Faced with his imminent death, Henry James is reported to have said, So it has come at last, thing. Distinguished? That seems an odd term to use, but James was a master at choosing right word, and he may have seen better than most of us what is all about. My dictionary defines distinguished as having an air of distinction, dignity, or eminence. Yet there is dissent from that judgment. The late theologian Paul Ramsey contended that there could be no with dignity. Death is too profound a blow to our selfhood, to everything good about our existence. James or Ramsey? For at least forty years now--Ramsey notwithstanding--a massive effort has been under way to bring about with dignity. The leading techniques have been use of advance directives, hospice and palliative care, and improved end of life education for physicians, nurses, and other health care workers. As Hastings Center Report 1995 special supplement on SUPPORT study indicated, that effort achieved only a mixed success; a decade later, this report describes progress since then, but points to long road for creating real and lasting improvement. There has always been some ambiguity in that effort. James and Ramsey, for instance, seem to be talking about meaning and place of in human life, not about what kind of care is desirable at end of life. Ramsey was no opponent of those efforts to improve end of life care. He objected to sentimentalizing of death: even best end of life care could not sugarcoat death's fundamental offense. Was he right? Unless it is possible to work out some reasonably satisfactory answer to that question, my guess is that care of dying will remain seriously hamstrung. I sometimes get impression that recent efforts to improve that care are managing, perhaps inadvertently, to evade dealing with itself, focusing instead on palliative techniques and strategies. I want to get at core question here--that of appropriate relationship between care of dying and our stance toward itself--by proposing some historical ways these two issues have either been blended or separated. My point of departure is premodern era, most plausibly described in French historian Philippe Aries's fine 1977 book The Hour of Death. He detailed the persistence of an attitude toward that remained unchanged for thousands of years, an attitude that expressed a naive acceptance of destiny and nature. He called that the tame death and showed how it was accompanied by practices at end of life that stressed death's public impact--the loss to community of an individual's life, underscored by rituals of mourning that made same point. How people died and meaning of were inextricably blended. Though Aries specified no particular time at which that long era ended, I believe it wound down in 1950s and 1960s. By then postwar medical progress, rapidly enriched with lifesaving drugs and technologies, was in full flower and eagerly embraced. Medicine could finally do something about death, and doctors were quick to take up new arms in a new cause, that of aggressively fighting to save lives, now a plausible effort. No quarter was to be given. I recall in 1960s arguing with physicians, educated in postwar years, who told me that they had a moral duty to save life at all costs. The quality of life, actual prognosis, or pain induced by zealous treatment were all but irrelevant. The technological imperative to use every possible means to save life was combined with sanctity of life principle in what seemed perfect marriage of medicine and morality. Then came backlash, beginning in late 1960s. Often bitter complaints about useless but painful treatments, about abandonment at end of life, and about in a cocoon of tubes and monitors, began to turn tide. …