Dissertation complete!

For those with an active RSS feed to this blog, hello and glad you’re still there. The dissertation is done and posted so I figured I may as well share it here too. Feel free to read, download and comment below.

As always with these types of things, now that I’ve written the damn thing, I’m probably in a much better position to go back and write the whole thing all over again and make it 10 times better but alas I have neither the time nor the energy for it. Thanks to all who participated in the emails, pub conversations and rants about this.

 

Dissertation Final

005 ‘dying well’ versus ‘the good death’

I’ve just started my M.Litt dissertation.  My supervisor suggested the practice of writing something every day, something akin to a journal entry rather than a formal academic piece.

I have neither the time nor energy to write every day, but I will when I get the chance and I suppose why not put it out here for the 7 people who read this to see it, critique and hopefully give me some feedback to make it better. 

The basic idea for the thesis goes something like this:

How does modern medicine’s domination of how we die form problems for the Christian tradition of Ars Moriendi

Here’s what I wrote today:

 

While on the surface it’s perhaps difficult to see the difference between the two terms

  • Dying well

  • The good death

Yet, if I’m correct (and it’s yet to be seen) then there’s an important difference to be drawn out.

Like most phrases like this, it all depends by what you mean by them. Both are so short as to carry very little specific meaning. There is some specific content to them but it’s also how, and by whom the two phrases are used that helps to bring out the differences.

Dying well has its origins in the Christian ars moriendi literature already discussed. The ars moriendi means the “art of dying well”. It was a specific body of Christian literature, coming in the time following the great schism and the black death. It was popular literature for those unfortunately accustomed to wide spread, horrific death.

Christians can die well, so the ars moriendi go. There may be temptations to avoid, and virtues to pursue but we can at least die well. There are many modern day Christians and non-Christians who continue to use the phrase ‘dying well’ as a goal for those confronted with their own mortality. Given the rampant medicalisation of our deaths, the contemporary idea of dying well has been a welcome asset. Palliative care is perhaps the best example that the medical field has put forward, with a focus on symptom control and dying at home. [Not that palliative care is without its problems as I’ve previously mentioned.]

The good death is (i hope to argue) a somewhat different term. Sitting on my shelf is a book of the same name, subtitled ‘the new american search to reshape the end of life’. The subtitle tells a tale in itself. When I talk about the good death, I’m taking about the modern notion that the good death is the death that is freely chosen. The modern emphasis on the self and on autonomy is the key here. What people often fear most in the contemporary world is the loss of choice, autonomy and independence that ill health brings. The only way that such a situation might end well is in the death freely chosen.

It is no coincidence that the language of the good death is perhaps most prevalent in those talking about ‘assisting dying’. One of the ways to make it slightly more palatable is to rephrase what we think about death. If death is ‘natural’ (hard to argue against) and so is childbirth then surely death is just one part of the journey. Indeed, death is the most natural thing in the world. We can avoid the nastiness surrounding our death by taking back ownership of it.

At present I have no real idea if that’s really what the new good death literature actually says. I may be painting a horrible caricature of it. But what I’m going to attempt to say is that as Christians, we can die well, we have all kinds of spiritual and moral resources available to us that perhaps not everyone does. However, I don’t think we can sign up to a good death. There was never anything good about death and yer man Thomas was onto something when he asked us to ‘rage against the dying of the light.’ Paul was onto something similar when he said his bit.

004 On Death and Dying by Elisabeth Kubler-Ross

I’ve just started my M.Litt dissertation.  My supervisor suggested the practice of writing something every day, something akin to a journal entry rather than a formal academic piece.

I have neither the time nor energy to write every day, but I will when I get the chance and I suppose why not put it out here for the 7 people who read this to see it, critique and hopefully give me some feedback to make it better. 

The basic idea for the thesis goes something like this:

How does modern medicine’s domination of how we die form problems for the Christian tradition of Ars Moriendi

Here’s what I wrote today:

Elisabeth Kubler-Ross [via the Simpsons]

On Death and Dying is so famous that even the Simpsons have covered it. This book, written in the hay days of medical advances of the the late 60s and early 70s, tells of insights gained by talking with the dying.

Elisabeth Kubler-Ross was a psychiatrist who set up a seminar (prompted by several theology students with an interest in the topic) in the university to be attended by students and staff from multiple disciplines. The idea was to get insight into how to talk to those who were terminally ill. Typically this took the form of a recorded interview between Kubler-Ross, the patient and often a chaplain. This was usually viewed by a group of students through a one way glass to make the patient feel slightly less intimidated.

The book works its way through the chapters outlining what Kubler-Ross saw as the stages a patient went through when faced with their own death. Most stages are presented in the form of the transcribed interview and from this some conclusions are drawn about how we react towards death. It is summarized in the (slightly dodgy) graphic below.

The book is remarkable as one of the first major contributions to understanding of how we die in the modern age. As already discussed, modern medicine has radically changed how we die. We die later in life, and in many ways we only allow ourselves to die when modern medicine says it is OK to do so.

Death is frequently a medicalised event that takes place not in the home but in the hospital. There are always opportunities for family to visit but this is usually strictly controlled by the hospital until the point is reached that the doctor decides that there is a change from curative to palliative care.

This is the medical context of death but this is surrounded by a much greater, and more pervasive cultural change to how we understand our lives, ourselves and our purpose.

On Death and Dying is effectively a qualitative, observational study. From an empiricists point of view, this type of study is not designed to describe causality, it merely describes people’s reactions to dying, not why they are reacting in such a way.

http://xkcd.com/552/

One of the underlying and unspoken assumptions in the book (and underlying the project of modernity) is that the story of your life is whatever you make it to be. You, as the autonomous self, the agent, are the free and unencumbered individual. This agent can be abstracted from the cultural and contextual ‘you’ in greater society. As Hauerwas puts it, “the project of modernity was to produce people who believe they should have no story except the story they choose when they have no story.”

It appears (though I cannot find it clearly stated as a purpose in the book) that the ‘steps’ or ‘stages’ of dying have guilt-free acceptance as their end point or telos. For example, “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 .” [Kübler-Ross, Elisabeth. On Death and Dying, Routledge, 1973, p159.] As stated above, this book is a qualitative observational study yet the conclusions drawn, at least implicitly, are that these stages should be normative for modern man. This is the telos of our death – a guilt free acceptance.

A guilt free acceptance of the end of our lives is no bad thing, yet, for the Christian, it is not the whole story, and indeed it deals insufficiently with what has gone before. If the telos in On Death and Dying is only directed at the death then it is insufficiently telological to provide to help us become people able to die well.  Modern death narratives, even at their very best as exemplified here, fail us by not paying sufficient attention to the life that comes prior. A guilt-free acceptance of death is no doubt a grand thing, but dying well may be much more than this.

Grapes of Wrath Quote

Just as the family have sold up everything and ready to hit the road for California.

“How can we live without our lives? How will we know it’s us without our past?”

Grapes of wrath p88

003 The ars moriendi

I’ve just started my M.Litt dissertation.  My supervisor suggested the practice of writing something every day, something akin to a journal entry rather than a formal academic piece.

I have neither the time nor energy to write every day, but I will when I get the chance and I suppose why not put it out here for the 7 people who read this to see it, critique and hopefully give me some feedback to make it better. 

The basic idea for the thesis goes something like this:

How does modern medicine’s domination of how we die form problems for the Christian tradition of Ars Moriendi

Here’s what I wrote today:

There are various phrases that come up in any contemporary discussion of death. ‘Quality of life, ‘A good death’, ‘Dying with dignity’, will all crop up in any such discussion. While it is by no means clear what we mean when we invoke these phrases, all are trying to get across the fact that how we die is somehow important.

This is hardly new, and throughout history the death bed has been scene to some important last words and defining moments. Christianity, it appears was no different. In the late 15th century, there arose a form of what could only be called popular literature on death. This became known as the ars moriendi, or the art of dying well. This had particularly Christian origins in an anonymous tract rejoicing in the name of the tractatus artis bene moriendi. This was a brief devotional piece, reproduced extensively across virtually every European language, often with detailed images to help communicate the ideas to those who could not read.

This developed over time, particularly in the English Protestant tradition into significant moral and theological works. It changed over time from its origins as advice to avoid avarice or pride on the death bed into a deeply thought out theology of life. “one thing is very clear about the protestant ars moriendi: it is a literature that was very much alive to the human and spiritual needs of people for whom death was a harsh, often brutal fact of life.” [Atkinson, David William. The English Ars Moriendi, Peter Lang Pub Inc, 1992. p9]  If they can be summarised briefly then it would be thus: if one wants to die well, one must live well.

Christopher Vogt makes the argument that what these authors were doing is now what we might call virtue ethics. The repeated and practised habits of the Christian are what will enable one to die well. Vogt writes, “all of these authors saw a strong need for the development of patience as a lifelong preparation for dying well.” [Christopher Vogt in Lysaught, M Therese, and Jr Joseph J Kotva. On Moral Medicine, Wm. B. Eerdmans Publishing, 2012. p 1070]

Christians have long reflected on what it means to die, attempting to avoid the dual errors of fear, so that they are paralysed in life, or embracing it as “the next great adventure.” Instead the ars moriendi provides with a tradition of serious reflection upon death that we can truly incorporate into our lives.

002 Problems with palliative care

I’ve just started my M.Litt dissertation.  My supervisor suggested the practice of writing something every day, something akin to a journal entry rather than a formal academic piece.

I have neither the time nor energy to write every day, but I will when I get the chance and I suppose why not put it out here for the 7 people who read this to see it, critique and hopefully give me some feedback to make it better. 

The basic idea for the thesis goes something like this:

How does modern medicine’s domination of how we die form problems for the Christian tradition of Ars Moriendi

Here’s what I wrote today:

NB Please don’t read this as a rejection of palliative care or a suggestion that others should reject it. Myself and my family have had tremendous interactions with palliative care professionals. 

Dame Cicely Saunders was the founder of the modern hospice movement. She saw her medical career and the development of the hospice as a calling from god. She devoted herself to the dying who she saw abandoned by the modern medicine whenever it realised that cure was no longer possible. She coined the phrase ‘total pain’ to describe, this was much more than physical pain but included the whole gamut of components that would later form part of ‘biopsychosocial’ model of medicine.

It is a reflection on the failing of modern scientific medicine to be present to the patient that the creation of the hospice movement and palliative care was required. It could be argued that all the hospice movement was providing was ‘good medicine’. Pain and suffering should always be addressed in medical care, why was a separate sub specialty required?

Jeffrey Bishop in his book The Anticipatory Corpse notes a change in modern palliative care. He sees it as a totalising influence in the patient’s life. His quotable phrase runs thus, “treating total pain with total care can be totalising.” [Bishop, Jeffrey Paul. The Anticipatory Corpse, 2011. p255] Palliative care, in an effort to establish itself in the house of medicine has sought to develop an evidence base for its assessments and interventions. It has attempted to define a quality of life and set out a path that those who are dying should navigate prior to passing. Its very development has led to expertise, and no matter how palliative care may seek to respect the consent and context of the patient, the very existence of an expert in the end of life commands an authority in the modern era.

Just as the white coat and the medical degree carries an aura of authority that the patient bows before, so too the dying will find themselves under the authority of the expert in dying. None of us are the free, autonomous selves that the principle of informed consent depends upon, and certainly the dying are defined more by their mortality and physical incapacities than most of us. As Hauerwas writes, “ironically, however, the stress on autonomy turns out to produce just the kind of ahistorical account of moral agency that so effectively disguises medicine’s power over us.” [Hauerwas, Stanley, and Charles Robert Pinches. Christians Among the Virtues, Univ of Notre Dame Pr, 1997, p168] Questionnaires on symptom control and spiritual well being come with assumptions and attached value. The Kubler-Ross model of the 5 stages of grief are not simply descriptive, they have become normative.

001 The making of a modern death

I’ve just started my M.Litt dissertation.  My supervisor suggested the practice of writing something every day, something akin to a journal entry rather than a formal academic piece.

I have neither the time nor energy to write every day, but I will when I get the chance and I suppose why not put it out here for the 7 people who read this to see it, critique and hopefully give me some feedback to make it better. 

The basic idea for the thesis goes something like this:

How does modern medicine’s domination of how we die form problems for the Christian tradition of Ars Moriendi

Here’s what I wrote today:

It is impossible to understand what a modern death looks like, or perhaps more accurately, how we have come to understand our own deaths, without first investigating how we got to where we are.

For thousands of years, a death without input from the physician was all anyone would expect. Even for those who paid for a doctor to attend the ill would not expect any intervention once it became clear that the patient was gravely ill. Medicine simply had very little to offer in terms of effective interventions. Leeches, blood letting and enemas were sometimes taken under duress but no one expected leeches to deal with a gangrenous foot the way a modern surgeon might.

There was usually more snake oil and quackery than there were life saving interventions.

Even socially, the doctor was not the highly respected pillar of society that he is today. While the doctor may have made an income, the doctor rarely ascended the classes or commanded the respect of the nobility. Too much time covered in the blood excrement of the poor and the dying tended to keep one excluded from the more exclusive social circles.

But the late 19th and early 20th century saw a remarkable change in the societal position and role of the physician. Foucault in the Birth of the Clinic charts the story of medicine and its attachment to the new science. Perhaps this is best exemplified by the white coat. The white coat was worn first by the laboratory scientist, not the physician. The scientist was trained in empiricism and hypotheses and experimental design. The physician was trained in the somewhat nebulous art of clinical examination and heuristics passed down from former generations.

By donning the white coat, physicians allied themselves to the new science. They committed themselves to hypothesising and testing. The great discoveries of the new science would soon be intimately linked to the physician. As the mythic function of the scientist grew (along with some actual world changing real world discoveries) so did the mythic function of the physician.

Alexander Flemming was one of the physician/scientists. His lab work, and almost accidental discovery of what became penicillin undoubtedly saved millions of lives from overwhelming bacterial infection. He wore the white coat and his tireless lab work was translated into a huge public health improvement. This sealed the deal for the physician – here we  had tangible and incontrovertible proof that science is progressing human existent with the physician at the centre.

Christopher Barnaard was a South African surgeon, famous for performing the first heart transplant. He shot to instant fame and the lifestyle of movie stars and models that go with it. His face graced the cover of Time magazine long after the recipient of the first heart transplant had died. Just 18 days after the operation. The almost immediate (in terms of functional life) death of Louis Washkansky is seldom remembered in a decade where science and medicine seemed capable of anything. It was of course the same decade that the united states landed a man on the moon. Optimism was running high.


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