November 1 marks All Saints’ Day on the church calendar, when many denominations remember the communion of all believers of all time, including the faithfully departed.
That the church instituted this holy day should come as no surprise. We Christians have rehearsed our belief in “the communion of saints” since the institution of the Apostles’ Creed in the fourth century. Yet the concept of a fellowship of the living and the dead has an eerie ring to it, a feeling not assuaged by what All Hallows’ Eve has become in Halloween.
One liturgical prayer says God knits together his elect in “one communion and fellowship in the mystical body” of Christ. The haunting image of sewing together the faithful living and dead members of Christ’s mystical body leaves us with a lot to unpack. But since the phrase is tucked into a longer liturgical script, we usually don’t think about it much.
In fact, apart from Ash Wednesday and Good Friday and the occasional funeral, the Western church tends to remain relatively close-lipped about death and the relationship between the living and the dead. Unlike our brothers and sisters in much of the world, people in the United States usually die in institutions, not at home in the care of family.
A lack of exposure to dying and death both in the church and at home has led to the emergence of two kinds of responses to death—people who run away from it and people who leap toward it. Yet a third way is to learn the life-giving art of dying well.
Some of the most agonizing and tragic deaths I’ve faced as a doctor are those of patients who adamantly refuse to acknowledge their mortality. They desperately latch onto every bit of available technology to delay the inevitable, regardless of whether it causes more harm than good—often causing further medical complications to snowball.
Years ago, I recall attempting to resuscitate the same elderly, cancer-riddled man three times in the same night. After his heart stopped and he died the first time, I discussed gently with his daughters how sick he was and how his heart likely would not keep beating for much longer. But they wanted us to attempt CPR again. His eldest daughter told me that they are Christians who believe Jesus can heal. She said that they believe in miracles and that we doctors should do whatever we can to keep him alive. He died twice more that night, and our third attempt at resuscitation failed.
In his dying process, my patient was subjected to painful medical interventions with no meaningful benefit apart from a couple more painful hours of life. He was placed on a breathing machine, which meant he couldn’t speak, and was transferred from the cancer ward to intensive care. His family spent their final moments in a harried state of crisis instead of sharing their last moments sitting, talking, and praying together.
Not as Those Who Have No Hope
Later reflecting on that situation, I wrote in my book The Lost Art of Dying, “This has always struck me as something of a paradox. It seems curious that the people who believe most fervently in divine healing also cling most doggedly to the technology of mortals.”
Data shows this to be a widespread phenomenon. A study by researchers at Harvard University found cancer patients with high levels of support by their religious communities are more likely to die in intensive care on advanced life support. They are also more likely to refuse hospice and palliative care.
And although religious people often seek guidance from their clergy on medical care at the end of life, a subsequent study found that clergy know very little about palliative and other care at the end of life. They are prone to overstate the benefits and underestimate the risks of medical interventions in an effort to encourage faith in God.
Most people wish to die at home surrounded by loved ones, but highly medicalized dying usually requires a high-tech hospital. What’s more, overmedicalizing the dying process rarely reflects the resurrection hope of all saints. Although medical technology is indeed a wonderful gift from God, we must guard against making it an idol. The fact is, all of us will die. From dust we came, and to dust we will return (Ecc. 3:20).
Not everyone runs from death, however—some leap toward it. Death anxiety or inexperience or a penchant for control prompts “leapers” to determine how they can choose the timing and manner of their death. Some end their lives through conventional suicide, while others do so through physician-assisted suicide (usually lethal pills) or euthanasia (usually lethal injection). It is critical that the church understand these terms and the differences between them.
In Canada, where medical killing is now the fifth leading cause of death, euthanasia and physician-assisted suicide were absorbed by the term MAID, or medical assistance in dying.
The language is quite clever. Who doesn’t want assistance in their dying? I certainly do. I want someone to bring a hot cup of tea or an extra blanket if I’m cold. If I’m feeble and frail, I hope for someone to help me out of bed to the bathroom. If I’m bedbound, I hope for someone to turn me regularly and give me sponge baths. I would love for people to read or sing to me while I’m on my deathbed.
But MAID is not about flourishing while dying, nor is it about nurturing life and community. Rather, it is about control and leveraging the goods of medicine to inflict death. It ends suffering by ending the life of the sufferer, and in the meantime, it relieves people of their responsibility to care for dying family members. It releases communities from their duty to address social isolation and absolves health care systems of their obligation to provide support services to the dying or those living with disabilities.
Canada’s MAID began in 2016 for terminal patients and expanded in 2021 to anyone with irremediable suffering. Let’s be clear about what this means. No longer must a person have a terminal diagnosis to be euthanized in Canada. If your doctor agrees your suffering is bad enough, then you, like an old dog, can be “put down.”
According to the government’s most recent annual report, 35 percent of MAID-seeking Canadians in 2022 said they wanted to die to avoid being a burden on family and caregivers. Another 17 percent said they sought MAID because of loneliness. Imagine: 2,264 people choosing death in one year simply because of loneliness! Still hundreds more may choose death because they can’t access or afford adequate palliative or disability services.
The line between prolonging life and delaying death is a very fine one. It takes wisdom and some medical knowledge and a good clinical team to know when enough is enough. But the line between caring for the dying and hastening death is a bold one.
The latter goes directly against the sixth commandment, “Thou shalt not kill.” And to obey God’s law in this context is quite literally to choose life. “I have set before you life and death, blessings and curses. Now choose life,” the Lord said, “so that you and your children may live and that you may love the Lord your God, listen to his voice, and hold fast to him. For the Lord is your life, and he will give you many years” (Deut. 30:19–20).
What do running from and leaping toward death have in common? They both fail to grant dying humans the reverence they deserve. The sad fact is that most people—especially Christians—aren’t prepared for death. This is a growing problem that pastors and other church leaders can’t afford to ignore in their congregations.
As Meagan Gillmore reported for CT earlier this month, one Canadian pastor said, “I think one of the strongest reasons why MAID has a lot of traction generally in our society is that nobody wants to talk about death.”
For years, I’d wondered how we could change the conversation and equip our patients to walk toward the inevitable. Then one day, in my reading of various books on the subject, I came across a concept known as the ars moriendi, which is Latin for “art of dying.”
I discovered an entire genre of literature—500-years’ worth of ars moriendi handbooks—on how to die well. The earliest version developed in the early 1400s after the bubonic plague, or Black Death, swept through Western Europe, leaving half the population dead.
The central theme of this genre was that dying well is very much wrapped up in how we live. If we want to die well, we have to live well. That includes cultivating a life of virtue, nurturing our communities, and attending to questions of salvific and eternal importance.
The ars moriendi handbooks became wildly popular and were translated into many different languages, circulated widely throughout the West and into the Americas. They were also adapted by a variety of religious and nonreligious groups. The genre remained popular for more than half a millennium.
It started to lose its cultural prestige about a hundred years ago in the wake of the First World War and the influenza pandemic, when it seems people grew weary of thinking about death. Also, as medicine advanced and hospitals proliferated over the 20th century, the need to prepare for death gradually withered away.
In my work, I have attempted to revive the ars moriendi for our modern, pluralistic context. I wrote the book for my patients, many of whom do not belong to religious communities. Yet we are all mortal, so we must all consider the status of our human relationships and the value we place on the medicalization of life and death.
All of us must answer questions about what it means to be human, about life’s purpose, and about what happens when we die. In our polarized world, where people increasingly approach the end of their lives by either running from death or leaping toward it, we must seek the wise path. Along with the psalmist, we should pray, “Teach us to number our days, that we may gain a heart of wisdom” (Ps. 90:12).
How might we cultivate a heart of wisdom with our mortal end in view? Across the ars moriendi genre, several themes emerge for how to practice living well to die well.
First, we must acknowledge our finitude, or finiteness. All the ars moriendi handbooks started from the premise that death is inevitable. That doesn’t mean we have to fixate on death, obsess about it, or grow overly morose. Nor does it mean we celebrate and glorify it. But it is precisely by numbering our days—by recognizing that life is limited—that we begin to understand how we might live well.
Second, we must nurture relationships and cultivate community. The ars moriendi handbooks all assumed that dying was a community affair. Yet communities today are fractured, and loneliness affects about a quarter of the world’s population.
I often encourage my patients to picture who they’d like at their deathbed and consider the state of those relationships now. If you know you’d like your children with you when you’re dying, and you’re currently estranged, then you’d best commit yourself to relational repair before it’s too late. Not only will your dying be better, but your living will improve, too.
Third, we must learn the benefits and burdens of medical interventions and seek guidance on using them prudently. I often encourage clergy to ask medical personnel to educate their congregations. Health professionals can also volunteer to share wisdom on clinical care at the end of life through classes, workshops, or even health fairs.
Churches already draw on the talents and skills of their members across many different industries—why not let clinicians teach congregations practical insights on dying well?
Finally, we cannot gain hearts of wisdom without considering the ultimate questions of human purpose and destiny: What is life for? Why am I here? What happens when I die? When it comes to answering these, Christians have a wealth of resources. Yet this is also where summaries like the Apostles’ Creed can bring our core doctrines into focus.
Do we believe, as the last line of the creed says, in the Holy Spirit, the holy catholic (universal) church, the communion of saints, the forgiveness of sins, the resurrection of the body, and life everlasting? As we gain confidence in our answers to these questions, we gain our greatest wisdom.
In the case of the ars moriendi handbooks, martyrs were seen as exemplars of faithful Christian living and dying. Illustrated versions even included images of martyred saints—Steven holding his stones, Catherine with her execution wheel. The idea is that all of us have much to learn from their lives and witness.
All Saints’ Day is the perfect time to reflect upon the living and dying of those who’ve gone before us—that great cloud of witnesses that surrounds us (Heb. 12:1)—and to consider what we can learn and apply to our own lives and deaths.
L. S. Dugdale is a professor and ethicist at Columbia University in New York City and the author of the book The Lost Art of Dying: Reviving Forgotten Wisdom.
