The Lost Art of Dying: Reviving Forgotten Wisdom by Lydia Dugdale 2020.
Lydia Dugdale is associate professor of medicine at Columbia University and this book looks back at the ancient art of dying and attempts to recast its insights for today. The book begins with the story of Mr. Turner, who was frail, elderly, and in poor health. His relatives insisted that he be given everything that medicine could provide to enable him to live as long as possible. The result was tragic. Doctors, obliged to follow the relatives’ instructions rather than their own clinical judgement resuscitated him twice in one day, bringing his heart back to life after it had stopped. Unfortunately, this didn’t last long. His heart failed a third time that night and he could not be resuscitated. Mr. Turner’s fate is a classic example of how someone was unable to die well.
Doctors tend to fail to guide patients to die wisely. Health care systems are like car assembly lines or freezing works in reverse (putting people together rather than taking dead animals apart). They are the opposite of slow medicine and a dialogue with patients that prepares them to die wisely. Ms. Capella is another example; she insisted that her doctor keep her alive at all costs, even though she was 95 and smoking had irreversibly damaged her heart and lungs. Resuscitation would likely result in painful rib fractures and she probably would be unable to live independently of mechanical ventilation. We can’t effectively prepare for death if we are clinging to an indefinite extension of life. Often patients aren’t aware of the likely downsides of treatment and haven’t had them adequately explained to them.In response to the horror of the bubonic plague or Black Death, a genre of literature emerged: the Ars moriendi, the art of dying. This was not focused on the pious or the rich; it aimed at everyone. Particularly popular was an illustrated version, which consisted mainly of woodcuts illustrating the various temptations faced by the dying. This made the book accessible even for those who could not read. The book aimed to counter the five temptations that the dying are susceptible to and to counter them with images of their resolution: disbelief and encouragement in faith, despair and comfort through hope, impatience and patience, pride and humility, avarice and letting go of the earthly. The temptation of pride gives an idea of what was involved:
An Ars moriendi woodcut showing a dying man with the temptation of pride. He has demons on one side and saints on the other, in a struggle for his soul.
It is important to have friends and family around us when we are dying. While each of us ultimately dies alone, having others around us, providing perspective and support, is encouraging. We are relational creatures. In the Ars moriendi, the dying are encouraged to confess their sins and to receive forgiveness from those around them. Until recently, most people died at home surrounded by friends and family, all of whom have a role to play.
Doctors may be tempted to regard patients purely physically, as a bundle of organs, but they are persons and deserve to be addressed as such. That means that spirit and not just body must play a role. Dugdale surveys non-judgmentally the various attitudes and beliefs that patients may have. Many people become interested in existential questions as they confront death. They wonder about the meaning of life: Why am I here? What is this life for? There are three main non-orthodox beliefs about life after death:
Complete annihilation. The dead are broken machines that turn to dust.
Reincarnation. We often hear at funerals, “I know she is here with us.” “I am in the sun and in the wind. I did not die, I am with you all.”
Spiritualism. Ouija boards continue to be popular, enabling the would-be receipt of messages from the dead.
Many people are “spiritual but not religious.” They reject a purely materialistic view of life and focus on inner experience. Others find that this is not enough and argue for an explicit commitment to a particular religious tradition. Many doctors avoid getting involved in such questions, but Dugdale is willing to “go there” with her patients. In so doing, she again becomes a physician, a healer aiming to see them flourish.