"And Then at the End, You Throw a Bedpan": Personal and Theological Reflections on End-of-Life Care, Ars Moriendi and The Wildness of Death
Joel Shuman, Ph.D., Professor of Theology, King's College
In an essay commemorating the twenty-fifth anniversary of his book Suffering Presence, the Protestant moral theologian Stanley Hauerwas argues that physicians must learn to embrace the finitude inherent in their own humanness and teach their patients to do likewise, to live through their bodies, rather than beyond them. This claim is based on his understanding that medicine is in part a “tradition of wisdom and practices through which physicians… remember, learn, and pass on the skills of learning to live with a body that is destined to death.” Reflexive objections notwithstanding, this account of medicine is one consistent with its traditional commitment to pursue, restore, and maintain health; as Wendell Berry writes, “Any definition of health that does not include death is silly.”
As many bioethicists and scholars of the medical humanities have long attested, medicine – American medicine in particular – seems not to have read the memo. Beginning in the second half of the twentieth century, as medicine and its armamentarium of technologies have grown increasingly adept at combatting disease and overcoming suffering, the profession has faced a near-constant temptation to name vitalism – to regarding the indefinite forestalling of death and the extension of the barest physiological existence – as among its aims.
Pushbacks from within and beyond the profession emerged beginning in the 1960s. The death awareness and natural death movements, the right-to-die movement, and the emergence and evolution of hospice and palliative medicine intertwined to offer alternatives to the indignities of aggressive death-prolonging treatment at life’s end. Each has served in its own way to make patients’ finitude part of many physicians’ diagnostic and therapeutic reasoning, even as the Borg of the medical-industrial complex has adopted, assimilated, and medicalized aspects of all and many patients continue to die subjected to aggressive intervention in critical care units or oncology suites.
A different strand of resistance to death’s medicalization, more resistant to assimilation, is a renewal of the medieval tradition called the ars moriendi, the “art of dying.” With roots in both Catholic and Protestant Christianity, the original ars pamphlets advocated the cultivation of practices through which Christians might embrace and embody their tradition’s foundational commitments about embodiment and
mortality, the fundamentally relational character of human existence (exemplified through the importance of reconciliation at life’s end), and the promise of resurrection from death into the renewed Creation at the end of history.
Even as one praises this renewal as an indispensable aid to the dying and those attending them, it is important to remember that neither the ars moriendi nor any other alternative to medicalized death assures a so-called “good death.” No amount of preparation – neither advance directives nor expert titration of opioids nor lifelong immersion in ecclesial disciplines – affords control of death. Death remains, in spite of our best and best-informed efforts, largely beyond domestication. The uncertain future, including and perhaps especially our dying, must be commended to the sovereignty of God, who remains faithful even as we lose control and become faithless as death looms.
In an essay commemorating the twenty-fifth anniversary of his book Suffering Presence, the Protestant moral theologian Stanley Hauerwas argues that physicians must learn to embrace the finitude inherent in their own humanness and teach their patients to do likewise, to live through their bodies, rather than beyond them. This claim is based on his understanding that medicine is in part a “tradition of wisdom and practices through which physicians… remember, learn, and pass on the skills of learning to live with a body that is destined to death.” Reflexive objections notwithstanding, this account of medicine is one consistent with its traditional commitment to pursue, restore, and maintain health; as Wendell Berry writes, “Any definition of health that does not include death is silly.”
As many bioethicists and scholars of the medical humanities have long attested, medicine – American medicine in particular – seems not to have read the memo. Beginning in the second half of the twentieth century, as medicine and its armamentarium of technologies have grown increasingly adept at combatting disease and overcoming suffering, the profession has faced a near-constant temptation to name vitalism – to regarding the indefinite forestalling of death and the extension of the barest physiological existence – as among its aims.
Pushbacks from within and beyond the profession emerged beginning in the 1960s. The death awareness and natural death movements, the right-to-die movement, and the emergence and evolution of hospice and palliative medicine intertwined to offer alternatives to the indignities of aggressive death-prolonging treatment at life’s end. Each has served in its own way to make patients’ finitude part of many physicians’ diagnostic and therapeutic reasoning, even as the Borg of the medical-industrial complex has adopted, assimilated, and medicalized aspects of all and many patients continue to die subjected to aggressive intervention in critical care units or oncology suites.
A different strand of resistance to death’s medicalization, more resistant to assimilation, is a renewal of the medieval tradition called the ars moriendi, the “art of dying.” With roots in both Catholic and Protestant Christianity, the original ars pamphlets advocated the cultivation of practices through which Christians might embrace and embody their tradition’s foundational commitments about embodiment and
mortality, the fundamentally relational character of human existence (exemplified through the importance of reconciliation at life’s end), and the promise of resurrection from death into the renewed Creation at the end of history.
Even as one praises this renewal as an indispensable aid to the dying and those attending them, it is important to remember that neither the ars moriendi nor any other alternative to medicalized death assures a so-called “good death.” No amount of preparation – neither advance directives nor expert titration of opioids nor lifelong immersion in ecclesial disciplines – affords control of death. Death remains, in spite of our best and best-informed efforts, largely beyond domestication. The uncertain future, including and perhaps especially our dying, must be commended to the sovereignty of God, who remains faithful even as we lose control and become faithless as death looms.