There is a growing consensus among medical professionals, historians and theologians about a troubling trend: Modern Americans do not think about or reflect upon dying and death, nor do they see purpose, meaning or significance in suffering. In his recent best-selling book, Being Mortal, Harvard physician Atul Gawande points out the current medical profession’s inability to contend with its limits. While medical professionals might have increasing technological tools at their disposal, they are nevertheless usually incapable of dealing with death. They have not been exposed to death in their medical training, partly because it signifies a certain failure of their ability to heal, which is after all, the “telos” of the medical art. Gawande seeks to provide resources based on the conviction that “death, of course, is not a failure. Death is normal. Death may be the enemy, but it is also the natural order of things.”
To enter fully into the eternal joy, one must prepare well on the journey below.
Jewish historian Shai Lavi, in The Modern Art of Dying traces the transformation of approaches to dying in America from the more traditional “ars moriendi” (the art of dying) to what he calls the “new deathbed ethic” governed not by the Aristotelian “techne” (art) but by the rise of bureaucratic and scientific technique. The current situation, he argues, results not only the medicalization of dying and the rise of policy-making in medicine but also from the failure of Christian churches to keep in mind the eschatological dimension of death in light of the resurrection of Christ. Death became a this-worldly accomplishment, a final witness of one’s faith rather than an abandonment into the merciful hands of the Lord and an acceptance of his sovereign will and providential rule over a redeemed creation, one which is still “groaning in travail” awaiting the fullness of the “redemption of our bodies” (Rom. 8:22-23).
RETRIEVING A RICH TRADITION
Both of these non-Christian authors open an important door for the contribution of Christian theologians, ethicists and pastors in an age of increasing lifespans, discussions of long-term care, increased awareness of aging and frailty and the rise of palliative and hospice-care movements. However, there is no need to look outside the Christian tradition to provide a credible and unique contribution to the urgent discussion of death and dying in America. Rather, the time is ripe for a retrieval of the rich tradition of the “ars moriendi” that was once the staple of Christian theological reflection and pastoral praxis.
In 1519, Martin Luther preached his “Sermon on Preparing to Die,” in which he proposed 20 points of reflection about death. In the heart of the sermon, he articulated a key theme that characterized much of the late-medieval and early-modern tradition. “We should familiarize ourselves with death during our lifetime, inviting death into our presence when it is still at a distance and not on the move,” Luther preached. Practicing this “memento mori” (remembrance of death) enables Christians to overcome the natural fear of death and to fight against the devil who, particularly at the hour of our deaths, seeks to frighten us with “dangerous and pernicious thoughts” and frightful images. In preparing oneself for death during one’s life, one must “impress upon one’s heart and gaze upon” the image of Christ and the saints, who is himself “sheer life,” and in whom all the saints have their own life. In the light of faith, calling upon “the holy angels … the Mother of God, and all the apostles and saints,” Luther preached, one can have sure belief that one’s prayer has been heard, since even death itself is something for which God gives “great benefits, help, and strength” and by which he can be “loved and praised.”
In this sermon, Luther exhibited several of the central components of the “ars moriendi” tradition, as it arose in late medieval Europe. The French historian Philippe Aries has shown that with the onset of the bubonic plague, or Black Death, in many parts of Europe in the 14th century, Christians were confronted in a new way with the reality of death. Death, though often grotesque, intimidating and unexpected, became an ordinary part of life. This prevalence of the dead and dying led to an increase in reflection on the topic, both among professional theologians and in anonymous woodcuts that began to circulate among the laity. In these woodcuts, whose modern-day equivalent might be a cross between devotional prayer books and self-help guides, death was presented as an opportunity to test one’s faith. Many of them presented the deathbed as a scene of final battle between God and his angels and Satan and the demons, with the cardinal and theological virtues being challenged by their opposite vices, symbolized in vivid illustrations by the demons.
GRAPPLING WITH A PARADOX
Theologians of the time began to take the ideas disseminated through these anonymous woodcuts and systematize the “Art of Dying” tradition, which refers to both the title of a widely-circulated anonymous book and also the name of the genre. Central to many of these theologians’ concerns was the necessity of articulating a practical way to navigate a very painful reality and to address the paradox that “God did not make death and he does not delight in the death of the living” (Wis. 1:13-14), yet it is “appointed for men to die” (Heb. 9:27).
By the early modern period, reflection on the topic became perhaps one of the few areas of ecumenical agreement, though Protestant and Catholic theologians each articulated their visions with different emphases. On the Roman Catholic side, Erasmus and the Jesuit Robert Bellarmine both wrote treatises on the topic in the 16th century, and Alphonsus Liguori, known as the father of Catholic moral theology, added his own contribution in the late 17th century. At the same time, Martin Luther preached sermons and wrote on the topic in the 16th century, as did the Puritan theologian William Perkins in his Salve for a Sick Man, while in the 17th century, the Anglican bishop Jeremy Taylor wrote his own treatise, The Rule and Exercises of Holy Dying.
Each of these authors’ texts is certainly worth study in its own right, and some have been treated recently by the Protestant ethicist Allen Verhey, in The Christian Art of Dying: Learning from Jesus, and by the Catholic theologian Christopher Vogt, in Patience, Compassion, Hope and the Christian Art of Dying Well. Among the various authors, several common themes emerge that became central to this tradition. First, the tradition acknowledges the ambiguous nature of death. Though, according to the biblical accounts of Genesis 3, death is a punishment for sin and thus enters the world only after the Fall, it is nevertheless the gate of heaven by which one enters into the completion of one’s journey, which is, in reality, life in its fullness.
Second, to enter fully into the eternal joy, one must prepare well on the journey below. Human life is thus portrayed as a journey. The human person is a wayfarer (“homo viator”) who must struggle with virtue and vice, and the best way to die well is to live well. To live the good life is portrayed as a life of the virtues, strengthened by the grace of the sacraments (at least for those theologians who accept a version of sacramental theology) and keeping in mind such sayings as “tempus fugit,” (time flies).
Third, central to this tradition are claims about human finitude, dependency, and the role of the church, family and community. While there is acknowledgement that death is ultimately a singularly individual task and reality (nobody can die in our place), there is nevertheless the recognition that suffering and dying present opportunities for families and caretakers to make amends, to heal relationships and to accompany the dying on the final stage of earthly life.
The “ars moriendi” tradition was present and operative among both Catholics and Protestants for several centuries, and it made its way to America with the arrival of the Puritans and Methodists on this continent. However, the 19th century saw major changes in the way that death was treated in America. First, the sheer number of soldiers who died in the American Civil War created a great need for swift, sanitary and efficient burial. This indirectly gave rise to the burgeoning profession of undertakers, who slowly began to replace clergy, families and ministers in handling the intricacies of death. As the mortuary industry arose, no longer was the body of the deceased a present reality in the home, at the family wake, where relatives and friends could visit and perform the robust and manifold rites of the work of mercy of burying the dead. Bodies were prepared in increasingly extravagant ways for burial, with the result that all marks of suffering, anguish, disease and frailty were removed, the deceased appearing better after death than during life.
The development of heroic medicine further contributed to the transition of death out of the home, where it was seen as a natural part of life. Instead, death became the domain of physicians, who began to replace clergy and family as the skilled experts who were supposedly trained in the art of dying. However, this training was rather the usurpation of the primary roles of family and the clergy, with the result that the person dying was now at the mercy of those perceived to possess certain skills. By the 20th century, the hospital had become the primary place of death, in which, as Jeffrey Bishop has argued in The Anticipatory Corpse, the living person was treated rather as a corpse in constant need of fragmented, analytical and scientific treatment.
FACING A CROSSROADS
Today we are at a crossroads: a medicalized and scientific approach toward death accompanied by a great fear of suffering. This fear of suffering usually manifests itself in two practical and diametrically opposed ways: On the one hand, it leads to arguments in favor of physician-assisted suicide (now legal in six U.S. jurisdictions). This is based on the claim that once a certain quality of life is no longer possible, the autonomous individual ought to be able to determine when she or he can take her or his own life. On the other hand, the fear of suffering also leads to the endless pursuit of new and experimental therapies. Treatment is pursued at all costs, without regard for the likelihood of success and without consideration of the disproportionate burdens that extraordinary treatments can present both to the individual’s quality of life and to the patient’s family. (Statistically, Christians are more likely to fall into this latter category.) Fear of suffering and death thus leads to practices that deprive individuals and families of the potential goods involved in accompanying, enduring and ultimately conquering death by sharing in Christ’s victory over it.
Thankfully, in recent years there has been growing recognition that something needs to be done about this problem. Founded originally by the devout Christian, Dame Cecily Saunders, the hospice movement, though threatened by the potential of depersonalization in being subsumed by health-maintenance organizations, still offers a contemporary opportunity to exercise a modern art of dying. Hospice care places primacy on the transcendent and holistic conception of the human person and human dignity, a dignity that is not narrowly defined as a thin notion of autonomy. Palliative care physicians such as Ira Byock and Farr Curlin provide robust accounts of the importance of palliative care. Palliative care also is effective in alleviating many of the worries and fears that arise at the end of life.
The art-of-dying tradition also continues, though perhaps implicitly, in the Catholic magisterial tradition, which as recently as Pius XII’s speeches to medical professionals in the mid-20th century and John Paul II’s apostolic letter Salvifici doloris (On the Christian Meaning of Suffering) has sought to articulate both a defense of the dignity of human life, especially for the frail and elderly, as well as to provide a reflection on the meaning of human suffering. Pope Francis has also reflected on the frail and elderly central themes of his papacy and calls upon Christians to build a culture and society based on the virtues “of gratitude, of appreciation, (and) of hospitality.”
Nevertheless, much work remains to be done. The Christian can affirm the goodness of medical progress; nevertheless, when medicine seems to fail, the Christian must be ready to remind others that death does not have the final victory (1 Cor. 15:55). Modern medicine, with its multifaceted technological approaches and experts trained in the application of complicated skill sets, will not be able to conquer death. However, death, even when it is experienced as a tragedy, is ultimately a step in the human journey that can bring with it various goods and blessed opportunities for human moral growth.
Pastors, theologians and ministers all have the important task of retrieving the resources of the Christian heritage and developing them. A contemporary art of dying can provide answers to some of the questions raised by non-Christian medical professionals. Such a task offers hope for continued ecumenical dialogue, because all Christians die, all Christians share in the hope of the resurrection of Christ, and all Christians share the heritage of the “ars moriendi” tradition.
In a culture and society that often finds it easier to eliminate or sequester in specialized facilities those who are terminally ill, frail or elderly, Christians shall have to stand accountable for what we have done to the least of these. While the throwaway culture of which Pope Francis has spoken increasingly seeks to legalize practices such as physician-assisted suicide or even euthanasia, Christians must always be ready to offer the “reason for the hope that is in them” (1 Pet. 3:15). It is of primary importance to develop an adequate and robust account of how to die well, and, in doing so, to show that death does not have the final victory, nor does it instill fear in our hearts, since we “have a great high priest who has ascended into heaven,” (Heb. 4:14) in whose death and resurrection we participate and by which even our own deaths are transformed.
John Sikorski is a doctoral candidate in moral theology at the University of Notre Dame and is assistant director in the Family Life Office of the Roman Catholic Diocese of Fort Wayne-South Bend.
Artwork: Benjamin West, via Wikimedia Commons