The Art of Dying Well

The scenario is all too common: the elderly woman with end-stage dementia readmitted to the hospital for the fourth time in three months for anorexia, now static cancer progressing despite all proven chemotherapy now pursuing a toxic experimental treatment, or the patient with a rampant infection leading to multiple organ failure who requires machines, medications, and devices to filter the blood, pump the heart, exchange oxygen, facilitate clotting, and provide nutrition. Modern medical science is adept at sustaining life.

The field of bioethics has, since its earliest days, debated end-of-life issues; yet American society more broadly remains ill equipped for the experience of dying. This can be attributed in large part to four factors. First, dramatic technological advance has obscured the distinction between death and life and has confounded the layperson’s ability to know whether death is imminent. Even when medical professionals agree that a patient is dying (as above), the patient and family often remain unaware. Second, our unwavering faith in technology’s abilities has prevented us from wrestling with the reality of death. Third, the secularization of Western culture has marginalized the role of religion in preparing individuals for death. Fourth, physicians—as the new intermediaries between life and death—are notoriously inadequate at discussing end-of-life issues with their patients. When death arrives, seemingly unannounced, patients and family members are shocked and confused, and they struggle to cope.

Given these factors, one of the pressing bioethical concerns for the coming generation is the formulation and dissemination of a framework for dying well. We need a modern version of the Ars moriendi, or Art of Dying, which expressed the societal and ecclesiastical response in the Middle Ages to the widespread death caused by the plague.

It is no secret that the population of the United States is graying. The Administration on Aging, the federal agency responsible for serving the needs of older Americans, reports that in 2009 (the last year for which statistics are available), 39.6 million Americans—12.9 percent of the population—were over sixty-five years of age. Average life expectancy for those who reach sixty-five is an additional 18.6 years. The Administration projects that by 2030, 19 percent of the population will be over sixty-five. So within twenty years, twenty percent of Americans will be elderly, and for this population, death is imminent.

These statistics can be reassessed in the light of history. The midfourteenth century bubonic plague, or “Black Death,” is considered to have been among the deadliest pandemics of human history. It has traditionally been attributed to infection by Yersinia pestis, a bacterium spread by fleas and rats. Historians generally agree that between one-third and two-thirds of Europe’s population succumbed to the plague. Death came rapidly; typically less than a week separated the first sign of illness from the grave.

According to historical accounts, the number of dead increased so swiftly that those spared could scarcely keep up with proper burials. The fourteenth-century Italian humanist Giovanni Boccaccio described the chaos of the period:

Few also there were whose bodies were attended to the church by more than ten or twelve of their neighbours, and those not the honourable and respected citizens; but a sort of corpse-carriers drawn from the baser ranks, who called themselves becchini and performed such offices for hire, would shoulder the bier, and with hurried steps carry it, not to the church of the dead man’s choice, but to that which was nearest at hand, with four or six priests in front and a candle or two, or, perhaps, none; nor did the priests distress themselves with too long and solemn an office, but with the aid of the becchini hastily consigned the corpse to the first tomb which they found untenanted.¹

Priests, of course, were themselves not immune from the plague. As the death toll mounted and traditional social structures disintegrated, the Catholic Church responded with advice to laypeople on procedures, protocols, and prayers for the dying. This advice came in the form of two texts known as the Ars moriendi...