Living Well and Dying Well: Practical Wisdom from the Christian Tradition with Dr. Lydia Dugdale

For those of you who’ve been here before, you’re probably expecting to see Cherie Harder, our president and CEO. She is on a much deserved sabbatical. She’ll be back in the fall, but she is enjoying some R&R, to which she is very much entitled. For those of you, if you’re first time with us, the Trinity Forum works to keep the Christian intellectual tradition alive. We want to nurture new growth in it for our time and make it available to everyone, and that’s why we’re here tonight. We’re thankful for all of you that have sustained the partnership with Trinity to allow us to do this. We’ve been here for over 13 years in Nashville and that partnership is due in no small part to MBA and Saint Paul, and we couldn’t really do this without them. We’re also very thankful for all of our sponsors who make events like this possible. I’m going to list them out: Lee and Mary Barfield, David and Janet Chestnut, Kevin and Jessica Douglas, David and Ashley Edwards, Jon and Laura Foster, Bill and Elizabeth Hawkins, Alan and Gretchen Horner, Ed and Molly Powell, Clay and Amy Richards, Gif and Anna Thornton, Chris and Eleanor Wells, The Charis Foundation. And then also, somewhat awkwardly, my law firm: Sims | Funk. And you’ll see in your seat those names are printed on a note card like this that’s in your seat, but on the back there’s a QR code, and the QR code is, if you click on that, that’ll allow you to join the Trinity Forum society. And that’s our group of supporters, who received lots of emails and information from us, readings and the like. And we just encourage each of you to take a look at that and consider joining us to support the work we’re doing.

On a housekeeping note, tonight’s event and frankly, all of our events are posted online on YouTube. So if you have friends that couldn’t be here tonight or you want to share this content with them, it’ll be up in the next day or two on the Trinity Forum YouTube site, so I encourage you to share it with them. You can also see lots of our prior presentations as well, as well as other programs we’ve done in DC and other areas across the country. With that, let me introduce our speaker for this evening. Dr. Lydia Dugdale is a professor of medicine and a director of the Center for Clinical Medical Ethics at Columbia University. Prior to her move to Columbia in 2019, Lydia was associate director of the Program for Biomedical Ethics and a founding co-director of the Program for Medicine, Spirituality and Religion at Yale School of Medicine. She is an internal medicine primary care doctor and a medical ethicist. She focuses on end of life issues, the role of aesthetics and teaching ethics, moral injury, and the doctor patient relationship. And tonight her presentation is going to draw from her book, The Lost Art of Dying: Reviving Forgotten Wisdom. And on a personal note, my wife Betsy and I met Lydia about a year ago, and we’ve connected with her several times, and we’ve just been so impressed with her thoughtfulness, her scholarship and her insight. And we’re just so excited to have her here in Nashville to talk about this fascinating and important topic. After Lydia’s remarks, Will Norton of Saint Paul is going to kick off our question and answer. We’ll ask the first question, then we’ll make it open to everybody who’s got questions for Lydia. So with that, Lydia, welcome.

Thank you.

Good evening. It’s really lovely to be here back in Nashville. It’s so green here. Really beautiful. Great to fly in this afternoon. And also, I noticed, this is not in my remarks, the age of the room is very distinguished. And so I’m delighted by that. But I, you know, do share this content with your younger family members because it’s relevant. So the Trinity Forum gave me this title, Living Well and Dying Well. And I know that the sort of latter half of it might be a little bit difficult to stomach for some of you. So I want to assure you that you are in the right place tonight. First of all, quick scan of the room, you are all alive. So, at least for the living part, you’re doing well. And now I’m going to just give you a little bit of data. Let’s see here. Is that okay? This you might notice is old data. It’s from 2023. But it does suggest that the dying portion is relevant to all of us as well. The lifetime risk of death is in fact 100%. So living well and dying well, then, are equally important. And I just want to assure you, you are in the right place. You all, I’m sure, have heard the famous quotation from Benjamin Franklin that in the world nothing can be said to be certain but death and taxes, right? Well, we know that taxes are optional these days, so it’s really just death, right? It’s just death.

So I’m so glad that you’re here. Now, the problem with a conversation on living well and dying well is that I think most of us would rather discuss the first half and leave the second half until, well, later. Who doesn’t want to live well? But we are known to be procrastinators, are we not? And so, speaking of procrastination, I have one more highly scientific slide for you. This is a map of states where residents tend to procrastinate the most. Now green states procrastinate the least and dark orange procrastinate the most. I had no part in this study. I got this from the internet. If you ask me, I would think the white states actually should be the biggest procrastinators because they didn’t even bother to turn in the survey, right? Now you’ll notice where Tennessee is. Let me see. Can you see my pointer here? Okay, Tennessee. Well, you know where Tennessee is. And I didn’t even have to look at a map to find it either. So Tennessee is orange. You all are procrastinators. This very famous study gives you a procrastination score of about 89%. Now, I’m not picking on you, and I want you to know I’m not picking on you because I’m from New York State. Currently, we are equally procrastinators and I grew up in Michigan, even more procrastination in Michigan. So we’re in good company.

In the interest of transparency, I will say that this study was actually performed by people who run a gaming website. I contacted them and asked for permission to use this graph, and they told me, could you please mention the name of our gaming website? And so you’ll see they’re solitaire.com. You too, you too, can play Solitaire online. Now I have no idea how many people they surveyed or whether the results are valid, but the gamers do say this in describing their study, and this is a quote: One tip for overcoming procrastination is to reward yourself for accomplishments. So the next time you tackle a task, try rewarding yourself with a mentally stimulating game. I come tonight bearing no mentally stimulating games, but I do hope the conversation will be mentally stimulating, and I think with these sort of preliminary remarks, now that we’re all comfortable talking about death, we’re going to dive in. And since we know this is a room full of procrastinators, myself included, I propose that we actually start with dying well and then move to living well, so we get the uncomfortable stuff out of the way. All right. So, most people, for most of history have paid serious attention to questions of dying. Why is this? Well, there are really two reasons that I can come up with. First, mortality has been extraordinarily high for most of human history. If you think about it, there’s plague, there’s famine, there’s war.

One statistic, not to bore you with too many, in 1800, about half of children died before the age of five. Now it’s less than 1% of children die. Right. So these are numbers that are really, really difficult to imagine. But the second reason that most people have thought about dying and death over the years is that for most of history, we’ve lived with an enchanted view of the world. Belief in God or the gods was ubiquitous. There was no attempt to explain away mystery with rationality. There was no Freud, no silo building social media, no institutionalization of death and no secularity. So we’ve lived in eras before, I would say the last 100 years, where talking about death and thinking about it was just common. We had not yet cultivated the squeamishness that we often feel when we think about death. And if you look, I’m not going to give you an extensive survey, but if you just look going back, what do we have? We see, well, in 2400 B.C., there were early funerary texts that were developed into the Egyptian Book of the Dead. About 1500 B.C. we have the death of the Hebrew patriarch Jacob. And what does Jacob do? Genesis 49 and 50. What does he do before he dies? He calls all of his sons together, blesses them, and then gives very, very specific instructions for how he will be buried. In the second and first century, before the common era, we find the Hindu Bhagavad Gita that deals with life, death and rebirth.

So my point in telling you this, and of course, in the Christian tradition, we have gobs and gobs and gobs of texts on death and resurrection. But my point in sort of just highlighting a few of these is that this is nothing new. What is new is that we try not to talk about death. So somebody was asking me before the talk how I got interested in this subject. And I would say that I became interested in dying well because I’m a primary care doctor, and I take care of patients both in an outpatient clinic and also in the hospital. And I have noticed that many patients absolutely refuse, they refuse to think about the end of their lives. There are kind of several different ways that the question of dying cut through to me and got me thinking about this as a young doctor. There were the patients who really cling to the technology of mortals, even when they clearly have no chance for a recovery. And actually, studies show that people who describe themselves as highly religious, well supported by their religious communities and in this study happened to be Christians, that very strong Christians are much more likely to die in the intensive care unit, much more likely to rely on advanced technology, and much more likely to refuse hospice and palliative medicine. Why is that? Why is it that the very group that has a well worked out theology of death and the afterlife is clinging to the technology of mortals? So this sort of group of patients, there are many, many, many, got my attention.

But I also became interested in dying because I’ve cared for patients who, in the process of actively dying, start to ask questions about meaning and purpose. They ask questions about God in the afterlife. Suddenly they realize those religious questions that they’ve tried to put off actually maybe matter, and I’ve cared for patients who have died before they’ve been able to fully reconcile and wrestle with these questions. And that got me interested in how we talk about our mortality and anticipate death. And then I would say the other sort of group of people that has prompted me to think about this is my own colleagues. I don’t know, I’m sure all of you have had some sort of doctor exposure. I have many, many colleagues who do not like to talk to their patients about bad diagnoses, about bad news. I have had colleagues say to me, “I don’t know why you’re interested in talking and writing about death, I myself am so afraid to die, I do whatever I can to avoid talking to my patients about this.” So it struck me rather early on that we needed to change the conversation, and, not necessarily rely on the medical profession to do this work.

So since I have proven to you that the lifetime risk of death is 100%, it seems that really none of us should avoid these questions even though we are prone to procrastinate. Okay, one more thing about me. Since most of you don’t know me, I’ll say that for me, growing up, death was never that scary. I grew up in a home where talk of death was quite common. And it wasn’t weird. It was just sort of part of the conversation. I had a larger than life grandfather who was a bomber pilot in World War II, and when he was in flight school, his airplane malfunctioned and crashed, beheading his flight instructor and landing my grandfather in the hospital with a crushed pelvis for many months. He was supposed to have an honorary discharge. He wanted to fight, so he entered the war when he had recovered well enough to fly bomber planes, and was shot down over Germany and taken prisoner of war in the Stalag Luft three prison camp, which is sort of famous for being the prison camp from which the Great Escape occurred. So he was in prison then, right after the Great Escape happened. It was pretty austere. And suffice it to say, you know, we thought the man was going to die for about 20 years before he did. My grandfather kept not dying, but he kept talking to us about his death. And so and he was just very funny.

And so it wasn’t a scary topic. It was sort of the idea that we need to get our stuff in order and Grandpa’s always talking about it. When he came back from the war, he did two things, two sort of very urgent points of business. The first was marry my grandmother, and the second was purchased cemetery plots for the two of them. It was quite the wedding present. So between my grandfather demystifying death and then being raised in the church where talk of life to come seemed so much more compelling than anything in this life, I never really thought that we were supposed to avoid death. It just seemed like part of life. And so I was surprised then when I got into medicine and realized that actually in the hospital, this isn’t this isn’t the way most people think. So in puzzling then on how to have these conversations with patients, how to have these conversations with friends and community members, I did a lot of reading and eventually came across a handbook from the 15th century that was a bit of a “how to” manual on how to prepare for death. And the manual went on to inspire a whole genre of literature that circulated widely throughout the West for more than 500 years. That genre is called, in Latin, the ars moriendi, which means art of dying, and it grew to enormous popularity.

Many, many different versions of the books for religious and eventually for non-religious people translated into many languages and yet most of us have never heard of it. The whole genre really lost favor about 100 years ago, and we just don’t practice the ars moriendi, the art of dying, anymore. Now, you might be wondering, well, okay, that’s interesting. There’s this genre of literature on preparing for death, and it disappeared after 500 years of wild success. Why would this genre even sort of show up on the western scene? And if you have that question, you’re right to ask. We don’t just sort of create new genres out of nothing and in fact, there was in the mid 1300s, many of you will know, an enormous outbreak of bubonic plague or Black Death that swept through Western Europe. Historians estimate that perhaps as many as one third to two thirds of the population died. Now, we can’t quite imagine those numbers, right? So most of you are sitting next to people. If you think there’s a person on my left, a person on my right, they would both be dead in the mid 1300s. And of course, you yourself would be spared. But these numbers are extraordinary, right? These numbers are extraordinary. And, you know, just by way of comparison, Covid, which is the closest thing to plague, we’ve sort of had, you know, depending on what metrics you read, it’s somewhere from one third to 7/10 of a percent.

Right, so less than 1% of the population died, when we’re talking about two thirds. That’s, you know, two thirds of the population you can’t even imagine. So there’s this devastating outbreak of plague thought by historians to be the most devastating in recorded history. And so what happens after that? Well, you have society trying to pull itself together. How do you go on living when that many people have died?  every, every aspect of society was disrupted. So what happens is people go to their local authority and start asking for help because they knew that death wasn’t going away. There would be more famine, there would be more war, there would be more plague. Something was coming back and they needed to prepare. However, those of you who know and love church history will be well aware that in the late 1300s and early 1400s there’s a bit of a problem in the church. This is pre-Reformation, right? So we’re talking about the Western church. And the problem was one that actually Rome does not have right now. The problem is that there were two and then three men simultaneously claiming to be Pope. And when you have a leadership crisis, the last thing you can do is actually address the needs of the common person. And so it took a while for the church to pull itself together. Suffice it to say, the church convenes in the early 1400s, and their first item of business after fixing the Pope issue is to begin addressing questions of how to help the faithful anticipate death and prepare. Specifically how to help the faithful anticipate death and prepare in their own communities, not necessarily relying on a religious figure to help them do that.

And for me, this was very interesting because I thought, well, this model of the ars moriendi, the art of dying, this is what we also need in the hospital, where doctors are not necessarily leading patients through practices related to preparing for death. So eventually related to this convening at the Council of Constance to fix the Pope problem, there begins circulating the very first handbook on preparing for death, which launches the whole genre. Now I am going to just give you a tiny bit of a glimpse of what this genre was about. We won’t spend too long on this because I don’t want to make it too academic, but there’s a lot to say. So the earliest text we know of dates to 1415. You have to think of it as kind of a dummy’s guide, right? Those yellow dummies guides. It has practical instructions on how to care for the dying. It also has practical tips on how to die well if you’re the one dying. There are prayers both for the community and for the individual, there’s protocols, there’s written instruction. So there are a few things that were central to this whole 500 year genre. One is that you can’t ignore death.

It’s coming for you, right? It’s always coming for you. And so you just have to live with a little bit of the end game in mind. The second thing that was really central to the whole genre was that we die best, just as we live best, which is in community. Rare is the person who dies alone and dies well. Now, I’m not talking about sort of, you know, Granddads in the hospital and he’s dying. And we are there all day, and everybody goes home to get some rest. And as soon as the last person walks out the door, he goes on and dies, right? We all know stories like that. That’s not dying alone. Granddad has been well supported by a moral community, a loving community, a spiritual community throughout his dying process. I’m talking about the kind of dying where there is none of that support throughout the dying process. So the ars moriendi would say, we live best in community, we die best in community. And there are a few things that community was supposed to do for the dying person. One is that friends and family were supposed to gather at the bedside and broach the uncomfortable subject of death. We’re actually supposed to bring it up. Now, why would you do this? Well, part of it is that if the sick person, the person on the deathbed is dying but doesn’t realize it, how can he or she get the spiritual house in order? Right? So there’s a way in which you have to, the community has to, broach that uncomfortable subject of death.

Another aspect of the ars moriendi is that you were not, and this is something that I contend with a lot in the hospital, you’re not allowed to offer false hope. It’s really difficult to figure out exactly what false hope is. But when it’s clear someone is dying, then you don’t offer false hope of recovery. Another thing that community members were supposed to do, they were supposed to encourage the dying to repent of sin. The logic went that it was better for the dying to fear for their physical well-being (So if you’re not sure, tell them they’re dying so that they repent and then get right with God) then have them believe that they’re actually going to survive and avoid doing the hard work of repentance. And then another thing that community members were supposed to do is to pray and read religious texts to the dying. So I just sort of flag a few of these things to illustrate that in the ars moriendi tradition, dying was very much a community affair. I was speaking once at Yale on this stuff, and a gentleman in the audience. Well, I said to the audience, you know, I want you to think about your deathbed and who you want to be surrounding you. Who do you want there when you’re dying? And a guy raises his hand and he says, you know, “I know who I want to be at my deathbed, but frankly, I can’t stand the guy right now. Is it okay if I wait to sort of repair the relationship until I’m closer to the end of my life?” You know, fair enough. Except none of us knows when we’re going to die, right? And so if the idea is that we die best in community, and our living well is very much tied to our dying well, then it’s best to work at restoring those relationships now. Because not only will our dying be better, but so will our living, right? And so that leads me, I guess, to a third aspect of the ars moriendi, which is that these two are tied together. The ars moriendi never said, figure out your dying in a vacuum and don’t think about your living. No, it said they go very much hand in hand. So I’m going to pivot now to this sort of living well part of the talk. And I’ll tell you that living well in the ars moriendi tradition didn’t just happen. It took practice and it took serious thought. So in the earliest versions, there were five ways that it was believed that people died poorly. And you can listen to these five ways and ask yourself, do I think this is the way that people die poorly? So the five ways are dying in despair, dying in a state of disbelief, dying impatiently, dying full of pride and dying in a state of greed. So if you look at any kind of imagery or texts from the, especially the early 1400s, those were the big five. If you died in those ways, you did not die well. But dying is tied to living, and it mattered very much that people attended to what it would mean to cultivate the opposite of those vices, if you will, the opposite of those. Some people call them emotions. And so if you wanted not to die in despair, then you need to be a person who cultivates hope. And that’s not just cultivating hope, you know, right at the end of life. Become a person of hope. Grow in a posture of hope, and you can see where this goes, right? You don’t want to die in a state of disbelief. That’s a terrible way to die. Well, nurture your faith and so forth, nurture humility, nurture generosity, nurture patience. So they always go together. Living well, according to the ars moriendi, meant cultivating a life of virtue and attending to related spiritual matters. Now let’s see if this works, just for fun. These are two images from the earliest illustrated versions. So we’re talking about the 1400s Western Europe. Most people are illiterate. When in medical training, we’re taught if you have to make a guess and you think it’s a high number, guess 85% and if you think it’s a low number, guess 15%, and usually you will impress your Senior. So we think about 85% of the population of Western Europe was illiterate at this time, but nobody really knows. But so those who are uneducated, undereducated or illiterate need visual ways to learn about the art of dying. And so that’s what this earliest illustrated version, which dates to about 1450, that’s what this would have taught. So what we see here is the temptation to despair. I told you, despair was one of the big five in the early versions, coupled with a consolation or a comfort through hope. So I think you guys can see the image pretty well, right? So on the left in figure one, we have the temptation to despair. So what’s going on in this image? Well, here we have the dying man in bed and he is surrounded not by his loved ones, not by his community, but by reminders of past indiscretions. This gets a little juicy, so bear with me. What is more liable to make a person despair in his dying, and to go into deep hopelessness, than a room full of beings that remind him of the myriad ways he’s hurt others. So if you look at the image at 11 o’clock, this guy, this guy is accusing the dying man of adultery, and he brings in a woman to show that he is, in fact, an adulterer and if that’s not enough, this scroll here basically calls him a fornicator in Latin. What’s more, this dying man is greedy. And how do we know that? Well, this demon here is saying that he’s greedy, and he’s pointing to this man who’s looking rather down on his luck, impoverished, he’s barefoot, he’s sitting on a box, suggesting that if this man were more generous, we wouldn’t have this kind of poverty. There’s another demon here pointing to a naked man thought to be naked also from his poverty, from the greed of the dying man. And this demon is clutching a bag of money. And there are other demons, and these scrolls all say, what’s going on? There’s a scroll that calls him a murderer. There’s a scroll that says he’s a perjurer. And if that’s not enough, there’s a blackboard here. And on that is written a host of other sins, reminding him what a sinner he is. So these damning taunts are enough for the dying man to despair his hopeless condition. But this is not where the ars moriendi wanted to leave the viewer, right? Dying well is always tied to living well. And so the commendation, the consolation, was to become a person of hope. And that’s what we see in figure two on the right. You can see there’s an angel here who is encouraging him not to despair. Some of you may be familiar with the work of the late theologian Alan Verhey, who is at Duke.

He writes really beautifully about this. And so I’m going to just quote him here. He says “hope is possible after all. And the evidence surrounds the bedside. There they are, sinners all, brought through the judgment by the grace of God. Is the accusation fornication? Well, there’s Mary Magdalene with her reputation as a sinner. Is the accusation avarice? Well, there’s the thief on the cross. Is the accusation murder? Well, here’s Paul, struck down from his horse on the way to Damascus to persecute and kill. Is the accusation perjury? Well, there is Peter right here, holding the keys of the kingdom. And there in the background are the heavens opening with a path for sinners.” Most of us aren’t accustomed to looking at images to learn our theology. But that’s what these images did. They reassured people that what frightens them most about dying doesn’t have to be true, and that they can cultivate a different way of living such that they die the way they live. The earliest ars moriendi texts taught that to die well, we need to live well and to live well, we need to cultivate these virtues, at least initially, of hope, faith, patience, humility, and generosity. You might add other virtues to this list, but it certainly offers a solid point of departure. I’m going to give you one more image to close out my formal remarks tonight, and then I’d be happy to chat and take this conversation any way you’d like.

There’s one final influence of the ars moriendi genre that I think bears mentioning, and that is its impact on visual art. So the literary tradition went on to influence the visual art tradition, and there became very popular a sort of symbolism or a motif that we see throughout visual art called memento mori, which is also Latin and means remember, you will die. And this was a symbol, memento mori symbol, put into a painting to help people reflect on their lives and think about how they need to live different lives, not just for living, but also to die well. So here’s the painting. This is Giovanni Martinelli’s Death Comes to the Banquet Table. It’s from about 1635. You can see what’s going on here. Again, this is memento mori, reminding us of our mortality so that we reflect on our living. Now, Martinelli painted this at a time when his Italy was experiencing not only multiple outbreaks of plague, not as bad as the earlier one, but also the 30 Years War. And so death was on the minds of the Italians. This painting depicts a dinner party in sort of full swing. You can see all kinds of sumptuous food. People are dressed quite finely for the time. And who comes in but Death, right? And Death is holding something which may be difficult for you to see. But this is an hourglass, and it’s empty, and he’s gesturing.

You can see at this, at this young guy who’s pointing to himself. You mean me? Time is up for me? The subtler details, like the pie sitting here in front of the victim reveals, possibly reveals deeper moral lessons. Some people think that Martinelli put this pie here, symbolizing the fullness of life, right? The full pie, the fullness of life. But it has a missing slice, which we see here and art historians will note that that slice is between a glass of white wine and a glass of red wine. Now, the glass of red wine is meant to symbolize the Eucharist, and it’s actually raised on a platter, it’s up, it’s elevated. The white wine, in the sort of way that art historians make sense of this is to symbolize the cares of the world. So here is the slice of life, as it were. Hardly, you know, hardly touched, if at all, next to the cares of the world, the non-sacred, right? And what all of this imagery suggests is not only is this a reminder that we will die, but it also is a reminder that we need to not neglect spiritual concerns. And for the Christian, of course, spiritual concerns, I think, supersede all else in living and dying. There’s a lot I think about with regard to the hospital, but spiritual concerns certainly supersede even what goes on in the hospital. And I was thinking about this recently with regard to Matthew 24 and 25, where the disciples are pestering Jesus about when he will return.

And there are a whole bunch of parables that Jesus kind of spouts off about his return. There’s the faithful and wise servant who is rewarded when his master returns, and he’s rewarded for managing the household well, but Jesus contrasts him with the servant who gets drunk and beats his fellow servants for failing to anticipate the master’s return. Then there are the virgins with the lamps. You remember the ten virgins? Five have extra oil while they wait for the bridegroom, and five decide they don’t need extra oil but then they’re out buying oil when the bridegroom returns and they’re left outside. And then, of course, there’s the very famous parable of the talents. And these stories are, you know, in the text they’re about preparing for Christ’s return, it’s true. But there’s also a way in which they’re about applying to our mortal lives. We are also to prepare for our inevitable end, our physical end on earth. And we do this by growing in virtue, by nurturing our relationships, by stewarding well our time, our resources, and our talents. And we are to live into the fullness of life, that full pie. And we’re to live wisely and faithfully. So, friends, we have been given so much. Let’s not procrastinate. Let’s steward our remaining days well. Attend to the tasks of living and dying well, and then reward ourselves with a mentally stimulating game. Thanks very much.

Lydia, thank you so much. And on behalf of Saint Paul, thank you all for being here. And thanks to Susan and MBA for hosting us so well. Loved the use of art in your presentation. I think the question I had, I was intrigued when, first of all, we will open up for questions now. So if you’d like to come forward and ask your question, then after my question, we will go through in sequence. And our three rules, if you haven’t been here before for questions, are the three B’s: Be civil, be brief and be a question. And we’d love to have you come up. But my question is, I was intrigued by your statistic with what happened in intensive care with those of faith versus those who didn’t. Do you see the challenge of dying well, as a crisis of faith or a crisis of emotional health? Is there kind of a predominant leaning? And then also in regards to doctors, which, you know, in regards to those, how do you feel like that, that bedside can be shaped in a positive way?

Great yeah, thank you. Thank you so much for that question. So my colleagues and I actually talk about this study in the book, but my colleagues at Harvard who did this study were very curious about why it is that strong Christians, self-described strong Christians, would be most likely to choose technology and to forego sort of natural deaths. What’s going on there? And again, it’s not about choosing technology appropriately. This is sort of choosing technology when you’re clearly dying. And so they did a follow up study. So I do have an answer. And the follow up study, they asked folks in their study, what’s going on? What is informing your decisions? And people said, well, when we have loved ones in the hospital and we need advice, who do we go to? We go to our clergy. If you need somebody to show up and visit your spouse in the hospital, you often invite members of your clergy. Clergy are still thought of as somebody that shows up at the bedside of the dying. Especially in communities of faith. And so then they did another study and interviewed clergy, and they said, what are you telling the faithful? And it turns out that clergy, because most of them lack any formal medical training, they tend to over-state benefits of particular interventions and underappreciate the downsides of particular interventions.

And in an effort not to cause the faithful to become hopeless, they encouraged them to move forward. And so many people, it is because their clergy encouraged them to keep going—don’t give up, you know God can still do a miracle. One of the hypotheses was that it was driven by belief in miracles. They didn’t uncover that. My colleagues didn’t uncover that in the study as much. But could a belief in miracles be linked to the desire not to have the faithful give up hope? Absolutely.  People will often say to me, you know, I believe in miracles, I want to keep going, we want to, you know, do everything. Do everything is the language. And, again, to be clear, this is not making prudent use of technology when technology will be beneficial. But these are circumstances where someone is clearly dying and yet we are what often feels like sort of prolonging the dying process and not allowing a death kind of free of the trappings of the hospital. And I say to my patients, I say, look, I believe in miracles, too. But Jesus does not need life support to raise the dead, right? We don’t need to be as aggressive, we don’t need technology for God to do miracles.

It’s a really, really fine line. These are really hard issues. I think the other piece that again, didn’t come through my colleagues study, but that I’ve seen particularly in Catholic communities, is the strong sort of pro-life rhetoric gets confused when you’re talking about maybe not, you know, maybe switching towards goals of comfort because cure is not possible. Well, then, are you saying you’re just going to let her die? Well, not exactly, no, but we’re also choosing to use the technology in a way to make her as comfortable as possible without sort of prolonging an agonizing dying process. Often when I have this conversation with people, there’s always someone in the audience who has some sort of pain about the way a family member died. And I’m just going to acknowledge that I don’t think any of us gets it exactly right. We have wonderful technology that does so much good, and it is very, very difficult to know when maybe we need to switch directions in making use of it. But it’s complicated. Complicated subject, to be sure. Yeah. Thank you for the question.

Hey, my name is Andrew Wilson. My question is about the story in the genre. You said it was, as you described it, it seems to have been a great comfort in use to people contemplating death. But I’m curious about why it went away and what could be done to bring it back?

Yeah, great question. So the ars moriendi genre died out, if you will, about 100 years ago. And there are a couple of societal factors that led to that. And I think this is very interesting in light of having just come through Covid. And I went through Covid in New York City. So I don’t know what it was like here in Nashville, but it was not, we definitely had Covid cases in New York City. So 1914 to 1918 is World War I, right? Yes, the US gets involved in 1917, but suffice it to say 1914 to 1918. We have massive global loss of life. Even before World War I ends, we have what the outbreak of influenza pandemic called Spanish flu, sort of most recently, the influenza pandemic that epidemiologists think lasted two full years and came in four waves. That’s sort of what they think, looking back at, however they look at this stuff. So that is six years of global death worldwide. And if you think of how you felt just trying to plan a vacation one year into Covid and it’s canceled, or you have to get Covid swab and now you have to quarantine it. It’s just all that stuff. And everybody kept saying, can’t it just go back to normal? I just want life to go back to normal. Imagine six years of sustained global loss of life. And it wasn’t just soldiers in World War I. One of the reasons World War I was so bad is because it was a lot of civilians as well.

And it wasn’t just older folks from the flu, it was everybody. In fact, they have autopsy reports of young soldiers. You remember, World War I was also one of those wars where kids lied about their age and they served younger than 18. So these are young people. And on autopsy they have reports of essentially removing the lungs, which if you’ve never, you know, done stuff with lungs, they’re filled with air right, we breathe. They would remove the lungs and could squeeze it out like a sponge. It was so full of flu inflammation. So what happens when you get to the other side of six years of sustained global death? No one wants to think about death anymore. And we see that in this country. We go into the Roaring 20s, right? Women get the right to vote. Penicillin is discovered. We have new forms of music. Many, many people get automobiles. Women are chopping their hair. They’re shortening their skirts. And then we have antibiotics in the 20s. By the 40s, they’re in widespread circulation. We’re starting to develop chemotherapies. By the 50s and 60s, we’re experimenting with cardiopulmonary resuscitation, with mechanical ventilators, with organ transplantation. If you were born after World War II, the idea that death was something you had to prepare for just doesn’t really cross our minds. We don’t see it that much. I’ll just say one other piece.

If you look at the number of hospitals in the 1870s and you compare it to the 19-teens, so sort of 40 years later, we went from fewer than 300 hospitals in the entire country to more than 6000. So suddenly it’s like Starbucks, right? There are hospitals everywhere. And why would you then care for a dying loved one at home when goodness knows there’s antibiotics, there’s treatment, and there’s hospitals everywhere? And so we started to see this enormous shift of taking care of the dying out of the home. You add to that industrialization, people moving off of, you know, homesteads and into cities to work in factories, all of those things. There’s no one to care for the sick, send them to the hospital. And so the whole genre died out. Sorry, I know I said one more thing, one more thing. If you look at the text of preachers and pastors and clergy from before World War I to after into the 1920s, you see a remarkable shift away from preparing their congregants for death to just not talking about it at all. Maybe you get it a little bit on Ash Wednesday and Good Friday, but that’s it. We don’t talk about death in the church. And, you know, it’s an interesting question. When was the last time you sat in a non Ash Wednesday non Good Friday service and had your pastor prepare you for death? Doesn’t happen that often. I bug my pastors.

I know this isn’t a question, but thank you. My question is, do you see a role narrative medicine playing in this? I’m fascinated by the work of Rita Sharon, maybe especially The Dying Whale, but also just in bettering our relationships with our physicians.

Yeah, I know Rita’s work. Do I see a role for narrative medicine? I’m sure, right. I mean, that’s sort of the world of Medical Humanities, which is using literature and imagery to, you know, to reflect on it and learn in part. And I think that’s where you’re going. Certainly that would be possible to the extent that any of us pauses and reflects on anything collectively. There can definitely be value there for sure. Yeah. Thank you for that.

Thank you. It seems like the literature on dying addresses pretty well the idea of dying before you want to die. But I’ve had a number of relatives who have lived into their 90s, and they addressed the issue of wanting to die and I can’t, how do you address the issue of dying well, when you can’t?

Yeah. So that’s a great question. That is the concern about dying impatiently. So I told you one of the original ways that people were felt to die poorly was impatiently. And I saw that with my grandfather. He wanted, he was ready. He was a believer. He was ready to meet his maker. He had a lifetime of pain. He, you know, he was ready, and he kept not dying. And I think that there is this, how do you cultivate patience? How do you rest? On some level, probably, if we reflect, all of us can find areas in our lives where we were pushed to cultivate patience. All different kinds of areas, not getting the job you want at the time you were planning to get it. Not being able to finish school when you were planning to do it because of X, Y, Z. Not, you know, marrying the person, whatever it is, right? If we reflect on our lives, I’m sure we can all see places where we would say, oh yeah, I had to learn patience then. But for those who have not had that gift of having to learn patience in their living, then there’s a real eagerness to go on and be done when it’s on schedule. And that, I think, partly gives rise to the movement to legalize assisted dying usually used to be called physician assisted suicide. Now is more often referred to as MAiD. There’s an eagerness to control the timing and circumstances of death. And why not? We can control so much in our lives. But I think it is, it’s a good exercise for all of us to consider the times when we have not been able to control our circumstances and what have we learned from that? And how can we continue to cultivate that, especially as we get older? Yeah. Thank you for that.

Yeah. I’ll give you my question and a little context. The question is what role. Do you think our increasing expectation of precision is in the world around dying? And the context is, I can watch the Weather Channel and know to the minute when the thunderstorm is going to come down my street, but I don’t know if this treatment is going to work. Why dad has pneumonia? Precisely when does life go from quality to quantity? And medicine is not precise, but everything else is becoming increasingly precise. Do you think that is confusing? Dying at this stage?

Absolutely. Yeah, I mean, absolutely. And that sort of ties back to why people are trying to control the timing and manner of their deaths. It does create, yeah, I mean. Yeah, it absolutely. It does create a lot of cognitive dissonance for people who control everything. You control the climate, you control your garage door. Not that we have those in New York, but, you know, you can control your menu. You can control when food is delivered to your house. You can control all of these pieces, but you cannot control the projection of an illness. And, personally, to me, we need to lean into that. And again, that’s a kind of suffering, right? There’s a kind of suffering when we feel out of control and suffering in the Scripture is not always an evil. Sometimes suffering is for our good. And so what can we learn from that? How can that change the way we go through life? How can that change the way we encourage others? Yeah, it’s probably not a satisfying answer. I think it’s a true answer. Yeah, please.

I’ve heard it observed that one of the reasons we’re putting nails in coffins is to keep the oncologists out. So my question is about this science and how it relates to the arts of dying that you describe. You might say that in an artistic way of looking at this is that acceptance and affirmation of death would be seen as an art. But those same acts in the framework of science might be seen as resignation and defeat. How do you put those two things together as a religious person and a doctor?

Yeah, not very well. I’m almost tempted, I was almost tempted to ask why you were starting your remarks. If there were any oncologists in the room, just so I can know how much trouble I’ll get into. But I decided I shouldn’t ask. There are, let me just put it this way. There are certain specialties in medicine that carry reputations for not wanting to give up, and I actually write about a friend of mine in the book who’s a young mom. When I was a young mom and we had kids, little littles together, and she was diagnosed with breast cancer. And her husband called me on a Friday night and he said, “I think this is, I think this is it. They tell me her liver is three times the normal size, that two thirds of it is just cancer. She’s bright yellow, which is from the bilirubin from destruction of the liver.  I don’t think she’s going to make it much longer.” I said, okay, it’s, you know, 9:30, 10:00 on a Friday night. I’m in the hospital in the morning, I’m on the wards. As soon as I’m done making the rounds on my patients, I’ll come and find you. And so I did that, and I went to the, she was hospitalized in my hospital, I went to the cancer floor. And it just so happened that I got to her door at the same time, her oncology team showed up and I introduced myself.

You know, I’m Lydia Dugdale, I’m a general internist here. I see patients on the general medicine floor, blah, blah, blah, right. I said, her husband called me last night, we’re family friends, he thinks this is the end. Oncologist says, “oh, absolutely. There’s nothing else we can do. She’s dying. She’s actively dying. I’d be surprised if she makes it a couple more days.” And I said, “okay, well, what are the options? What are you thinking?” “Well, really, it’s hospice, home or inpatient. They’re not sure that home hospice is going to work with the little kids.” And, okay. So it’s probably okay. All right. United front. We’re going to go in full empathy. This is my dear friend. Right. We’re going to, we’re going to have this hard conversation together. We went into the room and the oncologist says, well, there’s a pill we can give you. She didn’t want to have that conversation. My friend was dead three days later. So I think that there are some doctors, maybe many doctors, for whom death is failure. And when death is failure, you don’t want to fail, right? We get into medicine because we’re good test takers, right? So you want approval. You want good marks. A failing grade is not a good mark. And so it’s really hard. And if you’re not practiced and wise about having these conversations, then you go in and do what the young oncologist did.

And I actually. Yeah, I mean, I have so many stories like this, that’s the one I write about. So it’s sort of public. But I’m an ethics consultant in the hospital, and we regularly get consulted from teams of all different sorts on the inpatient side where, you know, so and so specialty says, whatever you do, don’t tell the patient they’re dying. But we’ve consulted palliative care, but we don’t want palliative care to tell the patient that they’re dying. So there’s a real resistance. There’s also an additional problem in medicine, which is that some physicians’ metrics, especially surgeons, are affected by survival after surgery. So you need to make it a certain number of days. You need your patients to stay alive a certain number of days to have good metrics. So you can imagine that complicates things. And if your ratings then for the public are tied to how long your patients stay alive. Yeah, so there’s a lot to say, it’s complicated. And, you know, at the end of the day, we’re all human and we want to be liked and we want to get passing grades, and we want people to live and go home, and we want people to have hope. But that translates into procrastination on the difficult stuff. Yeah. Thank you for that, sir. Oh I’m sorry. Ladies first.

Thank you. First of all, thank you so much. Yesterday I received the news that a grandparent is entering the final stages. And this, after a long illness, and so this resonates deeply right now. And I’m curious about the role of grieving well, or is there a role for grieving well as part of the living well and dying well spectrum?

Absolutely. Yeah. Thank you for that question. And I’m sorry to hear about your grandparent. Grief is so so good. This is also something that we have sort of lost. There’s all kinds of arts about grieving: lament. I strongly commend the Psalms of lament to you just in this season. Read them over and over. Cry them, pray them. It’s so good. What lament does is it not only sort of registers your complaint with God, but lament invites God into the pain and suffering and asks, the laments characteristically ask for intervention. Intervention does not necessarily mean restoration of health and life to an aging grandparent, but they’re still healing, right? There’s that healing balm that can come. So I really commend the Psalms of lament in particular. Ecclesiastes also, always a good one. One of the beautiful things, doctors will say that there are different ways that we die. There are different patterns of dying. One of the beautiful things about having time with someone who is dying is that you can do a lot of that grieving collectively, even before the death. One of the most painful kinds of death is the one that you did not anticipate at all, right. And just hits you out of the blue. I teach a class at Columbia called Living, Dying and the Meaning of Life, which I taught today.

And it’s full of undergraduates, and we have 100 undergraduates, and they largely self-select because they’ve had this incredible trauma. You know, I finished my final exam last year and my mom and dad were killed in a car accident kind of thing. It was just extraordinary trauma. So that that one, I mean, death always rips a hole in the fabric of a community. But that kind of trauma, it’s just a massive amount of grief after the fact. It’s almost unfathomable. But the joy, even, the beauty of being with a dying family member is being together and grieving together. And it’s also okay for the one who is dying if they’re able to grieve with you because they’re leaving, too. It’s always, it always affects multiple people. A death always affects multiple people. So sit with grief. I wish we still did sort of public wailing, and I think that’d be good for us, but probably not in Nashville, right? It seems very proper here. But yeah, I think to the extent that you can find ways to express that grief together with your loved ones and even with your grandparents. Yeah. Thank you. Yes, sir.

Thanks. I’d like to get your perspective on reconciling two different statements of perspective on death in the Christian tradition. And so Saint Paul says, on the one hand, to live is Christ, and to die is gain. On the other hand, the last enemy to be destroyed is death. And so should we be thinking of death as more of like an opportunity for gain and progression in our relationship with God? Returning to meet our maker? Or should we be thinking of it more as an enemy to be destroyed? And is there space for both these perspectives?

Yeah, I think death in the Christian tradition as a non theologian. I did go to divinity school, but I’m not a theologian. As a non-theologian, I think death exists in the Christian tradition as a paradox very much. I mean, Paul says all kinds of things about getting on with not being in this world, right? At the same time, we can’t be impatient because as long as we’re here, we have work to do. This is actually, actually I just read this this morning in 1 Corinthians 15, the very last verse. I think it’s verse 58. This is after the whole thing about “O death, where is your sting?” all of that stuff. And then verse, I obviously didn’t memorize it, didn’t know I was going to talk about this, but then verse 58 says something like, now get on with life, live into the fullness of life. So as long as we’re here and this I used to say to my granddad, you know, Grandpa, as long as God has you here, he has you here for a reason. And it might be, it might be to just pray. It might be to be the sort of patriarch that we all gather around. And it’s true that once the grandparent generation dies, the family often sort of, you know, doesn’t have that anchor. So maybe there’s a reason that a certain figure is still in a family. But as long as God has you here, he has you here for a reason. Yeah but I do think it exists as a paradox. I mean, death has been conquered in the resurrection of Christ, and then death is still the last enemy to be destroyed. The final resurrection of the dead. I think that’s what it’s getting at. We should get a real theologian to answer that.

Well, that’d be a great question to end on. And I’m going to ask you about money. Sorry.

That’s all right.

How did the financial interests work? You’re in a hospital setting. The financial motivations and influences, pressures, compromise, dying well, how did they influence dying well? Any comment about the pressures that are there?

Lydia Dugdale: Yeah, there’s so much to say about that. There’s so much to say about money in healthcare in general. Money and dying. So this ends up being quite, quite technical. But, you know, Medicare now reimburses based on a diagnosis related group. So there’s sort of, if you’re in the hospital with a hip fracture and you’re only there for the hip fracture, all of that sort of comes under one reimbursement scheme. However, if you’re there with a hip fracture and then XYZ happens, you know, and now this and now this, that’s a separate billable thing. I alluded to this before, but so I alluded to the surgeons who can’t let their patients die. You know, there was a long article a couple of years ago in ProPublica, which is an online publication that kind of keeps an eye on the medical system, among other things. And it tells the story of a transplant program in New Jersey that they had had so many patients die after heart transplantations in less than a year. You have to get a transplanted patient to a one year mark that this was their last patient, that if they let him, if he died, if he didn’t make it to the one year mark, their program was going to close. What happens when a transplant program closes? All those people lose their jobs, and it’s a lot of revenue for a health care system. So part of the reason this became an article in ProPublica is because there were, you know, it ended up getting leaked to the press that they were essentially maintaining the vital functions of practically dead person with zero hope for recovery for weeks and weeks and weeks, even though they all knew he would never, ever, ever leave the hospital.

So you see that sort of thing as well. Generally in the medical system, palliative care doctors don’t get paid as much as other people because their interventions are things like pain medicine and drugs for constipation and a little bit of oxygen to help you feel better. You know, it’s all really about the care of someone to maximize quality of life. But again, there are also various reimbursement mechanisms for oncologists as well, some of whom do receive kickbacks for every chemotherapy they prescribe or certain classes of chemotherapy. So it’s messy. Medicine is extraordinarily broken. Yes, money comes into it sometimes. I would say generally, if you are thinking about a less is more approach with healthcare, that is not the financially, that’s not the way that the institution is going to get the most money. So a medically less is more approach is, you know, sort of a more of a natural death, comfort measures. That is often the right way to go. That’s not the way the institution gets rewarded financially. Yeah.

Let’s all hear it for Lydia.

[applause]

Hi, just a few closing comments. I’m Tom Walsh from the Trinity Forum. Thank you so much, Lydia, for such a powerful and challenging and also encouraging set of messages. What we’ve just heard from Lydia this evening, I think, is a perfect example of what you were hearing about earlier. What we’re trying to do with the Trinity Forum is to keep the Christian intellectual tradition alive and renew it in our time. And that is what Lydia and a lot of our other senior fellows and others at Trinity Forum are trying to do. It’s not an easy thing to do. The challenges to that tradition are very many in our modern lives, and it’s a big lift. The challenges come from all directions, but we’re convinced that the need for this kind of wisdom is absolutely huge in our society now, and that it can renew our culture. So thanks to all of you who are part of this already, by being part of the community that we call the Trinity Forum society. If you’re not already a member. You heard earlier how you can become one but if you become a member tonight, we will give you a free copy of The Lost Art of Dying, signed by Lydia. And after tonight, we’ve had the taster, I would imagine pretty much all of us would want to give it a read. So there’s your offer. If you become a member, you’ll also become or start receiving our readings, which we send out each quarter by mail. Our latest is drawn from Les Miserables, just came out in the last couple of weeks.

Some others deal with people like G.K. Chesterton, William Wilberforce, Simone Weil, Frederick Douglass. We also have a lot of great online conversations coming up in the next few months. We have a series on leadership in May and June. We’ll be speaking with Beth Moore in July. Our podcasts, please subscribe if you haven’t already. You’ll hear a lot of the same great things. I really want to thank tonight’s sponsors, once again, listed on your program. They made it happen. And for those of you who are part of the sponsor’s dinner with Lydia, go up in that way. If you’re intending to go to the dinner, but you find yourself in what seems to be a dark parking garage, reverse course. Come back and go that way. And that’s where you’ll find us. We also want to thank MBA and Saint Paul, and also our volunteers, Langhorne Coleman here from MBA, Lelia Scogin from Saint Paul, Lindsi Necas, Ashley Larmer, and Amy Richardson. And I’d also like to thank my wonderful colleagues from the Trinity Forum, Campbell Vogel and Marie-Anne Morris, who came with me from DC to gather with you tonight, and also our two outstanding board members here in Nashville, Sam Funk and Gif Thornton. Thank you again, Lydia. Thank you all for joining us. We’ll be back in the fall, so plan to be here and keep your eyes peeled for an announcement of who and when, and at least for tonight: let’s all keep on not dying. Thank you.