The Lost Art Of Dying Well

(Lydia Dugdale, MD, MAR (ethics), is the Dorothy L. and Daniel H. Silberberg Associate Professor of Medicine at Columbia University Vagelos College of Physicians and Surgeons, and Director of the Center for Clinical Medical Ethics. She also serves as Associate Director of Clinical Ethics at New York-Presbyterian Hospital/Columbia University Irving Medical Center. Her scholarship focuses on end-of-life issues, medical ethics, and the doctor-patient relationship. She edited Dying in the Twenty-First Century (MIT Press, 2015) and is author of The Lost Art of Dying: Reviving Forgotten Wisdom (HarperOne, 2020), a popular press book on the preparation for death. A version of this essay was first published in March 2020 at Psychology Today.)

The Centers for Disease Control continues to report that COVID-19 remains much more likely to kill people over 65 than anyone else. That’s the bad news.

The good news is that there exists a time-tested model for the preparation for death. And if the COVID-19 statistics do anything for us, they should cause all of us to stop and consider whether we are prepared to die.

In the 1350s, the Black Death, also called Bubonic Plague, ravaged Western Europe. Historians estimate that up to two-thirds of the population died. Priests themselves were not immune to the plague, and the laity was often forced to face death without last rites or proper burials. As a consequence, people feared for their souls.

With the possibility of disease, famine, and war never far from the collective imagination, survivors of the Black Death asked for help. They insisted on knowing how to ready themselves for death’s inevitable return.

By the early 1400s, handbooks on the preparation for death began to circulate. Collectively they were known as the ars moriendi, Latin for “art of dying.” The author of the original text is unknown but was likely an affiliate of the catholic church, then Western Europe’s leading social authority. But the ars moriendi developed many spinoffs, including an illustrated version for the illiterate and instruction for the non-religious. Widely popular for more than 500 years, these various iterations meant that no one should meet death unprepared.

This art of dying fell out of favor about a century ago when the Roaring Twenties promised new life and luxury. The discovery of penicillin in 1928 suggested that death might be thwarted indefinitely, and societal norms began to shift—emphasis on the art of dying well quickly ceded ground to the art of living well. As cardiopulmonary resuscitation (CPR), life support, and organ transplantation proliferated, death was pushed even further from view.

It’s no wonder that the thought of death gives us anxiety. Few, if any of us, have given much thought to the preparation for death beyond life insurance policies and estate planning. This is true even for many of my physician colleagues. But it’s not too late. And several lessons from the ars moriendi literary genre merit our consideration.

First, dying well requires living well, and living well means that a person must live with the end in sight. Acknowledging human finitude does not mean dwelling on morbid thoughts, but it does mean inviting the possibility of death into daily existence. When my own middle school-aged children asked questions about COVID-19, I spoke openly with them about the death rates and about how good health is not guaranteed. It’s astounding that Americans are more comfortable talking to their children about safe sex and drugs—important as this is—than to their elderly parents about wishes at the end of life. We must reclaim a recognition of our mortality.

Dying well also requires community. No version of the ars moriendi expected that a person can die well in isolation; dying was always a community affair. The “art of dying” was sometimes described as a great drama in which the dying person played the starring role and community members were supporting actors. Everyone, including children, had a role to play. When a friend of mine with young children died, many in our peer group wondered whether the funeral was appropriate for our children. I took mine, and it made sense to them. By participating in the funeral, my children witnessed how a community can serve to bear the sorrows of its members, and they began to understand themselves as finite beings.

Ars moriendi woodcut by Master E.S., “Encouragement in Faith,” c. 1450
Source: Public domain

The ars moriendi developed in the late Middle Ages, an era arguably more enchanted than our own. It’s thus easy to see why many of its versions gave attention to metaphysical and religious questions. Even though religion is on the decline in the United States, it would be a mistake to assume that we have progressed past existential wonder. Seventy-seven percent of Americans still identify with some religious faith. What’s more, many of my patients ask religious questions as death approaches. Somehow death brings, “What happens when I die?” to the fore. These are the types of questions the ars moriendi encouraged its readers to consider.

Critics will doubtless assert that progress lies in looking to the future. But when sickness and death strike, sometimes guidance from the past offers the clearest path forward.

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who support mentally competent adults as they navigate their end-of-life journey.
Established in 2004, FEN educates qualified individuals in practical,
peaceful ways to end their lives, offers a compassionate bedside presence, and defends
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