Pastoral Care Of Persons Apparently Dead
Probably the most troubling experience of a priest engaged in parish or hospital ministry is the situation faced when the priest arrives on the scene and the person needing help appears to be dead. It happens occasionally for almost all priests when accidents are met on the road or the unforeseen occurrence when the priest responsible for the area is too far away to render assistance. What is to be done under the circumstances? If the person who needed help is certainly dead it is obvious that prayers for the deceased and consoling words for the relatives and friends fulfill the priestly obligations.
In the case of apparent death rather than certain death the proper procedure becomes more difficult to decide. The body may still be warm, or it may be known that the person was definitely alive within the past minutes or hours. Who is to say with certitude the actual moment when death occurs, exactly when the soul leaves the body? The problem to be solved relative to administering the sacraments, especially the Sacrament of the Sick, has been discussed for centuries. And the problem has increased, not diminished, with the technological advances in medicine.
Some priests follow a simple rule of thumb: there is no need to anoint if a doctor has pronounced the person dead. But the rule is too simple. Medicine is not an exact science; this is impressed on one when he is asked to sign permission for personal surgery, and the hospital form without doubt to protect the doctors involved reminds the patient in small but definite print, "The practice of medicine or surgery is not an exact art." And there is today the common practice of organ transplants from a person declared medically dead but the organ is quite alive, for otherwise the liver, the kidney, the heart would hardly be useful, to the recipient. What about brain "death," the new medical term which permits the legal transfer of organs in many states? Is brain "death" true death; (does brain "death" eliminate the possibility of the sacraments' helping the person spiritually?
A glance at the Catholic Periodical Index indicates the ferment now going on to achieve a clinical definition of death acceptable in law, medicine, philosophy and theology. The literature points to the conclusion that the doctor's pronouncement of death is only one of the criteria to be used by the priest in, making his decision to administer the sacraments or not. And it points toward the practice of being very generous in administering, conditionally to persons only apparently dead, the sacraments called for in the case.
When Does Death Occur?
Concerning the Sacrament of the Sick the generous position is substantially the same as that taken by Fr. Joseph J. Farraher in his answer to the question: "May we still anoint after apparent medical death?" in the May, 1982, Homiletic and Pastoral Review. Fr. Farraher's reply was in agreement with the June, 1974, Homiletic article by Msgr. Charles Keating, S.T.D., entitled "The Sacrament of Anointing the Sick." Both agree that as long as there is hope of latent life the Sacrament should be given to those apparently dead even after the doctor's pronouncement of clinical death. The purpose of this present article is to show the deep philosophical, theological and scientific foundation, which justifies this position. In other words, concerning the permission, "But if the priest is doubtful whether the sick person is dead, he may give the sacrament conditionally" given in par. #15 in the 1983 definitive Roman Ritual, when put into practice the words "may anoint" are to be interpreted "should anoint." The priest, not the doctor, must make the judgment concerning a Sacrament, and as in other cases of charity or justice, the power and licitness to perform an act can become an obligation to perform it.
The Priest Makes The Judgment
In addition to the rituals for Anointing and Viaticum, two articles and two books proved especially helpful as sources for this article: "A Philosophical Critique of the Brain Death Movement" by R. Mary Hayden which appeared in the Linacre Quarterly, August, 1982, and "The Sacrament of Anointing the Sick," mentioned above, by Msgr. Charles J. Keating, S.T.D., chairman of the Liturgical Commission of the Camden Diocese, in the Homiletic and Pastoral Review, June, 1974. The books: On Defining Death, an Analytical Study of the Concept of Death in Philosophy and Medical Ethics, by Douglas N. Walton, McGill University Press, Montreal, 1979; and Death, Real and Apparent, in Relation to the Sacraments, by Juan B. Ferreres, S. J., B. Herder, St. Louis, 1906. This is still a classic because of its thorough theological treatment, and medical advances since Ferreres strengthen rather than weaken his conclusions.
The 1974 provisional "Rite of Anointing and Pastoral Care of the Sick" gives the fundamental guidelines for the priest. Under the heading, "Subject of the Anointing of the Sick," par. #15 says:
When a priest has been called to attend a person already dead, he should pray for the dead person, asking that God forgive his sins and graciously receive him into his kingdom. The priest is not to administer the sacrament of anointing. But if the priest is doubtful whether the person is dead, he may administer the sacrament conditionally, (no. 135)
In this present article the provisional "Rite of Anointing and Pastoral Care of the Sick" is quoted because it is the ritual referred to in Msgr. Keating's article. However, the definitive ritual approved by the National Council of Catholic Bishops in 1983 now mandatory, indicates exactly the same theology. The 1983 "Pastoral Care of the Sick, Rites of Anointing and Viaticum" translates par. #15:
When a priest has been called to attend those already dead, he should not administer the sacrament of anointing. Instead he should pray for them, asking that God forgive their sins, and graciously receive them into the kingdom. But if the priest is doubtful whether the sick person is dead, he may give the sacrament conditionally, (no. 269)
Two problems are to be solved: why does a priest sometimes judge a person apparently dead even when a doctor has declared him clinically dead to possibly still have life? And what reasoning should lead the priest from the guideline, "He may administer the sacrament conditionally" to the decision he should administer it to the person?
R. Mary Hayden in her Linacre article "A Philosophical Critique of the Brain Death Movement" explains why a doctor's pronouncement of brain "death" does not prove that the patient is truly dead. She uses the analysis accepted in Catholic theology that the human person in this life is composed of body and soul, and that death occurs when the soul leaves the body:
. . . Death, as the negation of life, entails the separation of the soul from the body . . . Upon the separation of body and soul in death, the integrated vital capacities cease because the body is so destroyed that it is no longer capable of being animated by the soul . . .
This is not the definition of death used by the 1968 Harvard Committee, which, rather, in effect established death as being the irreversible cessation of all brain functioning. Consequent upon this definition of brain 'death,' the following signs or criteria of death were proposed:
1. Total unawareness to externally applied stimuli and inner need and complete unresponsiveness;
2. No spontaneous muscular movements or spontaneous respiration or response to stimuli such as pain, touch, sound, or light for a period of at least one hour.
3. Abolition of central nervous system activity . . . evidenced in part by the absence of elicitable reflexes;
4. The flat or isoelectric EEG, which is of great confirmatory value;
5. Repetition of the above steps 24 hours later. Test not applicable to patients with hypothermia or under the influence of central nervous system depressants (barbiturates).
Fulfillment of the above criteria does not (as its authors supposed) indicate a dead individual, because, as Step 5 warns, patients with hypothermia or drugged with barbiturates also meet the above criteria, yet are not to be declared dead! . . .
Harvard does not offer an explanation, though the explanation is simple; the guidelines only test the functioning of some of the soul's vital capacities, not all . . . (the guidelines . . . cannot distinguish the absence of vital capacities due to the separation of the soul . . . from the physical inhibition of their functioning by hypothermia or barbiturates (pp. 241-2).
Some . . . take the brain to be that which is responsible for integrating body functions into an organic whole. If this is true, then it can be argued that with the cessation of the brain's functioning, the body lacks organic unity and is therefore a corpse . . . But it is not true . . . to attribute the body's integrated functioning solely to the brain, for if the brain were the sole integrator, then the heart, which falls outside the control of the brain, could never be integrated in the body unity, whereby it acts for the good of the whole person. But the heart is so integrated . . . As long as body integration occurs, the body is animated by that principle whereby it is enabled to function, i.e., the soul. Thus death does not always happen when the entire brain ceases to function (p. 243).
What is shocking is a statement of Hayden in her Linacre article:
Brain 'death' is often legalized as an attempt to protect transplant surgeons from lawsuits. Lawsuits . . . have arisen because a heart can continue to beat spontaneously despite brain 'death,' provided a respirator supplied it with the oxygen it needs to survive. It is those hearts, which make good transplants. But a spontaneously beating heart by functioning for the good of the whole body is helping to preserve body integration. Therefore, it is a sign that the soul is still present. Death has not yet occurred, thus transplantation at this time kills the donor, though in the 27 states with brain 'death' statutes, no murder would have been committed . . ." (p. 245)
Walton in his book gives chapter III to the "new" criteria of death used in the United States and Europe, including the Harvard criteria, and at the beginning of his next chapter says:
For whatever historical reasons, the philosophical logic of death from a secular point of view has simply not been explored in recent times in any systematic way. Here we draw a contrast between the secular conception of death, total and irreversible extinction of consciousness and sensation, including the discontinuation of actual survival of the individual personality, and the religious conception of death that postulates actual survival of the individual personality, and continuation of post mortem consciousness and sensation . . . Both views deserve study, since both are widely accepted, but the secular view in particular contains inconsistencies and paradoxes (as we will show) to the extent that it may seem scarcely coherent (p. 41).
Practical experience also indicates the doctor's pronouncement of death not infallible. Dr. Kubler-Ross, probably the best-known modern researcher on death and dying, mentions that she and her assistants interviewed "hundreds" of people who were revived after being pronounced clinically dead (Cath. Standard and Times, Philadelphia, Oct. 26, 1978).
The above paragraphs attempt to answer our first problem: the pronouncement of the doctor that a person is dead is not the full answer for a priest. Now, what reasoning should lead the priest from the guideline "he may administer the sacrament conditionally" to the decision to administer or deny it in the cases of apparent death?
Msgr. Keating in his article in the June, 1974, Homiletic & Pastoral Review says:
The sick who have lost consciousness but, as believers, would ask for the Anointing were they conscious should receive unconditional Anointing, (par. 14 of the Rite) Those certainly dead should not be Anointed, although the priest should pray over them, but if death is uncertain conditional Anointing should be given.(par. 15 & 135)
Msgr. Keating quotes par. 8 of the provisional Rite: "There should be special care and concern that those who are dangerously ill due to sickness or old age receive this sacrament (Anointing)." Two paragraphs later he changes the "may anoint" of the Rite's paragraph's 14, 15 and 135 to "should anoint." The change is also justified by the broad implications of the previous direction of par. 4 of the Rite:
Not only the sick person should fight against illness; doctors and all who are dedicated to helping the sick should consider it their duty to do whatever they judge will help the sick both physically and spiritually. In doing so they will fulfill the command of Christ to visit the sick, for Christ implied they should be concerned for the whole man and offer both physical relief and spiritual comfort. (Par. 4 of the 1983 ritual has the same meaning.)
The sacraments which are the means Christ instituted to help men spiritually are of inestimable value; therefore if a sacrament can be conferred it should be, for, "All who are dedicated to helping the sick should . . . do whatever they judge will help the sick, both physically and spiritually . . ." There may be no hope for the recovery or comfort of the apparently dead, but they can be helped spiritually, and the virtue of charity obliges whatever spiritual help can be given to the neighbor in need should be given. It is theology that determines how the obligation of par. 4 is to be applied.
Following the new Rite, Msgr. Keating applied the theology of giving the Sacrament of the Sick to those only apparently dead. His guidelines agree with the theology expressed by Fr. Ferreres in his 1906 classic Death, Real and Apparent, in Relation to the Sacraments.
Ferreres did not have the modern technology of brain "death" and could refer only to cases where traditional signs of death were used, such as the absence of heart beat, respiration, reflexes. These criteria are still used by doctors and Ferreres' data show they are not infallible. Thus the brain "death" criteria now also in use merely increases the number of possible cases where doctors could pronounce dead those who are only apparently dead.
Fr. Ferreres gives concise theology to guide priests in their pastoral obligations. He discusses the administration of Baptism to fetuses and newly born infants apparently dead. He also examines Baptism and Penance for adults apparently dead. The principal Sacrament with which we are concerned is the Sacrament of the Sick, but his rules, mutatis mutandis, should also be applied to Baptism and Reconciliation. Ferreres cites medical and theological authorities and is very strong in rules he gives for the apparently dead, the "Dead On Arrival" of priestly experience:
1. It is possible to save, by administration of the Sacraments, the souls of the apparently dead. (chap. I, p. 43)
2. As long as there is a reasonable doubt, however slight, whether a man is alive or dead, the Sacraments may and should be administered to him. In summing up the theologians, including St. Alphonsus, Ferreres says that a priest is under a grave obligation to administer the Sacrament. Ferreres says the doctrine applies 'even to cases in which the probability of their being alive may be doubtful or very slight, and but indifferently founded, or based on the opinion of others and not our own.' (chap. II, pp 49-57)
3. Between the moment ordinarily held to be that of death and the actual moment at which death takes place there is probably in every case a longer or shorter interval of latent life, during which the Sacraments may be administered. As for the Sacrament of Extreme Unction, every Christian adult in the state of apparent death can validly receive it, and if it is certain he has attrition, or had it before he fell into such a state, the grave sins he has committed will be forgiven him. (p. 45) (from chap. III & I)
4. Besides putrefaction and, perhaps, cadaveric rigidity, there is no symptom that is a positive indication of death, (p. 67) 'If in the case where circulation is suspended,' says Dr. Blanc, 'the vital functions of the cell-life still continue by reason of the living energies of the soul, although they may have ceased for the time to renew their reserve materials, what reason is there for assuming that the soul has left the body when the phenomena of circulation and respiration cease at the instant of what is ordinarily called death'? (p. 68, chap. IV)
It is the data from philosophy, theology and the present state of medicine which justifies Msgr. Keating's changing "may anoint" to "should anoint." Fr. Farraher gives an excellent summary for practice:
. . . If there is no further sign of breath or heartbeat, but the body is still quite warm, anoint, but conditionally, as above. If a doctor has already pronounced the person dead, we must be careful not to occasion ridicule of the Sacrament. If the conditions . . . quoted from Jone (i.e. apparent death precedes actual death. A person dying after a long illness may be anointed within a half hour after he has drawn his last breath. Anointing may be done as long as two or three hours after sudden death) are still verified, you might explain to those present that real death in the sense of the soul's leaving the body does not necessarily coincide with clinical or apparent death. If danger of ridicule still exists, or if it is not easy to explain (e.g., accident with many people around) you could still anoint, but quietly, with the single anointing on the forehead and saying the words sotto voce. If there is any chance that the Sacraments can help a dying person, we should give that person the benefit of the doubt. (Homiletic and Pastoral Review, May, 1982)
It is difficult to see how any other practice can be morally justified. If there be a variation as to the time limit set by Jone for giving the Sacrament, since it is the critical moment when the patient is facing eternal judgment, it would be better to be more generous than less; the time limits should be extended rather than diminished. A final note might be added. The 1983 ritual entitled "Pastoral Care of the Sick" states for the conditional anointing of a person apparently dead the formula: "If life is in you, Through this holy anointing, may the Lord . . . etc." There is a presumption here that the person is baptized. In some situations the priest may not know whether the person has been baptized. Another condition could be used: "If you are capable of receiving this sacrament, Through this holy anointing, may . . . " This formula would protect the Sacrament in case there was neither life nor baptism. It has been accepted as in the past and would have the same justification now.
Reverend Edward J. Melvin, C.M., taught American History in St. Joseph's Preparatory Seminary, Princeton, New Jersey, and theology in St. John's University, Jamaica, New York. He authored two books on the Founding Fathers. More than twenty years of priestly experience in parish work included two parishes responsible for hospitals within their borders. Active in the Right to Life movement, he has also written articles defending the unborn.
© Catholic Polls, Inc. 1984.
© Catholic Polls, Inc. 1984.
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