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Life & Death
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The lost art of dying well and what we can learn from it today

Living well in order to die well doesn’t simply happen. It takes work. It takes preparation. For All Souls Day, Lydia Dugdale asks if we are prepared for death.

Lydia Dugdale is the author of The Lost Art of Dying. She is Professor of Medicine at Columbia University and Director of the Center for Clinical Medical Ethics. She is a specialist in both medical ethics and the treatment of older patients. 

A medieval book illustration of a person dying in bed.
A 15th Century ars moriendi, or ‘art of dying’ image.
Basel University, via WikiCommons.

The first of November marks All Saints Day on many church calendars—a day when we Christians remember our martyrs together with all the faithful, both living and departed. On that day, we celebrate that our communion is not simply with one another on earth but is also with all saints of all time, including those who have died.  

For some people, the notion of fellowship with departed saints might be quite exciting. They may have pondered questions about the saints since school assemblies or RE lessons. What was racing through Abraham’s mind when he attempted to sacrifice his son Isaac? What would Mary say a sinless Jesus was like as a toddler? Did Jonah float around inside the great fish, or did he find something on which to perch himself?  

But others among us might wish to skip All Saints Day altogether. Talk of dead saints feels positively medieval, even a bit morbid. Some of us might wonder about our own saintliness—or lack thereof. Could we really experience ineffable joy in an afterlife? Moreover, the very suggestion of an afterlife implies that we ourselves must die—an uncomfortable prospect for most of us.   

Such divergent reactions to the day are revealing. On the one hand, the idea of having saints to remember is to inspire us to live well. They invite us to examine their lives and to grow ourselves in response. On the other hand, they remind us that our days are numbered. And because our days are numbered, we should attend carefully to what it means to live wisely. Saints teach us that if we want to die well, we must live well. 

But living well in order to die well doesn’t simply happen. It takes work. It takes preparation. Which is why this year on All Saints Day it’s worth asking the question: Am I prepared for death? 

Death exists as a paradox for Christians—as something at once lurking and vanquished. 

In the late Middle Ages, the ars moriendi, or ‘art of dying’ genre of literature developed in response to mass loss of life from a fourteenth-century outbreak of bubonic plague. The genre consisted of a number of handbooks on how to prepare for death. Although the earliest text was anonymous, historians believe that its authorship had a connection to the Western Church. After the Reformation, Protestant versions began to circulate, and later handbooks omitted religious particularity altogether. The handbooks grew in popularity throughout the West for more than 500 years. 

This notion of living well to die well lay at the core of the various iterations of the ars moriendi. Early texts warned readers that five temptations lead to dying poorly—temptations to doubt, despair, impatience, greed, and pride. If you don’t want to die a doubting, despairing, impatient, greedy, and proud person, you must cultivate the virtues of faith, hope, patience, generosity, and humility now. But the ars moriendi texts were very clear that virtue did not happen to a person all at once at the end of life. Rather, it required habituation. Cultivating virtues was the work of a lifetime. If you want to be remembered as a person of sound character, a generous person of hope and good will toward others, you cannot delay making such attributes a regular practice. If you are willing to be martyred for your faith—as some of those early saints were—you have got to be sure it is a faith worth dying for. 

I once met a man who had converted from the religion of radical self-centeredness to Christianity. When I asked him why, he told me that of all the world’s religions, Christianity had the best story. As with the martyred saints, it was for him a story worth dying for. And All Saints Day reminds us that in Christianity, death is stranger than you might think. 

Death exists as a paradox for Christians—as something at once lurking and vanquished. Death is the enemy that at long last will be destroyed, and death has already been swallowed up in victory. But you might ask: if death has already been defeated, what remains to be destroyed? And if death will be destroyed, how has it then been defeated? This enigma might partially explain why many regular church attenders are neither physically nor spiritually prepared for death. Researchers at Harvard University have shown that people who describe themselves as most supported by their religious communities are also most likely to reject hospice care and instead to elect aggressive life-extending technology. 

The story goes as follows. Death is an enemy because it suggests rejection of God. From the beginning, God tells our forebearer Adam that he can freely eat of any tree in the garden but one. If he eats from the tree of the knowledge of good and evil, he will die.  Thus, from the beginning, God equates the possibility of human disobedience with the actuality of death.  

Of course, Adam and Eve eat the proverbial apple. And when they do, they don’t immediately die, but they experience a sort of death. For the first time, they become filled with shame and fear. They hide themselves from God. They cast blame. God tells them that moving forward their life will be filled with great suffering. God says to Adam, ‘By the sweat of your face you shall eat bread until you return to the ground, for out of it you were taken. You are dust, and to dust you shall return.’ Disobedience is what Christians call ‘sin’—and it brings death. Sin severs that once harmonious relationship between God and people—a fact that also grieves God, which is why God does not let death have the final word. 

The story gets better. Since we humans cannot possibly undo the drastic results of our disobedience, God becomes fully human in Jesus Christ, so liable to death, while also retaining full, divinity which cannot die. Then, as a human on a cross, he dies as the ultimate sacrifice on behalf of humankind. But this God-Man does not stay dead. After three days in the tomb, Christ is resurrected, defeating death, on what has come to be known as Easter Sunday. Christ’s resurrection functions as a sort of guarantee that all God’s people will one day be resurrected and receive new bodies, that day on which the great enemy of death will be destroyed once and for all. If Adam and Eve brought death into the world, the resurrection hope is that death will be no more.  

This year on All Saints Day we have the opportunity to consider what it means to commune with ‘all saints’ extending back to Adam and forward to future generations. We have the opportunity to study the saints and then examine ourselves. What sort of people are we becoming? Are we living well to die well, as the ars moriendi handbooks teach? And of all the stories out there, which provides the greatest hope in life and in death? 

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Assisted dying
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Life & Death
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The careless conflation of independence, autonomy and dignity

As Jersey begins to legalise assisted dying, there’s keyword confusion.
A elderly women in a care home stands and places her hands on the shoulders of a seated woman.
Eberhard Grossgasteiger on Unsplash.

Reviewing Canada’s legislation on assisted dying, one anonymously authored article raises the concern: “Does it make dying with dignity easier than living with dignity?” This insightful question cuts to the centre of the debate: dignity. Or more particularly, the unwitting conflation of dignity with independence, and of independence with autonomy.  

As Jersey becomes the first place in the British Isles to begin the process of legalising assisted dying, I feel that we should listen carefully as to how and where these terms are being used, both in the formal debate, and in the commentary that surrounds it. The States Assembly in Jersey voted to allow the development of assisted dying legislation for those with six months to live (or twelve months if their condition is neurodegenerative). A second vote to make assisted dying available more broadly to those who experience conditions that entail “unbearable suffering” was defeated by a narrower margin. Reading the flurry of press releases that followed the vote, these keywords, autonomy, independence, and dignity, are everywhere. But are we really thinking about what these words communicate?  

People in positions of wealth and power have more independence and autonomy, more choices and freedoms, but it is we who ascribe dignity to those in that position.

The word dignity comes from the Latin word dignus, meaning ‘worthy’, and this is still the primary definition given to the English word dignity today. The OED has it as “the quality of being worthy or honourable”, immediately followed by reference to “honourable or high estate”. If this is so, then dignity is not something that can be bought, nor assumed – it is a status conferred upon someone by the esteem in which other people hold them. The haughtiest person in the world can still be esteemed undignified, as can the richest. Moreover, the opposite is also true: we are never prevented from conferring dignity upon, and esteeming the worthiness of, those who live the humblest of lives.   

And yet, if we are honest with ourselves – do many of us not quietly associate the idea of becoming rich and powerful with becoming dignified? Do we not tend to assume the worthiness of those in high office – at least until we meet them and realise pretty quickly that they all put their trousers on one leg at a time, the same as the rest of us. This association happens because we have such a tendency to conflate dignity with independence (the ability to live without assistance from others) and autonomy (the ability to make one’s own decisions, and not have those decisions limited or interfered with). People in positions of wealth and power have more independence and autonomy, more choices and freedoms, but it is we who ascribe dignity to those in that position. It is society who sees the autonomy of those in high status, and esteems it as dignified.    

Does this not unwittingly suggest that choosing to live in a state of extreme dependence on palliative care is, by implication, undignified? 

Repeatedly ancient wisdom, in the bible, warns us not to assume that dignity comes with the freedom of wealth or power. All the great ‘heroes’ of that book suffer their indignities. Fresh from the success of his Ark project, Noah gets drunk and exposes himself. Elated from a victory against an enemy, King David dances half-naked through the streets. These are just two examples of the catalogue of embarrassments and mishaps that beset nearly all the kings and leaders whose stories are told as part of the Christian story. One after another, they stumble and struggle with life and leadership. The apostle Paul explains that this is because God uses the foolish things of this world to shame human pride, “for even the foolishness of God is still wiser than human wisdom.” Therefore, Paul argues, God chooses to speak to us through the weak and the lowly things and people of this world. Never was this demonstrated so clearly as when Jesus was born in a draughty stable, lived a life of poverty, and died a criminal’s death on a cross.  

But what has all this to do with the debate over assisted dying? Well, I am struck by how often the idea of losing one’s independence (through disabling or terminal illness) is conflated with losing one’s dignity, and so dying through personal choice (autonomy) is presented as regaining it. One campaign group that speaks to this debate even calls itself ‘Dignity in Dying’ – but does this not unwittingly suggest that choosing to live in a state of extreme dependence on palliative care is, by implication, undignified?  

Independence is not possible for everybody, or not possible to the same degree. And dignity? Well, dignity is possible for anyone. 

The Dean of Jersey, the Very Reverend Mike Keirle, has spoken of his concern that the change in legislation will make vulnerable people feel pressured to end their lives. Examples from Canada, where physician assisted dying is already available, show that his concern is not unfounded. In 2022, Canadian veteran and Paralympian Christine Gauthier phoned her caseworker to chase up the over-due installation of her new wheelchair ramp. She then describes how she was horrified to find herself being advised to consider assisted dying instead.  

"It is remotely just what they're doing,” says Gauthier, “exhausting us to the point of no return. […] I was like, 'Are you serious?' Like that easy, you're going to be helping me to die but you won't help me to live?"

Gauthier is not alone – she spoke out when she learned that four other Canadian veterans had reported similar experiences. In these unhappy moments, one can see how dangerous the assumption can be – the assumption that no one would want to live a life of needing help. Here are disabled people who do want to live, and this assumption, this careless conflation of independence, autonomy, and dignity, leaves them fighting for their right to do so. Why should anyone have to fight or even speak for their right not to commit suicide? It is little wonder that disabled actress, Liz Carr, describes assisted dying legislation as “terrifying” for disabled people. 

I respect that there are terminally ill people, and those who love them, who speak from a desire to end their suffering; it is clear that people on all sides of the debate need to have this difficult and emotionally charged conversation. But whatever the eventual outcome in terms of legislation, we must be careful that it is not based on careless assumptions, or on the conflation of one thing with an entirely different other. Independence is not possible for everybody, or not possible to the same degree. And dignity? Well, dignity is possible for anyone – it is a state that can be conferred whenever, and upon whomever society chooses to confer it. Autonomy is the matter in question – we are talking about autonomy in dying. And whatever happens, we should by no means legislate in a way that leaves disabled people esteemed unworthy, left open to the indignity of fighting for their right to live.