The Lost Art of Dying: Reviving Forgotten Wisdom, by L.S. Dugdale ★★★★
This book was recommended to me by my past surgery practice partner, Dr. D. King. It is written by an internist who directs a medical ethics center at Columbia University in New York City. Dugdale writes in a very personal fashion, recounting many of her patient and family experiences with dying. As a retired surgical oncologist, the stories she shares are very much in common with what I’ve experienced over my lifetime of a surgery practice that focused on cancer. I held in common with her many of her experiences with patient encounters and family encounters when death was imminent.
The strength of this short book is in recalling ancient wisdom. Much of the focus is centered on a manual titled ars moriendi written in the 14th and 15th centuries to guide folk in the art of how to die. There was an age when a person was surrounded by death, and society did not shield a person from observing the death process. People died at home among a community of friends. Dugdale doesn’t mention that the attitude toward death was radically different in medieval times, in that a good death was a long drawn-out painful event, and to die in your sleep was the ultimate bad death. Still, our historical fathers did not avoid discussions of death. The churchyard of every church older than 150 years ago had an associated cemetery in front of the church that you had to walk through before entering the church, a reminder of our true place on earth.
Dugdale does well at emphasizing how we have made death to be a theatrical, yet exceedingly lonely event. Nobody dies without being on a bucketful of expensive medications, all of which add to the misery of the dying process. Death is sterile, shielded from the prying eyes of family and friends. Dr. Dugdale describes some horrible scenarios that she encountered early in her training, such as a person who arrested three times in a night before actually dying, with each CPR (including the first) that never should have been done. Death in history is described, most notably entailing the plague (black death) from the 15th century. Death becomes a useful reminder of our personal finitude, that we here today, gone tomorrow. Dugdale speaks of how it has become common for people to die alone in their homes, only to be discovered days, weeks, and even months later, and how community in the process of dying is most relevant to offer the dying person the honor and dignity that they deserve.
Where we die is important. It is only in the last century that the end of life most commonly occurs in the hospital setting. There is no need for this, and in fact would be far better for death to occur at home. The fear of death is discussed as a component of the dying process, something that not everybody experiences. What about the body? What significance do we place on the corpse? Dugdale spends much of a chapter discussing the Isenheim altarpiece which illustrates Jesus on the cross and in death with skin ulcers similar to what would have been seen commonly during the plague. Dugdale then treads the issue of the spirituality of death. Here, she tries to be sympathetic to all faiths and beliefs, and struggles with the issue of being spiritual without being religious, ie., not trying to offend those that do not match her Christian faith. To this end, she comes up a touch short. If the reality of the Christian faith suggests a finality and ultimate judgment, it would be impossible to smooth out the stark reality of most people ultimately facing a judge rather than a savior. Is a generic spirituality really congruous with a person nearing the irreversible prospect of an eternity in hell? I don’t think so.
There is a chapter titled “Ritual” which discusses what we do with the corpse. Do we embalm it? Do we cremate it? Do we quickly bury it, as is consistent with Jewish tradition? Does the corpse become a meaningless hunk of matter, or, is there symbolism in the body that deserves respect even after death? This is not well addressed. Dugdale wraps up by insisting that in order to die well, one must live well. This is a truism that needs no further expansion. Indeed, part of living well is in accepting one’s mortality and preparing each day for death. To this end, nobody has tackled this issue better than the Puritans of the 16th/17th century.
This book is excellent at helping one reflect on death, and in preparing for death. Such an action is counter to our culture, which wishes to sterilize death and medicalize death. The stories about patients being abused at the moment of death by the medical-industrial complex are very familiar and consistent with what I experienced as a physician. I’ve seen patients whose lives were gone long before the family was willing to withhold interventions. I’ve seen patients who were undergoing CPR (cardiopulmonary resuscitation) while simultaneously receiving an intravenous infusion of toxic chemotherapy. Too often the intensive care unit was nothing but an insensitive care unit. In academia, too often the patient was maintained on life support solely to improve the numbers for some research project. I could go on and on. Where Dugdale most seriously misses the point is in the grasp of the entire nature of healthcare. Healthcare is intrinsically a religious activity, and secularizing healthcare, making it devoid of a Hippocratic ethic, does both the patient and the system an injustice. Having served for years as a chairman of a hospital ethics committee, too often ethics is reduced to an ephemeral “gut” feeling as to what is right or wrong. Ultimately, medical ethics committees are to placate the medical industrial complex for their misdeeds while protecting the hospital from liability in a diverse cultural setting where norms for ethics do not exist.
Cemeteries should return to the churchyard. Hospitals should return to the church. Death should occur in the context of the family, with a pastor/priest, and not with a highly technical health care system in attendance. Churches should assume a greater role in discussing death and preparing for the inevitable. To this end, Dugdale accomplishes the marvelous task of describing the contemporary 21st-century problem with how we approach death but fails in part at offering the best solutions to the death problem. Without Christ, death is a veritable tragedy. With Christ, the curse of death is overwhelmed by the victory of life eternal in the presence of God. Dying and the Christian faith cannot be held as soft options.