Imagining Death -- and Dying Well
Dying well in America is hard work. It’s a familiar complaint among the critics of the medicalization of death. We die badly, they say, when we die a lingering death, not at home but in a hospital, surrounded by technology rather than by family and friends, under the control of medical experts. This is all the result, they say, of the medicalization of death in the middle of the 20th century; it was then that death became a medical event rather than a human event, an event governed by medicine rather than by the dying person and her community.
Bioethicists who made such a complaint frequently urged that procedures be adopted to protect the patient’s right to refuse treatment; in that way control over dying could be wrestled away from the medical experts and returned to patients and their families. The death awareness movement also complained about the medicalization of death and proposed to remedy it by learning to regard death as “natural” and by unlearning our denial of death. But in spite of such proposals, dying well in America remains hard work. Dying well requires not just attention to the rights of patients, not just an end to our death-denial, not just even hard work; I am convinced that it also takes a good imagination, an imagination formed and re-formed by the biblical narrative.
The commanding image of death in “medicalized” dying is that death is the enemy to be defeated by the greater powers of science and medicine. This can be traced to the dawn of modernity. In the 17th century Francis Bacon expressed his confidence that empirical knowledge could provide mastery over nature and rescue the human condition from its mortality and vulnerability to suffering. Bacon traced his project to the biblical creation story and to the mandate of “dominion” over nature (Genesis 1:26, 28). Confident in the human capacity for dominion through empirical knowledge, Bacon rejected the ancient observation of medicine that some patients are simply “overmastered by their diseases.”
In the 17th century, when doctors were still as likely to kill someone as to save them, this must have seemed simply fanciful to many, but with the great successes of medicine in the mid-20th century, Bacon’s vision gained a firm hold on the culture’s view of dying. We should all be grateful for the successes of medicine, of course, but those successes also resulted in failures that were soon on display in the medicalization of dying. The imagination formed by the propositions of Francis Bacon prompted a denial of death. It would not allow us to think anyone was “overmastered by their disease,” or even that anyone was dying. The ancient “dying role” with its practices and responsibilities disappeared; the “sick role” with its passivity before the doctor took its place on the stage. This fueled only one fundamental goal: avoiding death. To preserve life, so Bacon said, was “the most noble” end of medicine.
One obvious failure of this perspective was that people still died, in spite of Bacon, but another was that they died sometimes lingering deaths. Dying became a medical event. The body of the dying person became the battlefield where heroic doctors and nurses wage their war against death. The lab reports and the body scans provide surveillance and dictate strategy, but the doctors remain in charge, even in the face of almost certain defeat. A medicalized dying is death in a hospital, in a sterile environment, in the company of technology, and under the control of those who know how to use it. The medicalization of death has made dying well difficult.
It is easy to blame physicians when people do not die well, but it is not their responsibility to teach people how to die well. The problem is not their skill but our imagination. There have been, as we have seen, complaints about medicalization and powerful challenges to it. Standard bioethics proposed “patient autonomy” as a way to allow dying patients to wrestle control over their dying away from the doctors. But the emphasis on patient autonomy failed to nurture an alternative imagination. In fact, patients themselves and their families frequently have a view of dying formed by Francis Bacon’s vision and the medicalization of death.
The death awareness movement promised that, if we would stop our silence and denial and learn to regard death as natural, then we could avoid a medicalized death. To regard death as natural does suggest an alternative imagination, but it has problems of its own.
Churches have been largely silent on the issue, content to surrender death to medicine. But the church can and should resist the medicalization of death, not by relying on the bioethics movement or the death awareness movement but by faithfully and creatively retrieving its own resources for the re-forming of our imagination.
One resource is the tradition of Ars Moriendi. These ancient instructions about how to die well were usually prefaced by a commendation of death. Crafte and Knowledge For to Dye Well, written in 1490, offered this commendation: “Death is nothing else than the release from prison and the ending of exile ... the entrance into bliss and joy.” One should welcome death as a “well-beloved and trusted friend.” This image for death is defended by citing biblical texts—but they are usually taken out of context. For instance, “Precious in the sight of the Lord is the death of his faithful ones,” (Psalm 116:15) is a favorite of the tradition. But in this psalm of thanksgiving for healing, it is life, not death, which God cherishes. That death is “precious” is not said to commend death but to insist that God regards death as something costly, as the loss of someone or something dear.
From such a commendation of death, the Ars Moriendi tradition typically moved to an account of the deathbed temptations of the dying person—temptations to faithlessness, despair, impatience, pride, and avarice—and to instruction concerning the virtues necessary to meet those temptations—faith, hope, the patience of love, humility, and the ascetic surrender of worldly attachments. Then the following elements would be included: a little catechism for the dying, an instruction to the dying that they should look to the cross and find in Christ a paradigm for their own dying, advice to those who keep company with the dying, and prayers.
There is wisdom here. There is no silence or denial. The death awareness movement might applaud. The dying person has decisions to make, and the doctors cannot make them for him. The bioethics advocates would be pleased. The dying person’s integrity, if not his autonomy, is of crucial concern. Attention is given to the virtues necessary for dying well. And most important of all, I think, is the instruction to find in the story of Jesus’ death a paradigm for a Christian’s dying.
But there are also problems. And the problems begin at the beginning, with its image of death and its commendation of death. It echoes Plato more than Christian Scripture. That Platonic dualism at the beginning—the bifurcation of the soul from the body and only the soul considered to have eternal value—runs like a virus through the whole, corrupting even its reading of the biblical text, its account of the virtues, and its attention to Christ as paradigmatic for a Christian’s dying.
Its account of hope, for example, becomes the longing of an individual soul for heavenly bliss. Its account of patience leaves no place for lament. Its call to humility is attentive to our sins but not to our finitude. And its call for an ascetic detachment from “carnal” attachments disparages relationships with family and friends. It is curiously inattentive to the place of lament in Christ’s dying, to his simple thirst, and to his concern for his mother and friend.