VATICAN CITY — Pope John Paul II died the way he wanted.
He spent his final hours in his Vatican apartment, surrounded by nine members of his mainly Polish inner circle. Three doctors were present, but no elaborate hospital technology to help prolong his life.
Just before the end, the pope's longtime secretary celebrated Mass and began to anoint the pope's hands with oil, according to one account. John Paul gripped his secretary's hand, an apparent farewell gesture to a faithful aide who helped the pontiff fulfill his wish to die unencumbered by tubes and machines. It was 9:37 p.m. Saturday.
The cause of death was septic shock and irreversible heart failure, according to the death certificate made public Sunday by the Vatican. John Paul's decision last week not to return to the Gemelli Polyclinic hospital where he had spent so much time in recent years mirrored decisions made every day by severely ill patients and their families.
His very public choice also highlighted profound moral questions within Catholicism about the balance of preserving life and accepting death.
The debate has intensified with advances in medical technology. Church teachings simultaneously emphasize the sanctity of life as well as the acceptance of the final embrace of God. The pope's ordeal has raised comparisons with the recent ethical and theological battles over the Terri Schiavo case, though churchmen and theologians said Sunday that his struggle was different because he was in a position to help dictate the terms of his final medical care and she was not.
John Paul's final hours, as described by doctors, churchmen and sources close to his inner circle, did not include aggressive efforts to revive him as his organs failed. No kidney dialysis machine was used in his apartment, and the insertion of a sophisticated feeding device in his stomach would have required a return to the hospital, sources said. Instead, doctors said, they relied mainly on antibiotics and a respirator.
"There were no therapeutic extremes," said Rodolfo Proietti, a longtime anesthesiologist on the pope's medical team, quoted Sunday in the Corriere della Sera newspaper.
Proietti and the pope's personal physician, Renato Buzzonetti, supervised John Paul's care in the final days, according to a doctor who recently treated the pope and asked not to be named.
The pope, assisted closely by Archbishop Stanislaw Dziwisz, his longtime secretary, played the central role in the decision-making, the doctor said. It was Dziwisz who held the pope's hand when he died, according to Father Konrad Hejmo, a Polish monk who later spoke to those present at the pope's bedside.
When the pontiff left the hospital March 13 after doctors performed an operation to ease his breathing, he made it clear to his aides that he did not intend to return.
Like many gravely ill people, the pope preferred to face death at home, not in the fluorescent glare of a hospital. His choice, according to a source close to papal aides, also reflected his keen awareness of church history and ritual: Popes die in the Vatican.
That determination and the ensuing medical choices were consistent with church teaching about not prolonging life at all costs, according to theologians.
"He just didn't want to go to the hospital for a third time," said Gerald O'Collins, a professor of theology at Gregorian University in Rome. "What would have happened if he had gone back? Aggressive treatment that might have kept him alive a few more weeks, but there's no moral obligation to accept this."
A Surprising Statement
Nonetheless, the pope himself appeared to complicate the issue last year when he declared that the feeding and hydration of critically ill patients was in fact a moral obligation. He said that such treatment constituted a "natural act" for patients such as Schiavo who were in vegetative states or comas.
As the church struggles to keep its ethical teaching apace with strides in medical technology, the pope's statement surprised some theologians. They read it as a sign the church was moving toward an endorsement of extraordinary measures as opposed to previous doctrine stipulating a lesser threshold of reasonable efforts to save the lives of the severely ill. Indeed, Schiavo's parents, seeking to reinsert her feeding tube, cited the pope's views in legal papers.
Other Christian ethicists said the concept did not apply to cases like the pope's in which organs were shutting down and death was imminent.
"After all of the controversy that surrounded the Terri Schiavo death, some people might get the impression that according to Catholic teaching you hold on to life no matter what to the last possible moment," said Father Thomas Reese, a New York-based theologian and editor of the Jesuit magazine America. "But ... if you are dying, you don't have to take every medical procedure to prolong your life another day, another month. At some point you can accept that you are dying as God's will and return to the Father."