Between Life and Death - A Review

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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.


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.


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.


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.