Matter and energy are neither created nor destroyed, or so says modern physics. The subatomic substrate that adds up to the eyes scanning these words, the fingers holding them within sight and all the rest of your soft, unaccountable self, used to belong to other things—an apple or a cow, maybe—and they will belong to yet others in the future. What we are now, as long as we are, is a temporary contraction.
A physician’s basic job, given this reality, is to study the normal, unspeakably complex system of unification that holds our bodies in being, and if some organ or node starts to divert from that system, steer those parts back toward the accustomed path. Until, that is, the gathering force—soul? Divine design? DNA? Choose your own poetry here—loosens its grasp, as it inevitably will, and our parts disperse. How should physicians, and the rest of us, approach this natural dispersal? This is the question animating Lydia Dugdale’s wise, humane book, The Lost Art of Dying: Reviving Forgotten Wisdom. It is a question made urgent by Dugdale’s very plausible suggestion that contemporary Americans are in the habit of dying very badly.
Dugdale is herself a physician and ethicist, and her book is an eminently readable mix of clinical anecdote and reflections drawn from history, philosophy and theology. Dugdale focuses especially on a medieval text called the Ars moriendi (Latin for “the art of dying”), which was drawn up by unknown authors in the wake of the bubonic plague, and which lays out practical advice about how to approach one’s final moments on earth. Written from a Christian perspective, the Ars moriendi contains advice and prayers for the dying, lists of deathbed vices to be avoided (despair, lack of faith, impatience, etc.), promises of consolation, rules to be followed by mourners and so on. Death will come: the text doesn’t deny it, but it insists that we can “die gladly and willfully,” if we approach things right. Dugdale is careful to acknowledge that many of her readers will not be religious, but she believes that a suitably non-metaphysical version of this view can be adduced. And, she argues, it should; death catches too many of us unawares and unprepared these days, because we prefer to look away, to deny the approach of the one most undeniable event.
One of the chief instruments of this denial is the modern hospital. Initially founded (in the West) as a refuge of last resort for travelers, the destitute and the friendless, hospitals have increasingly become the central site for the task of keeping one’s parts in proper order, for staving off death for as long as possible. As Dugdale writes, quoting the sociologist Paul Starr, the hospital rose to preeminence at the behest of “an industrializing capitalist society, which brought larger numbers of people into urban centers, detached them from traditions of self-sufficiency, and projected ideals of specialization and technical competence.” The tech-enabled expertise of modern medicine presents a shining mirage of omnicompetence to the average person. Here, we imagine, are the ones who can save us from our frailty, our confusion, our fear. Perhaps they can save us, at least for now, from death. Eighty percent of Americans report that their preference is to die at home, but a majority go on to die in the hospital, desperately waiting for salvation and/or guidance from the body-experts, “languishing,” as Dugdale puts it, “in a sterile medical ward, too sick to escape, imprisoned by illness, dependent on futuristic machines, at the mercy of an anonymous throng of health-care professionals.”
This off-loading of agency has its appeal, obviously. Among other things, it saves loved ones from the intimate burden of presiding over what can be a terribly difficult process. “Hideous sickness and indecent death,” Dugdale writes, have been safely “relegated to the institution.” All of this might be understandable, but Dugdale’s clinical experience suggests that it is the lesser way. Far better to die carefully and calmly, in the place and among the people in which and in whom we have found meaning. Dugdale doesn’t deny that death will be sad, and painful in multiple senses, but her advice is to look it as directly in the eye as we can, “to walk courageously—with those we love—toward the terror and sadness, toward the holes we will inflict.”
This call for clear-eyed courage extends from the dying person out into their community. Dugdale praises the traditional Jewish practice of tahara, a ritual cleansing of the body, carried out by a small group of volunteers from within the local Jewish community. The body is treated with loving respect—bathed in warm water, spoken and sung to, called by its Hebrew name—as it is prepared for burial. There are no lab coats, whirring machines or insurance forms in sight. Caring for the dead is seen as the natural responsibility of the community, and the community sees itself as adequate to the task. It is also, as it performs its duty, knitting itself together, Dugdale says, because “care of the dying, death, and funerals unite communities in ways that little else can.” Acknowledging that our acquired modern squeamishness will make the widespread revival of such practices unlikely, Dugdale insists that these kinds of rituals give us a salutary structure to follow. We eschew them at our peril.
Dugdale’s advice is good. It seems as though the requirements of dying and mourning well are to some degree nonnegotiable. We cannot, even if we want to, choose to simply slough off and forget our loved ones, as we would a totaled car or worn-out shoes. In life we make our world with those we love, and when they leave us, we go on as amputees; we cannot entirely control how long or how painful the recovery will be. Under the best-orchestrated circumstances, death and mourning are confounding, and with all our technologies and modern wisdom in hand, we still must submit to their dictates.
This path is unavoidably difficult. Apart from the emotional pain of losing or being lost, there is a kind of imaginative aporia to death. As Dugdale puts it, “We cannot imagine ourselves as nonexistent. We cannot grasp what it means.” Saul Bellow, musing similarly in his novel Ravelstein, writes of consciousness as a sort of picture show, and doubts whether anyone truly believes “that the grave is all there is. No one,” he writes, “can give up on the pictures. The pictures must and will continue.” Not even the staunchest materialist can truly accept the idea of permanent annihilation. “Nobody can and nobody does accept this. We just talk tough.”
If Dugdale and Bellow are right that we are ill-prepared to accept that the pictures will stop, the possibility of total annihilation still stalks us, and so long as it remains unconfronted, it can launch us into frantic, lifelong flight. Human civilizations have thus invented myriad ways of turning to face it. Dugdale reminds us of the memento mori trope (“remember that you will die”), very common in medieval Christian art, and the ongoing practice of smearing ashes on the foreheads of the faithful, while the priest advises them to remember that they are dust and to dust they will return. Many civilizations have developed the strange genre of tragedy, in which we gather to watch a fellow human, often innocent, mangled by the gears of immutable fate. In ancient Greece, tragedy was associated with the cult of Dionysus, the god of drunkenness, orgies and violence. We can only speculate as to the rationale for this association, but it seems that dipping into the pool of self-forgetting, via these various modalities, was taken to facilitate confrontation with the dispersal that is our eventual fate. Greek religion promised no paradisiacal afterlife, at least not for ordinary people, so the point was not to celebrate the passage from bodily life to a more exalted spiritual one. Aristotle suggests that tragedy, the artful conjuring of pity and fear, is meant to induce catharsis, a pleasurable kind of exhalation, in which existential horrors, duly confronted, shrink down to manageable size.
None of these time-tested methods for helping us face death bode well for Dugdale’s American audience. Her book is compassionate and true, and those with ears to hear should take its advice to heart, but all the ascertainable currents in our society seem to pull away from the practices she commends; one might go out on a limb and suggest that current-day America is the least tragic large group in history. Ours is a country of émigrés, innovators, searchers for fountains of youth, composed precisely of those who refused to sit still and accept the putative limits of their condition. This pioneer spirit, among other things, has led to various explosions of technological innovation, one of which, digital-communication technology, currently saturates American society. This digital ether we live in tells a tacit story of complete mastery over physical nature, escape from the limits of time, place and body. Our medical innovations, while unevenly distributed, are the envy of the world, and growing in power day by day. Pain relievers and mood-altering medications are plentiful and effective here. In short, willful confrontation with pity and fear are not our specialty, nor will they become so in the foreseeable future.
If American soil is inhospitable to tragedy, perhaps religion can help us face our final end. The modern persistence of religion has long been a remarkable and puzzling aspect of American society. We have, for many decades, bucked global trends around national wealth and development, which tend to correspond to a precipitous fall in religiosity. We have represented that rare combination—both modern and pious. Religion seems to be the traditional default for such coping—the various rituals Dugdale describes all take shape within religious frameworks—and you can see why. Religion has the power to change mightily our experience of death and dying. Take Christianity, the most common American religion, which promises a post-death eternity lived in blissful communion with the all-loving creator of the universe. The consolations offered here are far different than those described by Aristotle. Bereaved Christians do not believe that the loss of death is permanent, but rather that the deceased now occupy a different and better form of life, and that eventual reunion is in the offing. It is true that dying as a faithful Christian still requires courage, but it would be difficult to overstate the difference between dying into annihilation and into glory. But of course, everything that holds together eventually falls apart. In 2020, for the first time, only a minority of Americans reported belonging to a religious congregation, a fall of twenty percentage points since the turn of the century.
Another ancient and widely accessible source of consolation is children. To see that people whom we love so much, and with them our projects, genes, even a part of our very selves, will perdure, can relieve death of some of its heavy, stinging finality. But along with religion, reproduction also seems inversely proportional to expanding education and economic prosperity. Throughout the wealthy world, fertility rates are plummeting. For many years the United States seemed to buck this trend too, but then 2020 saw the lowest rate of fertility in the country’s history, well below replacement levels. We’ll have to see how much of this, if any, is a one-time pandemic dip. The general trend lines, though, remain clear.
These various discrete phenomena—medicalized death, declining reproduction, distaste for tragedy and disinterest in religion—live and grow in a common ferment, a clean progressive sense that existential matters are a bit passé—even, maybe, a bit obscene or dangerous. But if we in polite society think ourselves done with existential matters, these matters are not done with us. And if, as Dugdale suggests, dying well is intimately bound up with living well, some of our main resources for the former appear to be on the wane, and this bodes ill for our common life. Many things swing on pendulums; maybe our attitude toward death is one of them. Let’s hope so, because humans in headlong flight from the inevitable tend to grow anxious and desperate. They tend to hurl themselves into various addictions and evasions. They tend to turn on each other. Learning to live with what we are—both living and dying things—is a matter of deep importance, even civilizational urgency. Dugdale’s call to remember that we are dust, and then to keep remembering, is one that we need to heed.