Online Conversation | Being, Living, and Dying Well
with Lydia Dugdale
On April 2nd we were delighted to welcome professor and physician Lydia Dugdale. Dugdale is a New York City internal medicine primary care doctor and medical ethicist. She is the author of The Lost Art of Dying: Reviving Forgotten Wisdom, a book about a mostly forgotten ethical tradition and text that emerged in response to the Black Plague in the late middle ages: Ars Moriendi, “the art of dying.”
We hope you enjoy this conversation with Lydia Dugdale as we revisit ancient wisdom circulated in the wake of the Black Plague about living and dying well. Following our own plague and year of loss, we invite you to consider what the passion of Christ means for our living and our dying, and the hope and beauty that can be found, even in the face of death.
The song is “Windows” by Abby Gundersen.
This unfinished painting is called Sunset Sky by John Frederick Kensett, 1872.
Special thanks to the Yale Center for Faith and Culture, our cohost for this event
and to our sponsor, Goodwin House
Transcript of “Being, Living, and Dying” with Lydia Dugdale
Alyssa Abraham: Live from Washington, D.C., my name is Alyssa and I’m the director of advancement at the Trinity Forum. Thank you for joining us today on Good Friday, the somber but beautiful and reflective day. Before we begin our conversation, I’m going to briefly share what to expect during our time together. At the Trinity Forum, we wrestle today’s tough questions in the context of faith to equip leaders to live wisely and well. Because of this mission, we want to offer a reflection today on Good Friday on the challenging question of death to hopefully point to the one who conquered death. And we’re grateful to those who are joining us in this work and to our friends at the Yale Center for Faith and Culture at the Yale Divinity School, who are cohosting this event with us today. And many thanks to our organizational sponsor, Goodwin House. Goodwin House is a faith-based senior living and health-care services organization that serves older adults across the national capital region. And we love that Goodwin House Hospice integrates medical care with spiritual care and is rooted in the belief that every person has the right to die with dignity.
Cherie Harder: Good morning and welcome to all of you joining us for this Online Conversation on “Being, Living, and Dying.” It appears that my colleague Alyssa Abraham is having a few technical difficulties. So we want to just go ahead and get started. I’m Cherie Harder, the president of the Trinity Forum, and on behalf of all of us at the Forum, just want to thank you for joining us today on this Good Friday for this conversation with Lydia Dugdale. I’d like to particularly thank our friends at the Yale Center for Faith and Culture who are cohosting today’s event with us, as well as our friends at Goodwin House who are helping to sponsor, and to particularly thank all of you who have taken time out from your holiday to be with us. I believe we have nearly 2,000 people joining us. And just thank you for the honor of your time and attention. We’d love to give a particular shout-out to our first-time attendees. And I know there are several hundred of you who are with us, as well as our international visitors joining us from around the globe. I think we have close to 200 of you joining us from at least 27 different countries, including Afghanistan, Australia, Austria, Belgium, Brazil, Canada, Finland, France, Germany, Ghana, India, Ireland, Kenya, Malaysia, Malta, Mexico, Nepal, New Zealand, the Philippines, Portugal, Singapore, South Africa, Switzerland, Tanzania, Turkey, and the United Kingdom. So a particular thanks to you for joining us from across the miles and across the many time zones. If we have missed you in that litany, please let us know in the chat feature where you’re joining us from. We’d love to give you a particular shout-out and welcome.
If you are new to the work of the Trinity Forum, we seek to provide a space to engage the big questions of life in the context of faith and to offer programs and publications like this Online Conversation to do so and to come to better know the Author of the answers. We hope this conversation will be such an invitation and serve such a purpose.
We are now at the point where we are nearing the end of Lent, a season which in itself bids us to reflect on our own mortality and our limitations. And today, on Good Friday, we also mark the day that God incarnate himself suffered and died. So while at most times hosting a conversation around the grim topics of life, death, and dying may seem unusual, certainly countercultural, perhaps not always all that hospitable, it seemed fitting for us at this time, and on our fortieth Online Conversation since the pandemic began, to offer a chance for such discussion and reflection on the finitude and frailties of our own nature, the inevitability of our mortality, and the hope before us and what it means to live and to die well.
And to help us do that I’m delighted to introduce our guest today who has literally written the book on precisely that subject. Dr. Lydia Dugdale is an internal medicine primary doctor and a medical ethicist in New York City. She serves as an associate professor of medicine and the director of the Centre for Clinical Ethics at Columbia University and previously served as the associate director of the Program of Biomedical Ethics at Yale, where she was also the cofounding director of the Program for Medicine, Spirituality, and Religion at the Yale School of Medicine. She is also the author of The Lost Art of Dying: Reviving Forgotten Wisdom, which is a fascinating work around a mostly forgotten ethical tradition that emerged in response to the Black Plague of medieval times called the Ars moriendi, or the “art of dying,” which we’ve invited her to discuss today. Lydia, welcome.
Lydia Dugdale: Thank you. Thank you so much for having me. It’s great to be with you.
Cherie Harder: It’s great to have you here. So we’re just going to dive in at the very beginning, the Ars moriendi. This is not a commonly understood or heard term or concept. So to start us off, what is the Ars moriendi, and why did a very busy clinical physician in New York City decide to write a book about it?
Lydia Dugdale: Sure. So the Ars moriendi is Latin for the “art of dying,” and it refers to a body of literature that developed during the aftermath of the mid-14th-century bubonic plague outbreak that struck Western Europe. So think 1350s here. The plague is moving westward, came from what is probably China today, carried via rats and fleas. And it just decimated Western Europe. Historians estimate that perhaps as many as two thirds of the population of Western Europe succumbed to this particular outbreak of plague. Now plague was nothing new. And going back to antiquity, we have recordings of it. But this pandemic was destructive. And when society tried to collect itself in the aftermath of the bubonic plague, one of the first cries on the part of the people, one of the first petitions, was that they be empowered to anticipate and prepare for death themselves. Now, keeping in mind the leading social authority in the 1300s and 1400s in Western Europe was the church. This is pre-Reformation. So it was sort of the Western church. And it was the priests really who were responsible for helping people prepare for death and then conducting last rites and the masses and the funeral preparations. All of that was under the authority of the priests. But the survivors of the plague said, “Hey, we need help here. We want to be able to do this ourselves, not everything, but we want to be able to anticipate death and prepare for it.”
So for those—that I’m not a church historian—but for those of you who know the history of the church in the West, you’ll know that the late 1300s was not a particularly favorable time for the church. There were two men and then later three men simultaneously claiming to be pope. And so that meant that there was not really the infrastructure in place, if you will, to address the pastoral concerns, these very desperate needs, the petitions of the people. There was no one to address those. But when the church finally pulled itself together, resolved this leadership struggle in the early 1400s, one of its first items of business was to address this question of how to die well. And that led to the first iteration of the Ars moriendi or “Art of Dying” handbooks, which became a series of handbooks that didn’t just stay within Western Christianity but were adapted and adopted and translated by many different cultures and cultural groups, religious and non-religious, such that by the late 1800s, indeed the early 1800s, the preparation for death even in the United States was just a part of what it meant to be brought up well. The historian Drew Faust, who’s the former president of Harvard University, she’s written this lovely book on the Civil War, and she says, by the time of the Civil War in the United States, whether you were from the north or the south, attention to living well in order to die well was just part of life, religious or not; this was something that people needed to attend to.
So, Cherie, you asked why would a doctor be interested in this? And the answer is that I have seen so many patients, my own patients included, die poorly. And what started out was—even as a trainee, as a medical student, and then in the US, anyway, we go from medical school to residency so it’s kind of a junior doctor, an apprentice doctor status—in those very early roles, I would witness time and time again patients who were lingering in the intensive care unit with no hope whatsoever for ever getting out of the intensive care unit, but who either by their own stated wishes or their family’s wishes, wanted to cling to the technology of biomedicine that would maintain their vital functions, even without giving them a hope of life, of getting out of the hospital, of cure. And that seemed problematic because while, as a doctor, I’m all in favor of the goods of medicine and the goods of medical treatments, there’s a way in which we can cling too fervently to them and not do our own work of preparing for death. So then, so there’s this kind of over-medicalization of dying that I’ve experienced again and again and again in the hospital.
And then that is also related to questions my patients have asked me, existential questions you might say, these questions of human existence: “Why am I here? What is this life all about? I just got this terrible diagnosis. I know I’m dying. What is the meaning of life?” These sorts of questions patients have brought back time and time again into my primary care clinical office. And so through opportunities to talk with them and engage them in sort of interrogations of their own beliefs and what they read and what matters to them, I came around to combining those two, kind of the very practical—how do we use technology?—along with maybe the spiritual or the existential. And that’s what led to this book. So, long answer.
Cherie Harder: You mentioned just a few seconds ago the number of patients that you’ve had that have sort of lingered on indefinitely, when death was certain, but they were unwilling to let go. And in a way, you start your book out that way, too. You said, right at the outset, that dying well requires the recovery of a sense of finitude. And in many ways, this is a fairly countercultural assertion. I’m thinking about a lot of well-known tech tycoons who’ve invested literally billions of dollars trying to crack or even hack the code for our aging and our mortality or to freeze their brains so that in some way they can live on forever. In many ways that kind of approach is even valorized or admired, this sense of bravado, of knowing no limits. So I’m curious why you believe that the realization of our limits is the first and necessary step to dying well.
Lydia Dugdale: Yeah, great question. So this, the book that we’re sort of talking about today, was preceded by an academic book that is a collection of chapters where I got a group of really smart colleagues together to think through this question of what it would mean to die well. And part of that was looking at these various iterations over 500 years of the Ars moriendi and this body of literature—”art of dying” body of literature. And what was common to all of those iterations of these handbooks on dying well were two things, actually: this recognition, acknowledgement, of human finitude and the role of community in helping an individual prepare for death.
So why do we need finitude? Because if we’re going to do any work, we need to have the goal in mind. Right? So any project we undertake, we need to know what the end is of that project. And so if the project is, very matter-of-factly, preparing well to die, then we need to at least be able to name that we will die one day. And I’ll tell you, it amazes me the lengths to which we go as a society to avoid that. And so it’s not just the tech tycoons and the cryopreservation, these sort of freezing brains and freezing bodies in these super cold tanks in the hope that one day we’ll have a cure. So it’s not just that, but it’s sort of all of the ways that we are constantly remaking ourselves as individuals. And certainly the privilege and the affluence of the West underscores this theme that the new look, the new wardrobe, the new car, the new, new, new—it’s a constant remaking ourselves in a way to avoid thinking about our end. Right? And so that’s why, if we’re going to be talking very practically about how do we live well in order to die well, then we need to be able to name that we’re dying well.
And I’ll just say just briefly, many people are aware of the work on death and dying, I think from the 1970s, where they talk about the five stages of grief and that you have to come—the last stage of grief is coming to accept death. And I think specifically for Christians, our theology, the Christian theology about death, is one of paradox in many ways. Right? Death is overcome. That is what Christians celebrate on Easter Sunday. But death still has a sting. It still is bitter. It hurts. It rips a hole in the fabric of our lives. And so we hold in tension, or those who adhere to the Christian theology, hold in tension this idea that death has a sting but also is ultimately overcome. So we don’t need to accept death, but we need to start by acknowledging our finitude. And that’s why I kind of put that as the first plank in trying to revive an art of dying.
Cherie Harder: Well, your second point you just alluded to in that is the embrace of community. And it seems like there is a paradox there as well, in that, in many ways, suffering and death is an isolating process. You know, pain tends to isolate us from others. We don’t want to go out. We don’t have the energy to do that. Death itself is a solitary journey by its very nature. And so if the embrace of community is another vital plank in the Ars moriendi, to dying well, it means that others are going to have to surround the dying person. And I think almost all of us on this call most likely will have to care for someone who is dying before we die ourselves. So I wonder just both philosophically but also practically, as a doctor, how do we provide the encouragement and the relational care to bring community to someone who is dying so they can die well?
Lydia Dugdale: Yeah, so I tend to imagine three different levels of community, especially for my patients. The first level is that most intimate group. So an exercise that I give to my patients sometimes is this: “You know, you’re healthy now. That’s great. I’m so glad. So glad. But let’s just say you get to the point where you’re dying and you’re actually dying in bed. Who do you want to be surrounding you at your deathbed? And how are you investing in those relationships now?” So that’s sort of that most intimate ring of community, if you will. I gave a talk once and someone said to me, “Well, I know who I want to be at my deathbed. I just really can’t stand the people. And so could I wait until later in life to try to invest in those relationships?” And of course, it’s kind of a silly question, but think about it, right? If we invest in those relationships now, not only will they be stronger at the end of our lives, but there’ll be so much richer now. And for the time that we have remaining we’ll be able to enjoy those relationships so much more, the give and take of relationships. So family, whatever, close community. Sometimes people say to me, “Look, I’m kind of a loner. I like to be alone. There’s one person, maybe two people that I would put in that category.” That’s great. You know, we’re not talking about the whole village. There’s this wonderful book that’s a review of a thousand years of practices of dying in the West by a Frenchman, actually, Philippe Aries. I know there are people on this call from France. I’m sure I just butchered his name. But he has a wonderful review of practices of dying. And he talks about how there was a time in the Middle Ages when, if a person was dying, the village would be summoned and literally all the members of the village would parade past the deathbed. That’s overkill, right? We don’t want to go back to that. At the same time, identifying one or two people, investing in those relationships—absolutely critical.
But then the community moves out from there. Right? So some of my patients are very involved in religious communities or the senior center or, you know, a bridge club or something like that. So there’s sort of— in that next layer out, these might not be the people you want really in your business when you’re dying, but they are there to support. They’ll bring meals, they’ll help give rides. And some of this our kind of safety net system in the US has helped to provide. We have things like Meals on Wheels and different programs that will help meet the needs of older folks, particularly older folks, but also people with various kinds of impairments. And then the third level of community can often be, especially people with chronic medical diagnoses, that community of the health care team, which often increasingly includes not only the doctors and nurses, but also social workers and chaplains and care managers and kind of a whole team of people to help the person with this chronic or life-threatening illness to navigate living at home or getting to appointments and things like that. So there are these different levels of community that we can think of and invest in. And I think that’s, again, the second most fundamental task of preparing to live well in order to die well.
Cherie Harder: So you mentioned the parade of French villagers around the person who had just died. And while we may not want to go back to a parade around the dying, you do talk about the importance of ritual to help in dying well. And it seems like there’s already a number of rituals surrounding—certainly around health care and the pronunciation of death—but also around funerals in the care of the dying. But you’ve called for a reinvigoration of ritual. What rituals do you think we need to reinvigorate in order to encourage living and dying well?
Lydia Dugdale: So I have a chapter on ritual and it is not at all exhaustive, but in that chapter—and I’ll say, the book is not a religious book. It is a book that I wrote for my patients in order to help a broad audience think about their finitude and anticipate death and prepare. Having said that, I have a chapter on questions of spirituality and religion, and I have a chapter on ritual which pulls from not only secular rituals of the hospital, but also rituals from the the Western religious traditions, particularly from Christianity and Judaism. And what’s so fascinating about ritual is that it’s, well, for one, the work has been done. So there’s often the sense that in this modern era of having to reinvent ourselves and recreate everything, that we also need to write our own funerals, meaning we have to write the whole liturgy or we have to come up with all the— we have to sort of figure it all out ourselves. That work has been done and been done across religious and cultural traditions and is rich and deep and sort of attended to over thousands of years, so there’s so much from which we can draw.
But in the chapter in particular, I highlight a few things that were very provocative for me. So people often ask me, should we return to an open casket sort of across the board so that people are forced to kind of see death? And that’s a longer conversation. It has to do with whether you embalm and how quickly you bury, all of which— embalming is a pretty American thing. There’s so much to say about embalming. I’ll leave that. But prior to getting to sort of the open casket and the visitation, what about the dead body? So within Jewish communities, there’s a tradition of the chevra kadisha, which is groups of volunteers from within the Jewish community who agree to be trained especially in preparing the dead body for burial, which in the Jewish tradition tends to happen within 24 hours, and it has to do— the ritual itself includes three different levels of washing the body. The first level of washing the body is as if the body were still alive. So they use warm water and they only uncover the part of the body that they’re washing. And what was so fascinating to me when I was learning about this—this ritual is called tahara and I describe it in the book—is that the members of the Jewish community of the chevra kadisha would actually sing from the Hebrew book Song of Songs. They would sing the text to the body, a love song to the body, as they were washing it. I mean, think about the intimacy of that. The care of attending to the body of one’s own community in anticipation of laying that body to its final rest. I mean, it’s breathtaking.
But what do we do? I mean, most commonly in the US, Grandma dies and we call the undertaker and we call the funeral home. And I’m not— listen, I’ve never done this with a body. But it was for me, when I was learning about tahara, it was a challenge to me personally to think about how could we reimagine the care of a dead body even within our own communities? What is this wisdom? What are these traditions that we’ve lost, these rituals that have been written down and clarified? It’s there for us, right? And what does ritual do? It helps us navigate uncharted waters. So it gives us the foundation on which to stand when nothing is making sense. And of course, death does that. Death disrupts everything. So anyway, you know, again, I’m not speaking poorly of funeral homes or funeral directors at all. Please don’t misunderstand me. That is such important work. But I also am personally challenged to think about how we as communities, whether that’s religious communities or family units, could again care for our own dying and dead. So I’ll leave it at that.
Cherie Harder: No, that’s great. You know, I wanted to ask you about one of the, not just assertions, but in some ways an assumption of the book: a connection between living well and dying well. And you’ve said several times in the book that to die well, one needs to live well. But one can think of certain examples, both in real life, but also in literature, where perhaps the person had a life that was full of unmet potential or compromises or corruptions and yet had a death that seemed to be somewhat redemptive. One example of this is the character of Sydney Carton in A Tale of Two Cities who, you know, a bit of a wasted life, but a sacrificial and very redemptive death that— really evocative of a Christ figure. And so I guess I just wanted to get your thoughts on is that link between living well and dying well, in your view, inviolate, or are there ways where one can die well, even if one has been disappointed in their life?
Lydia Dugdale: That’s such a great question, and especially on Good Friday, right, because, I mean, the story that comes to mind—I haven’t read A Tale of Two Cities in so long—but the story that comes to mind for me is the thief on the cross. So for those who don’t know, Christ is crucified, which is what we remember on Good Friday, and he is hanging on a cross between two men who were criminals. And one turns to him and and essentially says, “You’re the son of God and I put my allegiance with you. Here we are. We’re hanging on the cross. We’re dying. But you are the one in whom I put my faith and my trust.” And Christ says to the thief, “Today you will be with me in paradise.” Now, theologians and I’m sure some on this call have all different ways of understanding that and explaining that. But the idea is that, for however corrupted this man’s life was, in his dying moment there is redemption. And that, I think, is really the story, the narrative, that undergirds the Christian story, which is that there is always the possibility of redemption. Now, having said that, whenever we’re setting out to do a task, we’re setting out on a pilgrimage. And even if that pilgrimage is ultimately to die well, the more we can prepare, I think the better off we’ll be. And certainly you could say, well, the thief on the cross or this character in A Tale of Two Cities, neither one had much occasion to live a very good life. And certainly that may be true. But the possibilities still remain for dying well. So it’s not that it’s impossible. But certainly with more preparation, you know, it often goes better.
Cherie Harder: There are so many more questions I could ask you, but before we turn it over to questions from our viewers, one I think that has to be asked is, you know, today is Good Friday and we mark the day in which our hope died, but it’s not the end of the story. And in two days, we will celebrate—we who are Christians—celebrate the triumph of the God who is love over death. And we’ll celebrate the fact that love won. And so just in our brief conversation, we talked about finitude and community and ritual. But it seems like we need to talk about the big Easter question. What does love have to do with it? How does love change, either inform or transform, our conception of dying well?
Lydia Dugdale: Yeah. So I know you told me you were going to ask me that right before this. And there are a lot of things to say about that. Maybe I’ll preface it by saying in the— going back to the earliest iterations of the Ars moriendi, these handbooks on the preparation for death, there were five virtues that were commonly espoused to help one die well, and they were in contrast to kind of five temptations to dying poorly, which is the way the writers of the booklets put it. But one of the virtues was the virtue of patience as a consolation to the temptation to impatience, the sense that I just want to die and get it over with. I’m just sick of the suffering. I just want to be done with it. And the Christian scriptures talk about how love is patient. And the way that we bear our suffering, the way that we bear our infirmity, is best done in the context of community that can help bear those burdens for us. And that is all undergirded by love. The theologian Alan Verhey, who was at Duke, died a few years ago. He has written a book on the theology of the Ars moriendi, and he talks about how this virtue of patience really is best understood as a virtue of love. So whether patience or love, certainly within the context of community, that is foundational and paves the way toward both living and dying better.
Cherie Harder: Thanks, Lydia. So we’re going to turn to questions from our viewers. And you can not only ask a question in the question section, which is at the lower center, slightly to the right. But you can also “like” a question and that helps us get an idea of what some of the most popular questions are. So for the next half hour, we’ll hear directly from you and your questions for Lydia. So with that, we’ll look just to see a few of the questions here. And I see several have already come in. Raymond Beasley asks, “What are the implications of so many having to die alone during the pandemic in the light of the wisdom of the Ars moriendi regarding the centrality of community in preparing us to die well?”
Lydia Dugdale: Thank you for that question. So I’m in New York City and I was taking care of Covid patients during the height of the pandemic here when it first really devastated New York City a year ago. And I have said again and again that this will go down as the greatest tragedy of the Covid pandemic, that by virtue of our policies, we forced people to die alone, cut off from community and their loved ones. Now, you could say, well, isn’t the worst part of the pandemic that people died? Well, yes, people died. We expect that in pandemic, even if we had worked out better how to address the pandemic. But I think in terms of tragedies, it’s really this policy-induced lonely dying. Cherie and I were talking yesterday about— I’ve actually been writing about this recently and I’ve been reading interview transcripts with individuals who lived in long-term care homes during the pandemic. And there is an elderly woman who lived in the same nursing facility as her elderly husband. But he was in a higher level of care. And she said at the time of the interview, “I haven’t seen him for 100 days.” One hundred days. And it just— these transcripts just break my heart. Was it important? I think initially it was; it was important to try to figure out how to thwart the disease. But goodness knows, we haven’t done a great job in the US at all. And we very quickly learned enough about the virus, I would say, within a couple of months to understand how it was spread and to understand that the N-95 masks were quite effective. And once we had enough masks, I really think that we should have changed the policies so that visitation and safe, socially distanced, whatever manner, could have been possible. So it’s a real tragedy, and I think it will go down as perhaps our greatest tragedy.
Cherie Harder: So I want to combine two questions from Jennifer Goodman and Joanna Lee. Jennifer Goodman asks, “How does euthanasia affect society in dying well?” And similarly, Joanna asks, “How does the concept of living and dying well apply to practices like act of voluntary euthanasia? And how should Christians respond to those type of practices?”
Lydia Dugdale: Yes. So this is something I also work on extensively. I’m a medical ethicist and this is a core issue in medical ethics. And it’s also— you know, euthanasia and physician-assisted suicide are— there’s a movement worldwide to legalize them. I mean, just in the last few weeks, several countries have actually legalized them, expanded in Australia, etc, etc, expanded in Canada, expanded in the United States. So there’s a lot of momentum to give people this choice. And the logic for it is primarily twofold, right: that it’s my body, my choice. So there’s this idea in which individual self-determination or you might say individual autonomy or right over one’s own body leads to the possibility of making one’s self dead when one is ready to die. Right? So there is a logic there. So autonomy is one argument. And the other argument is suffering. That if my suffering is so great, I should be allowed to end my life.
And yeah, there’s so much to say about this, but I will say a couple of things. Certainly within the Christian tradition and the Jewish tradition—actually, in most of the major world religions—there’s a prohibition on killing. So it’s easy to make, in some ways, a religious argument against it. Where it becomes a little bit more complicated is to make a non-religious argument against it. And here I think that we all do best to consider the impact of legalization of these activities on vulnerable populations, the uneducated, the elderly, those with dementia, those with disabilities who already regularly face discrimination in the health care system. There’s so many patients—I’m sure there are folks on this call—but so many people who live with chronic disabilities know that when they go into the hospital, doctors are constantly asking them, “Are you sure you want this? Don’t you just kind of want to go home and die?” There’s this idea of doctors having a sense—and I say this as a practicing physician—of what is health, of what is a quality of life. And it often comports with our own health and quality of life, whereas folks with all different kinds of impairments who have lived well with those know that it takes a different kind of orientation but it’s not a death sentence to have a disability of various kinds.
So I think, whether religious or not, probably the strongest arguments in opposition to euthanasia, which is the direct killing— OK, to distinguish the two: euthanasia is typically injection of the patient in order to make that patient dead. It is done at the patient’s request typically. Nowhere in the world is it legal to euthanize a patient against his or her wishes, although it does happen and actually the Netherlands and Belgium both report, they actually report cases of involuntary euthanasia, which defies the imagination, but they do. And then physician-assisted suicide—or it goes by a bunch of different names—but that’s where a doctor or increasingly a nurse will give a prescription for a lethal drug, which the patient can then take when he or she is ready to end the life.
So, yeah, a really complicated issue. I think the other way— you know, as a physician, I’m absolutely opposed, although increasingly my colleagues are in favor by the same logic of a right to self-determination and suffering. I guess on the suffering piece, I’ll just say very quickly, most people think of the need to euthanize or take lethal drugs because the pain will be too great. But when we look at the data from Oregon and Washington, the two states in the United States that have the most cases and the longest history of legalization of physician-assisted suicide, pain is actually not the number one reason. It’s actually almost— it’s way down the list in terms of the reason why patients are seeking lethal drugs. We actually are pretty good at managing pain. There’s almost no pain we can’t manage now. But about 90 percent of people who seek lethal drugs to end their lives in Oregon and Washington do so because of a loss of autonomy, a fear of becoming dependent, a fear of not being able to do the things that give their lives meaning, and therefore they want the right to just exit. But I don’t think this is what you want your doctors to be involved in. I suppose as a society, as a global society, if this is something that we uniformly want access to and people are going to vote for it, then I don’t think you want your physician or your nurse to be the agent of death. So just a few thoughts on that.
Cherie Harder: I want to combine two questions from viewers who are asking about helping friends with different convictions prepare for death. So Jennifer Cromarty, asks, “How can we help members of the Christian community move from fervent prayers for healing to preparing for death and for heaven?” And in contrast, Richard Reeves asks, “It seems like those who struggle most are the spiritual but not religious. Perhaps in some ways the worst of all worlds. All of the uncertainty, but none of the ritual. Is that your experience? And if so, how can we best help that group, who may be the fastest growing segment of the population?”
Lydia Dugdale: Is the fastest growing, I think, in the US, but not in much of the world. I’m going to go to your first question first, which is a point I meant to make earlier. There are some colleagues up at Harvard have done a study, actually a number of studies, that show that people who describe themselves as highly supported by their religious communities are much more likely to die in the intensive care unit on life-extending or you might say death-delaying technology—so kind of hooked up to tubes and machines that aren’t going to do any good ultimately—and to refuse hospice. Right. So kind of strange that— and in their study, which was in Boston area, it was mostly Christians who were the group that described themselves as highly supported by their religious communities. But here we are, the same group of people that supposedly believes in life after death, believes in a resurrected body, a new body, right? This is the same group of people that also is refusing to give up on the machines. It’s a little kooky. And so it does create some difficulty, and part of that—so they did a follow-up study: “why is this?”—and part of that is probably a belief in miracles. They actually asked clergy people how they counsel their parishioners about end-of-life matters. And it turns out that the clergy far overestimated the benefits of particular medical interventions. And partly they just didn’t have that much experience in the hospital and they didn’t really know what this technology would do. But also, there was this desire on the part of the clergy to encourage the faithful not to give up hope. Right. “We don’t want to take hope away, so maybe this will work. Maybe this was a little bit better today.” You know, there’s like all these little— You know, the patient is dying. The patient is clearly not going to recover. But we fixate on these little markers, this one lab value. All the lab values are terrible, but one is a little bit better, and we fixate on that. But really to the detriment of a patient, sort of in many ways dying free of the apparatus of the hospital.
So it’s tricky. We have a belief in miracles. Well, I should say religious people tend to have a belief in miracles. The clergy don’t want to take away hope. Doctors have their own anxiety about death, right? So it’s not– just because doctors deal with death all the time, doesn’t mean they’ve worked out their own existential questions. I have a colleague who has told me, “I don’t know why you write about death. I never tell my patients that they’re dying.” I think, “What? A patient is dying! He’s received a terminal diagnosis. You’re not going to tell him what that means?” But she has so much, my colleague has so much of her own anxiety about death that she doesn’t go there with her patients. So imperfect humans in an imperfect system. But that complicates things.
So what can we do, right? So what can we do? And particularly for those on this call who are embedded in religious communities, live within the context of religious communities, you can start many different ways. But I think a personal practice is read some funeral liturgy, like read the Catholic liturgy, go to the Book of Common Prayer. I mean, just read how have people made sense of death and funerals and burials. Think about the hymns or the songs that you would want sung at your own funeral or the passages. Now, some of these liturgies have prescribed passages. Others give a little bit more freedom. What texts speak to you? Who would you want to read those texts? Who would you want to speak? I mean, this is just kind of a personal exercise. I actually had to do this when I was in divinity school at Yale. Thanks to Yale for their support of this program today. And it was such a fantastic exercise to think about. I mean, reading the text of old hymns, of old funeral hymns, it’s profound. But then this is also a project, an exercise, that could be done in the context of a religious community where—I already mentioned tahara and the actual preparing the body—but where this is something that religious leaders or lay leaders in a church context could invite the community to a Saturday morning sort of exercise of working through this type of thing. And really, this is an activity that needs to be repeated. In some ways Lent and Good Friday is actually, it’s the perfect season to address these matters as a congregation.
But, yeah—Cherie, I didn’t write down your second question.
Cherie Harder: Our second question came from Richard Reeves, and he was asking about the group who call themselves “spiritual but not religious,” who in many ways seem to have the worst of all worlds, and whether you had any thoughts about essentially trying to aid that group in their dying well.
Lydia Dugdale: Yeah. So, you know, most of my medical practice has been in Connecticut. And I would say it’s not a particularly religious existence in New Haven, Connecticut. And then now I’m in New York City, which is probably summarized the same way. So what’s fascinating is that whether people are within a religious community—or just because people are in a religious community doesn’t mean they’ve got this stuff worked out either, right? On some level, we are all working through these questions of human existence, of why are we here? What happens when we die? What do I believe? And so on some level, the conversation, the questions that I ask as a doctor—now, I will say, I don’t bring this up to my patients. But when patients come in to me and say, “This is the bad news and I’m freaked out and I don’t know what I believe,” which has come up more times than you would think. Everything comes to the primary care doctor, everything. So this is definitely one of those questions. Then I feel like my role is to sort of ask questions back to them. And a lot of people who are spiritual but not religious have some sort of a deeper foundation that they may or may not have really tapped into. But it’s not a far stretch to go from spiritual but not religious to religious. But again, I just reiterate that just because people call themselves religious doesn’t mean they’ve worked through this either.
Cherie Harder: So our next question comes from Wilda Brady. And Wilda asks, “Could you discuss forgiveness as a condition of dying well?”
Lydia Dugdale: I love that. I have been criticized for being Pollyanna-ish about the possibility of reconciliation at the deathbed or at the bed of a dying individual. At the same time, as a doctor, I’ve seen so many occasions where families have come together, have overcome past grievances, even if it’s temporary, even if it’s not perfectly overcome or perfectly resolved. But there is a way in which forgiveness and reconciliation can feature to die well. There are a lot of examples of this throughout history. I’ll just say briefly that the Methodist, which was an offshoot of the Church of England in the 1700s, the Methodists really fixated on dying well, and particularly the last words. It became very fashionable for a time in Methodism in the 1700s and 1800s to record what they called bibliographies of the dying. And this is not your standard obituary, which is basically a rehearsing of somebody’s resume or CV and all their wonderful accomplishments. But this was really, how did they manage their dying, and what was the last thing they said? And they published these in newsletters for their church and circulated them and studied them so that they would get ideas of how to die well. Now this, I think, is problematic for many reasons. It puts a lot of pressure on people to get their last words right, which, you know, I mean, that’s— And just because you say the right thing doesn’t necessarily mean it reflects on a life well-lived or on certain religious or spiritual convictions or even on reconciliation or forgiveness. At the same time, it’s an interesting exercise, again, to— as we read about how others die, to think about what we need to change or do differently, with whom do we need to reconcile in order to die well.
Cherie Harder: So I’m going to, again, combine a few questions, because we’ve had quite a few from Kathy Comp and from others on how to handle tragic, unexpected, sudden deaths, including the death of a child, and whether there are rituals or practices that help one walk through, essentially experience or grow through, the death of someone who, by all means, shouldn’t have died.
Lydia Dugdale: Yeah. So one of the reasons that I love the Ars moriendi, this “art of dying” body of literature, is because when we keep the possibility of our finitude always before us, it makes an untimely death a little bit less shocking. It’s always a tragedy. It’s always a tragedy. But so, as an example, I’ve been living in Manhattan in this tiny apartment for the last year through the pandemic—two kids, my spouse—and I’ve been taking care of Covid patients. And from the very beginning of the pandemic, I said to my children and my husband, “You know, it is highly likely that we will get to the other side of the pandemic and we won’t all be alive.” That’s the reality of this sort of a virus, and I think probably everyone on this call knows either someone who had Covid or someone who died. I have personally lost family members and I’ve personally lost patients. So we have held that. That’s been a part of our conversation. And when my pre-adolescent girls are fighting, which is not infrequent, we pull them back into that narrative that actually our days are numbered. We don’t know the number of our days, but why don’t we turn these days rather from struggle? Let’s turn them from struggle and fighting into days where we really grow as a family and enjoy these days together and sharpen one another as iron sharpens iron. So that’s what I do like about the Ars moriendi is it’s this keeping finitude ever in focus and even preparing. And the preparing is meant to be done over the course of a lifetime. Again, this isn’t “let’s just wait until we’re really old and we’ve got nothing else to do and then we’ll sort of sort out our mortality stuff.” But this is the work to do now. This is the work that I do with my children now, with my husband now, with my patients now, with a view to the end game, really.
Cherie Harder: We have far more questions than we have time. And there’s so many great questions. But we’ll take one from Alberto Cole and Alberto asks, “How do you strike a balance between living in the joy of the resurrection while acknowledging the sad and the tragic reality of death? After all, Jesus wept when he heard of Lazarus’s death before he raised him from the dead.”
Lydia Dugdale: That’s right. That’s right. I actually have that— I have that in my book, that particular scene. I think the Christian life is a life of tension, right? I mean, we’re here and we are supposed to be, you know, as in Babylon, building homes and planting gardens and investing in the good of this city. And yet this city isn’t our home. Right? We have the hope of Easter Sunday and we are stuck in Good Friday. And actually, more often than not, it feels like Good Friday, especially in my line of work. There’s so much tension. I think this is what the Book of Ecclesiastes captures very well, right: “For everything there is a season.” And I guess my encouragement would be not to overlook or fast-track through the weeping and the mourning in order to hang out in the joy. And maybe that’s the greater temptation in the West particularly, where we try to paper over tragedy. We probably need to spend a little bit more time sitting low, to use the language of the the Jewish tradition of shivah, sitting shivah, the seven days after death from burial, seven days of just sitting low and mourning. We probably need to do a little bit more of that, to sort of keep that balance. But I also don’t know that balance— it’s not like we can fill out a score card and have it perfectly balanced. But we do need to sort of attend to not rushing past one to get to the other.
Cherie Harder: Lydia, thank you so much. In just a moment, I’m going to give you the last word. We talked about last words—no pressure. But I want to end with you, final thoughts from you. But before that, I want to share just a few things with our viewers. Immediately after we conclude, we’ll be sending around a survey or feedback form to each of you. We’d really appreciate and love to have your thoughts. We read every one. We take it in mind and we try to use it to continually enhance the value of these conversations. And as a special incentive or thank you for you to do that, we’ll send you a code that you could have a download of the free Trinity Forum digital reading of your choice. So we encourage you to take advantage of that. In addition, we’ll be sending around tomorrow a video link of today’s conversation that you can share with your friends or loved ones to start important conversations of your own. We’ll also include different readings and resources to kind of further give context and depth to the conversation today in case you want to go further and would just commend that to you. So that will be coming around tomorrow, probably in the early afternoon. Also, just want to encourage everyone to check out our other Online Conversations. As I mentioned earlier, this is actually our fortieth such Online Conversation since the pandemic started. And we have covered topics ranging from polarization to poetry, the redemption of shame, conspiracy theories to culture care. So there’s quite a variety of topics that have been covered, and all of those are available on our website at www.ttf.org.
In addition, we would love for you to get involved with the Trinity Forum Society, which is the membership society that makes programs like this possible. Your support through that society helps us carry out our mission. It also connects you to a community who cares about conversations and big questions like this. And there are also several benefits of being involved in the Trinity Forum Society, including a subscription to our quarterly Trinity Forum Readings, which takes the best of literature and letters, adds an introduction giving context and background, discussion questions in the back. So that’s essentially a book club in a bag. Coming out in the next 10 days is our selections from Pride and Prejudice, which we would commend to you, and as a special incentive for anyone who either joins today or with your contribution of $100 or more, we will send you a signed copy of Lydia’s book on dying well, The Lost Art of Dying. And we really commend that to you.
In addition, next Friday on April 9th, we’ll be hosting another Online Conversation entitled “All the Lonely People: Isolation, Connection, and the Common Good” with Ryan Streeter and Francie Broghammer, in partnership with the Pepperdine School of Public Policy. You’ll be able to register on the link provided in the chat feature and would love for you to join us next week. And with that, as promised, the last word to you, Lydia.
Lydia Dugdale: Thank you. Well, thank you so much to everyone. I’ll just say it has been tremendous and tremendously difficult year for everyone across the globe. And there’s a temptation to think that as hopefully the pandemic starts to wind down, hopefully, and the vaccines become more available, that those of us who make it to the other side are home free. But mortality is 100 percent. And if it’s not pandemic, it’ll be something else. And we’re not a people without hope. So I encourage you to take this season to think well and think hard about dying well and then to work backwards toward your living, to examine how you might live well today and for all of the days that remain. Thanks again.
Cherie Harder: Thanks so much, Lydia. Thank you to all of you for joining us. Have a good Friday and a joyful Easter.