An Ars Moriendi for the Modern Day
Why we should applaud Brittany Maynard for publicly demonstrating the art of dying well.
When expiring, early Christians stretched out their arms to form a cross and faced east toward Jerusalem; Jews in the Old Testament turned their faces to the wall. So too does Tolstoy’s Ivan Illych. The Tibetan Book of the Dead advises lying on one’s right side in the sleeping lion position assumed by the dying Buddha, with the left hand on the left thigh, and the right hand in place under the chin, with a finger closing the right nostril, so as to block the “karmic wind” of delusion that travels through the subtle channels on that side. Hindus suggest expiring as Gandhi did with the name of God — “Ram” — on one’s lips. Muslims aspire to make the Prophet’s last words their own: “To Allah we belong, and to Allah we return.”
All of the great world religions have protocols for dying, and in all poise is as important as posture. Death is to be met with serene acceptance. Raging against the dying of the light is not advised. Pace Dylan Thomas. How do we master the exit that comes but once in each life? Through practice counsels the various manuals on the art of dying.
Spiritual masters believe that the more complicated our lives, and the greater our attachments, the more essential it is that we take this training seriously. Indeed, the Ars Moriendi composed in the late Middle Ages was a response to a suddenly burgeoning love of life among Europeans. As Philippe Ariès observes in his seminal book The Hour of Our Death, this moment marked the evolution from “tame death” to “a death of one’s own.” Up until the first half of the twelfth century, most people accepted their impending demise with resignation. Everyone in the community crowded around the expiring person as witness. Goodbyes were said, reflections made, lessons acknowledged, last rites given, and then silently death met. For Christians, salvation was assured. Death was tame, because life was spartan, communal, and hard. People had few expectations of, much less attachments, to life.
Later in the Middle Ages, as more people attained lives of relative independence and comfort, a new sense of selfhood emerged, changing how death was perceived. No longer was it viewed as a collective fate, but as an individual end, “one’s own.” It became harder to die. Christian theology changed to address this new focus on the individual self.
It was no longer enough to be a believer to insure safe passage to heaven. The Church warned that those rueful about leaving their earthly existence and who died in despair would have their souls snatched by the Devil. To die well, and so preserve one’s soul, one needed instruction.
Hence, the Ars Moriendi advised the frequent contemplation of death as a path to the renunciation of earthly pleasures. Indeed, to this day, Jesuit priests regularly meditate on the decomposition of their bodies. Abiding the similar counsel of the Prophet Mohammed, Muslims speak often of “the destroyer of delights.” And Hindu yogis end their daily asana practice with the corpse pose. For Tibetan Buddhist monks, who drink tea out of the caps of human skulls, such contemplations are not meant to breed contempt for worldly things but enlightenment. The word for “renunciation” in Tibetan is nge jung. Nge means “definitely”; jung means “to be born.” So the term implies a rebirth into the world, an awakening from the sleepwalking of mundane existence, so that we may truly see life for what it is.
According to the great eschatological texts, the dying require equanimity to successfully enter into what we would today call an altered state of consciousness. In this liminal realm, the dying travel back and forth between this world and the Beyond as they prepare for their ultimate departure. The depictions of this journey and what may occur along the way uncannily mirror the visions related by those dying from protracted illnesses. They also correspond to the reports of near-death survivors.
Are these “sensations” actually hallucinations induced by the confluence of altered endorphin levels and other biochemical factors brought on by the physiology of dying or are they actually the opening of consciousness to another dimension of reality? Skeptical physicians and scientists suspect the former, although they have yet to offer viable explanations as to how near-death survivors can recall what was said and what happened around them when they had in fact “coded.”
Whatever the near-death experience may be, observers generally agree that those who enter into it, even those enduring great suffering, undergo a profound spiritual transformation, afterward possessing a greater sense of life’s meaning and of peace about the afterlife and their own end.
Yet, despite this evidence, we moderns neglect the old etiquettes. In the face of the inevitable, some of us rage and flail, others turn away in denial. Curiously, we may seek control over every other aspect of our lives, from contraception to movies on demand, but over our deaths we willingly relinquish it. We want to die without warning — of a sudden heart attack on the ninth hole or asleep in our bed.
In medieval times, a sudden or accidental death was considered tragic, even embarrassing. It left no time to tie up a life’s loose ends, to heal its psychic wounds. By the Victorian age, the deathbed had become a grand existential stage for dramatic last acts of atonement, forgiveness, and farewell.
In the East, dying in full awareness is deemed the spiritual culmination of a well-lived life. When Hindus hear the call of Yama (the god of death), they spend their last days making pilgrimages and cultivating detachment through meditation and prayer. They don’t seek desperate last measures, believing that if they willingly give up life while cherishing it, they will not experience it as a loss. The Tibetan Buddhist protocol for dying requires the believer to meditate, and for his spiritual master and loved ones to chant special mantras to guide his soul in its passage into and through the afterworld — a collective undertaking which continues for nearly two months after death.
The most spiritually adept Tibetan Buddhist monks not only choose the moment of their death but also dispose of their own corpses. In such an instance, a master in secluded meditation will withdraw his consciousness from his body, and then disperse its elements back to their source. During this weeklong process of dissolution, brilliant rays of light reputedly emanate from his room. When completed all that remains are said to be the impurities of hair and nails.
Only the rare mortal is this facile with his molecules, but all of us may at death reveal ourselves to be bodies of light. Hospice workers relate tales of the dying becoming incandescent. The glow, depending on the stillness of the room, can last for a moment to an hour after death. Mircea Eliade referred to this luminosity as the “rupture of planes,” through which higher energies filter. Tibetan Buddhists call it the dharmata bardo, the moment when the dying encounter the clear light of their innate Buddha nature. This can be the moment of enlightenment; but only self-realized souls may recognize it as such.
Few witness such phenomena because the majority of us die in the rushed, fluorescent glare of hospitals. And so it is largely doctors who control when and how we die and what loved ones see of dying. Viewing death as an insult to their medical prowess, they fight on long after the battle has been lost, oblivious not only to the suffering of their patients, but to how their misguided efforts prevent those patients from preparing for their existential exit.
In fact, studies show that doctors postpone telling patients they are dying because they so dislike being the bearers of bad news. In his best-selling book, How We Die, Sherwin Nuland referred to a survey claiming that those who practice medicine have higher personal anxieties about dying than any other profession! Hospital staffs admit to preferring patients cheerfully ignorant of their impending ends to those quietly resigned, despite the little care they require, because their lack of hope depresses them.
When helping care for my friend Lem who was dying of AIDS back in 1992, when that disease was all but a death sentence, I asked his physician if I should research hospices, as the end seemed near. Frowning, he paused for a moment to consider my question, and then inexplicably changed the subject. I felt abashed, as if I had broken some magical silence protecting Lem from otherwise certain doom. Apparently the doctor believed his sole concern should be keeping Lem alive. Nevertheless, within six weeks, Lem was dead.
Having not made the proper preparations earlier, Lem’s other caretakers and I had to scramble to find him round-the-clock nursing, leaving no time to educate ourselves in deathbed practice. His death, which we had imagined would be full of loving goodbyes and newfound peace was instead fretful and confused. Uncomfortable with his patient’s mortality, that doctor cheated my friend out of a serene demise.
When my mother was dying, I practically had to pry her out of the clutches of the hospital’s doctors. Suspecting that she was in death’s early stages — in the space of a few weeks, she had stopped eating, lost continence, and then her ability to walk — I called a local doctor to have her admitted to a hospice. (Her own longtime physician was in an adjoining state and so was unable to authorize an admission in the state she now lived.) The new doctor told me I had to take her to the hospital first, so he could determine if she were indeed dying. Once there, he and his colleagues began offering ways to treat her symptoms. They suggested placing a tube in her stomach to feed her. Claiming she might have a bladder infection, even though she exhibited no symptoms, they proposed a bladder biopsy to be certain, rather than a simple urine culture.
I had to keep insisting that my mother was in the final stages of Alzheimer’s to dissuade them from these and other invasive actions. At last they crankily relented and signed the necessary papers and she died peacefully in a hospice ten days later. There, the nursing staff washed, powdered, coddled, and massaged her as if she were a newborn. If I had not acted like a bitch daughter, my mother would have been cut open and prodded, and ignored by a staff of lackadaisical nurses.
Most experts on dying suggest that if you want to die well, you should flee the hospital. The place to die is at home or in hospice. Hospices are not gloomy places. Far from being grim repositories for the hopeless, they radiate an extraordinary aura of warmth and calm in stark contrast to the tense, sterile atmosphere of the hospital. This is because they are sanctuaries not just from the suffering imposed by aggressive cures, but the very harshness of life. Here small acts of compassion — a nurse’s caress of a hand, a doctor’s attention to easing pain, a chaplain’s patient listening to a life’s travails — become magnified. No longer fighting for their lives, patients can for a moment savor the elemental goodness of earthly existence and most of all human kindness.
However, hospices do not alone a good death make. Nor does a spiritual practice entirely prepare someone for the death struggle. In fact, the notion of “a good death” may itself be misleading. In the last stages of terminal illness, a person may suffer from pain, helplessness, and the humiliation of physical deterioration. There too may be anguish over letting go of loved ones. In his modern classic The Tibetan Book of Living and Dying, Sogyal Rinpoche writes about how his much-revered spiritual master, whom he considered a true bodhissatva, always spoke about fearing death because it was an incommensurable.
The current tale of the 29-year-old Brittany Maynard is a case in point, one that illustrates too the ethical and emotional divisions even among those committed to a more enlightened approach to dying. Maynard suffers from a grade II Astrocytoma, a rare malignant brain tumor that her physicians predict will, over the next six months, cause her increasingly frequent seizures and pain as it robs her first of her personhood and then her life. This young newlywed, who just a few short months ago thought she had a long happy life ahead, has bravely announced via social media that she is moving to Oregon to benefit from the state’s Death with Dignity Act. And so on November 1, with her husband, mother, and best friend at her bedside, she will take a physician-prescribed drug concoction and peacefully end her own life.
While Maynard’s decision has been championed by Compassion & Choices, a right to die advocacy group, it has distressed others in the palliative care movement, like Dr. Ira Byock. He has argued that with the aid of modern medicine, Maynard could endure the seizures and physical deterioration that lies ahead with a minimum of pain, and so benefit from the spiritual transformation that so often accompanies a well-managed death. Byock has been a brave and humane pioneer in demonstrating the critical role physicians can play in helping ease us out of life when death is inevitable. But his belief that we must die the death a terminal ailment dictates, no matter how gruesome for the patient and torturous for loved ones, seems deeply misguided. Yet Byock argues that to do otherwise is to go down the “slippery slope” to “euthanasia.”
But are doctors, who over the past century have insisted that death be fought in the hospital until the battle was lost, and have thus robbed so many of peaceful ends, the ones who should continue to dictate the terms of our dying, even if they have become more enlightened about death’s role in life?
Perhaps, Maynard’s choice to die on her own terms is reflective of her own new spiritual understanding of life in the face of her dying. As the ancient eschatological texts advise, she is nobly renouncing her attachment to life and loved ones. In time we may come to see Maynard as a role model, as someone who having suffered a cruel life blow mastered the art of dying in an age unsure whether science or religion was God or whether there was any God after all.
