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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.

Dissertation tag line

Something, my smarter, more beautiful better said ages ago and I jotted it down in a text file.

“Medicine robs of us of our ability to tell the story of our death.”

“A community’s willingness to encourage children is a sign of its confidence in itself and its people. For children are a community’s sign to the future that life, in spite of its hardship and tedium, is worthwhile.”

Stanley Hauerwas
A community of character p209

Spiritualising Lazarus

“But please, where does the story about poor Lazarus say anything about his ‘heart’?… The really frightening thing about the story is precisely the fact that it is not moralised but simply tells about the poor and the rich, the promise to one and the threat to the other.”

Bonhoeffer on the errors of “spiritualising” a text like Luke 16:19-30

In “reflections on the bible”
Hendrickson 2004

The church of medicine

organised medicine has practically ceased to be the art of healing the curable, and consoling the hopeless and has turned into a grotesque priest hood concerned with salvation and has become a law onto itself. The policies that promise the public some control over the medical endeavour tend to overlook the fact that to achieve their purpose they must control a church, not an industry.

P249
Ivan Illich
Medical nemesis.

Wonderful quote that is forming the question for my dissertation even as I read it.

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