent graduates that I have worked with who have little cultural awareness (outside of the memes and hot-button issues they have been inundated with) and lack the ability to learn.

One of the key changes Carr highlights is the shift from deep reading to skimming. The internet fuels this, as people spend less and less time on a given website. Our brains reward us for changing the source and nature of the stimulation we receive with a little hit of dopamine. This is why many kids’ shows and even recent, popular movies change camera angles at a nausea-inducing rate. This is why when I see people outside at a scenic destination, they are less overwhelmed with the grandeur of the sights and more concerned with posting their selfies and checking to see who has affirmed them for sharing.

The change in the ability to read has become apparent in my own life. Since I have adopted a smartphone and the internet is only a click away wherever I am I have a harder time focusing on deep reading. Even when my phone is across the room, my eyes wander off the page periodically as I begin to wonder what is going on outside of my immediate vicinity. There is a constant pull to be stimulated that I was less subject to before I spent my day at an internet-connected computer with a supercomputer in my pocket.

It is not clear what changes will evolve in humans and in society in the coming years, but there is a case to be made that many of them will be a net negative. As Christians we need to think carefully about what technology is doing to us and, more significantly, what technology is for. It seems as if easy access to the internet is making us shallower as individuals. If that is the case, then we must find ways to resist the deleterious effects that may limit our ability to meditate on Christ and become more like him.

The Gardeners' Dirty Hands - A Review

in ,

Noah Toly is Professor of Urban Studies and Politics & International Relations, as well as Director of the Center for Urban Engagement at Wheaton College in Illinois. He has previously studied theology academically. His book, The Garderners’ Dirty Hands: Environmental Politics and Christian Ethics, is more political science of environmental concerns than theology, but it written from a distinct theological perspective that sits well within the bounds of orthodoxy. The book seeks to offer an approach to environmental policy that is more helpful than more idealistic perspectives.

The weakness in many approaches to economics and environment is the failure to recognize the need for tradeoffs. Solutions must be either black or white. Businesses must be either evil monstrosities or saviors of society. Either you are for certain environmental policies or you want to pillage the created order.

These sorts of positions on political problems are rewarded by society today. However, they are rarely honest representations of reality. There are always tradeoffs. When we close coal power plants, a number of people lose their jobs, are dislocated from their neighborhoods, and have their lives disrupted. When a new wind farm is put in place, there are going to be birds killed and people unhappy about the noise and sight of the turbines. The funding for the cleanup project may take money from another socially beneficial plan. We can’t have everything.

Most activists and theoreticians retreat from these prickly realities into vague generalities. The easy part of politics is coming up with a goal that sounds good to enough people that you can get elected. The hard part is wrestling with the realistic impact of the steps necessary to achieve that goal.

The chief triumph of The Gardeners’ Dirty Hands is that helps explain there are no perfect solutions and provide some ideas on how to approach the real implications of environmental governance.

9780190249427.jpg

The book is brief. It contains only five chapters after a brief preface. In Chapter One, Toly introduces the concept of the tragic, which frames the argument of the book. The tragic is the idea that there is no solution that provides only benefits. Chapter Two builds on the concept of tragedy and adds scarcity and risk as additional forms of the tragic for environmental decisions. In the third chapter Toly provides some examples of the tragic in environmental ethics in the real world, discussing limitations, harm, and the prevalence of economic analysis to ignore instances of abuse and oppression. Chapter Four provides some handholds intended to assist the reader in using the Christian tradition to respond to environmental tradeoffs. In the fifth chapter Toly argues that the ability of humans to impact the global environment is more significant than ever and likely to stay that way. It is imperative that we begin to wrestle with the tradeoffs and not to ignore them for the benefit of or to the detriment of the environment.

The crux of the book, I think, can be summed up by quoting the first sentence of Chapter Four:

“The burden of environmental governance is to weigh competing claims, measuring risk against risk, right against right, confronting moral dilemmas of extraordinary scale and scope in the context of increasing power to shape the future of the planet.” (p. 79)

If this volume begins to shift the balance of arguments about environmental policy toward actually doing these things, it will have accomplished a great deal. This is a worthwhile volume.

The argument made in this volume is limited the repeated reliance on Bonhoeffer’s ethics to show how we should reason through difficult moral decisions. Bonhoeffer is helpful in many regards, but his basic ethical methodology is one of conflicting absolutes. That is, God’s moral law can conflict with itself leaving humans in a situation where all options lead to sin. That position is problematic on several fronts, not least because it raises Christological concerns.

Conflicting absolutes feels right for environmental ethics, but its problems remain. In reality, the majority of the conflicts can be solved by properly defining the summum bonum and what, scripturally speaking, defines sin in a particular instance. This is, of course, much more difficult to do than to say, particularly on a societal level.

Additionally, part of the dirt on the gardeners’ hands is there because many penultimate goods are treated like ultimate things. And proverbial dirt is also generated by the simple inability to know what will come from a given action or even what the real impact a particular environmental policy will have. We are beset by complications on all sides, but we automatically fail by ignoring obvious problems because of complexity.

The Gardeners’ Dirty Hands requires readers to wrestle with the hard questions of environmental policy. Serious thinkers about the relationship between politics and ecology––particularly those working from a Christian worldview––would do well to read this book and begin to recognize both the importance of the questions and their complexity.

NOTE: I was given a gratis copy of this volume by the publisher with no expectation of a positive review.