Explainer
Creed
Death & life
5 min read

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? 

Authors
Article
Assisted dying
Care
Comment
Death & life
Suffering
5 min read

Why end of life agony is not a good reason to allow death on demand

Assisted dying and the unintended consequences of compassion.

Graham is the Director of the Centre for Cultural Witness and a former Bishop of Kensington.

A open hand hold a pill.
Towfiqu Barbhuiya on Unsplash.

Those advocating Assisted Dying really have only one strong argument on their side – the argument from compassion. People who have seen relatives dying in extreme pain and discomfort understandably want to avoid that scenario. Surely the best way is to allow assisted dying as an early way out for such people to avoid the agony that such a death involves?  

Now it’s a powerful argument. To be honest I can’t say what I would feel if I faced such a death, or if I had to watch a loved one go through such an ordeal. All the same, there are good reasons to hold back from legalising assisted dying even in the face of distress at the prospect of enduring or having to watch a painful and agonising death.  

In any legislation, you have to bear in mind unintended consequences. A law may benefit one particular group, but have knock-on effects for another group, or wider social implications that are profoundly harmful. Few laws benefit everyone, so lawmakers have to make difficult decisions balancing the rights and benefits of different groups of people. 

It feels odd to be citing percentages and numbers faced with something so elemental and personal and death and suffering, but it is estimated that around two per cent of us will die in extreme pain and discomfort. Add in the 'safeguards' this bill proposes (a person must be suffering from a terminal disease with fewer than six months to live, capable of making such a decision, with two doctors and a judge to approve it) and the number of people this directly affects becomes really quite small. Much as we all sympathise and feel the force of stories of agonising suffering - and of course, every individual matters - to put it bluntly, is it right to entertain the knock-on effects on other groups in society and to make such a fundamental shift in our moral landscape, for the sake of the small number of us who will face this dreadful prospect? Reading the personal stories of those who have endured extreme pain as they approached death, or those who have to watch over ones do so is heart-rending - yet are they enough on their own to sanction a change to the law? 

Much has been made of the subtle pressure put upon elderly or disabled people to end it all, to stop being a burden on others. I have argued elsewhere on Seen and Unseen that that numerous elderly people will feel a moral obligation to safeguard the family inheritance by choosing an early death rather than spend the family fortune on end of life care, or turning their kids into carers for their elderly parents. Individual choice for those who face end of life pain unintentionally  lands an unenviable and unfair choice on many more vulnerable people in our society. Giles Fraser describes the indirect pressure well: 

“You can say “think of the children” with the tiniest inflection of the voice, make the subtlest of reference to money worries. We communicate with each other, often most powerfully, through almost imperceptible gestures of body language and facial expression. No legal safeguard on earth can detect such subliminal messaging.” 

There is also plenty of testimony that suggests that even with constant pain, life is still worth living. Michelle Anna-Moffatt writes movingly  of her brush with assisted suicide and why she pulled back from it, despite living life in constant pain.  

Once we have blurred the line between a carer offering a drink to relieve thirst and effectively killing them, a moral line has been crossed that should make us shudder. 

Despite the safeguards mentioned above, the move towards death on the NHS is bound to lead to a slippery slope – extending the right to die to wider groups with lesser obvious needs. As I wrote in The Times recently, given the grounds on which the case for change is being made – the priority of individual choice – there are no logical grounds for denying the right to die of anyone who chooses that option, regardless of their reasons. If a teenager going through a bout of depression, or a homeless person who cannot see a way out of their situation chooses to end it all, and their choice is absolute, on what grounds could we stop them? Once we have based our ethics on this territory, the slippery slope is not just likely, it is inevitable.  

Then there is the radical shift to our moral landscape. A disabled campaigner argues that asking for someone to help her to die “is no different for me than asking my caregiver to help me on the toilet, or to give me a shower, or a drink, or to help me to eat.” Sorry - but it is different, and we know it. Once we have blurred the line between a carer offering a drink to relieve thirst and effectively killing them, a moral line has been crossed that should make us shudder.  

In Canada, many doctors refuse, or don’t have time to administer the fatal dose so companies have sprung up, offering ‘medical professionals’ to come round with the syringe to finish you off. In other words, companies make money out of killing people. It is the commodification of death. When we have got to that point, you know we have wandered from the path somewhere.  

You would have to be stony-hearted indeed not to feel the force of the argument to avoid pain-filled deaths. Yet is a change to benefit such people worth the radical shift of moral value, the knock-on effects on vulnerable people who will come under pressure to die before their time, the move towards death on demand?  

Surely there are better ways to approach this? Doctors can decide to cease treatment to enable a natural death to take its course, or increase painkillers that will may hasten death - that is humane and falls on the right side of the line of treatment as it is done primarily to relieve pain, not to kill. Christian faith does not argue that life is to be preserved at any cost – our belief in martyrdom gives the lie to that. More importantly, a renewed effort to invest in palliative care and improved anaesthetics will surely reduce such deaths in the longer term. These approaches are surely much wiser and less impactful on the large numbers of vulnerable people in our society than the drastic step of legalising killing on the NHS.