Assoc. Professor Lydia S. Dugdale MD is the Associate Director of the program for biomedical ethics at Yale School of Medicine, in New Haven. She recently edited a book on death and dying, Dying in the Twenty-First Century: Toward a New Ethical Framework for the Art of Dying Well.
BioEdge asked her to explain some of her ideas on the modern way of confronting death.
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BioEdge: Why are current approaches to dying problematic? Most people (in the developed West, that is) die in hospitals where patients are clean, well-fed and adequately cared for medically, aren’t they?
Lydia S. Dugdale: The question in my mind is whether current medicalized approaches to death are sufficient to solve the existential quandaries of my patients.
I have had office visits with patients whose only goal is to talk about what’s going to happen to them. And they don’t mean what physical dying is like, although sometimes they do. Often they are more interested in talking with me about their thoughts on an afterlife, God, etc. Sometimes patients want to discuss the religious practices of their families or their childhood beliefs. Many of my patients know that I work on end-of-life issues. Others tend to view the doctor’s office as a “safe space” for discussing existential concerns that they don’t feel comfortable discussing with friends or family or colleagues.
So while, yes, current approaches to dying maintain the cleanliness, nutrition, and medical care of patients, the services of a medical clinic or hospital insufficiently address these big questions that seem to matter to so many of my patients.
You argue that we need to recover a religious sense of dying, an ars moriendi. But what does religion add to the way that we die other than a few prayers?
I believe that all Westerners, whether religious or not, have much to learn from the ars moriendi (Latin for “art of dying”) tradition with its focus on the lifelong preparation for death. But I am not arguing that we – meaning all Westerners – need to recover a religious sense of dying.
What I do argue is that for Christians, the community of fellow theologically-formed Christ-followers offers the best context for navigating and surviving the choppy waters of medicalized dying. Christians can do this by corporately rehearsing their story through readings, meetings, and rituals, such as the sacraments.
Christians can, as they were known to do in the 1st and 2nd Centuries, revive and expand practices of visiting and caring for the sick and dying. They can corporately discuss and complete advance directives. Medical professionals from within congregations can serve as informal guides to managing the complexities of modern biomedical health care. All of these activities help to foster cohesion within the ecclesial community and empower its members to engage medicalized dying with wisdom.
I should add that it’s not only Christian religious communities that can do this. Other communities – religious or not – can commit to this sort of engagement. But the Christian understanding of death – that it is an enemy that has already been defeated – offers a certain kind of healing balm to dying believers.
You see three stages in the gradual medicalisation of death. Could you briefly sketch them out?
In the paper, I start with the ars moriendi as illustrative of religious dying and show how (in the United States at least), Industrialization, the American Civil War, the development of medical technology, and the rise of the death and dying movement had the collective effect of secularizing death.
The ars moriendi refers to a series of handbooks on the preparation for death that developed during the aftermath of the mid-14th Century bubonic plague in Europe. The initial manuscript is thought to have been circulated by the Catholic Church, but these “dummy guides to death” became wildly popular, were translated into many languages, adopted by the religious and non-religious alike, and spread all over Europe, even to the United States. They remained in use until the early 20th Century.
Industrialization challenged the ars moriendi’s community-centric approach to preparing for death, however. As people moved from the countryside to the city in search of work, they abandoned larger homes to inhabit crowded flats with other factory workers. With a coincident rise in health care institutions, the hospital, rather than the homestead, became the destination for the sick and dying.
The American Civil War also dramatically altered the dying process in several ways: Dying well came to mean dying courageously, rather than faithfully; the federal government established national cemeteries, relocating the bodies of dead soldiers out of their communities; and a generation of soldiers died without participating in any of the Christian rituals that had attended dying in the antebellum period.
The 20th Century rise of medical technology, the advent of the ICU, antibiotics, CPR, and other life-extending technology obscured the line between living and dying and offered a new, tangible physical hope for those who might otherwise have died.
How did the 20th Century transform hope for religious salvation into hope in medical salvation, with power passing from the Divine to the Doctor?
The tremendous development of life-sustaining technology means that as our days on earth grow longer, the prospect of a certain death becomes more distant. Focusing on the preparation for death – though fashionable for more than 500 years – came to be seen as antiquated and somewhat morbid in the post-WWI period.
Preachers began focusing instead on helping their faithful to live well, and as medical technology became more specialized, clergy had little authority in the hospital. Sure, they could still visit the sick – as they do today – but the doctor was the one who came to have power over life and death. It was the doctor who could connect and disconnect the life support.
You seem to be chronicling a decreasing sense of the meaning of death and an increasing desire to control death. What do we lose in this process?
The meaning of death raises questions about the meaning of life. If death is meaningless, then what purpose does life serve, apart from the gratification of our immediate desires? (And by “immediate,” I mean the desires of our 60 to 80 years on earth.)
I see this all the time with my patients. When this life is strictly about maximizing the experience of the here and now, patients try to get it all in before they die. This is broader than simply checking items off the bucket list. They might strive to maximize or influence all aspects of their lives, whether by spending on themselves or giving to others, traveling to exotic places, experimenting with new forms of spirituality, planning their deaths, restoring estranged relationships, pursuing new sexual relationships, or ultimately deciding – after a lifetime of promiscuity – to end on a monogamous note. Clearly this is not all bad. But these decisions are made from the vantage point that this life is all there is.
When death is imbued with meaning, however, life is imbued with meaning, and we can cease striving to determine all aspects of the imprint we are going to leave. When our story is part of a grander narrative, we concern ourselves with a different kind of legacy – a legacy centred around faith, hope, and love.
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Lydia S Dugdale
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