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Intro. [Recording date: June 13, 2023.]
Russ Roberts: Today is June 13th, 2023, and my guest is physician and author Lydia Dugdale. She is the Dorothy L. and Daniel H. Silberberg Associate Professor of Medicine at Columbia University, Vagelos College of Physicians and Surgeons, and Director of the Center for Clinical Medical Ethics.
Her latest book, which is the subject of today's episode, is The Lost Art of Dying: Reviving Forgotten Wisdom.
Lydia, welcome to EconTalk.
Lydia Dugdale: Thanks so much, Russ, for having me.
Russ Roberts: You're a doctor and you've seen a decent amount of death. Why did you write this book?
Lydia Dugdale: Yeah, for several reasons. That's a great question. So, as a young doctor, and even as a medical student making my way through the hospital, I witnessed instance after instance of patients dying in ways that seemed--well, they seemed unnatural. Of course, we have this incredible medical technology, and it's wonderful to use it to delay death and to heal disease, but to use the same technology to drag out the dying process in a manner also that was sort of antithetical to what both the patient and patient's families valued just seemed wrong. It seemed like we were missing something. There was a disconnect.
So, that was sort of one of the questions early on that drove me. There has to be a better way to talk about this, to talk about the way we die, to talk about the prudential use of medical technology. So, that was a driving interest.
But then, that was coupled with conversations with colleagues, also physicians, who would say things to me like, 'I never tell my patients that they're dying because I myself am so afraid to die.' Or, they would say, 'If we talk about dying for patients, that is suggestive of the failure of medicine; and we don't want medicine to be a failure. So therefore, we should not talk about dying.' And so, there's a sort of professional sense of failing that meant that my colleagues often weren't doing a good job of informing patients of their mortality, of poor prognoses.
And then, that was coupled with the fact that I grew up in a home where talk of death was quite common. So, death was really kind of destigmatized out of the gate for me. I grew up in a home where my grandfather had been a bomber pilot in World War II and had had multiple plane crashes, had been shot down, taken prisoner of war. He sort of was this extraordinary character who we thought for 20 years would die. So, all of the cousins would fly home every year just to make sure we could see Grandpa one last time. And he just never died. He lived until the age of 95 despite having just this extraordinary contact with death so many times.
So my grandfather, then, sort of created an atmosphere where we could be very frank and honest about our mortality. A death was a fact of life, and therefore we should prepare. It's just sort of--part of living well through life is making sure that we are ready.
So, that was the environment I grew up in. So, it made no sense to me then when I found myself in medicine that colleagues would be resistant or that the structures of healthcare would not necessarily be conducive to facilitating these conversations, which are so important for, really, all people, right? Because all of us face our mortality.
Russ Roberts: So, let's--we have two things. You're more comfortable with death than some of your colleagues. And two, you see a lot of things that are not ideal, perhaps, in how patients are being treated or how they face their own death. So, you got started with this idea of--this very old idea--of Ars moriendi--I don't know how to pronounce it--but it's the Art of Dying. Talk about that ancient manual for death and how it inspired you.
Lydia Dugdale: Sure. So, I was puzzling over this question, really from the earliest part of my training when I was exposed to patients dying in these really awful circumstances that didn't have to be. And I wondered a couple of things.
I wondered how can we start the conversation earlier? And, I also wondered: How can we empower individual patients? So, if the structures of healthcare--which really largely have become the mediators between life and death--if the structures of healthcare aren't going to do a great job, then how can we empower individuals in the context of their communities to do this well?
And so, that's when I was sort of scouring and reading everything I could on end of life. And, I'm an ethicist, so I was reading things on end of life ethics. And I discovered this Ars moriendi. You pronounced it correctly. So, it's Latin for The Art of Dying. And, it referred to a genre of literature that started in the early 1400s and really circulated widely throughout the West until the early 1900s.
So, for more than 500 years, this was in vogue--the earliest handbook. And these really are best thought of as handbooks on the preparation for death--kind of, you know, those yellow Dummies guides. It would be that sort of thing. This is the thing you'd pick up if you need to know how to think about your mortality, prepare for death, and die well.
So, the earliest version is anonymous in its authorship, but historians believe that it is affiliated--that the author or authors were affiliated with the Western Church. This is pre-Reformation when you have Protestants breaking off from Catholicism. It's just the monolithic Western Church. And so, the earliest version had that association and, of course, then was deeply religious. This is late Middle Ages. It's a very sort of enchanted time in Western history.
And then, of course, this begins circulating with the printing press in the early 1400s. You then have it going all over Western Europe. It's being adapted by different cultures; it's being translated. Then once you have the Protestant Reformation, in the early 1500s there are Protestant versions circulating.
And then by the 1800s, former president of Harvard University Drew Faust, in her book on the Civil War talks about how the Civil War changed dying practices in the United States. And she talks about Jewish iterations of the Ars moriendi, and even secular iterations. So, this wasn't something that just stayed in Christendom: it was broadly adapted.
So, by the time of the Civil War, if you weren't religious, you still knew that this art of dying was part of being brought up well. Really, a central thread in all of these manuscripts is that if you want to die well, you have to live well.
And so, the soldiers then on the battlefield--let's just say they weren't religious--they might say something to their buddies like this, 'If I don't make it, take this message back to my family. I died full of courage and for the love of my country and my fellow man.' That might be some ways. So, this defining moment of your death then suggests not only courage in the face of death, but a life of courage, a life of service, of sacrifice for one's fellows as well as for the country. So, that would then tie this dying well to a life well lived. And that was really the central thread of the Ars moriendi.
So then, in different cultural groups, in different religious or nonreligious groups, this might take on different forms. To die well might mean, in certain contexts, to die full of hope or to die full of generosity, of spirit, patience--sort of these virtues, these classical virtues. And so, to mitigate dying poorly, then you have to cultivate that sort of character, those sorts of habits over a lifetime. So, that was what the genre was about.
When I discovered this, I thought, 'Wow, this is really a tool for empowerment of individuals and their communities so that they did not need to rely upon clergy or social authorities.'
And, part of the reason the genre developed that way is because during the aftermath of the mid-14th century bubonic plague outbreak in Western Europe, the social authorities were sort of nowhere to be found. Right? So, priests either skipped town to try to avoid getting sick or they died in care of their parishioners, during the plague.
So, this was the sort of thing--I mean, the plague was devastating. One-third or two-thirds of Western Europeans died in this particular outbreak. So, because it was so devastating then, there was a paucity of social authorities; and that's where this need for individual preparation in the context of community became really important. And so, that's what gave rise to this genre.
And, I thought, 'This is great. This is what we need in healthcare. We need a way to talk about death that individuals in the context of their communities can do together.'
Russ Roberts: Well, in the old days, you relied more on clergy or your family because the doctor wasn't very helpful. In today's world, we expect the doctor to be--much closer to clergy, actually, have a direct line to God--and prolong my life with one more pill, one more device attached to me, one more treatment.
And, you talk in the book--it's very poignant--about a patient who dies three times in a very short period of time. Talk about that just a little bit--because I think--you know, I'm lucky to have my mother still alive. My father passed away about three years ago, and when he was dying, we had a lot of conversations about end-of-life issues, partly mitigated through Jewish practice and Jewish law, but also with the goal of being respectful to my father, which, of course, is the ideal of that kind of Jewish law.
But the challenge, of course, is that the words don't always match the actions. So, CPR [cardiopulmonary resuscitation]: 'Do you want us to revive your father if his heart stops?' 'Well, of course, we do. Why wouldn't you?'
And as you point out in the book, you see people get CPR on TV and it's like, you might not be eager to do it, but you'd certainly want to receive it. But of course in a hospital, it's a really different thing and it's much more complicated. Talk about that a little bit. I think it's useful for people who might have to think about these issues to have some idea what it actually is.
Lydia Dugdale: Sure. So, it's helpful to note that CPR is most often not successful--full stop. Across the board. That's just true. CPR is more likely to be successful, even in these very small numbers, in a hospital setting. So, what we see on television, then, is almost always fantasy because a person surviving a resuscitation, what we say 'in the field,' right?--wherever--is so, so rare. They usually don't survive to get to the hospital.
Now, resuscitation in the hospital is still rarely effective, and when it is--as is the story that I tell in my book--those patients still rarely survive to hospital discharge.
So, why is that? Well, classically understood, death is when the heart stops. When the heart stops, breathing stops; there's no blood flow anywhere; the brain is done, everything is done. So, when it comes to the point of a heart stopping, if it's in an older person or a quite ill person, it's hard to get that heart going again.
Now your best chance for survival, just to be sort of very blunt, are the kind of under-50s who have a bad heart attack. Those hearts are still generally healthy organs. They're just all clogged up with cholesterol. And once we sort of do the Roto-Rooter, the heart itself is still quite vibrant.
Now, the gentleman whose story I tell at the beginning of the book, he was in his late 80s. He had been treated for cancer some 20 years earlier--adequately treated. He went into remission and was sort of cancer-free for decades. Cancer returns. It's all throughout his bones. It's in his brain; and he's emaciated because of--the cancer is just eating him up. He couldn't keep up with the caloric needs to feed the cancer, in a sense. So, you have this very frail, very elderly, very sick gentleman, and his family insisted that we attempt resuscitation. And we were successful twice getting his heart started again, but we knew as soon as we got that heart started again, it wasn't going to last. This was not a gentleman who would survive to hospital discharge. And, the associated stress of crushing ribs and assaulting the body when we know he's dying, that to doctors often feels very wrong.
Russ Roberts: In some sense, there's no such thing as: 'We know he's dying.' There are miracles, in the sense of patients surprise doctors almost, I'm sure, every day. Things happen that aren't expected.
For me, the real issue here is the assault on the body. It did resuscitate him. He did come back to life. Not for very long, and it might be the difference between a family member being able to come or not--come for a visit. There's obviously special circumstances for every case.
But what is, I think, hard to understand in this setting is that you're probably going to break his ribs because you're not just going to push on the chest: You're going to do something really dramatic. And on top of that, he's probably not going to be able to breathe on his own; and you're going to have to put a breathing tube in. And he might end up, quote, "for the rest of his life" on--
Lydia Dugdale: A ventilator--
Russ Roberts: '--on a ventilator.' Which is a horrible quality of life. But, it's probably going to be really short. So, why are you really abusing this person physically who is a shell of what he once was?
Again, many times the answer to that might be there are good reasons, but I think the violence of it is unappreciated and the consequences of it--until you actually sit down and hear the truth. And it's important to hear the truth.
Lydia Dugdale: Yeah, no: that's exactly right. That's exactly right. I mean, this particular gentleman, we already knew he had cancer in his ribs. So, we knew that even the lightest chest compression, which you do have to push hard a couple inches, would just disintegrate his ribs. And if any of your listeners have ever had rib fractures, enormously painful. So, we're inflicting all of this pain. And you're right: Do miracles happen? Miracles absolutely happen. What I often say to my very religious patients is, 'Yes, but God does not need a mechanical ventilator to do a miracle.' Right?
So, there's a way in which we can care well. We can honor the dignity of human beings. We can honor the dignity of the body, of just caring well for bodies even as they are ailing; and we can hold out for miracles. That's fine; but miracles don't require all of these medical interventions, especially when they feel like they're--I mean, your word 'violent' is interesting because I don't think--I've spoken about my book hundreds of times, but I haven't ever used that word, 'violence.' And it is a form of violence. Doctors often use the word 'torture.' We feel like we are torturing patients to death, which is terrible. That's not what we want to do in medicine at all. So, it's very interesting that you use that word.
Russ Roberts: As you say many times in the book, there are different religious traditions; secular, unreligious people, nonreligious have their own ethical codes. They might have their own preferences--of course, they have their own preferences.
So, for me, what is powerful about this is that the current system is a conveyor belt. The default is resuscitate. The default is prolong. And the desire of almost all the participants, whether it's the doctor who doesn't want to inform people that it's over or the patient who doesn't want to confront their own mortality or the family members who will feel horribly guilty if they haven't used every single possible technique--the default is resuscitate, one more chemo, one more pill.
And I think what's powerful about your book is you're saying: you should go into this--think about it now. Don't think about it later. Of course, once you start thinking about it now, it leads to lots of other thoughts we'll talk about. But, the idea that you should have some idea of what you're getting yourself into because if you've never seen a modern hospital in America with the full array of every possible measuring device, tool, assisting thing--and it leads to a belief that it's never over. I think I've talked about on the program, a good friend of mine--emergency doctor--says, 'When you tell people that there's nothing left, they literally can't believe it.' 'Well, there must be another pill, a different treatment.' And he said, 'No. There's nothing left it. Your father's going to die, and that's part of life.'
And, it's very hard for a modern American, and other cultures that have similar techniques, to accept it. And I think part of your goal in your book is for people to confront it.
Lydia Dugdale: That's right. Yeah; and I would say not necessarily to accept it, because I think there are--there are strong arguments for sort of hating death. Right? I mean, death is so destructive: and it destroys families, it destroys relationships. But to acknowledge it, to confront it, to walk toward it, to prepare for it. All of that is the language that, sort of in contrast to Elisabeth Kübler-Ross, who kind of said you have to walk through these stages and in the end accept death. I don't think that's true, actually, at all. But, you can't ignore it.
And, that's what the Ars moriendi genre did so well--is, sort of put it on the table.
The closest we get to it now, frankly, Russ, is estate planning, purchasing long-term care insurance. That's the sort of closest we get in the modern era to anticipating and preparing for death. But we really need to be critically engaging the hospital, the technology of the hospital. We need to think critically about how to talk to our care team, the healthcare professionals.
But then also, there's all this other stuff that's a part of living and dying well, such as legacy. You know, what sort of character? And I'm not talking about financial or even the stuff we do, but how do you want to be remembered by your children and grandchildren? Were you the greedy, cranky, aloof old person? Or were you engaged, investing in the next generation, practicing and demonstrating generosity and humility? Right? That's also part of living and dying well.
Russ Roberts: Nobody on their deathbed wished they'd spent more time at the office. It is one of my favorite expressions.
Russ Roberts: But, I want to say one other thing that you remind me of. You talked about, in the 19th century, Americans got very into thinking about mortality. Garry Wills in his book on Lincoln at Gettysburg talks about how people used to go for an outing to a cemetery. It's not where many of us would choose to spend a free afternoon, but it was the thought that that was good for building character.
And I will say that when I go to funerals--and I always encourage people to go to funerals; I think it's a good thing for the survivors, and it's good for you--that when you're at the funeral and you're hearing this incredible litany of great behavior, nobody ever says, 'My dad was an aloof, cranky, old guy.' They talk about how wonderful they were. And I'm thinking, 'I'm never going to get a funeral like this.' And it does spur good behavior.
Lydia Dugdale: That's great. That's great. Yes, and on that note of funerals, people often ask me, 'What about kids?' Children absolutely need to be part of funerals. They need to see this. And actually, I would say, in my experience children understand death and can talk about it more easily than adults can because children see a bug crawling on them and what do they do? They smack it and squash it, and now it's no longer crawling. There's this sort of , 'Wow. That which was alive is now dead. I have been the agent of death.' There's something final about this that children intuit from a very early age. So, bringing them in to funerals and things is really important.
Just one other thought is: One way that the Ars moriendi genre was described is as a great drama where the dying person is the central actor in this great drama, and all of the community members are understudies. So, in any big show, the lead actor--on Broadway, where I am--always has one or two understudies. Well, really, all of us are meant to be understudies for that lead role because all of us one day will play the lead role. So, all the more important, then, to attend funerals, to support grieving families, etc., because one day we will be in that role.
Russ Roberts: The word 'macabre' comes to mind, but I think it's a healthy thing. Obviously, it's a question of balance. I want to make it clear when I was earlier talking about end of life treatment: It's not that. I don't believe in euthanasia. I don't believe in saying, 'Well, the person's old, it's not a big deal.' I'm talking about at the very, very, very end when, really, barring something extraordinary, it's over. And it's just--we never want to face that. Your book encourages us to face that, which I think is a very good thing.
I want to read, if I may, a poem that your book reminded me of, by Jane Kenyon, which I think captures part of what you're talking about. It's called "Let Evening Come."
Let the light of late afternoon
And that's--it's going to come. There's no way around it. It's just the way it is. What I love about that poem is it looks at that as a--there are beautiful things in the night. It's not all dark and scary.
Lydia Dugdale: That's right. That's right. What's interesting about that poem is that there's an appeal to the Divine for providing comfort. Right? So, in the book, I make a case for the need to address our sort of existential angst, our death anxiety.
I've cared for many patients who've sort of shown up and said, 'I'm a million years old and I realize I have no idea what I believe.' I've literally had patients walk in and say that and that.
And, it's good that they're acknowledging that while they're able to think through those questions, because going to the grave with no kind of reconciliation with one's sort of eternal beliefs or religious beliefs does really result in dying with quite a lot of anxiety.
And, as you know, the book is not prescriptive. I'm not telling people what to believe. I think the great traditions, the great religious traditions in the world have wrestled with these questions of meaning and purpose and what happens when we die or what doesn't happen when we die. There are well-thought-out answers for this. So, I'm not attempting to tell people what to believe, but, to do that work now while it is possible--sort of finding one's peace with the Divine, as it were, I think is really important both to living and dying well.
Russ Roberts: Tell the story about the patient who had a near-death experience or a death experience and it scared him as much as anything.
Lydia Dugdale: I was speaking somewhere at one point in the Midwest, I think, and a gentleman came up to me at the podium after I had finished my talk. And that's not uncommon. He introduced himself--I think he was in his late 70s or 80s at that point, older gentleman. And he told me that he was a physician. He had been a physician for his career.
And he said, 'I need to tell you something.' He called me away from the podium--there's a little crowd gathering to chat after the talk--and he called me away from the podium, and he told me about how he had died on the operating table. And, you know, patients have all kinds of stories about what they experience when their hearts stop. And scientists attempt to explain it, 'Oh, maybe they see white lights and hear people calling their name because of chemicals in their brain or these things are culturally relevant respective in different cultures, so different cultures hear different things.' There's all these sorts of explanations. But the truth is we don't really know.
And he says, 'I died on the table and I didn't see anything. Completely black. Nothing. No lights, no one calling my name.' To be honest, I wasn't really sure what to do with this. He was clearly afraid. This was very disturbing to him, that there was nothing. And then I said, 'Well, maybe it's because it wasn't your time to die.' And, he kind of acknowledged that and then just walked off.
And, it was very interesting. And, since then, actually, I had another woman also tell me that she died and didn't see anything. But both of them are still alive. So, clearly it wasn't their time to be summoned to the whatever--hereafter. No one was summoning them. They saw nothing and they're still alive, walking around.
So, yeah, it is interesting.
Russ Roberts: I want to say one thing about the preparation you're talking about or confronting the fear of death and the reality that we're all going to die. There's a book by Irvin Yalom called Looking at the Sun, which is about the terror--he calls it the 'terror of death.' We can't look at the sun. You have to look away. And, I think when you say, as you do, to grapple with this or to try to come to terms with it, a lot of people who don't have a faith tradition or a faith practice will say, 'But, I can't pretend to believe something I don't believe in. It would have been great if I believed in God, but I don't.'
And I think it's a misunderstanding of what religion is about and the role it can play in your life. Faith is not a zero-one switch that's on for some people and off for others. I do think people have certain abilities to feel spiritual things--and it varies by person--but it's certainly possible to read about and explore and put your toe in the water of a faith tradition without being a card-carrying believer. And, even so-called card-carrying believers are filled with doubt in 2023, including myself.
So, my listeners know I'm religious. I think nonbelievers--professional atheists is all I'm talking about, people who don't have this faith tradition or practice--assume that people who do have no doubts. And therefore, they're not in. That's just not the way it works, as far in my life or the people that I know. Maybe it's true in other religions other than Judaism. Maybe people are locked in all the time, but not in my experience. In fact, I loved in your book when you say that this Ars moriendi is are for nonreligious people. And I think modern atheists go, 'Well, there weren't any unreligious people in the Middle Ages. Everybody was religious. They all believed in God, thought they were going to die and go to heaven. Or hell.' And I just don't think that's true. It's a complicated situation.
Lydia Dugdale: It's very complicated. In fact, one of the ways that the earliest versions of the Ars moriendi said you died poorly was to die full of doubt. So, a decent part of the earliest handbooks were to help the dying person think through what he or she believes, to sort of affirm beliefs like, 'Okay. What is it that my community, what is it that my priest has taught me, my clergy has taught me? What is it that my community has endorsed? Do I believe that? Can I walk through and affirm those beliefs?'
And then, if the dying person couldn't, the community still doesn't want the dying person to die in this state of doubt. So, there were prayers for the community to utter on behalf of the dying, in a sense to be the hope for the dying person, to speak words of faith on behalf of the dying person. Because, really, we all live and die best in community. So, the community then helps uphold that person in his or her weakness.
Russ Roberts: I think a lot of people hate that idea, by the way. If they don't believe if in God, the idea that people would pray for them, they find it--I think a lot of people find it offensive. I wouldn't, I don't think. I don't find it offensive if a Christian wants to pray for me to be saved, even though I don't think that is relevant for me.
Russ Roberts: But, the community part is very important. Why don't you talk a little bit about the power of the bedside and hospital versus home, alone versus lonely? There's something very, very, very sad about somebody dying alone and lonely. The combination is horrific. But if it's only alone, it's not as bad--meaning if you have loved ones in your life who care for you, and if they're not literally at your bedside, it's still a good thing it seems to me.
Lydia Dugdale: That's right. So, central to all versions of the Ars moriendi, I said that a central thread was living well in order to die well, and vice versa. A central thread is this acknowledgement of human finitude.
And then the third thing that is really absolutely critical is the role of community. Human beings are by nature relational beings. How do we know that? Because no one does well in isolation. That's just true. Right? Whether it's being thrown into solitary confinement in prison--which is awful for people who have been in prison and they'll tell you that--or even people who fancy themselves hermits still have to come back to civilization every so often to sort of get their fix. No one thrives and flourishes in isolation. And so, the same is true in dying.
Now, in the book, I do distinguish between dying alone versus lonely dying. So, that is: People who throughout their lives, for example, hate to be a burden on others--which, parenthetically, I would say we need to practice being a burden on others and we need to practice receiving the burden that others impose on us. This is one of the reasons why practicing hospitality is so good and we should do it more in the modern era, because it's an imposition on the host to have others come in and all that that entails.
So, how is it that we can practice being a burden on others? I--you know, I confess that I really like my independence and like not to be a burden on others. But that's not how human beings do 'human being' best. We really are meant to be in relationship. But: so, people who don't like to be a burden on others will often wait until everyone leaves the hospital room or wait until everyone goes to bed at night to allow themselves to die. That's really common. We do see that all the time. That's not lonely dying, though. That's just, 'Grandma always took care of us. She would never let us take care of her. Everybody went to bed that night and then Grandma gave up the ghost,' so to speak. That's a pretty typical thing.
But the lonely dying is something different. And so, in the book I talk about both in Tokyo, Japan and in New York City--and those are just emblematic of other large urban centers--where people have really lived in their towers, in their small apartments in isolation for so long; they moved to the big city to escape whatever it is that they're escaping. And then they die, and no one knows. Maybe people find out when finally--their automatic payments for their rent exhausts their bank account. Or maybe the neighbors find out when the corpse, the decaying corpse, the smell becomes so overpowering that the neighbors call the police. But there are many, many people who die that way now.
Certainly, during COVID we saw this. In the United States at least, nursing homes were really on lockdown for the better part of 20 months. Twenty months. This is something that didn't get a lot of attention, but even though the Centers for Medicare and Medicaid Services tried to open up nursing homes, they made the requirements of very few cases. It had to be low community rates and low rates in the nursing homes to open up. And most nursing homes were unable to meet those requirements for the first 20 months of COVID.
And so, it wasn't until--what?--November of 2021 where nursing homes were allowed to open their doors sort of freely. And then of course, we had omicron hit in the United States, and a lot of them had to close their doors again.
So, we saw a lot of lonely dying during COVID. We saw it here in the hospital where the doctor holding up the iPad was the intermediary between the dying person and their families. So, that really is a tragedy.
One thing I say to people is: Do this thought experiment. Most people say they want to die at home and most people die in institutions. That's just true in the United States. So, think about who you would want to surround you on your deathbed, and then ask yourself what the state of those relationships is now. Because, if dying well is very much linked to living well and you know now who you want to be with you at the end, why not nurture those relationships now? Invest in those relationships now. Reconcile now, so that your living is so much richer; and then your dying will be that much richer as well.
I once had a guy ask me--he raised his hand and said, 'Look, I know who I want to be at my deathbed, but frankly, I can't stand the guy right now. So, can I just wait to reconcile with him until I'm closer to the end?' And everybody laughed because, of course, none of us knows when the end will come, but this idea that reconciling now while you can, while you're able, while you can get together for meals and be in each other's lives, your living will be so much richer, as will your dying. So, that's really important.
And just one other word maybe, Russ, on this phenomenon of how we came to die in institutions. In 1873, there were a couple of hundred hospitals in the United States--and I know the United States best, obviously, because that's where I am. By the nineteen-teens, there were more than 6,000. So, in really, what, 45, 50 years, there's an explosion of the hospital. And this, then, is coupled with the discovery of antibiotics in the 1920s. Really, the antibiotics were in widespread distribution by the 1940s. 1940s, we also see the advent of chemotherapy. By the 1950s and 1960s, we're experimenting with organ transplantation, we're experimenting with cardiopulmonary resuscitation and the mechanical ventilator. By the 1970s, we have combination chemotherapy.
So, really, if you were born post-World War II--which we have a huge boom that was, right?--dying really became optional on the whole. There's always another technology. There's always another intervention. There's always something we can do to stave off death. So, why not go to a hospital because they're everywhere; and why die at home? You might not be dying anyway. We don't know. It's very confusing. So, go to the hospital and see what they can do. So, that explains in part how we came to die in hospitals.
And then the final thing I want to say is on the question of loneliness, circling back to your earlier comment about opposition to euthanasia. Indeed, we should be opposed to euthanasia. I think Canada now is giving us much to be concerned about. In 2021 in Canada, the last year for which we have comprehensive data from the government, the Canadian government reported that more than 1700 people who were euthanized that year--there were more than 10,000 euthanized in 2021 in Canada--more than 1700 of them said that they were being euthanized because of loneliness. This is reported in the Canadian government's annual report from 2021: 1700 Canadians euthanized for loneliness.
We can treat loneliness many ways, but physician-assisted killing is not the way that we want to do that. Rather, we should really look around us and invest in our families, in our communities, see who is lonely and invest in them, practice hospitality and being a burden to one another.
Russ Roberts: So to speak. I encourage listeners to put this episode on pause and call that person you don't get along with and who you'd like at your deathbed--or even maybe before your deathbed--and make amends, and you can come back in a few minutes after you've made that phone call or written that email.
The other humorous part of that, of course, is that why would you want somebody at your deathbed you don't get along with? But it reminds me: I tell the story in one of my books. It's a true story. I fictionalized it, but it's a true story of an entrepreneur who, his product was finally--he finally got his product to come to life. He said, 'All I could think of was I wish my father was alive to see this.' And he said, 'I don't even like my father.' So, you may not like your parents--it's not your parents you want at your deathbed, you want your children or your friends at your deathbed--but if you have friends and family, if you want them there, maybe, if you can handle it, but I like to think you want them around before you die.
I think we often, speaking for myself, I think I've often neglected the power of friendship and connection. So, if there are people out there in your lives, folks who you've lost touch with or are sparring with, maybe put down the weapons and see if you can have a meal or a cup of coffee with them and do some repair work.
Russ Roberts: Let's talk a little bit about the power of ritual. You spend a significant chapter on ritual and, of course, death is--every culture, every religion, ritual plays an important role. It's not untouched. It's a huge thing. Talk about why it's important and what you've seen in your own practice of people dealing with death that way--with ritual.
Lydia Dugdale: Sure. I think I'm a product of sort of a lack of tradition in some ways. I grew up in the Christian church, but very low church is the way that I would describe it, so not a lot of ritual. Listeners who'll know the Christian context know that there's high church and low church. I was super-low: no liturgy, no prayers, no formality. It was sort of poo-pooed. And as an adult, I discovered some of the richness of my tradition and was floored at how carefully, for even thousands of years, some of the words of these prayers or the texts that were to accompany momentous occasions such as dying and death, sickness and death were so carefully crafted, so much attention to scripture.
Anyway, so that made me realize, 'Wow, you don't need to a funeral and play the Beatles and read some random poem. The work has been done.' Again, if people want to reinvent the wheel or invent a new wheel, that's fine, but the work really has been done; and it's so rich and so deep and there's so much across the world's traditions, the world's religions that it's worth diving into.
As you know from the book, I am very struck by Jewish death rituals. I worked with a Jewish chaplain from my hospital when I was writing the book, and she was very gracious to teach me so much. But she said something like, 'Of all the things Jews do well, we do death the best.' She said something like that--
Russ Roberts: Yeah, we're good at death--
Lydia Dugdale: I really was so struck because, for example, the mourning process of first 24 hours, get the body in the ground; the one week shiva; one month, one year, that maps on--maybe it's because of the influence of Jewish practitioners on psychology and psychiatry, that may be true, but we think of normal grieving as being up to a year. Right? And that's exactly the prescription--in the medical world, we think of that--but that's also the prescription that comes through Jewish expectations for mourning.
As you know, the washing of the body--women washing female bodies, men washing male bodies--and the ritual washing and preparing the body to be laid to rest that is done so beautifully in traditional Jewish communities is compelling. For me, that was one of the most extraordinary things I discovered in the process of writing the book.
So, the ritual of Tahara, for those who don't know, is what I just said. Volunteer members of the community will prepare the bodies. This society of volunteers is called the Chevra Kadisha. In the ritual washing, the members of the community who are washing the body will sing essentially love poetry--it's from the Song of Songs, from the Hebrew scriptures--will sing this love poetry, this Hebrew love poetry to the body, calling the body by its Hebrew name. It's just so extraordinary--so tender, so human, deeply human, so intimate. What a wonderful gesture of a community to a member of its community who is now being prepared to really be laid to its final rest and depart the community in a sense. So, it's just extraordinary what's out there, and I encourage people to dive in.
Russ Roberts: As you point out, the body is treated with respect. It's covered, except for the part it's being washed. There's no talking, there's no chit chat. Doctors and surgeons always will, often nurses will talk about--you know, what happens in a serious surgery: people will be talking about their golf game or whatever. And yet in this ritual, there's the utmost respect for the deceased, to the extent that you don't talk about mundane things, at least as far as I know.
And if you're not a believer, you'd say, 'Well, that's ridiculous. The person is dead. Doesn't matter what you talk about in front of them, they're not there.' The idea of it, though, is to create reverence for human beings who are alive, because if you're respectful around a body that has no life in it, think how respectful you should be around a body that does have life in it. And if you are doing this activity, you inevitably are forced--as we've been talking with other examples--to reflect on your own mortality. So, it's a very powerful thing.
Russ Roberts: I interviewed Michael Brendan Dougherty about his book, My Father Left Me Ireland, and he talks about when he had to face a death of a parent--and I think it was his mother--because his father had not given him Irish tradition, he didn't know about a wake, he didn't know about what was available to him. In that conversation, I suggested, 'Well, you'd think that'd be even better because now you could just pick the best one.' I've been at shiva houses--as they're called, where a person is mourning the loss of a parent--and the non-Jewish people say, 'This is what I want when my parents die.' But of course, you don't have a community. You can sort of create it, but even if you create it, it's not yours; and I think it's partly the power of the connection to the past that rituals establish.
And, I just think it's interesting that--it's one thing to say, 'Explore other traditions--explore rituals.' I think that's good advice, but I think it's good to start with your own, even if you don't own it, even if it's not part of you yet. I think it's worth looking into if you haven't looked into it.
Lydia Dugdale: I think that's exactly right. That's exactly right. Although, there is much we can learn from one another. So, actually, there is a group of us here in New York that have been exploring the possibility--what would Tahara look like, washing the body, here in New York? I mean, I don't even know how you transport a corpse, frankly. If I had a family member die in the hospital, can I just go and get the corpse and take it home and wash it?
But then it turns out, as I've been speaking on this--on my book--there is a tradition of preparing the body in the Eastern Orthodox Christian tradition of washing the body.
And then I was speaking in Tennessee, and some nurses came up to me afterward and they said, 'Well, don't you know that the nurses wash the body in the hospital?' And they proceeded to tell me about a young woman they had taken care of who was dying of a brain tumor, and all three of them--the two nurses who cared for her the most and this young woman--were all, belonged to Christian tradition. And the young woman, the patient, often played certain music in her hospital room. And so, the nurses, then, when she died--and this was a great loss to them personally because they'd grown so close to this young woman, and she was so young and she's dying of a brain tumor, and it's terrible--as they washed her body, they put on the music that she had loved. And it was sort of--
Russ Roberts: I'm going to cry--
Lydia Dugdale: it was sort of an act of worship to God and caring for her and sort of, yeah, being--so I guess my point is there's so much we can learn from one another, but there are ways that some of these things--I didn't even know as a physician that the nurses are assigned to wash--I never thought about it. Who washes--somebody washes the body in the hospital.
Russ Roberts: So, my father died in the hospital. And, if I remember this correctly, when he died, the nurses left us alone at that moment, but then they came back in and they--it's a terrible verb; it's not the right respectful verb--but they tidied him up. I don't know if they washed him, but what they did was--he was connected to so many things and they wanted to disconnect him and then prepare him so that we could all say goodbye in a more natural state than a wired-up thing--
Lydia Dugdale: That's right--
Russ Roberts: And, there was just an incredible amount of love and tenderness in that that's not different from what happens in the Jewish ritual. And this was, quote, "just in a hospital." It was really a beautiful thing.
Russ Roberts: I want to say one more thing about rituals, not related to your book. You can react to it any way you want. But, there's so many rituals I have total disdain for. I have many rituals in my life because I'm Jewish. So, I always feel like I have plenty. Like, marching at graduation with that goofy hat and robe and colors and the tassel thing--it just doesn't do that much for me. But for other people, that's, like, the only time they get to dress up. And it goes back centuries, so they do it.
And I was just struck by the Coronation of King Charles. I have no interest in, really, in King Charles. I didn't follow the Coronation at all. But, for other people who are--the King is not really a thing in England other than a symbol. But for them--and these are serious people-- they were deeply engaged by the coronation, and the stone that went under his chair that has been used since 1318 or 783 or whatever it is. And, it's an amazing thing. Human beings like it.
Lydia Dugdale: That's right, and thinking too that the word 'ritual' is from the word 'rite.' So, this marks a transition--as opposed to practice, which is something you might do every day. Right? Your prayers are part of your practices or whatever it might be.
But the ritual really marks--it's a rite of passage. There's a transition moment. And it's tied to this longer story, this bigger narrative, this history.
So, the fact that the Coronation represents the continuity--I'm married to an Englishman, so we like the King.
But it ties to this bigger story and this longer history. And there's something deepening in our very transactional society where everything is, you know, easily disposable and there's no continuity. The continuity that that represents, maybe it's almost a religious experience for some people who don't have religion, right?
Russ Roberts: Oh, for sure, and it's a--in a weird way, it's a type of immortality to look back, not just look forward--
Lydia Dugdale: That's right--
Russ Roberts: to look back and say, 'I am the continuation. I am an English citizen. I am part of this tradition.' And: Just as it has gone on for this long, maybe it will continue for some time longer. Although, I don't know about this particular one. But for sure: it's a source of meaning. It's a source of connection, and it's powerful. I think it's hard to--it's not a rational thing.
Lydia Dugdale: Yeah. Yeah.
Russ Roberts: One of my favorite lines in your book is not related to death or dying, but it's related to living--very much so--and of course, in that way it belongs in the book. You talk about your grandmother--and what you wrote about her, by the way, I'm not going to read it; I'd cry and it's really beautiful. If people want to, you can read about it. You have a beautiful little one-paragraph eulogy for her. But, you talk about how that she had a stormy marriage and you say, you quote her saying, quote, "If it took 50 years for your grandfather to become the man he became, it was worth the wait." Talk about that.
Lydia Dugdale: My grandmother was an extraordinarily gracious woman, really rather stately, but of that generation where the expectation was she would get married and be a homemaker. But, she was sort of endlessly curious; and she taught herself a bunch of languages. And my grandfather, after the war--he had always been an artist, so he ended up becoming quite a big graphic designer in Chicago, had a big studio. So, he was a big man--just sort of a character, and socially. So, she always lived in his shadow. And she was a horrible cook, and he was a wonderful cook. So, even though she was supposed to do the cooking--right?--all these things she was supposed to do, she wasn't good at. But she was really good at kind of teaching herself and of hosting people graciously. I think grace is probably what would characterize her.
And then, when I talk about my grandmother, I see her very differently than my own mother sees her. And I don't know exactly how my own mother sees her. The grandmother that--
Russ Roberts: That is sooo shocking--
Lydia Dugdale: Right!
Russ Roberts: Of course, you see her differently!--
Lydia Dugdale: The grandmother that I knew was very committed to God and to family. And, despite sort of living in the shadows of my grandfather and not having the opportunities that women have today. And, yeah: so, she was just beautiful. She was just beautiful, sort of spiritually and socially and relationally.
So, when she died--you know, I knew she was dying and her memory had started to go quite strongly by the end. But it really felt like a loss to the beauty in the world. A loss to the beauty in our family and the relational richness that would now--it's irrecoverable, what she gave.
And, the charge, then, really is for the next generation.
I'm 46, and a lot of my peers in our late 40s are looking around, saying, 'Oh, I guess, you know, we now are the rising wise people. We're sort of now becoming the mentors to all--we're not in our 20s anymore. Our kids are growing up.' All these things. Right? So, suddenly you see yourself.
And so, really, then, the charge is when you lose such a wonderful presence in your life, is: 'Well, how can I now grow into that? How can I exude grace and love and wisdom to my family, and my kids' friends? Could we be a home where my kids' friends feel safe and loved and welcomed?'
So, yeah, no--when I wrote that last chapter, I said to my husband, 'I have a feeling somebody's going to die while I'm writing this chapter.' And it was my grandmother. Yeah. So, it was quite raw when I wrote it.
Russ Roberts: Which is all very beautiful. But, the part I like that you didn't talk about is that she did not see her marriage as the sum of its costs and benefits. She put her eggs into the end--into the ending--which I think is what we do as human beings. We care about how the story ends disproportionately. So, even though her marriage may have been rocky, something emerged from it. There was a growth of character apparently in your grandfather that she may have been primarily responsible for and took pride in, which--I like to think of life as an adventurer that isn't set in stone, and you don't know who you're going to become. She may have not always found it easy to be with him, but what he became, she thought was worth the wait. I thought that was just lovely.
Lydia Dugdale: Yeah, you're right. No, you're right about that. I did that in my eulogizing her. I forgot about that story.
Russ Roberts: That's okay.
Lydia Dugdale: No, that's right. Yeah, no, I think my grandfather was very difficult, and she stuck with it. He had a--conversion is the wrong word because he was churched all the way through, but he had a kind of come-to-Jesus moment, as it were, 50 years into their marriage and really became so gentle and loving; and he was transformed. So, it was worth the wait, which--yeah, no, we don't think that way. We don't think that way. It hearkens back to the importance of being aware of these communities and the relationships and the depth of the wisdom and the ritual and all of this that traditions bring to bear and our communities bring to bear. We do need to tell each other these stories.
Russ Roberts: This is not related to your book, but I'm curious, this idea of softening with old age. The stereotype is that when you get older, you get cranky, you get more selfish. That wasn't true of my father; it's not true of my mother. They're more like fine wine improving with age. As a doctor who watches, you see a lot of human interaction across a hospital bed, of course, with family members. Do you have anything to say on that question?
Lydia Dugdale: That's a terrific question. I'm just trying to think through--I'm cycling in my mind really quickly through all of these different patient scenarios and wondering if I can generalize. Which, of course, is terrible, but sort of what you're asking me to do.
We see both. We see both all the time. Is it fair to say that women soften more than men? I don't know. It is true that people who have suffered a lot in a lifetime might find that the dying process or not being able to take control of one's health is just an extension of the lack of control that they've had throughout their lifetime. But I do think it's probably true that far fewer people rage against dying than think they might when they're healthy.
So, I described Susan Sontag in my book--you know, the literary giant--who really went to her death just stuffing fistfuls of chemotherapy pills into her mouth trying to delay death, and would not let anyone in her family or community tell her she was dying. Refused to hear it. Doctors couldn't say it, no one could say it. She raged--raged--against the dying. Right? I do think that's an exception, though, from what I've seen. Partly, it's that the hundreds of assaults on our physical bodies as we age, maybe starting with a cavity and then getting to the glasses and then the knee replacement and all these things as they propel--even if we want to resist talking about it, we're aware in the back of our minds that we're not quite as strong and able-bodied as we were in our 30s. I think if we're honest with ourselves, we know that that will progress and eventually we'll have to give up control.
Russ Roberts: Yeah. Aging humbles you. I guess that would be my hope: that my stereotype--the anti-stereotype I'm suggesting that people get maybe a little gentler as they get older--maybe comes from that. Or maybe as you lose your dignity as you get older, maybe you just kind of give up. I'm not sure. Neither one's a little more pleasant than the other. I'm not--
Lydia Dugdale: Well, you don't lose your dignity. You might feel that you're losing some of your control, but still, your dignity is inherent in you as a human being.
Russ Roberts: I like that idea.
Russ Roberts: Let's close with a question of current hospital practice that's sort of the default, whatever it might be. Is there something that you would single out--and you make a lot of suggestions in the book, and we've talked about many of them here: build your community, build your rituals if you can in advance of your death, live well so that you can die well. It's a beautiful, inspiring book. But on the practical, policy side of the norms and maybe regulations of current hospital practice that create that conveyor belt, are there things that you would like to change that you feel would have a minimal cost in terms of the human impacts? Forget the monetary part of it for now. Just, things you wish were a little different? [More to come, 1:07:15]
Lydia Dugdale: So, I think that one way that patients--and this is what--I'm a primary care doctor, so I will often counsel my patients when they go into the hospital, warn them that: Number One, doctors are poor prognosticators. But, Number Two, doctors often have a lot more information than they give you. And there's all kinds of reasons for that. So, when someone, especially in advanced age or poor physical health, is thinking about a major intervention--chemotherapy, a big surgery--really pushing the medical team for a sense of the efficacy of this intervention, the impact it will have. Right?
So, I think classically of a patient that I cared for as a medical student was in her 90s. They discovered a tiny colon cancer, and they decided to take out part of her colon. Major surgery--
Russ Roberts: Horrible--
Lydia Dugdale: for someone in her 90s, for a cancer that is unlikely to kill her. But the family wanted that cancer out. I just remember thinking, 'Is she even going to make it off the table?' Right? 'Is she ever going to recover and be able to walk with her walker again?'
So, really, I think pushing doctors--you know, patients sometimes will say, 'Well, if this were your mother, what would you do?' Some doctors don't like that question. I think it's a great question, because I will--I mean, we're all stuck in this place of medicine has become increasingly consumeristic, in the United States in particular. Patients expect to be treated like consumers, 'Just give me the information and I'll decide. I will choose,' and doctors are now abdicating their responsibility to teach their patients. And again, the word 'doctor' in the Latin means teacher. So, we've abdicated that. Because patients, they want autonomy. They want to choose. But they aren't trained like we are. They haven't seen the thousands of cases like we have.
And so, it really behooves patients to say, 'No. Truly, what is wise in this situation? What would you do for your family member? What would you recommend?' And, if you feel like you're not getting good advice there, push the doctor a little bit more and/or seek a second opinion. I mean, that's always up for grabs.
As you know, where we are in New York City, we have a large Orthodox Jewish population, and there's often an insistence on using all technology that we have--right?--to keep every breath going. Sort of delay the moment of death as soon[?long?] as possible.
Russ Roberts: Jewish law tends to want a Type One versus Type Two error. Jewish law is always going to--and I don't know if I get the Type One/Type Two right--but Jewish law wants to lean toward extending life whenever possible, almost always. It's a little more complicated. As technology has advanced, it's gotten a little more complicated, but yeah.
Lydia Dugdale: And sometimes we, in working with rabbis and families--and this isn't just for Jewish families--but, people who really want to cling to that technology, even when everyone on the medical team is saying, 'This is not doing anything. This is only torturing this person to death,' we've been able to--not withdraw: we're not going to turn the switch; we're not going to unplug someone--but to just sort of hold steady state. So, we're not going to keep adding more and more and more. We already know everything is slowly deteriorating--actually, rather, quickly deteriorating. We're not going to keep adding more. We're going to hold steady state.
Then, in a way, it provides the possibility of not dragging out this active dying process, but also not just cutting it off and having families feel like, 'Wow, they flipped the switch and now he's dead.' Right?
So, just sort of: Think with more wisdom, a little bit more prudentially, about how to engage healthcare. Insist on answers, engage your doctors, ask questions. All of that is enormously important and I think will help translate into better dying ultimately in the healthcare setting--if that's where one chooses to die.
Russ Roberts: So, I use that trick all the time. And it's been on Twitter recently--I don't know why. But I ask the doctor, 'If this were you?' Now, of course, the doctor doesn't have to play along. They can answer the question by still--because it's not their mother. It's interesting that the phrasing of it is supposed to force the doctor into assessing it--the cost and benefits, the trade-offs, whatever, the probabilities--for themselves, as if it were them. But they can always ignore that if they want. Why do you think it makes doctors uncomfortable? Because I think it puts the full responsibility on them?
Lydia Dugdale: Why being forthright with patients makes them uncomfortable?
Russ Roberts: No. Why that phrasing? Or is that not what you meant?
Lydia Dugdale: Because--well, that's an interesting question.
Maybe because it makes it so personal, because we know that what we would hope for for our family members is often different than what we would hope for for our patients. And, by that I mean that we as doctors often spend a lot of time talking about what goes on in the hospital--and, of course, not private patient information, but generalities--with our families. So, my family has heard me talk about this so often that I think they're quite ready to order the simple pine coffin and be done, just be done--because they've heard me talk about this. And so--but your average non-medical patient, so not-medically-sophisticated patient--really thinks the hospital is a place for miracles where we can delay death indefinitely. And so why wouldn't we do that?
There's such a sort of experiential and knowledge gap there that we kind of assume that most patients are of the variety where they just want everything done and don't want to actually weigh this wisely and prudentially. Whereas with our families, we're often having these conversations about, 'Watch out for this. Don't let them do that. Whatever you do, don't do that.'
So, I think that's where it's like a big chasm, and it's not that--I've always tried to practice medicine in a way that I think of my patients as my family members, which is actually quite a helpful way to think about it because I have family members that are frankly unlovable and I have patients that are unlovable, but I still want to care for them all well. So, thinking of patients as family members, not as friends--because friends you choose and want to be with--is a helpful way. And then, I try to be very clear and honest with them, as you might imagine; but I think that is an uncomfortable place for many physicians.
Russ Roberts: So, you wrote an academic book on this topic, and then you wrote this book, and you spent years on these two books, I assume, and all your life was going along, along the way, during that writing. How did just the writing of the book change you, if it did in any way?
Lydia Dugdale: Huh, interesting. No one has ever asked me that. I suppose I--well, I'll say from a standpoint of the creative process, writing the second book, the one that we've been talking about, because it was not academic, it gave me a freedom in writing that I hadn't quite known I could experience. I come from a very artistic family and I was always the nerdy academic one and didn't really think I had much artistic anything in me. So, being free to write in a way that is imaginative and full of story and poetry and philosophy and theology, bringing all this to bear, it made me realize that there's a whole different world out there, and actually did change my writing.
I suppose I also--I went to divinity school while I was writing both books. I finished. I went to divinity school to get my masters of ethics--went to Yale--and dragged that out over five years because I was working full-time at the medical school while I was doing that degree. So, to read philosophy and theology, I actually took a Liturgy of Death class. I took a poetry class while I was there. So, all of that affected my writing in the end. I don't know. I suppose I grew up a bit during this, 15 years of working on this.
Russ Roberts: Did it change your view of death at all?
Lydia Dugdale: I don't think so because I've really been thinking about death since I was a very little girl and said to my mother, 'Well, if in our tradition we have this understanding of the afterlife and it's going to be better, why are we hanging out on earth? Why don't we just die and get it over with?' She said, 'Oh, well, St. Paul had something to say about that,' and proceeded to give me a little lecture. But yeah, I don't know that I have changed my views on death very much, just more expanded the way that I want to talk about it and then help patients and my family members prepare.
Russ Roberts: My guest today has been Lydia Dugdale. Her book is The Lost Art of Dying. Lydia, thanks for being part of EconTalk.
Lydia Dugdale: Lots of fun. Thanks so much, Russ.