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Disclaimer

The contents of this website are for contemplative purposes only. No medical advice will be given, and emails asking for medical advice will be ignored.

Although patient vignettes are based on my experiences with real individuals, I liberally change details to maintain patient confidentiality.

I also reserve the right to change old postings to correct errors, and to delete comments that include obscene language or that I deem abusive to me or other commentators.  If you are looking for a open mind, I suggest you consult a neurosurgeon.

Saturday
Jun252016

California's Right-to-Die Law

If I tried to write everything I could about California’s new right-to-die law, and, by extension, about euthanasia, I would have to write a book. But I will strain to be brief.

There seems to be a movement, at least among liberal states, to legalize physician-assisted suicide. Five states — Washington, Oregon, Montana, Vermont, and now most recently California -- have some type of legal provision that allows doctors to write prescriptions for lethal doses of medication, for the purpose of facilitating the suicide of patients.

And I understand the reasoning behind these laws. The miracles of modern medicine, while remarkable indeed, sometimes enable people to live long beyond their time. Patients can be brought back from the brink of death again and again, up to the point where extreme pain and suffering make death a considered alternative to fighting on.

No one wants to live on indefinitely in misery. No one wants to suffer. Modern people, who enjoy so many comforts courtesy of technology, are unused to hardship and seem to fear physical pain especially. We are used to anxiety, depression, stress, divorce, loneliness — but are terrified of the dentist.

I can understand the fear of dying of a dread disease (usually cancer), the fear of having no way out and nothing but a long path of pain — physical pain — to look forward to until the end. This very thought often leads people to also desire the power to end it.

But one thing is never discussed when the right-to-die comes up: Right-to-die laws have little to do with the right to die. From a practical standpoint, everyone already has the right to die. In most states, suicide is technically illegal. But has anyone ever been prosecuted for it? If someone attempts suicide and succeeds, that person is beyond the reach of the law; if he attempts suicide and fails, he goes into psychiatric treatment. No one is ever prosecuted for attempting suicide. So strictly speaking, the "right to die" is not the issue here. People who want to kill themselves can do so if they choose.

Right to die laws are really about authorizing certain people to help others commit suicide. And who is permitted — even mandated — to help? Doctors. That’s the long and short of it — the right to die isn’t about the right of suicide, it is about making it legal for doctors to kill their patients.

Oh sure, the laws pussyfoot around. They are larded with regulations, such as that the patient has to be terminally ill, and that the doctor is supposed to provide the means of suicide, but not to actually administer it. And that, I guess, is supposed to absolve the doctor. As a physician, I am expected to explain to the patient that he is terminal, that he will die a horrible death, that I am going to write him a prescription that could allow him to end it, and then turn him loose, to do whatever his conscience allows.

That isn’t absolution, legal or otherwise. And I don’t see why a physician should be forced to do it.

Forced, you say? No way -- no one is forcing anyone to do anything. The doctor can refer the patient to another doctor. Right? But while that is technically true, the reality complicated. The very existence of physician-assisted suicide has the potential to sabotage the doctor-patient relationship. As a doctor, I may take care of a patient for years, but then, when the patient is diagnosed with a terminal illness, because of my objections to euthanasia I am forced into a very difficult situation when the final days begin. And the patient slips in to a difficult situation as well.

I have to tell my patient I am personally opposed to euthanasia and must require that they agree never to ask me to do such a thing, and if they wish to pursue this option they must seek another doctor. What this means in practice is that the majority of doctors who have objections to euthanasia will refer all of their terminal patients to the few doctors who will assist with suicide. In other words, the medical community will divide itself the same way it has over abortion, with a large majority who won’t do it and a rare few who will, thus leaving all abortions to a handful of full-time abortion doctors.

But the circumstances with the terminally ill are not the same as they are with abortion. In the case of abortion, most doctors can avoid the problem by choosing not to take care of pregnant patients on a regular basis. They simply go into internal medicine, or cardiology, or dermatology, and avoid the problem altogether.

This cannot be the case with the right to die. Since the dying process is a natural endpoint in almost every area of medicine, there are very few doctors who can avoid caring for the terminally ill. A small number — the pediatrician, the dermatologist, the psychiatrist — can largely evade dying patients because of their patient population, but none have the ability to run a death-free practice. Eventually every doctor will be faced with counseling a dying patient. And it is wrong that a doctor who has treated a patient for years should be forced to send a dying patient away simply because he has moral reservations about assisted suicide.

If you are one of those people who wants suicide as an option when facing a terminal illness, fine. But understand that if you want to die in the face of terminal illness, that decision should be yours. It is not fair to ask another person, let alone a medical professional, for a seal of approval.

Because that is what assisted suicide is. To qualify for the right to die in California, you have to have the opinion of two physicians that you are in a terminal condition and have less than 6 months to live, and that you are mentally competent. These are all medical decisions. Thus, the ball sits in the court of the doctor. Not a lawyer, not a judge, not a counselor, not a clergyman. Lawyers and politicians carefully wrote themselves out of this law because they are smart, and don’t want people coming to them from the street asking for permission to kill themselves. So they dumped the responsibility on doctors.

As a doctor, I don’t have the ability to make decisions like this either. I never, ever tell my patients they have 6 months to live. I don’t own a crystal ball. I have seen patients I thought had six months last 2 years. I have seen patients I thought had 6 hours last a month. Any doctor will tell you -- there is no magic book in our libraries that we can consult to look up the patient’s diagnosis and physical findings and get a lifespan estimate. Everything is a guess, and any doctor who says differently is not telling the truth.

The matter of patient competence is even more difficult. If a patient comes to me who has a terminal illness, this is a person who is likely to be depressed and very anxious. Is such a person fully competent? Would you, under most circumstances, think a person who is depressed is in a place to decide if he or she wants to die or not?

Standard medical practice says otherwise. Psychiatrists are authorized to lock up a suicidal patient against his will precisely because the medical community does not believe a severely depressed person is mentally competent.

And there is more. People with terminal diseases are profoundly ill. They may be taking chemotherapy, they may have cancer metastases in the brain. They may be on painkilling drugs. Again, how do you judge competence in such cases? While I would agree that many of them are competent, not all of them are, and as a doctor I certainly would not be comfortable standing as judge in such difficult circumstances.

In my medical career, I have never had a patient or a patient’s family approach me and ask to euthanize a patient. And as a physician who specializes in hospital medicine, I have seen many, many terminal patients. Perhaps this is a function of the community I live in. Mississippi culture is different from the culture of California and Oregon in many ways.

But also, I think it is a function of life. The number of people who are actively dying and want to be euthanized is vanishingly small. In a state like Oregon, who has legalized assisted suicide for quite some time, the practice is rare. I am sure that most Oregon doctors, like me, more often have the opposite problem. The most common problem I run into with dying patients is not that they want to die, but that they continue to struggle against death when death is inevitable. I see patients suffer mightily from this. I see family members who think their 80 pound grandmother will one day walk again, or that a patient whose brain is riddled with metastatic cancer will be cured if he just gets one more chemo treatment.

We are all born to die. It is the great human equalizer. There is nothing any of us, including us doctors, can do about it. Many patients cannot accept this, and I watch with sadness as they struggle against an invincible opponent. Instead of making the best of the time they have left, they spend their time extending their suffering to no good end.

Death simply is. You don’t get out of it by fighting until the end. And you don’t get out of it by committing suicide before your time. While some people think those who seek physician assisted suicide are bravely facing death, I do not. I think people who want their doctors to help them die are mostly looking to the doctor, one of the few authority figures modern society has not discredited, to agree with them that they are justified in seeking suicide.

As a doctor, I am not willing to extend my seal of approval to anyone’s suicide. If a patient wants to die, he can do so without my help. And it is not right that state governments, frightened to accept responsibility for the right to die themselves, are now writing laws to absolve themselves of responsibility in the matter, and turn it over to the people whose jobs are to heal, relieve suffering, and comfort in the hour of death.

Monday
Jun132016

About the Orlando Shooting

The recent shooting in Orlando prompts the following thoughts.

The difficulty with the gun rights debate in America is that when you ask a gun totin’ conservative why he feels it is good to carry a weapon, he says that he is safer when he is armed.  He will sometimes take this a step further. He will say, when you are with me and I am packing, you will be safer, because I know how to use a gun correctly.

Let’s just assume this is true. (In fact, it is nowhere near true, but I won’t concern myself with that particular argument right now.) But even if it were true, it raises a second question. Maybe you in particular are safer because you have a Glock in your purse. Maybe, to take the argument further, you are a superhero and all the world is safer because you have your trusty Glock and will only use it for God and country.

But what about the person sitting next to you who is also packing? Is he a superhero? Can we trust him to use his gun as safely as you will? If everyone packs, is everyone safer? Or is it more likely that if everyone is packing, a large number of people who aren't safe to be handling guns will be carrying them?

Note that I am not talking about "bad guys" who are carrying guns. We can address that problem later. For now I am concerned about "good guys" who lack the physical skill, smarts, and judgment to handle a weapon in an emergency.

There are two kinds of safety -- safety for me and safety for everyone. I could be a skilled tightrope walker. For me, walking a tightrope could be perfectly safe. If I live in a 40 story building and want to visit my friend in a neighboring 40 story building, it might be perfectly safe for me to cross over on a tightrope.

But that would be illegal. Not because it isn’t safe for me, but because it isn’t safe for everyone. The government is in no position to decide who is able and who is not able to walk a tightrope. What might be fine for me could be dangerous for someone else, and there is a real danger to the people on the street below if inexperienced tightrope walkers are crossing the street 300 feet above.

The problem is that while tightrope walking may be safe for me, it is not safe for everyone -- and when the wrong people do it, there is danger to everyone.

In the same way, there are some people who are safe to carry guns. Who have good judgment. Who don’t have a tremor or cataracts. Who can handle the recoil of a weapon powerful enough to take a chunk out of a brick wall. Who have the coordination and athletic skill to get a gun out of their pockets, click the safety off (yes, you DO have to have the safety on if you are going to carry a pistol in your pocket or purse), take aim, and pick off a bad guy with one clean shot before the bad guy can turn his AR-15 muzzle back at them.

Maybe. Sounds like a tall order to me, though, and I sincerely doubt 100% of the "good guys" possess that kind of skill. I strongly suspect a substantial number of people who choose to pull a gun in a high-risk situation will in fact make the situation more dangerous.

The fact is, since no U.S. state requires a license to possess a firearm, since no one is asked to pass a competency test before getting one, there are all kinds of people carrying them. There are people who have won shooting competitions. There are people who couldn’t lift a full glass of water to their lips without spilling some of it. Both types can legally carry semiautomatic handguns in the US.

Let us assume you are perfectly competent to shoot a pistol. Is it therefore safe to say that every other person who has one is also perfectly competent to shoot a pistol? That is to say, is what is safe for you safe for everyone?

This is where the problem begins. Laws are for everyone. The government can’t know every single person who is competent to fire a handgun. It is doubtful that the government could identify with even 80 percent accuracy people who are safe to carry one in public. Gun possession on a public street is a matter of safety. Since everyone can’t do it, society might be better off limiting who can do it.

It may be that carrying a gun is safe for you. But if everyone does it, is everyone safer? I don’t think so.

It is extremely difficult for a private individual to successfully challenge an armed killer when a mass murder is happening. As I suggested above, to be successful you would have to get your weapon out, take it off safety, aim, and get off a clean kill shot before you are seen. If you miss your first shot, you have to re-aim, which is very difficult because the recoil of the gun puts you off target, and while you are doing that the killer has turned in your direction. Then it is a fifty-fifty game at best. This probably explains why, with all the mass murders that have occurred in recent years, there has never been a story of an armed hero who was able to stop the murdering in progress, without police help.

The problem with carrying a weapon to prevent events like Orlando is that such events are extremely rare, but handgun deaths are not. It remains a fact that most people who are murdered by handgun are murdered by people they know. And more people use their own guns for suicide attempts than ever use them to stop an attacker.

So when you leave your home with a pistol, you are carrying a deadly weapon with you that has the potential to kill you or one of your family members, all to prevent the extremely unlikely possibility that you end up in a public place with a rampaging member of ISIS with a semiautomatic weapon.

Put another way, you are carrying dynamite around with you just in case you get caught in a mineshaft and need to blast your way out, when the greater risk is that the dynamite will accidentally blow you up. Statistically, carrying a firearm makes no sense.

Finally, to lay to rest the argument that if honest people don’t carry guns, only the bad guys will have them:

As noted above, since a gun poses more of a risk to you than it ever will to a bad guy, you are going against the odds.

Second, even if you have a gun in the right place at the right time, if you don’t use it correctly you could get killed or end up killing an innocent.

Third, you always have your cellphone and can call the police, who are much better equipped to deal with the matter than you are.

Last, if there are reasonable gun laws in this country, the police can do more. Do you know what a cop does when he stops a man who has a semiautomatic weapon in his car? When somebody goes online and buys 10,000 rounds of armor-piercing bullets? Nothing. It is isn’t illegal.

The police can’t stop these crimes because it isn’t illegal to possess weapons of mass murder. Imagine how hard it would be to stop drug dealers if it were legal to possess cocaine, just illegal to use it, and you have grasped the situation exactly.

Sunday
May152016

The Woman (Race) Card

Although Bernie Sanders would have it otherwise, the final round of presidential campaign, Trump v. Clinton, appears to be underway. Mr. Trump’s opening broadside was (no surprise here) a personal attack on Ms. Clinton, in which Trump opined that if Hillary Clinton were not a woman, she would be at “5% in the polls.” Secretary Clinton, Trump charged, is playing the “woman card” to get ahead in the campaign.

In response, Secretary Clinton said that if fighting for equal rights for women is playing the woman card, then “deal me in.”

“Woman card” is a euphemism, and it is incumbent upon us political observers to unpack euphemisms. What does it mean?

Woman card is a derivative of the more often-used term race card, and so to understand the one we have to look at the other. Race card is a derogatory term applied to people who are perceived as using the accusation of racism to advance a political idea or cause. In its original, standard usage, if a political candidate appears to be calling his opponent a racist, he is using the race card.

Recently, the term has often been expanded into a second, broader meaning, and can to refer to anyone who complains about racism or racial oppression in the political arena. When used in this sense, the implication is that anyone who brings up racism in politics is doing so to advance his or her own interests. That is, when someone is playing the race card, he or she is using the accusation racist as a weapon to bash opponents. The word racism becomes nothing more than a form of character assassination.

I would agree that calling your opponent a racist in a political contest is non-productive and should be avoided. It is demeaning, and very hard to prove or disprove. It does nothing to improve debate, and often has the opposite effect of shutting down the conversation. No one thinks of himself as a racist, not even real racists. More importantly, there are only a few people who qualify as pure racists — the majority of people who could have that label applied to them have a combination of views that cannot easily be reduced to plain hatred. To call these individuals racists is to inflame them when calm conversion is what is needed. For example, the civil rights conflict in the 1960s was decided not only by the brave protesters, but also by the millions in the middle of the road who chose to reject segregation, even if they could not reject prejudice in its entirety.

In this narrow sense of the term, the phrase race card has some validity. It is not a good idea in most situations to accuse opponents of racism. To do so hurts rather than helps the cause of racial equality. It is probably helpful in some contexts to point out that a person who indiscriminately accuses others of racism, thus playing the race card, is making a tactical, if not a moral, error.

But that is not the way the phrase race card is often used. Instead, it is frequently hijacked by people who want agitators against racism to shut up and go home. Members of the Black Lives Matter movement, for example, are sometimes accused of playing the race card. In this context, they are not being accused of calling individuals racist (the first sense of playing the race card) — they are being accused of bringing up race as an issue in the first place, something it seems polite company would prefer that people no longer be allowed to do.

This is an inversion of political correctness, perpetrated by the very people who claim to despise it. Shouldn’t honest political discourse include grievances? An African-American has as much right to complain about perceived prejudice as anyone else. Black Lives Matter is not necessarily accusing any individual of racism. It is demanding better treatment of black people by police, and this is something African-Americans have a right to ask for.

Back to “woman card.” When Trump complained that Clinton was playing the “woman card,” he was implying that Clinton is using her womanhood to political advantage. He was not accusing her of calling him a misogynist (which, to my knowledge, so far she has not); he was accusing her of benefitting politically from being female. That is to say, he wasn't using the woman card idea in the first sense, but instead in a broader, "sit down and shut up" sense.

And my complaint here is the same objection I have people who use the term race card in the broader sense. Which is: So what? Doesn’t a woman have the right to complain about perceived injustice? Isn’t complaining about injustice what politics is all about? Hillary Clinton is a woman. It is not unfair for her to use that reality to inform and even advance her politics. Just as a 7 foot, 2 inch center has a right to use his height advantage on a basketball court, a woman has a right to incorporate her gender into her politics, and even take advantage of it if she wants to. We aren’t all eunuchs here. We are individuals, men and women, and our opinions have to come from someplace. Ovaries are just as good as testicles for that purpose. And anyone who thinks testicles have never been a source of political opinions needs a good shot of steroids and a very long stretch in a history classroom.

But just as race politics has limits, gender politics has limits, too. The limit is that no woman has a right to say an opponent is an inferior candidate just because he is male. But since no female candidate has ever done that, this charge is null. On the other hand, a woman certainly has a right to argue that her experience as a mother, or her experience of succeeding in male-dominated fields, is relevant to politics. An Army Ranger would claim military experience as a qualification. A teacher would claim classroom experience as an advantage, and a doctor would claim medical experience as well.

I have no objection to a female candidate using her gender as part of a campaign. Sarah Palin’s entire political career has been based on this, and no one ever accused her of playing the “woman card.” Because Palin didn’t. She used a female perspective to bring interest to conservatism. For all the odd things Sarah Palin has done, I don’t ever recall her calling a male opponent sexist, or claiming womanhood made her superior to a male.

No woman has ever played the woman card in this sense. This is the sense in which Donald Trump used it, and this is why his charge is vacuous.

Sunday
Apr172016

The Mississippi Anti-Gay Law: The Assholes Prevail

A week ago, the Mississippi state government passed an anti-gay law. The law, titled in propagandist fashion the Protecting Freedom of Conscience from Government Discrimination Act, seems to follow a recent pattern in conservative politics, which is to pass a controversial legislation so quickly that there is no time for debate. This has been done repeatedly with the gun laws, voting laws, and welfare reform. Now that the NRA, the plutocrats, and the misanthropes have been appeased, we move on to homophobia.

The anti-LBGT law was introduced into committee in February, where it hid among the sea of bills that float around legislative committees, before surfacing rather abruptly the last week of March. Within a week of first being reported in the Mississippi media, it was passed, and signed. It was first proposed in February, but after bouncing around for a month it was voted on in its final form in the State House on March 30, passed by the Senate on April 4, and signed into law April 5. Breakneck speed for a state that took 5 years to complete construction on a train bridge near my house.

Its proponents call it a religious freedom law. Some Christians, the argument goes, believe the Bible condemns gay people as an abomination (Leviticus 18:22 and 1 Corinthians 6:9 are commonly cited examples). Thus, to force a religious person to have anything to do with a gay or transgender person is a violation of his or her rights. While technically applying to any religion, the law is intended to protect Christians — no one seriously thinks the Mississippi legislature would pass a law to protect a belief specific to Muslims.

So we now have a law, possibly an unconstitutional law (although its constitutionality may depend on who fills Antonin Scalia's place on the Supreme Court), which explicitly says that a citizen cannot be prosecuted for refusing any kind of service to a gay or transgender citizen, or for firing someone from a job because of sexual orientation.

Bigotry is not, and never has been, a crime. The law, however, especially in the South, has a history of protecting and reinforcing the bigot. From slavery to Jim Crow to the old law that permitted a husband to beat his wife with a stick as long as it was less than the width of his thumb, the law has often protected prejudice. After decades of backing away from the old ways and adopting a neutral stance toward bigots, it seems that the state of Mississippi wants to go back. As a result, we now have a law that says, “Do you want to be an asshole? Sure, go ahead. As long as you are a religious asshole, you have the approval of the state.”

How this relates to the religious freedom guaranteed in First Amendment is difficult to pin down. Yes, governments do have the responsibility to protect religions from prosecution. But just because people choose to use religion as an excuse for being an asshole, doesn’t mean the state has to extend its protection to the behavior. Asshole and religion are not the same thing.

Even before the law, business owners could refuse to deal with certain customers. All they had to do was avoid showing obvious racism in doing so. A restaurant manager can throw a customer off his property for almost any weak reason he can think of. The weaker and more vague the reason is, the better. Throw a black family out because they are black, and there could be a problem. Throw them out because their shoes are ugly -- that's perfectly fine. As long as the owner doesn't make it obvious that it is a racial decision, no state in America is going to prosecute.

Since homophobia is, under this system, more or less protected from the law, additional laws are not necessary. That is why this law is nothing but bigotry. It doesn’t extend the law; it simply puts a government imprimatur on bad behavior. For a state to come out and say, “If you don't like gay people, great! We support you!” is to move from merely permitting people to be assholes to making assholery state-sponsored behavior.

There is a difference between stupidity and assholery. Stupid people can’t help being stupid. Assholes choose to be assholes.

Like, you know, by enacting a law.

What does an asshole in action look like? Take our governor Phil Bryant, on whose desk the bill landed on April 4. Bryant announced that he would "consider if the bill was best for the citizens of Mississippi," which he did for a grand total of 24 hours before signing it into law. Twenty-four hours isn't enough time to consult with business and social leaders. Twenty-four hours isn't enough time to ask the State Attorney General if the law is constitutional or not, or to consider the possibility that promoting bad behavior might put LGBT Mississippians in some kind of danger.

No, twenty-four hours is only enough time to allow the Guv to tell his loyal supporters that he thought about it for awhile before he chose to be an asshole.

As a regular churchgoer, I am aware of the fraught relationship religion has with homosexuality. While the Bible's proscriptions against homosexuality are more complicated than the typical fundamentalist is willing to admit, it is true that the Bible mentions homosexuality by name and singles it out as a sin more than once. Thus, tolerance does represent a theological problem for many churches.

Without going into great detail, my view is that the Biblical condemnation of homosexuality has more to do with behavior than sexual orientation. In Biblical times, many cultures had religious practices that included elements like animal and human sacrifice, slavery, castration, prostitution, and homosexual sex. When early Judaism rejected these practices, it did so for both ethical reasons and to differentiate itself from more primitive faiths.

Back then, homosexuality was not understood as a physiological state, something people are born with. It was thought of as a behavior, like eating pork or drinking too much, or adultery. Thus, the condemnations were of acts, not people. St. Paul, when he rejected homosexuality, was rejecting a practice, not an orientation. Paul would not have understood same sex relationships as an outgrowth of orientation. Paul also counseled against marriage, telling his followers to get married only if they lacked the discipline to live a chaste life. These are not the words of someone who rejected an orientation. They are the words someone who thought some behaviors were more compatible with spiritual growth than others. For Paul, the problem was the sex, more than who it was with.

And all this has to be tempered with the understanding that Paul was addressing an ancient audience who lived lives very different from ours.

Modern medicine has not yet proven that gays are born and not made, but the data is strongly moving in that direction. There is a lot of behavioral science research that shows gay people don’t simply behave differently — they are different. Some of these differences appear very early on in life, in childhood — long before a gay person would be sexually aware enough to make a conscious decision about sexual orientation.

If gays are born, not made, this presents a serious problem for religion. It means God intended gay people to be gay. Homosexuality is a natural state.

From this it follows that God intends that there be gay people. Anyone who disputes that, who argues that to be homosexual is to be sinful, is arguing that gays are "born wrong," which is blasphemy. God doesn't make mistakes, as the old Christian saying goes. To challenge the sexual orientation that God willed gays to have, is, from a religious point of view, to challenge God’s decisions.

Whatever accommodation Christianity is going to make for the existence of LGBTs, it cannot be the legalization of bigoted behavior. Not only is this approach immoral because it implies that some people are better than others under the law, but it does nothing to address the more serious religious issue, how to resolve the ancient theology of marriage with the scientific evidence. A gay man cannot marry a woman without making himself a liar. Nor can he pretend to be straight for the benefit of religious teaching. I wouldn’t think the goal of religion would be to make innocent people into liars.

This isn't a religious freedom law. Religious freedom means the right to believe whatever you want to and to attend the church of your choice. This is the Freedom to be an Asshole Law.

As a Christian, I object to the conflation of the meaning of the words "religion" and "asshole." And fail to see how encouraging people to be assholes under the guise of religion does anything at all to forward the cause for Christ in the world.

Saturday
Mar262016

Seven Last Words: "It is Finished"

“It is finished.” John 19:30.

One of the things people look for when they consider death is closure. The dying look for it, and the bereaved look for it for as well. Closure, depending on who you talk to, means many different things. Sometimes it means making amends with others. Sometimes it means completing a job of a lifetime. And sometimes it means making provisions for the safety and well-being of those who depend on us.

But most of all, closure means finishing life with a sense that the life lived had a meaning, a purpose, extending all the way to the last moment. Closure implies that the life lived was worth something. No one wants to think that he or she lived for nothing.

Ultimately, Christianity says that none of us can live for nothing, because we are loved by God, and God’s love is never meaningless. But most of us yearn for something beyond that. We want to be able to say that we took the life God gave us and made something meaningful out of it.

All of this hints at the centuries-old Catholic-Protestant conflict: Are we justified — that is, saved by God — simply because we believe in Him, or do we need to perform acts of goodness as well to make it to heaven?

The words “it is finished” provide an answer. And the answer is that both views are correct. Jesus’ death — the death of a slave, in a far-flung province of the Roman Empire, on a nondescript day, at the hands of an otherwise obscure Roman governor — is extremely remote from our experience. So remote that it shrinks into insignificance. Nothing about the the death of Jesus, from a historical perspective comes across as special. Tragic and unjust, yes. But special? No. No city was won, or war decided with Christ’s death. No empire was created. No earthly victory of any kind was achieved. Yet his death was an act of universal redemption. It was extraordinary not because of the bare facts, but because God wanted it to be. In other words, Christ’s life and mission had meaning because God’s love made it so. This is another way of saying that faith in God is enough to justify a life.

And yet, Jesus’ last words also illustrate how his entire life was centered around acts of goodness. “It is finished” reminds us that Jesus’ death was the final sentence of a lifelong story. The moment of his death was only part of his act of sacrifice. His entire life was the rest.

This thinking is reflected in the theology of the Eucharist. When the priest at Mass says the words “this is my body, which was given up for you,” that instant is not, as many believe, the moment of consecration. The entire Eucharistic prayer is the act of consecration. It is not the act of holding the host aloft that consecrates the bread, it is the entire Mass that does so.

As humans, we tend to put a premium on specific moment — the moment the ring goes on the finger, the moment the trigger is pulled, the moment the diploma is placed in the hand, the moment the paper is signed. But “it is finished” reminds us that this is not so.

Yes, the crucifixion is the heart of Christ’s sacrifice. But in truth, his entire public life was his sacrifice. Every moment he spent away from home, every night he slept outdoors, every sermon he gave, every time he was chased from a town by an angry mob — these were all sacrifices. They all are part of the moment on the cross, when Jesus gave up the last of himself.

So there isn’t really any separation between justification through faith and justification through good acts. A good act is faith itself. It would be impossible for us to just believe and not do anything about it, and it would have been impossible for Jesus to climb up on the cross and simply take his punishment unless an entire life had been spent in devotion to God, in preparation for exactly that moment. Jesus’ entire life is the sacrifice we see come into its fullness on the cross.