How Ought We Die?

Secular medicine’s original exclusions prevent us from understanding the process of death.

Imagine the dying patient today: sitting in the intensive care unit, hooked up to a ventilator that artificially pumps their heart and a feeding tube because they can no longer eat on their own. The patient could be on several drugs or antibiotics, hooked up to devices that keep an eye on every bodily function, or even need hemodialysis because their kidneys have failed. All the while physicians scramble about doing everything in their power to keep this patient alive as long as they possibly can, even when they know that time is limited. Why? Because this person is a patient in a hospital and everyone knows you go to hospitals to get better, not to die.

Lydia Dugdale gives such a description in her Hasting’s Center Report article “The Art of Dying Well.” Dugdale claims that American society is ill equipped for the experience of dying. Instead a physician’s focus is solely on perpetuating life as long as possible, and the family often times desires the same thing. According to Dugdale, today’s focus on continued life doesn’t make dying any better than in the mid-fourteenth century in Europe during the Bubonic plague epidemic. Then, the constant presence of death turned society’s attention to ensuring that the dying would receive a good death.

To aid laypeople in giving their loved ones good deaths, the Catholic Church created a text called Ars Moriendi, the Art of Dying, in 1415. It guided the layperson through the dying process by teaching them the appropriate prayers, preparations, and listing questions that the dying person should consider and answer about their life as a way of confirming that they lead a repentant and righteous life. But one could start considering what it meant to die well just by being in close proximity with the dying. By encountering the prescribed preparations, others involved were able to think critically about death and the inevitable end of their own lives. The Ars Moriendi in time expanded into its own genre, with numerous religious authorities reinterpreting what it meant to die well and promoting their own texts. These guidebooks were written for centuries after.

The original Ars Moriendi consisted of six separate sections, each serving to help either the dying individual or his or her close ones through prayer and guidance. Part two, for example, deals with five temptations that the dying person faces in death: lack of faith, despair, impatience, vainglory, and avarice. These temptations were devils that came to the dying man’s bedside and tried to tempt him towards hell. For despair, the devil says, “Wretched one, look at your sins which are so great that you would never be able to acquire grace.” But with each temptation comes a remedy, the words of a good angel meant to inspire and comfort. In this case, the angel reminds the dying of the sinners who confessed late and still received grace. And after each temptation, the devils admit defeat and move on.

While the text describes a conflict between angels and demons over the dying person’s soul, the real purpose is consolation of the living. The five temptations are the fears and challenges a person faces when dying, and each angel serves to help people remember how to face those fears. The rest of the Ars Moriendi is the same: Each part attempting to remind Christians that while in dying there can be comfort, in death there can be redemption, and that dying does not have to be a lonely affair. The entire fifth chapter is dedicated to instructing family and friends how to pray for and minister to their dying loved ones. In the medieval period, dying was not lying alone in a hospital bed surrounded by professional strangers in white coats. It was a communal process where mourning as well as contemplation could be done together.

Later versions of the Ars Moriendi changed in content, but the message was always the same. Take the texts written after the Protestant Reformation in the 1500s. Traditionally, Ars Moriendi texts utilized the doctrine of uncertainty – the ideal candidate for heaven was suspended between hope and fear (rather than sure of salvation or despairing of hell). Luther believed that these texts did not offer enough consolation to the dying, instead leaving them fearful of certain damnation. In his "Sermon on Preparing to Die", Luther’s goal was to assure the dying that they were saved and could even be happy because of Christ’s victory over death. Texts that came afterwards during this period fit Luther’s view that by focusing on the gift of grace all Christians had received from God, dying well was achievable for anyone.

Society’s attitude towards death only really started to change during the 20th century, thanks to the growth of medical power. Before then, the medical field did not enjoy the prestige it has today, often serving as the subject of ridicule. Doctors were the purveyors of strange miracle cures and elixirs, practitioners of bloodletting, and generally considered quacks. But throughout the 1800's medicine started to adopt the scientific method, altering the focus of their field to observation and reproducible results. Then in 1928 medicine had one of its biggest breakthroughs, the discovery of penicillin. Suddenly infections could be effectively treated and syphilis could be tended. Penicillin saved many soldiers from death and amputation during WWII; it was experienced as a real miracle treatment.

And penicillin was just the beginning of the medical field’s transformation. Vaccines saved children from common scourges, and organ transplants showed that doctors could even save us from death caused by the failure of our own bodies. The development of the heart transplant was especially important: The heart is still thought to be the seat of life. To be able to replace a person’s heart to keep them alive was symbolic of medicine’s power over death, a treatment that redefined what society thought was possible. With these innovations, the hospital, which originally was a place only utilized by the poor, became the new house of miracles and the medical profession gained a prestige and authority that it never held in the past.

Unfortunately these transformations in medical science also made death the enemy. Society’s focus shifted from dying well to living well; even the Church abandoned Ars Moriendi texts in favor of the powerful medical technologies developed throughout the 20th century. Suddenly the dying process was a battlefield where the physician fought illness and patients saw their bodies as foreign to their selves. This is where we are today; our image of dying is the elderly patient lying in bed, intubated, and surrounded by devices that preserve something akin to life. It’s certainly not any form of life that we’ve ever known before. But when life is oriented around the absolute fear of death – really, the fear of an alienated body – what choice do we have but to cling onto this reduced existence? Dugdale ends her report by saying that we do have another choice. It is up to bioethics to “create a framework for teaching the population to prepare for death and support one another through the dying process.” A society as secular as ours can no longer rely on religion, but instead needs secular ethical authorities to create a new Ars Moriendi that can accommodate a society’s belief in medical science, not the church.

The problem currently is that bioethics has already tried and failed at creating a modern day Ars Moriendi. These would be advanced directives, official forms which indicate what sort of treatment a patient wants to be used in the event of becoming incapacitated. Advanced directives allow a person to make decisions based on what they want or believe about death. Each state has a slightly different form, but typically it allows an individual to decide which standard forms of end-of-life treatment they would accept or reject. All prolonging measures can be accepted, or one could reject prolonging life at all.

But even if advanced directives were heavily utilized, they still would not be the solution that Dugdale hoped for from bioethics. The forms only have the purpose of ensuring that a patient’s wishes will be fulfilled and rely on legal language to achieve that goal. The exercise of filling out an advanced directive is far removed from the critical thought about death and dying people clearly need. It is a fitting evolution: the religious texts which filled in for the inadequacies of pre-modern medicine have become soulless paperwork to accompany the competence of the modern hospital. We face numerous questions about what kinds of care we would desire or refuse, but those questions can’t help us reflect on whether we lived a good life or help console us as we die. Advanced directives do not help patients think about and face death; they only serve to give their caregivers some idea as to how a patient would have wanted to be treated. Comfort and peace of mind are what the Ars Moriendi of the past offered.

Advanced directives give patients an idea of the numerous medical decisions they may have to make, which, as bioethics’s sole offering, is a paltry comfort. At best filling out an advanced directive may provide a useful jumping-off point for a person to truly start considering what it means to die and die with dignity. Maybe it even gives them a way to bring the conversation up with loved ones. However, the content of that discussion is missing. What questions should I ask myself to determine what it means to die with dignity? How do my beliefs about death affect the medical decisions I could face in the future? We need a new script for talking about impending death, a guide to teach the population how to prepare for it and how to support one another through the dying process.

While bioethics should consider creating a proper Ars Moriendi among its many goals, simply writing one new text will not solve the problem of ensuring patients a contemplative death. Dugdale was focused on America’s aging population and the image of intubated medicalized death. But that is only one kind of death that patients experience in hospitals. Who will benefit from a renewed focus on dying well? Health care workers will have to determine what cases and under what conditions some level of contemplation is achievable. For what other dying populations is dying well realistic? What needs to be done to maximize the use of a new Ars Moriendi for those populations? What can be done for patients whose deaths regrettably seem to fall outside the purview of even the hospital’s unfulfilled promise of a good death? These are questions that need to be answered for a holistic Ars Moriendi to be effective.

Take the debate over access to trauma centers in Chicago’s predominantly African-American communities. Residents argue that their communities need hospitals to open new trauma centers to serve the Black youths who are often injured or killed by gun violence. In response, hospitals talk survivability, with the idea being that opening new centers will not improve death rates. But having trauma centers in closer proximity could give patients more time. Even if their deaths are inevitable, perhaps they would have the chance to face death on their own time and pass away with dignity. If dying well rather than avoiding death becomes the aim of the hospital, then how can we ensure the good death’s equal distribution, not only for hospital deaths that are typically slow but for sudden deaths that the hospital may have the power to stall? Healthcare discussions we are having today could change if our society started to reconsider the importance of dying well.

A new Ars Moriendi will not give society the answers like its predecessors. But what we need are the right questions, starting points for people to change their expectations about death and treatment, and seek out their own particular truth. People can find out for themselves that treatment does not always mean cure, that sometimes it’s just a kinder way of stalling death. And society can come to understand that the hospital is not always a place where science performs miracles; sometimes people go there to die.