Barriers to Dying Well in Late Modernity

Dissertation for the degree: MLitt Bible and the Contemporary World

Andrew Neill Student ID: 110018281 20th March 2014

Declaration

I hereby certify that this dissertation, which is approximately 16370 words in length, has been composed by me, that it is the record of work carried out by me and that it has not been submitted in any previous application for a higher degree. This project was conducted by me at the University of St Andrews from September 2013 to March 2014 towards fulfillment of the requirements of the University of St Andrews for the degree of MLitt Bible and the Contemporary World under the supervision of Dr John Perry

Signed

20th March 2014

Introduction

A good deathone that is free from avoidable distress and suffering for patients, families, and caregivers; in general accord with patients and families wishes; and reasonably consistent with clinical, cultural, and ethical standards.1

Is dying well simply a matter of developing and utilising technical excellence to alleviate suffering, or is there another way in which we might understand it?2 Phillipe Aries in his book The Hour of our Death3, charts the history of our changing attitude toward death over the past one thousand years. He clearly demonstrates how our attitudes and experience of dying is vastly different from that of the pre-moderns who came before us. That our attitude towards death has changed is obvious but the controversy lies in whether it has changed for the better. There has been recent interest in the idea of dying well or a good death in late modernity but it is by no means clear what we mean when we talk like this. This thesis seeks to answer the question: how did contemporary attitudes towards dying develop and why are they insufficient in providing the resources necessary to die well? Contemporary death narratives will be contrasted with a well-established Christian tradition of dying well. Dying well requires a person to live well and this is best seen teleologically as exemplified in the polis and practices of the church.

To answer this question will require some substantial background work. Chapter one deals briefly with the development of modern medicine and how !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
1

Marilyn J Field, and Christine K Cassel. Approaching Death: Improving Care at the End of Life, (National Acadamies Press, 1997). John Swinton and Richard Payne, Living Well and Dying Faithfully, (Wm. B. Eerdmans Publishing, 2009), xvi. Phillipe Aries, The Hour of Our Death, (New York: Alfred A Knopf Inc, 1981).

it prompted a crisis of dying in late modernity. We will review two main responses to this crisis in the form of 1) The death awareness movement attributed to Elisabeth Kbler-Ross, and 2) the palliative care movement. Central to our discussion of the death awareness movement and palliative care is that both are therapeutic in their approach. Shuman and Meador have described it like this, the therapeutic perspective has become a taken for granted part of everyday life. It provides culture with a set of symbols and codes that determine the boundaries of moral life.4 These contemporary approaches to death highlighted in chapter one will be referred to as the therapeutic approach. Chapter two reviews the genre of Christian literature known as the ars moriendi as a source or approach to dying well. Contrasts with the approaches in chapter one will be noted. Fundamental to this thesis is the idea of teleological ethics and in particular the idea that the virtues are essential to dying well. Following from MacIntyre5, practices, based within specific traditions are central to the development of virtuous people. The approach to death highlighted in chapter two, the ars moriendi, will be referred to as the practices based approach. Chapter three will focus in much greater detail on the contrasts between the practices and the therapeutic. Ultimately we need an approach to dying that goes beyond the mere therapeutic and allows for a broader moral imagination than that which late modernity can provide.

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Joel James Shuman and Keith G Meador, Heal Thyself, (Oxford University Press on Demand, 2003), 80. Alasdair MacIntyre, After Virtue. (Duckworth, 2007), 187.

Chapter 1: The Making of a modern death

Modern scientific medicine has made huge advances in the treatment of many conditions, however, this seems to have been accompanied by increasing difficulty in accepting and dealing with our mortality. There have been attempts in recent years to engage society with its mortality, most famously through the death awareness movement. However, the resurgence of interest in death came about because of the problems generated by the modern medicine that preceded it. In order to discuss contemporary approaches to death I am required to give a brief account of modern medicine and how it has been seen to be a problem. We begin by examining the position of medicine in society and some of the ways that medicines narrative can pose a problem for the dying. We will then move on to discuss several responses that contemporary society has offered with regard to dying well; what I have termed the therapeutic approach. These include the work of Elizabeth Kbler-Ross and the palliative care movement.

1.1 A short history of modern medicine and how dying became a crisis

In its summer 2013 advertising campaign, Cancer Research UK made the following statement.

Research has beaten polio. Research is beating HIV. One day, research will beat cancer. Help us make it sooner.6

The link here is made between polio (an infectious disease that was driven from western nations over fifty years ago through the use of vaccines) and !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
6

TV advert, summer 2013, Cancer Research UK, Cancer Research UK, accessed November 11, 2013, https://www.youtube.com/watch?v=OL-gWUHWkR0.

cancer (a term used to describe a huge variety of often poorly understood diseases associated with older age and smoking). The chain connecting the past (polio) and the future (curing cancer) is HIV, another infectious disease that is by no means cured but has become, with huge investment of resources, a manageable chronic disease. The past, the present and the future are combined together in the statement with the implicit assumption that medical progress is inevitable no matter what the disease.7 Space does not permit a substantial rebuttal to this idea, however there is no scientific reason that a cure for cancer is inevitable, yet the narrative of modern medicine prevalent in contemporary society has led us to believe just that.

Jeffrey Bishop contends that medicine has presented us with a simple narrative of progress when in reality it is much more complex. Medicine tends to perpetuate a certain naive understanding of its progress8 Modern medicine is reported as an unstoppable force of progress. Each month, there is a new discovery or breakthrough, a new test or a new treatment. What might have killed our parents may well not kill us. In reality, medicines progress and position in society today is much more complex than that. As an illustration, consider the following two examples of medical advancement in the twentieth century: Alexander Fleming and the discovery of penicillin and Christian Barnard and the first human heart transplantation.

Alexander Fleming was one of the physician/scientists that emerged from the new 19th century idea of the physician. His lab work, and almost accidental discovery of what became penicillin in 1923, undoubtedly saved millions of lives from overwhelming bacterial infection. He wore the white coat of the scientist and his tireless lab work was ultimately translated into a huge public health improvement. The incontrovertible success of penicillin was tied to the !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
7

On their website, in a section entitled our ambition, is the statement, Sooner or later we will find cures for all cancers. Lets make it sooner. Our Story, Cancer Research UK, accessed November, 2013, http://www.cancerresearchuk.org/about-us/who-we-are/our-story. Jeffrey Paul Bishop, The Anticipatory Corpse, (University of Notre Dame Press, 2011), 61.

physician and the white coat of the scientist. Here we had tangible evidence that science was progressing human existence with the physician at the centre.

Christopher Barnard was a South African surgeon, famous for performing the first heart transplant in 1967. The late sixties were a time of high optimism for science and the future of the human race. This was at the height of the space race, two years after the first heart transplant, man would walk on the moon. The successful transplantation of the human heart (traditionally seen as the seat of the soul or the emotions in late western culture) fitted seamlessly with the science fiction reality of the day. The almost immediate9 death of the recipient, Louis Washkansky, is seldom remembered in a decade where science and medicine seemed capable of anything.

There is a marked contrast between the two discoveries. Penicillin is a low risk intervention and has prevented, at a relatively low financial cost the premature deaths of countless numbers of human beings. In contrast, heart transplantation is available only to a very small number of human beings who are usually older and have other chronic medical problems. It requires colossal medical resources, carries a high short-term risk of mortality and even patients who receive a successful transplant carry a relatively limited life expectancy. Both are regarded as major medical advancements with the same origins in modern scientific medicine, yet one is a major advance for its genuine impact on public health and the other could be considered a major advance for simply doing what no one thought could be done.10 For the patient this leads to a belief in medicine, that if they can transplant a heart for that man then surely I too can benefit. The point here is that any description of !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
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Washkansky died just eighteen days after the heart transplant.

10

It should be said that heart transplantation has become a much more successful procedure in recent years and has provided significant quantity and quality of life for many recipients. However it will still only ever be available to a small number of patients and remains dependant on the supply of organs from beating heart donors which comes with its own ethical problems which are beyond the scope of this study.

medicine that is a simple narrative of progress is somewhat reductive. There were many factors that led to medicines central place in our thought and in our culture. It is deeply tied up with what we want to believe about medicine. Ivan Illich puts it this way; it provides them with an abstract assurance that salvation through science is possible.11 Modern scientific medicine gave us a narrative powerful enough to sustain the myth that medicine can help us to avoid the reality of our deaths. Hauerwas writes, in such social orders, medicine becomes an insurance policy to give us a sense that none of us will have to come to terms with the reality of our death12

1.2 What modern medicine has taken from us

Ivan Illich, the Austrian philosopher, wrote in 1975, the medical establishment has become a major threat to health. and with regard to pharmaceuticals, the pharmaceutical invasion leads him to medication, by himself or by others, that reduces his ability to cope with a body for which he can still care.13 Illich was severely critical of modern scientific medicine and its role in society and individuals lives. He viewed medicine as deeply damaging to the basic nature of human life and existence. He thought that physicians, who, as societys arbiters of the body, were the only people able to declare the individuals status as sick or healthy. This authority undermined peoples ability to selfcare for their bodies. He suggested, more health damage is caused by people's belief that they cannot cope with their illness unless they call on the doctor than doctors could ever cause by foisting their ministrations on people.14 Our ability to self-care for such simple conditions as sore throats and cough has been compromised by the pervasive presence of medical !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
11 12

Ivan Illich, Medical Nemesis, (Bantam Books, 1977), 120.

Stanley Hauerwas and Charles Robert Pinches, Christians Among the Virtues, (Univ of Notre Dame Pr, 1997), 169. Illich, Medical Nemesis, 11, 85. Illich, Medical Nemesis, 66.

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practitioners. Prior to the widespread availability of physicians to see such minor conditions, people had to develop their own resources for self-care or draw upon the resources of the community in which they find themselves. Illichs denial that modern medicine has made any positive impact on society somewhat weakens his overall message as there are many clear examples where a medical advance has made a positive impact on both quantity and quality of life. Despite this, Illich makes a strong argument that by deferring so much to modern medicine, especially in minor health matters, we have lost something that was truly valuable to us: namely our ability to self care for our own bodies. This is not to suggest that we should abandon our doctors but it is a reminder that our bodies are just that our bodies. They do not belong to the physician.

1.3 Death as a crisis in modernity

The death we hope for is a mixture of statistics and optimism. The average life expectancy in the UK is now just over eighty years of age.15 Many people live independently in their homes with good health until their death in old age. However, a simple walk through a hospital, nursing home and hospice shows that for many people, a healthy, independent life until eighty years of age is simply not going to be possible. The ultimate belief is that it is modern medicine that will enable us to live this healthy, independent life ending in a quiet peaceful death in our sleep at the age of eighty. The statistics give us numbers that lead us to believe a quiet peaceful death at the age of eighty is not just something we can hope for but something to expect. Illich puts it this way, in our century a valetudinarian's death while undergoing treatment by clinically trained doctors came to be perceived, for the first time, as a civil right.16 This expectation that medicine can keep us from what we perceive as !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
15

Life Expectancies, Office for National Statistics, accessed November 11, 2013, http://www.statistics.gov.uk/hub/population/deaths/life-expectancies. Illich, Medical Nemesis, 200.

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a premature death is a major obstacle to dying well. If we have lived a life where death was expected to be far away and controlled then we are challenged when it falls below this expectation. This description of the role medicine plays in our lives is leading us towards the idea that death has become a crisis in late modernity, one that we do not have sufficient resources to deal with.

As we have seen our relationship with medicine when we are healthy lays a foundation for our relationship with medicine when we are ill. Perhaps most significantly, when we have a terminal illness it is the doctor who tells use we are ill. It is not just that the doctor has the power to name the disease, they also name and define our very health or ill-health. Frequently the patient will not feel like they are dying. Someone whose widespread, incurable lung cancer is diagnosed following a cough does not feel ill. They have a cough; they do not feel like they are dying. Yet this is exactly what the doctor tells them. While the doctor does not create the disease, it is in the act of naming the disease to the patient that creates the sick person. For some of us, it is only when the doctor says we are dying that we allow ourselves to believe it. As a result, few of us are willing to consider our deaths until they have been named by the doctor as inevitable. We depend on the medical profession to either help us avoid illness through prevention or to define our deaths for us. On the journey medical advancement has brought us on we have lost understanding of the narrative of our deaths. To be sure there is a narrative but it is not our own, instead our deaths are kept separate from our lives and it is difficult to see the relationship between the two.

1.4 Contemporary responses to the dying crisis

What has preceded is somewhat of a caricature of how we die today attached to machines, cared for by disinterested health professionals who instrumentalise the human body, fearful and out of control in our final days. In reality, there are many who recognize the limitations of modern medicine and !
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the care it provides for the dying. There have been numerous attempts at dealing with the dying process and providing a modern narrative to death. An attempt to provide a good death is an increasing response to the somewhat cold and technological aspects of modern illness. There is no shortage of books and articles, both in the medical literature and in the lay press, about how dying has become increasingly difficult in an age where death and dying is dominated by modern medical care.

I approach the modern notion of a good death from several directions. Firstly I examine the work of Elizabeth Kbler-Ross whose seminal work On Death and Dying and work that followed heavily influenced how those of us in late modernity understand the dying process. Secondly we will examine palliative care, or the hospice movement, as an example of modern medicines own attempts to deal with its shortcomings in the care of the dying. Together these form what I have called the therapeutic approach.

1.5 On Death and Dying and The Death awareness movement.

On Death and Dying was first published in 1969 and was formed from the transcripts of interviews with terminally ill patients between Kbler-Ross, the patient and often a chaplain. She famously described five stages17 that a patient underwent as they approached their death. On Death and Dying is a remarkable book as it was the first major account of modern, medicalised dying. All the patients in the interviews were inpatients in a hospital, many undergoing active surgical or chemotherapy treatments for what were inevitably terminal illnesses. Many patients were unaware of the fact that they were dying, either due to withholding of such information by their physicians or a denial of their deaths as Kbler-Ross explores.

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The stages as described in the book are: denial and isolation, anger, bargaining, depression and acceptance.

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As a scientific study (which is how Kbler-Ross viewed the seminar that formed the basis of the book), On Death and Dying is an observational study. She is providing descriptive, qualitative data on dying in the modern age. However, what is implicit in the book is that what Kbler-Ross described is normative for human beings. In other words the stages that she observes are what we ought to experience in order to die a good death. Kbler-Ross is not by any means explicit on this but it does seem implicit in her work. Some of her statements in the book are revealing as to what she perceives as the good death, if we tolerate their anger, whether it is directed at us, at the deceased, or at God, we are helping them take a great step towards acceptance without guilt.18 Acceptance without guilt is the goal here, there is no discussion on larger questions as to what life and death is for, if indeed it is for anything. Acceptance without guilt is the telos of the good death in KblerRosss view. This is in marked contrast to the Christian telos of dying well that we will discuss in chapter two.

Kbler-Rosss book is vital in that for the first time it really listened to the patient and what they were experiencing. It took them away from the context of the hospital and allowed them to talk freely about their experience. It taught generations of those who deal with the dying ways of speaking to them and understanding their situation. However, it assumes the central philosophies of the day: the patient is an individual, the free, independent moral agent of modernity. In other words patients are individuals and must be at the centre,19 or at the very least, that the patients understand themselves as being at the centre. Secondly it assumes that guilt is a bad thing; that it is pathological. If a guilt free acceptance of death is the highest good for the dying then it is not clear if Kbler-Rosss method deals sufficiently with that guilt. Underlying these is the more fundamental problem of methodology; !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
18 19

Elisabeth Kbler-Ross, On Death and Dying, (Routledge, 1973), 159.

She states, it would take so little to remember that the sick person too has feelings, and has - most important of all - the right to be heard. Kbler-Ross, On Death and Dying, 7.

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namely, that a descriptive account of modern dying does little to tell us what modern dying should look like. It is assumed here that guilt-free acceptance is the highest good but there is little to substantiate this. Despite the fact that Kbler-Rosss work has been used to describe and even give guidance for a good death, it provides insufficient moral discourse to justify or enable such use. To put it another way, it is insufficiently teleological to provide individuals or communities with sufficient resources to help them understand and deal with their dying. This will be discussed in much greater detail in chapter three.

Interestingly Kbler-Rosss ideas show a degree of development over time and in later works she increasingly articulates how death is not the end of life. In an article titled, Death Does not Exist, she wrote

Death is simply a shedding of the physical body like the butterfly shedding its cocoon. It is no different from taking off a suit of clothes one no longer needs. It is a transition to a higher state of consciousness where you continue to perceive, to understand, to laugh, and to be able to grow... the only thing that you lose is something that you don't need anymore, and that is your physical body.20

Here we have an expression of mind-body dualism that is often present in contemporary literature on death. There is a persistent denial of a Christian after life, but there remains the idea that something of us continues after we die. This idea is a powerful and pervasive one that is commonplace in those who write about the good death. It is not always expressed in spiritual terms but often in how one lives on, either in the work we have produced, or in the relationships we had with people we loved. There is great resistance at a popular level to the idea that our deaths have no meaning. Death is frequently !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
20

Elizabeth Kbler-Ross, Death Does Not Exist, CoEvolution Quarterly, Summer (1977), accessed January 12, 2014, http://www.wholeearth.com/issue/2014/article/379/death.does.not.exist.

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bound up with questions of meaning.21 The rhetoric here is intended to lessen peoples fear of death, and while it may indeed have that effect, its not clear if that achieves anything. The Christian ethicist, Paul Ramsey was deeply critical of the idea that death could be regarded as a neutral event,

Death is simply a part of life, we are told, as a first move to persuade us to accept the ideology of the entire dignity of dying with dignity. A singularly unpersuasive proposition, since we are not told what sort or part of life death is. Disease, injury, congenital defects are also a part of life, and as well murder, rape, and pillage. Yet there is no campaign for accepting or doing those things with dignity.22

Ramsey makes an important critique of Kbler-Ross and others arguing that the issue is more complicated and ultimately depends on what you think life is for and how death fits into that view. We will return to such ideas in detail in chapter three.

1.6 The hospice movement and the development of palliative care

We turn now to palliative care, a movement to improve the care of the dying from within modern medicines own ranks. Palliative care dealt with one of the major problems that modern medicine faced what to do when cure was no longer possible. With its relentless success against disease, the battle that modern medicine fought was primarily one of cure. New frontiers were being opened yearly in the middle of the twentieth century with diseases that were previously thought to be universally fatal now having effective treatments. The aggressive curative approach to the patient became the dominant mode of thought for the physician. However, many patients still succumbed to !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
21

For a much broader discussion on this see, Charles Taylor, A Secular Age, (Cambridge: Belknap Press, 2007), 720-726. Paul Ramsey, The Indignity of 'Death with Dignity' in On Moral Medicine, ed. M Therese Lysaught and Jr Joseph J Kotva, (Wm. B. Eerdmans Publishing, 2012), 1044.

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diseases, even those for which physicians thought they had effective treatments. With all the focus on curing the patient, there was little thought given to those who could not be cured. They received less attention and less care than those who remained potentially curable. Palliative care sought to address this need.

The origins of palliative care lie with Dame Cicely Saunders, who worked as a nurse, social worker and physician at various points in her career. She felt called by God to attend to the care of the dying. From her early days as a nurse, she felt that medicine had abandoned those for whom no cure was possible and did not even deal well with the physical pain of the patient.23 This involved not just the treatment of physical pain but what Saunders called total pain which included the loneliness and abandonment felt by those who were dying. Total pain involving all aspects of the patient would naturally require total care. There is no doubt that palliative care met a need in this regard for the care for the dying.

There have been many critiques of palliative care in recent years. These criticisms are largely directed, not at the origins of palliative care but how it has changed and developed over the years. It is helpful at this point to examine some sections of the World Health Organisation (WHO) definition of palliative care as a reflection on the philosophies underlying it.

Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with lifethreatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. Palliative careaffirms life and regards dying as a normal process integrates the psychological and spiritual aspects of patient !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
23

Bishop, The Anticipatory Corpse, 254.

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carewill enhance quality of life, and may also positively influence the course of illness.24

Perhaps the most important thing that should be said about the definition is that it seems to not merely describe what palliative care is, but goes further to describe what a good death, under the auspices of palliative care will look like. In The Philosophy of Palliative Care, Randall takes similar issue with the definition saying, it seems that its function is not simply to state what palliative care is about, by way of a description of the way things are, but rather to fulfill a normative function in stating the way things ought to be.25 We see here a similar issue to that of Kbler-Ross. Implicit in the description of how we might die is the normative account of what a good death looks like. This is important because it suggests palliative care is putting forward an ideal of what is required for us to die well. While it may not give specifics on what they think a good death is they are stating which aspects of our existence are important to be addressed. For example it states that palliative care affirms life and regards death as a normal process. While it is of course true that all must die, saying that death is a normal process suggests that anger at the fact that one is dying, or that ones loved one is dying is inappropriate. Why should we be angry at something that is normal? Any anger at death must therefore be pathological.

The definition also claims relief of suffering from dying by means of early identification and impeccable assessment and treatment of pain and other problems. The implication of this is that you will suffer without the involvement of palliative care. Palliative care possesses a knowledge and skill that you as an individual, or your community do not. These resources are not just pharmacological resources for treating pain but extend to the whole !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
24

WHO definition of Palliative Care, World Health Organisation, accessed November 19, 2013, http://www.who.int/cancer/palliative/definition/en/. Fiona Randall and R S Downie, The Philosophy of Palliative Care, (Oxford University Press, 2006), 13.

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process of what it means to die as a human being. In other words, just as the patient can only die when the doctor says that they can, so too the patient needs an expert to instruct them in the manner of dying. Death becomes an expertly managed process. In The Anticipatory Corpse, Bishop speaks critically of this absolute tendency in palliative care, treating total pain with total care can be totalizing.26 Again it should be stated that it is only recently that palliative care could be seen as moving towards a positive articulation of a good death. In its early origins, Saunders work was primarily seeking to redirect medicine towards its primary responsibilities for the patient and to promote caring even in the absence of potential cure. Ultimately, the dying patient under palliative care is controlled and managed in a similar manner to medicalised dying even though on the surface it appears that the patient is the one at the centre making all the decisions and achieving their own goals.

1.7 Conclusions

In summary therefore there have been several advances in combating the problems of modern medicialised dying described in the early part of this chapter but neither the work of Kbler-Ross nor the palliative care movement have paid sufficient attention to the moral complexities involved in how we die in the modern age. Both have an overwhelming focus on the free, autonomous moral agent and while both deny claims at being prescriptive for what constitutes the dying well, it can be seen that both make implicit claims for how we should die. When we return to the therapeutic approach to death in chapter three, we will explore in detail how the prevailing philosophies of modernity have contributed to such an insufficient and incoherent view of death.

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26

Bishop, The Anticipatory Corpse, 255.

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Chapter 2: The Christian tradition of dying well: the virtues reborn

We have already examined the therapeutic approach to dying, both in its most problematic aspects and attempted corrective efforts orientated towards the good death. We have noted some problems with even the best death model that contemporary society has to offer. We turn now to exploring specifically Christian traditions of dying in order to find a structure, or approach to death that may be of some benefit in the contemporary era. This chapter focuses on the ars moriendi genre of Christian literature and in particular on two contemporary studies of the ars moriendi literature, Allen Verheys The Christian Art of Dying and Christopher Vogts Patience, Compassion, Hope, and the Christian Art of Dying Well. I refer to the approach to death found in the ars moriendi as the practices based approach. As the chapter unfolds I will highlight the importance of the practices contained within the tradition. The ars moriendi (the art of dying) refers to a substantial body of Christian literature on death and dying that first emerged in the 15th century and continued as an identifiable genre that continued well into the 17th century. Christopher Vogt has written on the later ars moriendi literature and we will examine this in due course but firstly we turn to the earlier, medieval ars moriendi.

Verhey describes the early ars moriendi literature as the late medieval equivalent of the self-help literature you can find at your local bookstore.27 He says this, not to undermine its value but to point to its popularity, accessibility and decidedly non-elitist audience. Verhey examines two of these very early works in the ars moriendi tradition, the first, the wood block, pictorial series referred to here as Ars Moriendi and an anonymous tract linked to it called The Crafte and Knowledge for to Dye Well.28 The most popular 15th century version of the ars moriendi was a pictorial, wood block series with images !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
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Allen Verhey, The Christian Art of Dying, (Wm. B. Eerdmans Publishing, 2011), 79. This will be referred to as the Crafte from here on.

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contrasting the virtues and temptations facing the Christian on their deathbed.29 These wood blocks allowed the non-literate to be educated in how a Christian might die well. They were incredibly popular as evidenced by the fact that twenty percent of the surviving wood block books in the world are actually copies of this early 15th century Ars Moriendi.

2.1 Problems with the medieval ars moriendi

The wood block series contains reflections of the dominant theology of the time, which had marked Hellenistic with Stoic and Platonic tendencies. These influences warrant examination as they have relevance to the attitude with which Christians view death. For example The Crafte quotes Psalm 116:15, Precious in the sight of the Lord, is the death of his faithful ones. The author uses this quote as a commendacion of death. Death, for the Christian is something to be embraced, to be greeted warmly. It suggests that the Psalmist is focused on life after death. This quote from the Psalms is accompanied by quotes from Seneca, the stoic writer. Verhey takes issue with this and suggests that the idea that death can be commended and embraced is not consistent with the scripture cited. He quotes multiple scriptural sources and highlights that Psalm 116 sees death as a threat and enemy. Verhey sees the Platonic idea of the immortal soul as having influence here, it is the conception of the immortal soul that is finally in control of the commendation of death.30 Verhey sees this aspect as the most problematic part of the 15th century ars moriendi - the idea that death is to be embraced. The soul will finally be able to escape the weakness, sins and frailties of the body and so death is not something to be feared and can even be greeted warmly. There is no mention of the resurrection of the body and even the relationships we engage in are regarded as sinful temptations that distract us from pure !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
29

These images are freely available at the following address and will form a useful aid to the text. Ars Moriendi, Wikimedia Commons, accessed January 14, 2014, https://commons.wikimedia.org/wiki/Ars_moriendi. Verhey, The Christian Art of Dying, 105.

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devotion to God. It is fascinating to see that the very thing we are most critical of in the medieval ars moriendi is something that is prevalent in the contemporary literature on death and dying.31

Verhey attempts to redirect focus from the commendation of death with which he takes issue towards a celebration of life, which he is keen to promote. He states that the focus on celebrating life is required by the Biblical narrative and he provides ample evidence that a preparation for death requires lifelong preparation. Again we see a contrast with the therapeutic approach, which only begins when someone is dying. Scant attention is given to the deaths that lie before us all and death is something that many of us consider only once its inevitability is finally apparent. Contemporary notions of the good death or death with dignity both take a positive view of death as something natural, similar to childbirth as discussed in the first chapter. Verhey does well to state that the medieval ars moriendi gets it wrong in commending death Christians are unable to see death as a natural event that we can embrace. While the ars moriendi was wrong on this issue, Verhey makes a good argument that the ars moriendi is out of step with the more substantial body of Christian tradition on this point.

Further problems arise in the wood block ars moriendi with its focus on the deathbed drama. The fundamental issue here is that the entire relationship with God and the eternal salvation of the dying man, Moriens,32 is dependent on his mental and spiritual attitude at the time of death. The deathbed is the focus of life and salvation and little attention needs to be paid to the life that comes before it. This I see as a major flaw in the ars moriendi, especially if a virtue ethic approach is used in appropriating such material for our time. It also seems to set the medieval ars moriendi in marked contrast with the later, !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
31

See chapter one and the discussion on Kbler-Ross and her later writings on death as growth. Moriens is the central character of the Ars Moriendi and it is he who is on the deathbed in each scene.

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ars moriendi literature, which described a much greater emphasis on the importance of a life well lived in order to approach a good death. Verhey mentions this shortcoming in the early stages of the book saying, it was not a reminder of death that we may live well it was not an ars vivendi33 but he pays insufficient attention to something that I see as a major shortcoming of the wood block ars moriendi. I think that this somewhat undermines his later conclusions that a good life is essential to a good death, given that his primary source material makes no such claim.

It is interesting to note a further connection here to the therapeutic approach of chapter one. The focus in On Death and Dying is that the patient appropriately moves through the five stages in order that they may reach a guilt free acceptance of death. While there is no threat of lost salvation if a palliative patient does not reach this point, there remains a focus on the deathbed as the central part of dying well in the therapeutic approach. The later ars moriendi in particular moves beyond the deathbed to a focus on the life lived and the type of person you become as the key to dying well.

2.2 The virtues, polis and the practices required for dying well

Despite these significant shortcomings in its theology, Verhey points out that this wood block series of images still has several important contributions to make to the Christians understanding of their death in our contemporary medicalised context. It is to these that we now turn in anticipation of further examination in the final chapter. There is a sustained focus on the virtues for dying well. Each wood block image is paired: the virtue of faith paired with the temptation to despair for example. Each deathbed temptation is presented with a paired virtue to counter it. Verhey names these as, faith, hope, patience, humility and one that he names letting go. While it seems reasonable to describe faith as a Christian virtue, it is by no means clear in !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
33

Verhey, The Christian Art of Dying, 81.

23

Verheys text what it is that makes faith a virtue, or if what the ars moriendi and Verhey describes as a virtue is in any way comparable with contemporary notions of virtue and virtue ethics. The book itself has a substantial index but there is not a single entry for virtue, which seems a remarkable oversight given its conclusions. Indeed, while a faithful Christian is considered to be in a better position than one without faith, it is not clear how we develop such faith, or how such faith enables us to resist despair. The simplistic suggestion is that simply believing and trusting in God is the virtue here described. I commend Verhey for his focus on the virtues as a key feature of dying well as a Christian, however there is insufficient description here on the development of the virtue of faith.

Verhey notes that the Crafte does instruct people to reflect on Jesus, his life, his passion and his death. He says, our effort to imagine a contemporary ars moriendi will take this as the fundamental clue from the fifteenth century, that the story of Jesus' dying is somehow normative for a Christian's dying and caring for the dying. He goes on to focus on Jesus life, stating, when we are formed by the story of Jesus, these virtues will be formed in us.34 It is at this stage that the relevance of the virtues for dying well becomes clearer. A life formed and shaped by Jesus life and death will be one where the person can die well. The virtues here are not just things we believe or acknowledge but are deeply integrated into our lives and character and subsequently shape our lives and deaths. This description of virtue is key to our understanding the barriers posed by contemporary notions of dying well and we will explore this aspect of virtue as being formed by a story in the final chapter. The other aspect that stems from Jesus as normative for our living and dying is that is not an isolated, individual task. Christians have always understood that being shaped by Jesus is not something one does on ones own. For now it is sufficient to say that the ars moriendi require us to be more

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34

Verhey, The Christian Art of Dying, 163.

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than individuals, in contrast to the therapeutic approach where who we are socially is of much less importance.

Although I have so far been critical of the medieval ars moriendi for paying insufficient attention to the preceding life of the dying, it is worth noting that embedded in all the wood block images are various practices of the church that support the virtues. For example in the wood block depicting faith, there is an angel at the bedside of Moriens reading scripture. The practice of reading scripture is common in the life of the Christian, either in personal use or public worship; the reading of scripture is ever present. While it is not made explicit in the wood blocks,35 the presence of scriptures in the life of the Christian and the Church do indeed suggest that the life prior to death had significance and required habituation or at least a community that exists where these practices can be sustained. As further examples of such practices consider the following: in the illustration of the virtue of hope, the angel cites Saint Bernards invitation to meditate on the cross; the illustration on the virtues of love and patience depict Moriens praying to the saints; the illustration of humility shows Saint Anthony, famed for his care for the sick, as an example for Moriens to remember and here it can be assumed that the practice of the care for the sick would be commended in life prior to ones dying moments; finally in the illustration of the death of Moriens, Jesus is pictured on the cross (as we remember in the Eucharist) and a monk with a candle at the bedside of Moriens, praying the words he cannot himself say.36 In each of these scenes various practices of the Church are demonstrated to the reader. While this is all in the context of the deathbed drama, it seems fairly obvious that these practices would be performed better if they were commonplace in the life of the individual as indeed would have been the case. It needs emphasised again, however, that all of these practices, so key to the ars moriendi view of !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
35

Given the context where the church and Christianity was so deeply embedded in life of the people there was little need to make this explicit. For more discussion see the section on social imaginaries from Taylors A Secular Age in chapter three. Verhey, The Christian Art of Dying, 113-134.

36

25

dying well, were not practices of the individual and indeed would have made no sense without the community that sustained such practices. This is in contrast to the therapeutic approach where the individual must navigate his death on his own, all be it with the guidance of experts around him. There is no necessary sociality or tradition in the therapeutic approach and as result no community to sustain such practices.

In summary, the wood block Ars Moriendi and its counterpart The Crafte and Knowledge for to Dye Well have a focus on the virtues for dying well and a focus on the life and death of Jesus as normative for Christians. In particular these virtues appear to be attained in association with the common practices of the church. While the contemporary Christian will find many problems with these 15th century texts there is undoubtedly the opportunity for discussing such ideas in a modern context of dying.

2.3 Development of the ars moriendi tradition

Vogts book, Patience, Compassion, Hope, and the Christian art of Dying Well,37 focuses on the later, mainly English, works in the ars moriendi tradition, again with a view to examining the virtues required of a Christian to die well. He states, the authors of these works viewed dying as a task or an art a learned behaviour that one could perform either well or badly.38 Again, we have the focus on the virtues as the key to dying well, and in particular, a practice based, life-long approach to virtue that leaves us prepared for death.

Vogt begins his commentary on the ars moriendi with Erasmus Preparing for Death. Preparing for death is regarded as the seminal work in this area, decisively shaping the genre as a whole.39 He notes, just as Verhey did, that !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
37

Christopher P Vogt, Patience, Compassion, Hope, and the Christian Art of Dying Well, (Rowman & Littlefield, 2004). Vogt, Patience, Compassion, Hope, and the Christian Art of Dying Well, 2. Vogt, Patience, Compassion, Hope, and the Christian Art of Dying Well, 16. 26

38 39

these later, mainly English works, also had enormous popular appeal and were translated into multiple languages and were widely read by both Protestants and Catholics, something quite remarkable given the pervasive conflict between the two.

Perhaps one of the most significant differentiating features of Preparing for Death, from the earlier medieval ars moriendi is the shift in focus from the deathbed to a reflection on the content of the Christian life. Vogt counters this idea with a quote from Preparing for Death, no matter what kind of death befalls us, we should never be judged by it.40 This is an important development in the literature and mirrors Christian thought developing at the time. It leads to the idea that the virtues are not merely something to be exercised on our deathbeds as a way of warding off the Devil, but something that must be expressed throughout our lives; in other words we must become certain types of people in order to die well.

Erasmus goes on to describes his view on the virtues thus, an action continually repeated will become a habit, the habit will become a state, and the state become part of your nature.41 Here Erasmus is particularly talking of reflection on the death of Jesus and the Eucharist, but the point is clear that if one reflects often on the death of Christ and what it means for the individual then this will better prepare us to face our own deaths when the time comes. Erasmus goes on to emphasise the repeated practice of mercy and of regularly spending time with those who are dying as ways of preparation for death. This focus on character development appears absent in the therapeutic approach of chapter one. While the death awareness movement was engaged in getting society to reflect on their death prior to their deaths it was largely in an attempt to encourage people to reflect on the type of death they !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
40

Erasmus, Preparing for Death (De Preperatione Ad Mortem), in Collected Works of Erasmus, ed. John W O'Malley, trans. John N Grant, (Toronto: University of Toronto Press, 1998), 420-421. Grant, Preparing for Death (De Preperatione Ad Mortem), 421.

41

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might want. Did they want to have invasive, aggressive medical therapies in later years? Did they have preferences for where they died? Palliative care was there to assist individuals to reach their own goals for their deaths. There was an absence of reflection on what type of person you might need to be to achieve those goals.

2.4 The English ars moriendi

In addition to Erasmus work, we will briefly examine William Perkins work and that of Jeremy Taylor for evidence that the virtues were key to Christian dying. William Perkins, the English Puritan preacher and theologian, wrote A Salve for a Sicke Man in 1595, writing on similar themes to Erasmus with advice for how the Christian could die well. He advised, as Erasmus did, that the Christian should spend time with the dying as a means to develop the virtue of compassion. Vogt suggests a link between compassion and faith here. Compassion ultimately finds itself redirected towards the renewal of faith. So the individual who spends time comforting the dying not only has to develop dispositions of concern42 but also has to prepare to communicate and nurture their own faith so that it will help to bolster and renew the faith of the dying person. Compassion here is a virtue in the sense that it needs to be practiced and developed. Spending time with the dying in the context of faith helps us to develop compassion for our fellow Christian. If we are people who are compassionate with the dying then that will help in our preparation for own deaths.

The second virtue that Perkins highlights, is that of patience:

he that would able to beare the crosse of all crosses, namely death itselfe, must first learne to beare small crosses which I may fitely

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42

Vogt, Patience, Compassion, Hope, and the Christian Art of Dying Well, 28-29.

28

terme little deathsbefore we can well be able to beare the great death of all.43

Perkins suggests that we must learn to express patience with the smaller, less consequential troubles in life in order to be prepared and capable to go through the more significant traumas. Perkins links this patience to obedience to the divine will. Enduring suffering requires obedience to the will of God, and of course that links it back to the repeatedly highlighted virtue of faith. 44

The last text in the ars moriendi tradition that Vogt examines is Jeremy Taylors Rules and Exercises for Holy Dying. Taylor usefully divides his book into consideration and exercise. By consideration he refers to reflection upon life leading to death and by exercise he refers to specific practices that the Christian can engage in as preparation for dying. Like Perkins and Erasmus, Taylor also emphasises the importance of the lives we live for how we die. He has a particular focus on patience in suffering. He uses the model of Jesus and the cross for this and sees the example of Jesus developing the Christian in two ways. Firstly the Christian who is patient in suffering learns obedience to God, just as Christ was obedient to God on the cross. Secondly Taylor saw suffering as a kind of school for virtue.45 He writes,

we may reckon sickness amongst good things, as we reckon childbirth, and labour, and obedience, and discipline: these are unpleasant yet safe it is the opportunity and proper scene of exercising some virtues. It is that agony in which men are tried for a crown.46 !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
43

William Perkins, A Salve for a Sicke Man, in The English Ars Moriendi, ed. David William Atkinson, (New York: Peter Lang Pub Inc, 1992), 141. Vogt, Patience, Compassion, Hope, and the Christian Art of Dying Well, 30. Vogt, Patience, Compassion, Hope, and the Christian Art of Dying Well, 38. Jeremy Taylor, The Rule and Exercises of Holy Dying, (London: W Pickering, 1850), 85.

44 45 46

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This idea is problematic, as feminist scholars have heavily critiqued the kind of selfless endurance of suffering that is used as a justification to maintain the oppression of the powerless in society. If one can only become virtuous by the endurance of suffering then how can one justify fighting against injustice? In the context of sickness, the idea that we must suffer as we die in order to die well is problematic as it may lead to the Christian declining even pain relief in the days leading up to their deaths. That being said, there is no doubt that many people experience significant spiritual growth in the context of suffering, so the idea that suffering may lead us to develop virtues has undoubted merit, the issue here is more with the somewhat Stoic idea that suffering should be embraced or even sought out.

Virtually all of the authors examined by Vogt have an emphasis on memento mori, or remembering the facts of ones mortality.47 This reflection on the fact that we will all one day die was seen as a fundamental pre-requisite to the cultivation of the virtues for dying well. It would not have been particularly difficult to be reminded of the frequency of death five hundred years ago. Life expectancy was less than fifty years and infant and maternal mortality rates were huge. The ubiquitous presence of death to those who were alive would allow frequent practice of memento mori. In the artworks of the period that Jeremy Taylor was writing there is often a skull present on the desk, or in the study of the painting. The skull represented an ever-present reminder of the immanence of death.48 This obviously stands in stark contrast with contemporary society, which is frequently referred to as death denying, where most of us will die, not in our homes but in medical facilities. Here we find contrast with the therapeutic approach in that the ars moriendi encouraged people to reflect on their deaths long before they expected to die. !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
47 48

Vogt, Patience, Compassion, Hope, and the Christian Art of Dying Well, 41.

Grosveror Essay No 9, (The Doctrine Committee of the Scottish Episcopal Church, 2013), 21.

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2.5 Christian practices of dying well

As with the medieval ars moriendi, there are numerous appeals to Christian practices that are encouraged as an aid to dying well. Erasmus work recommended frequent confession with a priest. This was not just so that souls were spiritually prepared for death but that the repeated practice of confessing ones sins was integrated into their life so that it would be more naturally continued on the deathbed. Vogt writes,

repeated examination of conscience and repentance are not important merely to increase the chances that one will not be in a state of sin when death strikes; rather the repetition of these acts themselves is important because of their effects in our ability to perform them.49

For Erasmus, and Vogt following him, the repeated habituation of Christian practices was important on several levels for those who wish to die well. The first level is rather like that of riding a bicycle: you need to do it several times to attain proficiency. On a deeper level, habituation helps to shape and form our character. As noted earlier, an action continually repeated will become a habit, the habit will become a state, and the state become part of your nature.50 Reception of the Eucharist is described in a similar fashion. The significance for us here is that the traditions and practices of the Church not only communicate theology and spiritual truths but also are instrumental in forming the character of the faithful who will approach death as a particular type of people prepared in a particular way for their deaths. Here we begin to see how somewhat abstract theological virtues such as faith and hope are deeply embedded into the character of the church and the faithful. People who

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49 50

Vogt, Patience, Compassion, Hope, and the Christian Art of Dying Well, 23. Grant, Preparing for Death (De Preperatione Ad Mortem), 421.

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spend time on their knees in patient prayer before God will be more patient people.

2.6 Some problems with the later ars moriendi

The texts that Vogt highlights are not without their problems if they are to be adapted for contemporary use. They come from a diversity of theological backgrounds, many of which have been heavily criticised by contemporary Christian theology. While Erasmus and those who followed him emphasised the importance of living a good life, all of them saw the world as a deeply sinful place that was to be rejected in favour of union with Christ. They share this idea with the earlier, wood block Ars Moriendi. This form of dualism is considered highly problematic in contemporary theology. The authors were theologians of their time and it is hardly surprising that texts from the Middle Ages and beyond are not immediately applicable to contemporary situations, however, that in itself is not a reason to disregard them altogether.

2.7 Contrasting the ars moriendi with the therapeutic approach

There are assumptions that both the medieval and the later versions of the ars moriendi hold in common. Both assumed some of the underlying fundamentals of Christianity, in particular, that the life of Christ was somehow paradigmatic for how we as Christians should die. The medieval ars moriendi had a much stronger focus on the deathbed than the later literature that focused more on the good life required in order to die well. However, both had a recurring theme of remembering what God has done for us in order to remain faithful until our deaths. The later ars moriendi in particular had a clear articulation of what the good life, or its telos looked like. For Vogt, this was a life characterised by patience, compassion and hope as its central virtues. This good life articulated in the ars moriendi contained the practices of the church such as prayer, gathering together and the sacraments of the church. There is an underlying epistemology in the ars moriendi tradition that is in !
32

stark contrast with contemporary, secular notions. The ars moriendi tradition holds that the highest sources of knowledge and authority are those of scripture and the authority of the church whereas contemporary medicine holds empiricism as the arbiter of truth and the therapeutic approach holds the individual as the highest arbiter.

A further distinct characteristic of the ars moriendi literature is the practices associated with it. Be it the sacraments of the church such as the Eucharist, or the simple gathering of the faithful with the dying, or even the practice of individual prayer all these practices require a specific context or a community in order to make sense. Moriens is not required simply to reflect on his spiritual condition but to engage in the practices of the church. Although I have criticised the medieval ars moriendi for its deathbed focus and paying insufficient attention to the life before death, it does require the dying to engage in many of the same practices that they will have been performing throughout their whole lives, so even if it is not explicitly emphasising the importance of a life well lived the medieval ars moriendi assumes that Moriens will be well versed in the practices of the Church. These practices are of course not arbitrary but carry with them the embedded theology of the church and the story of Jesus. This is more clearly articulated in some of the later ars moriendi literature but it is there never the less. In the final chapter we will examine the importance of the fact that these practices are embedded in a polis with a distinctive tradition and associated goods.

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Chapter 3: Barriers to dying well in late modernity

The therapeutic and practices bases approaches to dying

To summarize what we have covered so far, we first described a brief history of modern medicine as a hugely successful enterprise with its main focus as the maintenance and restoration of health, however loosely that was defined. Despite its success in the prolongation of life, people still die suddenly and without warning at a young age, and ultimately death still awaits us all when medicine eventually reaches its limits of restoration. As patients approach their deaths they are left in somewhat of a vacuum, as the previous arbiter of life and health (the physician) has in a sense abandoned them. For the patient it is unclear how they should approach their dying. The death awareness movement attributed to the work of Elizabeth Kbler-Ross, began a public conversation on how we die, and if not necessarily intending it, offered an approach to death and a form of good death that one could aspire to. The palliative care movement arose from within the house of medicine as a necessary corrective to a medicine that was somewhat helpless in the face of a patient it could no longer cure. Palliative care not only offered physical symptom control but also endeavored to engage with the patient on a holistic and even spiritual level in order to achieve, if not a good death, at the very least the least worst death. In recent years, the idea of a good death and death with dignity have been increasingly discussed with particular emphasis on individual autonomy, and an emphasis that death is a natural event, somewhat akin to child birth. We termed the modern approach to death as the therapeutic approach as both of the sources we considered in chapter one stem from the therapeutic sensibility that has its roots in the moral imagination and ideology of late modernity that we discuss below.

This contemporary approach to death was contrasted with the Christian ars moriendi literature, a range of theological literature spanning the 15th to 17th centuries, articulating for the laity, the importance of dying well as a Christian. !
34

We noted an understandable theological evolution in the development of the genre but also a consistent focus on the importance of the virtues for dying well and an increasing focus on the necessity of an ars vivendi (a good life) in order to die well. Spread throughout the literature is an emphasis on Christian practices such as Eucharist, prayer and the reading of scripture in order to develop the virtues needed to die well. We termed this the practices based approach to death.

Some critiques of both the therapeutic and the practices based approach to death have already been offered in their respective chapters. At this stage I examine some of the more detailed theological and philosophical differences between the two and highlight the challenges facing someone who wishes to die well in the context of late modernity. I also articulate how a practices based approach like the ars moriendi gives a better account of human flourishing in death than the therapeutic approach. In chapter one I made the assertion that therapeutic approaches to death are insufficiently teleological to deal sufficiently with the challenges faced in dying well. This requires some substantial exploration in order to see its relevance to our primary question.

3.2 A brief philosophical history of the therapeutic approach

The argument I am putting forth on the philosophical underpinnings of the therapeutic approach depends heavily on the work of Alasdair MacIntyre and in particular his book, After Virtue. A thorough history and critique of modernity is well beyond the scope of this thesis and so my account will be necessarily brief. It can be very briefly summarized thus: the changes in moral imagination since the enlightenment have centered on the idea of the free, unencumbered self as the primary moral agent. This required the rejection of teleological ethical accounts and the institutions and practices associated with them. In their absence there is pressure on the individual to cultivate their own notion of self. This self is each individuals private good and other people are

35

there to be used as needed to bolster the development of the self.51 The therapeutic approach to death we outlined in chapter one has its origins in such principles.

The ideas contained in the above paragraph need some further brief exposition. In After Virtue, Alasdair MacIntyre outlines the problematic nature of current moral discourse highlighting its origins in the enlightenment rejection of teleological ethics and a shift to Kants idea of the free, unencumbered self as the primary moral agent. He writes, The most striking feature of contemporary moral utterance is that so much of it is used to express disagreements; and the most striking feature of the debates in which these disagreements are expressed is their interminable character.52 Because of the fundamental changes in moral discourse that have occurred since the enlightenment, the resolution of moral debates seems impossible. In essence, MacIntyre makes the argument that in the modern era of liberal individualism there is an absence of discussion about what constitutes the good in society. Indeed, as Shuman notes (quoting MacIntyre), The motto of modern individualism may be put thus: I am what I myself choose to be.53 Moral arguments are interminable because we have not articulated what life is for. This absence of a clear idea of the good has its origins in the fact that a group of radical individuals who make up a society have no shared practices or traditions that enable them to communicate any such goods coherently. This is reflected in the therapeutic approach to death that, in the absence of a robust notion of the good, effectively suggest that the best death one can achieve is that which you can choose for yourself. This change in the way we think and imagine our lives is central to the difference between the practices based approach to death and the contemporary therapeutic approach. That !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
51

I am indebted here to Joel Shuman and Keith Meador and their book Heal Thyself as useful summary and condensation of many of MacIntyres arguments. MacIntyre, After Virtue, 6. Shuman and Meador, Heal Thyself, 76.

52 53

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we have identified a difference in the way people imagine themselves in the 21st and 15th centuries is hardly a revelation but what I am suggesting here is that the change has been deleterious and to this we now turn.

3.3 Why the therapeutic approach is insufficient

There are two main ways in which the therapeutic approach fails. First is in its failure to articulate any clear notion of the good in society and secondly, and related to this, is the pressure on the self to continually establish itself and articulate for itself its own version of the good.

Regarding the first point we turn to Gerald McKenny who has written about human enhancement or advanced medical possibility in a way that is illuminating to our discussion of the origins of the therapeutic approach. By human enhancement he means to distinguish a kind of medicine that is distinct from that which is generally accepted as therapeutic. As an example, he would view antibiotics for pneumonia as an accepted therapeutic medicine but gene therapy for male baldness as falling into the category of human enhancement. McKenny holds that modern medicine, for us at the turn of the millennium, is a primary (perhaps the primary) discourse and practice through which we articulate and pursue views of the good.54 Modern society certainly does not possess a robust view of the good in a manner that Aristotle may have expressed but when we examine modern medicine we see reflected in it a contemporary narrative of what society sees as the good. McKennys insight here is useful to us as it allows us to use medicine as a means of examining the goods of society. The vast popularity of the technologies that McKenny outlines as human enhancement, suggests that the good that we are pursuing through medicine is somewhat similar to that of popular consumerist culture. McKenny argues that certain of the human enhancements are orientated !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
54

Gerald P McKenny, Enhancements and the Quest for Perfection, Christian Bioethics 5, (1999): 99.

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towards ends that are incompatible with Christian faith and practice. While Christians may be encouraged to value beauty with thanks to a good creator, human enhancement of beauty may not be orientated towards the same end. Ultimately McKenny finds the quest for perfection through human enhancement deeply problematic as as there is no telos or normative anthropology to determine the content of the perfection we seek and/or its proper limits.55 Modern medicine (and modern society in general) has abilities that far outpace any notion of what the good of society is. While contemporary society is set out in pursuit of many different goods (such as the eradication of male baldness,) it has no clear articulation of what human flourishing looks like. This is expressed nicely through the difficulties McKenny finds in the quest for perfection in the human body through enhancement technologies. McKennys insights are vital as the therapeutic approach to death has its roots in the very same ideas that he critiques.

Modern medicine, up to a point, has a reasonably clear sense of purpose or telos. The modern physician understands his role to be the maintenance and restoration of health. He applies physiological and anatomical knowledge to the patient and with the use of diagnostic technologies, therapeutic medicines and surgery he aims to eliminate disease from the body and restore health to the individual. It is just at this very point that the telos of modern medicine runs into difficulty. How is the person meant to live when the physical disease is over? What does it mean to be healthy? From the perspective of medicine there is no clearly articulated, normative notion of what the body is for when it is free from disease.56 Shuman puts it this way; we have become unable to speak of the body or its goods without doing so in the technical language of !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
55 56

McKenny, Enhancements and the Quest for Perfection, 102.

While this may be true for medicine, on a broader view it may be better to say that late modernity hides from us what it wants from our lives and our bodies. In fact as Shuman suggests, the final ends of both medicine and religion are increasingly determined by the desires of the individual consumer of medicine and religion, desires that are shaped in advance by the radically individualized consumer culture of this latest stage of modernity. Shuman and Meador, Heal Thyself, 26.

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sickness and disease.57 Extending from this, and more problematically for our subject is that modern medicine has no clear idea of what its purpose is when it can no longer restore the body to health.58 The dying body does not fit anywhere in modern medicines telos; it has no place for death. If McKenny is correct in his suspicion that medicine is the primary discourse and practice of the good in our society then it is no surprise that we run into significant problems when it comes to death because medicine itself is limited in its ideas of what life is for.

McKennys insights here are illuminating when applied to the therapeutic approach to death. The death awareness movement and palliative care practitioners pride themselves for taking a holistic approach to the individual. And indeed, in comparison to the violent, totalising medicine that Illich articulated, they have taken great steps in approaching the individual in their entirety. However they both fail in that neither articulates a clear and coherent normative anthropology; neither articulates clearly what the good of life is; neither is able to give a clear sense of what human flourishing looks like. Death is of course inevitable and comes to us all, and any account of the good life must deal with death and dying in some manner. However, without an idea of what this life should look like or what it should be orientated towards, it inevitably leads to a fundamentally inadequate view of life and therefore how to incorporate our deaths into any idea of human flourishing. Despite its insistence on not trying to provide a normative account of dying well, the therapeutic approach inevitable suggests one. Practitioners involved in modern end of life care have no desire to be prescriptive on what dying well looks like but whether they like it or not, a lot of contemporary reflection on death has assumed a normative role, no matter how conflicting and incoherent it may be. Modernitys rejection of a teleological approach to !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
57 58

Joel James Shuman, The Body of Compassion, (Basic Books, 1999), 82.

In contrast, Shuman talks about the significance of Christian practices such as baptism and Eucharist in defining the body for the Christian. In baptism our being is transformed and in Eucharist our body becomes part of Christs body. Shuman and Meador, Heal Thyself, 90.

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ethical questions has led to a confusing and incoherent discourse surrounding death in which well-intentioned contemporary movements have been unable to provide the dying with the resources necessary to die well.

We turn now to our second reason why the therapeutic approach fails. The post-enlightenment narrative is that we are in fact a people without a narrative, free to choose our own. As Hauerwas notes, ironically, however, the stress on autonomy turns out to produce just the kind of ahistorical account of moral agency that so effectively disguises medicines power over us.59 Hauerwas highlights here how the emphasis on autonomy, while meant to free us from the controlling, violent nature of modern medicine, has actually quite the opposite effect. The therapeutic approach originated out of objections to medicines controlling influence in our lives and deaths, but the account of death that it proposes does not possess the resources capable of sustaining a death that can in any sense be seen as ones own. There is certainly an irony here, that enlightenment rejections of traditions as basis for moral practice have not produced the free moral agents that it assumed we were. Instead, as Hauerwas notes, we are unable to escape the controlling influence of medicine. The work of Kbler-Ross and the palliative care movement may have made major steps in helping people to die well but they are fundamentally limited because they are rooted in the ideas of late modernity.

Shuman and Meador are deeply critical of the therapeutic sensibility and describe the culture of late modernity as deeply narcissistic on this point,

But all this self!talk, this emphasis on self!determination and self!actualization, is, in the absence of traditional social structures and practices, terribly problematic, leading to an emphasis on the welfare of

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59

Hauerwas and Pinches, Christians Among the Virtues, 168.

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the individual that borders on the pathological the self is called upon to assume tasks with which it cannot successfully cope.60

While their focus is not specifically on dying as a task to be performed, their comments are pertinent to our broader discussion. They argue that this pathological focus on the self leaves the individual with little option but to embrace the project of continual cultivation of the self,

Deprived of the institutions and practices that in traditional societies narrated the world and its history teleologically the modern subject is presented with a set of decidedly stark alternatives: Either she can engage as an individual in a deliberate and sometimes obsessive cultivation of the self, or she can face the ostensive meaninglessness of life in a world whose history is potentially just one damn thing after another.61

The emphasis on the autonomy of the radical individual of late modernity has the ironic effect of limiting their choices and driving them further into themselves and does not give them the option or opportunity to understand their lives and deaths in a broader manner. This tendency to encourage the development of the self has been recognized as a problem, especially within the palliative care literature. One of the major textbooks of palliative care, when discussing the good death has this to say,

much of the empirical work defining a good death has involved English-speaking Western populations in which individual decision making and autonomy is culturally rewarded the implication is that one can define a good death, and should achieve it. Unfortunately, !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
60 61

Shuman and Meador, Heal Thyself, 78. Shuman and Meador, Heal Thyself, 79.

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though propelled by positive intentions, such definition risks imposing an unintended paternalism.62

While there is some insight here that the good death is one that the modern person must create for themselves, and that this might be a problem, there is unfortunately no suggestion how to avoid the problem or indeed how it originated.

Hauerwas and Pinches in describing the violent, aggressive nature of modern medicine, note:

the simple fact is that we are getting precisely the kind of medicine we deserve. Modern medicine exemplifies a secular social order shaped by mechanistic economic and political arrangements, arrangements which are in turn shaped by the metaphysical presumption that our existence has no purpose other than what we arbitrarily create.63

They suggest that it is the assumptions of late modernity that created the type of medicine that we now feel is doing violence towards us in our lives and our deaths. This social imaginary, as Charles Taylor64 would put it, not only has produced the type of modern medicine that we are now reacting against, but it also determines the therapeutic approach to death that emerged in opposition to modern medicine. It does not have the possibilities or the resources to challenge the modern medicine it has created. It is limited by its abandonment of a teleological approach and therefore, as positive as examples such as On Death and Dying and the growth of palliative care have been, they are fatally flawed from the outset. If it can be accepted that the therapeutic approach is somewhat lacking then we need to examine how the practices based !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
62 63 64

Geoffrey Hanks, ed., Oxford Textbook of Palliative Medicine, (OUP Oxford, 2011). Hauerwas and Pinches, Christians Among the Virtues, 170. See the discussion on Taylors A Secular Age below.

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approach is not just different but how it is better equipped to give an account of human flourishing, even in death.

3.4 Fundamentals of the practices based approach

In order to understand what is central to the practices based approach such as that in the ars moriendi, we need take into account the gulf that divides the ars moriendi from late modernity. The differences are not merely in terms of technology and the disenchantment that came with the arrival of the enlightenment. Charles Taylor makes a compelling argument in A Secular Age that the contemporary narrative of secularity is inadequate and far too simplistic to explain the development of something as complex as contemporary secularity. There is no doubt that we, in western society, live in a secular world, an essential part of this secularity includes a move from a society where belief in God is unchallenged and indeed, unproblematic, to one in which it is understood to be one option among others, and frequently not the easiest to embrace.65 Certainly belief in God has changed in the period between the ars moriendi and Kbler-Ross Death and Dying. Yet the change is much more complex, and much deeper than that. Taylor uses the term social imaginary as a way of framing the social context that enables certain peoples at certain times, to carry out collective practices.

Our social imaginary at any given time is complex. It incorporates a sense of the normal expectations that we have of each other; the kind of common understanding, which enables us to carry out the collective practices, which make up our social life. This incorporates some sense of how we all fit together in carrying out the common practice. This understanding is both factual and normative; that is, we have a sense

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
65

Taylor, A Secular Age, 3.

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of how things usually go, but this is interwoven with an idea of how they ought to go, of what mis-steps would invalidate the practice.66

In Taylors view it is different social imaginaries that enable certain practices, that to us appear incoherent and absurd, to make perfect sense in the context of the social imaginary within which the practices exist. Taylor uses the term the buffered self to describe the modern self. The self who sees themselves as separated from the world they exist in and able to create its own meaning, As a bounded self I can see the boundary as a buffer, such that the things beyond dont need to get to me, to use the contemporary expressionThis self can see itself as invulnerable, as master of the meanings of things for it.67 Taylor contrasts this with the pre-modern porous self where the boundaries between the other and the self are much more fuzzy. Taylor does not have a nave, romanticised view of the porous self but remains critical of the modern buffered self. D. Stephen Long, in summarizing Taylors book, phrases it like this, Communion is the alternative in Taylor to the atomism of the modern moral order and its buffered selves. To live in communion is to live as porous selves implicated in each others' lives, in the cosmos, and in God. If the modern moral order thrives on mutual benefit, communion does so on agape.68

Taylors book is instructive in helping us to understand why something like the ars moriendi appears so strange to us. But it is also useful in helping us understand the importance of practices if we are to try to incorporate such approaches to dying in the contemporary age. Macintyre has defined a practice as: !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
66 67

Taylor, A Secular Age, 172.

Buffered and porous selves, The Immanent Frame, accessed February 26, 2014, http://blogs.ssrc.org/tif/2008/09/02/buffered-and-porous-selves. D Stephen Long, How to Read Charles Taylor: the Theological Significance of A Secular Age, Pro Ecclesia 18, (2009): 95.

68

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a coherent and complex form of socially established cooperative human activity through which goods inherent to that form of activity are realized in the course of trying to achieve those standards of excellence.69

The practices associated with the ars moriendi as described in chapter two are consistent with this definition. We have previously discussed how virtue is related to character development; that repeated practices form you to be the type of person who acts in such and such a manner. In their commentary on this definition, Shuman and Meador state, the primary point of practices is the activities themselves and the kind of person they form.70 Eucharist, prayer and being present with the dying are all forms of practices that the ars moriendi promoted as important in dying well. These practices required a polis, a socially established community, in order for them to be intelligible. How we, as ordinary people, imagine our lives and our world has changed. We do the ars moriendi a disservice if we read with modern eyes and pay no attention to the social imaginary and the necessity of the traditions that made it possible.

3.5 Why we need the virtues and what difference they make to our lives

If I have rightly named the problems and barriers to dying well in our current time, then it follows that I should try and give some account of why we need such an approach and what difference it makes to have a teleological approach to dying. If the ars moriendi were right in this, then what kind of difference must it make to be a Christian who dies well? The issue that I am contending here is that any account of a good death requires an account of the goods inherent to life; something that late modernity is unable to provide. The approach to death highlighted in the ars moriendi places virtues at the !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
69 70

MacIntyre, After Virtue, 187. Shuman and Meador, Heal Thyself, 91.

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centre, and any account of the virtues requires a polis; a politics; a group of people with shared practices and telos. It is assumed in the therapeutic approach to death that the avoidance of suffering is the ultimate goal in the context of death, and while this is a key part of thinking about death it does little to help us understand and deal with our deaths and indeed, the emphasis on avoiding suffering is so strong that it requires the perhaps totalizing influence of palliative care expertise. A practices based approach possesses a broader moral imagination and allows us to think of our deaths in the context of the lives we have lived and in relation to the people around us. Shuman has emphasized the importance of the community of the church in the Christians understanding of their telos in the context of their suffering. Quoting Hauerwas he writes, there is no reason why even the suffering we undergo from illness, suffering that seems to have no good reason to exist, cannot be made part of the telos of our service to one another in and outside the Christian community.71 The care of one another and dependence on each other that is required as part of the life of the Church is capable of incorporating even our suffering and dying into our idea of human flourishing.

Both Hauerwas and Pinches, and Christopher Vogt have named patience as a key Christian virtue for dying. As we saw earlier in our review of the ars moriendi, there is a vital significance to the ars vivendi, the importance of a good life in becoming someone who is able to die well. Hauerwas and Pinches state, if medicine attempts to form us into virtuous people on its own turf it will inevitably fail, for it will be too little too late. Indeed, if the first time we are called on to exercise patience is as patients, we will surely be unable, for there is no worse time to learn patience than when one is sick.72 The modern desire to achieve and produce - something commonplace in contemporary society, where the purpose of our existence is something that we create for ourselves leads to a great impatience with our bodies when !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
71 72

Shuman, The Body of Compassion,103. Hauerwas and Pinches, Christians Among the Virtues, 171.

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they do not work the way we want them to. Our impatience when we are sick, or worse when we are dying is something that the Christian is expected to challenge. The practice of patience is one that must characterize our lives if it is to become a virtue we can exercise when it comes to our deaths. Hauerwas and Pinches see the life of Jesus as the ultimate example of patience for the Christian, the patience of God made it possible for him to be conceived in a mothers womb, await a time for birth, gradually grow up, and even when grown to be less than eager to receive recognition, having himself been baptized by his own servant.73 This is in stark contrast to the lives most of us live where we cannot wait for our bodies to be well so we can continue in pursuit of the goals we have created for ourselves. The Christian is called to model a life of patience; modeled on God and his patience with his creation. We are called, to practice the patience of the body as we learn that we are not our own creations.74 Our anger and impatience with the bodies that fail us is tempered for the Christian with the truth that our bodies, like our whole lives belong not only to ourselves but also to God.

Vogt takes a similar view to Hauerwas and Pinches, that Jesus is paradigmatic in terms of the Christian virtue of patience. However, he is at pains to point out that Christs patient suffering was not of the Stoic variety where one may embrace the pain itself. The Christian is not called to embrace pain but instead,

to endure unavoidable suffering associated with dying in order to pursue other goods that come in the midst of and sometimes as a result of that suffering, such as coming to terms with ones own mortality and dependence, experiencing the compassion of loved ones and to be a model of hopeful, patient endurance.75 !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
73 74 75

Hauerwas and Pinches, Christians Among the Virtues, 172. Hauerwas and Pinches, Christians Among the Virtues, 176. Vogt, Patience, Compassion, Hope, and the Christian Art of Dying Well, 75.

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For Vogt, patience in suffering is essential for dying well, and it is key to see here that it is not just for the individual but for the community of people around him that patience matters. The impatience that comes with the limitations of our ailing bodies is contrasted with the virtue of patience that recognizes the limitations of our autonomy. This is not to leave us in a state of passivity, embracing without question whatever suffering is thrust upon us, but it does mean recognizing, as Hauerwas and Pinches noted above, that we are not our own creations. This is yet again, in stark contrast with the death awareness movement and with palliative care philosophies with their emphasis on the individual and their autonomy at all costs. The idea that your body is not in fact your body is anathema in modern society and for many suggests connotations of the medical paternalism that they were set against. But limitations to autonomy here are not the totalitarian type imposed by the medicine characterized by Ivan Illich, instead, Vogt suggests, it entails coming to know that I myself am not the centre of the universe, that in many ways I am incomplete and limited.76 This is not paternalism for the Christian but the discovery of a central Christian truth.

Vogt finishes his section on patience with the important point that the Christian notion of patience is bound up with hope. To be patient in a Christian manner is also to wait expectantly for Gods activity in the world to be revealedan expectation that suffering, pain and death are not the final words about life.77 Hope is inherent in all Christian reflection about death, in a manner in which it seems impossible, or at the very least, deeply problematic in any contemporary, secularized model. While the medieval ars moriendi had a tendency towards an escapist type of hope (that soon you will escape the misery of your mortal life), the hope that Vogt describes is not a mere panacea for the dying. This hope is deeply set in the life of the Christian who !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
76 77

Vogt, Patience, Compassion, Hope, and the Christian Art of Dying Well, 75. Vogt, Patience, Compassion, Hope, and the Christian Art of Dying Well, 77.

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is compelled to love the life he has and is allowed to mourn its passing but is also capable of, if not welcoming, at least incorporating their death into their idea of what it means to have lived a good life.

All of this raises an important question, however: can patience and hope only be seen as virtues for the Christian? Indeed, is dying well, as here described, only available to those within the Christian tradition? This is a difficult question to answer, as what I have been describing is the contrast between a teleological, virtue ethics, practice based approach to death and that of a therapeutic, secularized approach. It may well be that a secularized, teleological approach to death may be possible, but it is not clear that such an approach exists or what it might look like, so for now the question remains largely unanswerable. All we can do is describe how Christians might die well and hope we can encourage others who are dying and those who care for them. In particular,

We might find we have something to say, not only about how illness and death can be met with grace and courage, but also about how those called to be physicians and nurses might care patiently for their patients78

Hauerwas and Pinches suggest here that instead of the health care workers teaching and encouraging the patients, it might just be the other way round.

The alternative is to try to generate a generic, non-Christian teleological approach to death that could easily be taken up by all colours and creeds and even those with no creed. However, I hope it has been made clear that to do so would be simply repeating the errors of the enlightenment project in trying to reach an independent justification of morality and in the process of stripping

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78

Hauerwas and Pinches, Christians Among the Virtues, 178.

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away the specifics of the traditions that fostered such moralities, all but eliminated the very moral imaginations that came with them.

A final point worth noting on patience is related to the tendency in the ars moriendi to glorify suffering and its emphasis on the physical nature of things. This is, as noted, particularly problematic to translate into contemporary settings as it could easily be taken to mean that Christian patience requires that one endures physical suffering as a routine throughout life and something to be endured, without the option of pain relief while we are dying. However, Vogt makes the excellent point that this is not the type of patience we must be expected to practice. Our unwillingness to be patient when we are sick is related to our distaste for dependence. It is difficult to surrender our physical needs to a caregiver. We do not need to endure the physical cross bearing of suffering but we will likely have to endure loss of physical abilities and a dependence on others for care. For this we will need patience. What we must prepare for is to be handed over to the care of others. What we must prepare for is to accept the loss of our independence.79 This is something for which many of us are all too unprepared and often contributes to expressions of preference for a sudden death and a desire not to be a burden.

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79

Vogt, Patience, Compassion, Hope, and the Christian Art of Dying Well, 132.

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Conclusion

Medicine, as we know it today, is a creation of modernity, and in many ways a victim of its own success. The crisis in dying brought about by advanced medical possibilities met a much-needed response in the writings of KblerRoss and the flourishing of palliative care. However it became clear that neither were able to articulate a sufficient notion of dying well as both were tied to post-enlightenment ideas of the autonomy of the self and ultimately anyones notion of dying well must be self-generated. The practices based approach of the ars moriendi stand in stark contrast to the therapeutic approach in that they advocated a life time of preparation for death articulating the idea that in order to die well, one must live well. The traditions, practices and virtues of the church were all necessary to this explicitly teleological ethical approach. If we are to be people who know something of what it means die well, then we must pay attention to what it means to live well and the type of person we must become in order to do so.

There are several things that need said in conclusion to this necessarily brief survey of dying. Firstly, some might object that the therapeutic approach I have described is somewhat of a straw man in my argument. I attempted to avoid this by not just presenting Illichs view of a violent, totalizing modern medicine but also what I regarded as the best secular, late modernity had to offer. Those writing from within those approaches have already noted many of the problems I have highlighted regarding the therapeutic approach. Palliative care in particular has been critical of its own tendency to become a totalizing approach. That being said, I have found no clear alternative or corrective measures that avoid these problems. I am certainly not advocating that Christians reject palliative care when they are faced with their own dying, and as mentioned already there is no reason to reject symptom relief because of some mis-guided Stoic ideal of embracing suffering.

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It should also be noted that I do not want people to take a romanticized view of the ars moriendi. While I remain committed to the idea that the ars moriendi has a great deal to offer the contemporary church as a resource for dying well, there are many problems with any wholesale appropriation of it. Many of these problems have been highlighted in the relevant chapters but it perhaps needs stated again that I do not view the time prior to the enlightenment as some pre-modern ideal. Our moral imagination has been in many ways closed by the rejection of teleological ethics that came with the enlightenment, and the ars moriendi provide us with resources, not to find our way back to a premodern ideal, but to understand ourselves as teleological creatures in our own context of late modernity.

Finally it is by no means clear that the contemporary church exists as a tradition sufficient to sustain practices necessary for dying well. There is, in reality, often little to separate the politics of the contemporary church from that of the very same secular society I have contrasted it with. That the church as Christs body is not what it should be is not contested. However, that does not mean that Christ is not present within it, or that such a radical politics is unable to exist within it. Christians are committed to the idea that Jesus has not abandoned his church, no matter how much it seems that Christians have. The church, its people, their practices and virtues stand as a witness to contemporary society that neither medicine, nor even death can define who we are. This idea has several implications. Firstly, as mentioned, I do not think that one must be a Christian in order to die well an individual in the right context may well generate a teleological understanding of his death and view his death with a broader moral imagination, but this would be going against the flow of the dominant social imaginaries of the age. However, the church, if it stands as a faithful witness, may well be a useful source of inspiration to many people that there are broader moral possibilities than those on offer from contemporary society. The church, in this same role, may even stand as a witness against the medicine that we fear will not allow us to die well. The churchs witness of faithful living and dying may help medicine to better !
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understand its role and hopefully correct some of its totalizing tendencies. Hauerwas puts it this way, if medicine can be rightly understood as an activity that trains some to know how to be present to those in pain, then something very much like a church is needed to sustain that presence day in and day out.80

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80

Stanley Hauerwas, Why Medicine Needs the Church, in On Moral Medicine, ed. M Therese Lysaught and Jr Joseph J Kotva, (Wm. B. Eerdmans Publishing, 2012), 73.

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Shuman, Joel James. The Body of Compassion. Basic Books, 1999. Shuman, Joel James and Meador, Keith G. Heal Thyself. Oxford University Press, 2003). Swinton, John, and Payne, Richard. Living Well and Dying Faithfully. Wm. B. Eerdmans Publishing, 2009. Taylor, Charles. A Secular Age. Cambridge: Belknap Press, 2007. Taylor, Jeremy. The Rule and Exercises of Holy Dying. London: W Pickering, 1850. The Immanent Frame. Buffered and porous selves. Accessed February 26, 2014. http://blogs.ssrc.org/tif/2008/09/02/buffered-and-porous-selves. Verhey, Allen. The Christian Art of Dying. Wm. B. Eerdmans Publishing, 2011. Wikimedia Commons. Ars Moriendi. Accessed January 14, 2014. https://commons.wikimedia.org/wiki/Ars_moriendi. World Health Organisation. WHO definition of Palliative Care. Accessed November 19, 2013. http://www.who.int/cancer/palliative/definition/en.

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