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BY: FR. THOMAS NAIRN, OFM, PhD

Illustration by Cap Pannell

Recent years have witnessed a revival of the ars moriendi, the early modern Christian practice of the "art of dying" in preparation for death.¹ Even though this tradition formally began in the 15th century, it has its roots in the Middle Ages. Essentially, the ars moriendi described a series of temptations that a person might face prior to death, along with the specific virtues that help overcome the temptations,² virtues that needed to be practiced by the person preparing to meet Jesus in death.

Using medical science to prolong life, as we understand it today, simply was not possible during the Middle Ages and Renaissance. A belief that physicians had a duty to prolong the life of a dying person did not arise until the writings of Francis Bacon in the 16th century.³ Prior to that time, most people shared the conviction that, although the physician may be responsible for care during illness, it was the responsibility of the priest to care for the dying in order to prepare them to enter eternal life.⁴

This early understanding of the ars moriendi rested on two foundations: (1) that for the Christian, it was more important to prepare for death than to prolong life; and (2) that the most appropriate preparation for death was the way one had led his or her life in general.

PROLONGING LIFE OR PREPARING FOR DEATH?
St. Bernardine of Siena, a 15th-century preacher and spiritual writer, exhorted his hearers that trying to extend one's life in the face of dying was, in reality, an attempt to evade death and therefore demonstrated an attachment to life that is "sinfully loved."⁵

As the science of medicine became more and more capable of extending life, this attitude changed. Especially because of technological developments during the last half of the 20th century, the possibility of prolonging physical life today has become virtually unlimited. The acceptance of these technological advances has become so much a part of life and culture in the United States that we tend to believe there is a technological solution to every medical problem. The philosopher and medical ethicist Daniel Callahan, PhD, has termed this phenomenon "technological monism" and has described it as the belief "that all meaningful actions [in medicine] are technological, whether technological actions or technological omissions."⁶ He adds that because of this phenomenon, death itself is no longer seen as natural, but rather as the result of discontinuing technological interventions.

Such dependence upon technology also has affected Catholic moral reasoning. In a reversal of the tradition, many Catholics now demand that physicians preserve life at all costs, believing that to do less would be immoral — an act of euthanasia. Callahan explains the irony of this position: "Thus was created the perfect double bind: If you are serious about the value of life and the evil of death you must not stand in the way of medical science, our best hope to eliminate it. If you hesitate to use that science to the fullest … you are convicted not only of failure of hope … but also a lack of seriousness about the sanctity of life."⁷

Advances in medical technology have increased the patient's choices, which in turn have heightened the importance of patient autonomy in medical choices. Originally seen as an antidote to excessive paternalism on the part of physicians, autonomy has now come to mean, for many people, "total self-reliance, personal preference, and self-assertion."⁸

When there was little that medical technology could offer to preserve life, patient autonomy had little meaning. This is no longer the case. Patients desire to die "on their own terms," and among their greatest fears is the possibility of losing control and becoming a burden to others.

Unfortunately, this combination of advances in technology and heightened patient autonomy often has led to the overuse of technology at the end of life. Hospice and palliative medicine have been developed in reaction to this overuse. They provide patients with relief from the symptoms and stress of serious illness, allowing many patients to heal more quickly. For those patients with a chronic progressive terminal illness, such care helps them live as fully as possible in the time they have left.⁹

The United States Conference of Catholic Bishops has praised palliative care, affirming it as "a readiness to surround patients with love, support and companionship, providing the assistance needed to ease their physical, emotional, and spiritual suffering . . . anchored in unconditional respect for their human dignity."¹⁰

As helpful as palliative care has been, it is not the entire answer to the inappropriate use of life-sustaining technology. Here is where a contemporary Christian art of dying enters the picture. Although palliative or hospice care is an appropriate element in preparation for death, it is only an element of such preparation. The "art" in the early modern Christian ars moriendi implies that a good death does not simply happen. It is a task in which the patient must engage.

Farr Curlin, MD, a physician and ethicist who teaches at Duke University, has explained that palliative care is not a substitute for an "art of dying," but, rather, is its handmaid. By relieving the patient's symptoms, it allows the patient to participate in the task of dying well, but the dying patient still has to engage in the task.¹¹ Patients must confront the temptations and practice the virtues that help them prepare for a good death.

A key constituent of this task is the virtue of patience.¹² Both Christopher Vogt, PhD, MTS, chair and associate professor of theology and religious studies at St. John's University in Queens, New York, and Allen Verhey, PhD, who was, until his death, professor of theological ethics at Duke University, see patience as an antidote to excessive demands for autonomy. Vogt explains that patience is not "toughness and indifference to pain," but, rather, "a learned attentiveness to God's call and presence" in one's suffering and a willingness to hand oneself over to that presence.¹³ Similarly, Verhey explains that patience at the end of life is watchfulness, knowing that God can be trusted. He continues, "God is faithful when we are dependent, as we always are. God is faithful when we are dying, as we all will."¹⁴

Note, however, that this task is the opposite of contemporary attempts by many facing death to remain in control. The task that is part of a contemporary Christian art of dying demands not self-reliance, but reliance upon others, and especially upon God. It demands trust, moving one from a sense of one's self-sufficiency to dependence upon another — and especially upon the Other. The task involved in the contemporary Christian art of dying demands surrender rather than control, handing oneself over to God without clinging to life at all costs. Yet such surrender goes against our contemporary American understanding of what it means to be fully human. In this sense, autonomy and the desire for control can be seen as temptations at the end of life rather than virtues.

AS WE HAVE LIVED, SO WE DIE
In the original ars moriendi, the temptations at the end of life were seen as attempts by the devil to pull Christians away from the life of virtue that they already were living. This is evident in the woodcuts that often accompanied the writings.¹⁵ The ars moriendi called upon one to re-affirm a way of life already embraced.

Notice the difference today. It almost seems as if the virtues called for in a contemporary Christian art of dying are the aberration. These virtues seem to be in direct contradiction to the manner of life many embraced prior to serious illness. Most Americans — including many Christians — embrace autonomy and control as important aspects of their lives.

To develop the proper virtues at the end of life — virtues that lead to a good death — one must begin to develop them while healthy. Both Vogt and Verhey explain that "living well is the key to dying well" and that the practice of virtues that forms a contemporary art of dying must be developed throughout the Christian's life.¹⁶

What these authors fail to note, however, is how foreign the practice of these virtues may appear in our contemporary culture. Our highly developed medical technology has created the attitude among many Christians that we are in control — and that we should be in control. Even proponents of palliative care tend to explain its benefits in terms of patient preferences and choice. Autonomy and control remain key elements in end-of-life care today, as they remain elements of life today.

Nevertheless, if authors such as Vogt, Verhey and Curlin are correct that one of the tasks involved in a contemporary Christian art of dying is developing patience, we seem to be asking those who are dying to begin to develop virtues that were never integrated into their previous life. In fact, we might be asking our dying brothers and sisters to begin practices that contradict what they have been taught as virtuous prior to serious illness.

Many have described Christianity as "countercultural." Too often, this term has been merely rhetorical. Yet, it seems that if Christians are to undertake the tasks involved in the contemporary art of dying, we truly must become countercultural.

Verhey, for example, has challenged contemporary Christian bioethics "to talk candidly about the difference it makes to be a believer, to speak prophetically concerning the culture, and to draw out the implications for bioethics of such faith and criticism."¹⁷ There might be no place where this is needed more than in developing early in our lives those virtues that are necessary at the end of our lives.

Christians must be allowed to confront how our way of living can make it difficult to die well. For example, the Catechism of the Catholic Church explains, "Life and physical health are precious gifts entrusted to us by God. We must take reasonable care of them, taking into account the needs of others and the common good."¹⁸

This attitude can be present in the dying person only if concern for the needs of others and the common good already have been developed earlier in the person's life.

Individuals normally cannot develop by themselves the virtues they need at the end of life. They need a faith community to support them. If those who are dying need to develop the virtue of trust, that cannot occur unless they have been able to experience others in their family or community as trustworthy. Those facing serious illness will feel a burden to others unless family and faith community have the habit of responding as reliable witnesses, showing that the person's dignity can be preserved even when autonomy is relinquished. To be able to rely upon another at the end of one's life, one needs to have experienced the reliability of others throughout one's life and to have shown oneself also to be reliable.

Christians are taught that illness and death are a part of life. As much as we might try to deny them, they always will have a hold on us. Yet our faith teaches that God is present even in the midst of these apparent evils. They can become opportunities for the Christian to encounter Christ in death by engaging in the task of developing the virtues needed for dying well. This is the attitude behind the ars moriendi. And this attitude challenges contemporary Christians that preparing for death is a task — one that acknowledges that dying well is at least as important as preserving life and that the best beginning for such preparation is trust and acceptance — what the tradition has called patience — throughout one's life.

FR. THOMAS A. NAIRN, OFM, is provincial minister of the Franciscan Province of the Sacred Heart, St. Louis.

NOTES

1. See, among others, Christopher P. Vogt, Patience, Compassion, Hope, and the Christian Art of Dying Well (Lanham, Maryland: Rowman and Littlefield, Publishers, 2004); Allen Verhey, The Christian Art of Dying: Learning from Jesus (Grand Rapids, Michigan: William B. Eerdmans Publishing Co., 2011); and Lydia S. Dugdale, ed., Dying in the Twenty-First Century: Toward a New Ethical Framework for the Art of Dying Well (Cambridge, Massachusetts: The MIT Press, 2015).
2. A typical list contains the virtue of faith corresponding to the temptation to lose faith, hope corresponding to despair, patience corresponding to impatience, humility corresponding to pride, and surrender corresponding to avarice. See Verhey, 110-35.
3. Darrell W. Amundsen, Medicine, Society and Faith in the Ancient and Medieval Worlds (Baltimore, Maryland: The Johns Hopkins University Press, 1996), 41-42.
4. See Yves Ferroul, "The Doctor and Death in the Middle Ages and the Renaissance," in Death and Dying in the Middle Ages, ed. Edelgard E. DuBruck and Barbara I. Gusick (New York: Peter Lang, 1999), 31.
5. Franco Mormando, "What Happens To Us When We Die? Bernardino of Siena on ‘The Four Last Things,'" in Death and Dying in the Middle Ages, ed. DeBruck and Gusick, 112. Mormando is quoting from Bernardine's sermon on the Friday after the First Sunday of Lent, De duodecem doloribus quos patitur peccator in hora mortis.
6. Daniel Callahan, The Troubled Dream of Life: In Search of a Peaceful Death (Washington D.C.: Georgetown University Press, 2000), 68.
7. Callahan, 86.
8. Autumn Alcott Ridenour and Lisa Sowle Cahill, "The Role of Community," in Dugdale, Dying in the Twenty-First Century, 154. The authors are quoting Margaret Farley, Compassionate Respect: A Feminist Approach to Medical Ethics and Other Questions (Mahwah, New Jersey: Paulist Press, 2002), 29.
9. For a fuller description of palliative and hospice care, see Palliative and Hospice Care: Caring Even When We Cannot Cure (St. Louis, Missouri: The Catholic Health Association, 2016). This is one of CHA's "End-of-Life Guides."
10. United States Conference of Catholic Bishops, "To Live Each Day in Dignity: A Statement on Physician-Assisted Suicide." www.usccb.org/issues-and-action/human-life-and-dignity/assisted-suicide/to-live-each-day/upload/to-live-each-day-with-dignity-hyperlinked.pdf.
11. See Farr A. Curlin, "Hospice and Palliative Medicine's Attempt at an Art of Dying" in Dugdale, Dying in the Twenty-First Century, 79.
12. See Verhey, 278-82, and Vogt, 131-36.
13. Vogt, 133.
14. Verhey, 279.
15. For examples of these woodcuts, see Verhey, 110-35.
16. Vogt, 130. See also Verhey, 356.
17. Allen Verhey, Reading the Bible in the Strange World of Medicine (Grand Rapids, Michigan: William B. Eerdmans Publishing Company, 2003), 20.
18. Catechism of the Catholic Church, 2288. Emphasis added.