By Timothy Cahill ’16 M.A.R.
It was late March, and the governor had ordered us to stay home. But my family needed milk, and my daughter needed a walk. So here we were, traversing the valley of the shadow of death in search of essentials. … We are new New Yorkers, having arrived last summer for my work in medicine and ethics—two disciplines with sudden relevance. From urgent meetings about ventilator allocation, to redeploying clinicians to care for desperately ill patients, my work never stopped. Yet in the words of Seamus Heaney, “There was no sense of what to anticipate.” The wail of death was the only certainty.
—L.S. Dugdale, “From Sirens to Song”
Three years ago, when Lydia Dugdale ’18 M.A.R. began writing her new book, The Lost Art of Dying: Reviving Forgotten Wisdom, the physician, bioethicist, and Yale Divinity School graduate never imagined its publication in a world beset by COVID-19. Dugdale had set out to revive a medieval treatise on “dying well,” gathering intelligence from an age made grimly intimate with death during the Black Plague. Had her book appeared at any other time, its subject would have seemed more timeless than timely. At this fraught moment, however, with a deadly virus pushing the worldwide death toll toward one million victims, Dugdale’s work could not feel more uncanny and necessary.
Dugdale began to examine modern attitudes toward death a decade ago, while completing a medical residency at Yale New Haven Hospital. Though she had seen the pain and hardship endured by the poor around the globe, it wasn’t until the young doctor was working at an advanced American hospital that she witnessed what struck her as suffering at its most intense—induced, paradoxically, by the very technology designed to save lives.
The methods used by modern medicine to prolong life, and the lonely deaths patients can experience in the grip of these advanced treatments, compelled Dugdale to explore how individuals and society might improve the American way of death. Her inquiries eventually led her to the Tractatus artis bene moriendi, or “Treatise on the Art of Dying Well,” an anonymous 1415 instruction manual on care for the dying. As its title suggests, the treatise presents preparation for death as something one can perfect through attention, study, and practice.
The Tractatus became the prototype for a genre of texts called ars moriendi, the “art of death” in Dugdale’s title. Ars moriendi were in steady use among physicians and churchmen from the fifteenth to nineteenth centuries. These manuals “ignored the question of whether death is good or bad,” she writes in her book. Rather, they taught that “in order to die well, you must take mortality into account, even when death seems a long way off.”
In reviving the ancient wisdom, Dugdale was taking aim at our modern illusion that the right balance of diet, exercise, pharmaceuticals, and plastic surgery can prolong life indefinitely. “You can push back against death and still die well,” she insists. “But you cannot ignore death.”
Equal parts history, anecdote, exegesis, and argument, The Lost Art of Dying is an ars moriendi for the twenty-first century. It opens with a meditation on “finitude” and the physical and metaphysical mysteries of our mortal impermanence, and goes on to describe how “dying well” is impacted by various forces, including community, fear, the body, spirituality, and ritual. The book concludes with an essay on the “unseemly inspiration” of the ars moriendi and how its focus on death, paradoxically, adds to the richness of life.
Veritas Forum video: Lydia Dugdale discusses the lost art of dying
Dugdale was born in 1977 and came of age in and around Kalamazoo, Michigan. During the 1980s, she saw layoffs, plant closings, and globalization bring a protracted recession to the region and press hard times on numerous families, including her own. Despite the downturn, she was able to fulfill a teen-age yen to travel with the help of her uncle, who as a baggage handler for a major airline was eligible to buy airfare for next to nothing.
While still in high school, then, Dugdale was “able to see the world a little bit.” She didn’t go the usual tourist route. Instead, guided by a sense of empathy for others, she traveled to developing countries to acquaint herself with their lives and struggles. The experience guided her life path. “Even if I felt poor relative to my peers,” she says of her family life, “I saw real poverty on those trips abroad.”
As an undergraduate at American University, Dugdale majored in International Relations and spent summers in clinics and rural orphanages from Haiti to Russia. She was preparing for a career in international relief until a mentor suggested she consider a career in medicine. Not entirely convinced, Dugdale discovered that Harvard offered an affordable pre-med program through its extension school. She did so well in her coursework that Harvard sponsored her application to the University of Chicago’s Pritzker School of Medicine.
At Chicago, however, Dugdale battled the tedium of med school’s heavy doses of basic science. “Even though I knew I was where I was supposed to be,” she recalls, “I would sometimes think, ‘Oh, my goodness, what have I done?’”
“Then I found medical ethics,” she says, “and I thought, this is it.”
Ethics transported Dugdale to a realm of “thoughtful reasoning about questions of life and death, with people who examine … right and wrong in a context of suffering.” Philosophy refined her career path, from advocating for the “global poor” to addressing questions of “suffering in general.”
After Chicago, Dugdale completed a three-year residency at Yale School of Medicine, then joined its faculty as assistant professor and primary-care doctor. During her fifth year on the faculty, she was appointed Associate Director of the newly created Yale Program for Biomedical Ethics, a post she held from 2014 to 2019. In this capacity, she also co-founded the Yale Program for Medicine, Spirituality, and Religion with Dr. Benjamin Doolittle ’91, ’94 MDiv., ’97 MD, organizing a series of multi-faith talks at the Medical School.
At Yale, Dugdale began her study of the ars moriendi, eventually serving as general editor of the 2015 volume Dying in the Twenty-First Century: Toward a New Ethical Framework for the Art of Dying Well. To fund the work, she applied for a grant from the John Templeton Foundation, a philanthropy located at the intersection of science, religion, and ethics. The foundation supported her application, but with an unexpected string attached.
“Templeton said to me, ‘The selection committee was unanimous, you have to go to divinity school during this grant.’ I said, ‘What?” and they said, ‘We are going to give you [additional] money to offset your educational expenses because you need to go to divinity school.’”
The stipulation wasn’t all that unlikely. As a doctor working in a secular academic setting, Dugdale is circumspect about her faith life, but her work is deeply influenced by her religious convictions. The intellectual milieu of Yale Divinity School was a natural fit. She earned an M.A.R. in Ethics over eight semesters, while working full time at the School of Medicine and caring for her young family.
Dugdale contracted with a publisher to write The Lost Art of Dying while still at YDS and completed a first draft of the manuscript as a thesis project there. Jennifer Herdt, Senior Associate Dean of Academic Affairs and Gilbert L. Stark Professor of Christian Ethics, served as thesis advisor.
Dugdale “had wonderful instincts about how to write the book,” Herdt recalls. “She approaches her work as a healer, and firmly believes that there are ways of facing the truth that build community.” The book, “doesn’t come from a place of judgment but one of deep empathy for people and for the suffering that comes from denial.”
Dugdale made an immediate impression on the dean and ethics professor. “From the beginning, she struck me as a person of great intensity,” Herdt recalls. “She really listens. She’s one hundred percent present and wants to make every moment count.”
Templeton’s nudge toward divinity school was obviously the right one for Dugdale. Papers she produced for classes were adapted for the book, and a quarter of those named in her acknowledgements are YDS faculty. One, poet and professor Christian Wiman, is quoted at length in the chapter titled “Fear.”
YDS “more fully equipped Lydia to do what she was called to do,” Herdt observes. Dugdale agrees. “Some part of the richness of my book is because I went to divinity school,” she says. “No question.”
In 2019, Dugdale left Yale to found the Center for Clinical Medical Ethics at Columbia University’s medical school. In less than a year, having traded a home in New Haven for a small apartment on Manhattan’s Upper West Side, she and her family found themselves in the epicenter of America’s COVID crisis. She described the experience in the August 2020 issue of First Things:
“By the second week of May, the morgues in New York City were full,” she writes. “Sirens still whined past my windows—four sirens in the space of an hour.”
As ambulances filled the empty canyons, they echoed in the doctor’s mind with the song of poems, prayers, and psalms. Amid the chaos, she observed first-hand that “as we seek to accompany the sick and face our own mortality, art remains indispensable” to “rescue truth and beauty from the catastrophe of history.”
She had sent the First Things essay to me after a long telephone conversation we’d had in early August, as a follow-up to themes we’d touched on during our talk. The interview below, drawn from that conversation, was edited for length and clarity by the author in collaboration with Dugdale.
Timothy Cahill: Why was it important to you to write this book?
Lydia Dugdale: I lay out a story in the first chapter that explains a pervasive problem, which is that so many of our patients die in highly medicalized settings and are not at all prepared for death, and that their family members are often left unhappy with the way they died. Patients who’ve been in these settings sometimes say they never want to be there again. I wrote the book after seeing so much misery related to dying, with the thought, “There must be a way to do this better.” So many physicians either are not able to take the time to carefully talk through preparations for death with their patients, or are unwilling, perhaps because of their own existential angst or death anxiety. The best way to help patients, then, is to empower them. When I discovered the ars moriendi, I thought, “This is incredible. This truly is the handbook for patient empowerment. It gives people the resources that they need to be able to navigate their aging and dying.”
TC: It’s amazing to think that all the while you were writing the book and going through various rounds of editing and fact-checking, COVID-19 didn’t exist—
LD: That’s right.
TC: —and by the time it was published, we were in the midst of a pandemic, with more than 185,000 American deaths. If I had read your book under “normal” circumstances, I’m sure I would have greeted it more abstractly, with a layer of protective critical distance. But now it feels as urgent and unsettling as today’s headlines.
LD: I’ve thought there’s no way that my book coming out now would work. People just can’t think about death. They’re so overwhelmed. I have a sense that many people are not ready to go there.
TC: But that’s a big part of the book’s urgency. This moment we’re in—it’s all so sad and confusing. How do we process all those people dying alone in ICUs? How can we get people to take the threat seriously, when some percentage of the population won’t even wear masks? Death is dancing all around us and a third of the country is in denial.
LD: That’s absolutely right—mass denial, the denial of death, when it’s staring us all in the face.
TC: You write at length about what you call “dying well” and the importance of community to the process. To me, some of the most poignant parts of the book are when you write, “rare is the person who dies alone and dies well” and, later, “ars moriendi was never intended to be practiced by an individual in isolation.” I can’t help thinking about all those people alone on ventilators, isolated from family, friends, and community.
LD: When I wrote that, I was describing “lonely dying,” those who die in total isolation, where nobody knows that they’re dead and nobody can tend to them. That’s the worst. And there are patients for whom we cannot find any family member or friend or anyone who will come to the hospital and visit, and there he or she lays dying. And now COVID, oh my goodness, lots of such people dying in the ICU.
TC: You discuss the importance of rituals, both before and after death, to give comfort to the dying, to honor their memory, and console and instruct the living. But such rituals are often not possible now. What do you think death has become during the Coronavirus?
LD: Ritual provides order in chaos, but now, in this extreme season of chaos, we often have very little semblance of ritual because of the inability to gather. I know people who have buried a loved one during this time, and it’s meant very small gatherings, fewer than ten, socially distanced. That prevents the larger community from the corporate practice of mourning, which is going to be hard on the community in the long run. At the hospital here, we have had a number of evening memorial services to remember those who have died, both within our community and outside it. I think if we had had something like that on a national level, it would have given us an opportunity for healing the national soul. Why not a national day of mourning? It wouldn’t have been that difficult to do, and it would have gone a long way toward bearing one another’s burdens and shouldering one another’s grief.
TC: You write about an 86-year-old woman who became difficult and argumentative with the hospital staff. Her health was rapidly failing, and you came to understand that the friction was a symptom of existential crisis, her fear at not knowing how to make sense of her death. How were you able to help her?
LD: Doctors typically don’t want to go into those questions with patients, because there’s no quick fix—no pill to prescribe. I’m not a psychiatrist, but so many patients come in with stuff they just want to talk about, and they don’t have anyone else to turn to. They just want to be able to talk through their anxieties. So, starting from a posture of humility, I know I can’t fix things for them, I’m not a savior, but I can come alongside and walk with this person, I can listen, I can promise not to abandon him or her. Now with the case of the woman in the book, she started to open up a little bit. I learned that she was a fighter and had made her own way, and I came to realize that she was anxious about dying, so we started to get into that. But she ended up declining so quickly we weren’t able to go very deep.
TC: In the book, she says to you, “What happens when I die? I don’t know what I believe.” And you observe that a lot of people are like her. They don’t know if they believe in an afterlife, or what it might look like, and are completely unprepared.
LD: That’s the whole spirit of the ars moriendi, the idea that preparation for death occurs over the course of a lifetime. It’s never too early to start having these conversations in the context of family and community. What do we believe about living and dying? What happens when we die? What is life for?
Figuring out what you believe about this existential stuff takes work, and one of the things that the ars moriendi did was have people rehearsing their story, their common narrative, since youth, which means they had a lot of time to do that work. It meant they were able to do it when they had more energy and their faculties were intact. Today, many people only think about these questions as they get older, in their 70s and 80s. But sometimes that’s too late, not just physically, but also because it does take a commitment to thinking and reading and talking and engaging. People who are older, or suffering a life-threatening illness, may not have the energy for it. People who are committed to wrestling with questions of meaning and purpose should be able to do that no matter their age. But it is a commitment that requires effort and time.
TC: Reading The Lost Art of Dying, I continually found myself thinking about how the modern world, for all its progress, seems bent on stripping us of belief in the soul. Yet it offers no replacement to console us in death. Do you agree?
LD: I do. I write about a conversation I had with a professor colleague who made an offhand comment about “all that religion nonsense.” I found myself thinking, “Are you kidding? I’m taking care of dying patients, of course religion matters. Of course it does.” It may not matter for everyone, but it matters for a lot of people, and the closer death comes, the more it matters for many, many people.
Timothy Cahill ‘16 M.A.R. writes on religion and art. His forthcoming book is titled Selling Norman Rockwell: Art, Money, and the Soul of an American Museum.