The Way We Die Now (26 page)

Death may not be the inevitable conclusion to the broad narrative sweep of one’s life. It is more commonly banal – just another episode. Perhaps the idea of ‘death with dignity’ is yet another manifestation of our unwillingness to accept meaninglessness, both of life and of death. More importantly, we, as a species, have come to believe that everything that happens to us – including death – is our fault, our doing, our responsibility. Human agency has replaced the powers of nature, ‘majestic, cruel and inexorable.’

Alexander the Great, of all figures from history, embodies the aristocratic ideals of nobility, courage, dignity and style. His death is perhaps the greatest example from history of dying as one has lived. In 323
BC
, at the age of thirty-two, Alexander fell mortally ill in Babylon. There has been much debate as to the nature of this illness: theories include malaria, schistosomiasis, endocarditis, influenza, strychnine poisoning, alcoholic liver disease, and acute pancreatitis. Although I am not an adherent of the ‘who-killed-Cock-Robin?’ school of medical history, it was probably typhoid fever. Over a period of ten days, his condition steadily deteriorated. On the day of his death, his soldiers mobbed the gates of the palace, and suspecting that his death was being concealed from them, demanded to see him for themselves. Alexander instructed that the entire army be admitted, in single file, to his chamber. It was his final order and last parade. Although he was mortally weak, and probably in great pain, he greeted each one of them – they must have numbered in the tens of thousands – with a nod of his head, or a flicker of his eyes. The parade lasted for several hours.

Mary Renault, author of the
Alexander Trilogy
(
Fire from Heaven, The Persian Boy, Funeral Games
) – surely the greatest sequence of historical novels ever written – wrote a short biography,
The Nature of Alexander
, based on the classical histories of Plutarch, Curtius and Arrian. She describes how Alexander died as he had lived:

Ever ready to die in war, he must long have been prepared to die in pain, and resolved it should not diminish him. The exhaustion must have shortened his last hours, but it is unlikely that at this stage he could have recovered. The necessary suffering he accepted in return for what had been essential to him all his life: to be equal to his legend; to be beloved; and to requite it extravagantly, regardless of expense. Whether sustained by pride, by philosophy, by belief in the immortality of his fame or of his soul, he met his end with no less dignity, fortitude and consideration for others than Socrates himself...

Sisygambis, mother of the defeated Persian Great King, Darius, was nominally Alexander’s prisoner. She and Alexander formed a close friendship: he admired her nobility and courage, and addressed her as ‘Mother’. She saw in her Macedonian conqueror all the kingly qualities her own son lacked. Mary Renault concludes her biography thus: ‘Sisygambis, the Queen Mother of Persia, survived the news of his [Alexander’s] death five days. On receiving it she bade her family and friends farewell, turned her face to the wall and died by fasting.’

Alexander’s equanimity in his final days may have been, in part, a result of his belief that he was divine. After his death, he did achieve a kind of divinity, when he was worshipped as a god. But this sort of death is remarkable in its rarity, as were the less exalted, but no less noble, deaths of Hume and Wittgenstein. Most of us do not possess the spiritual or intellectual stature of these men. We need to have less lofty ambitions for death: such as a death without terror, a death without futile medical intervention, a death that is not hidden from the dying, a dying that takes place with a degree of respect and decorum.

Even so, death cannot be sanitized, work-shopped or managed. In death, there is only affliction. When our time comes, let us say our goodbyes and die as creatures. If we choose to turn to the wall, to withdraw from our families and the world, then there is no shame in that. The dying have turned to the wall since the time of Isaiah. And we who attend the dying must accompany them. We must not avert our gaze. Doctors must once again return to their role as the
amicus mortis.
And let us not hesitate to be brave.

Death has been a regular presence in my life, professionally and personally, over the past few years. What have I learned? I have concluded that I am – in the phrase of F. E. Smith – no wiser, but considerably better informed.

The contemporary discussion on death and dying has been hijacked by the extremists on both sides. In the barren and neglected middle ground are truths that we have conveniently ignored. As contemporary issues, assisted suicide and advance directives are both a symptom of a deeper malaise (namely, the obsession with control) and a distraction. They are a distraction because the real issues are elsewhere. Our sense of common decency − of kindness − has become sclerosed. Can common decency be regenerated by regulation and government diktat? We have witnessed, to our cost, the paradoxical effects of the regulation of professionals, as well as the poisonous effects of targets.

Modern scientific medicine, for all its achievements, has never been so unsure of itself. After the glory era of the mid-twentieth century, we are now in a late period of doubt and uncertainty: medicine has lost its nerve. It is in desperate need of reform – spiritual renewal might be a better term. And the reforms I mean are not the anodyne statements about professionalism piously promoted by the various august medical bodies. Medicine has slowly, almost imperceptibly, been transformed from a profession into a service industry. After thirty-two years of practice, I find myself out of step with many of my colleagues. I have witnessed a profound disconnect between our publicly-proclaimed pieties and what we actually do every day in our treatment of the dying, which is notable not for kindness, but for cowardice, evasion and humbug.

I have described the culture of medical excess, and the resistance movement against it. This movement, however, is patchy, under-subscribed and disorganized. There is a danger, too, that when you question the prevailing medical culture, you can find yourself unwittingly in the same tent as the Gerson Therapy faddists and the anti-vaccine campaigners. We must, as a profession, call a halt to the madness that characterizes much of modern medicine. The leaders in cancer medicine set a good example with the publication of The Lancet Oncology Commission Report in 2011. We must teach the public, the politicians, the media and the judiciary that we can’t offer every conceivable option to every patient. The era of scientific triumphalism is over. Medicine needs to embrace a new phase, characterized by thoughtfulness and a creaturely approach to our patients.

But kindness should be a common currency for all – not something to be doled out solely by the professionals. Could the perceived ‘problem’ with death be partly due to the fact that, after decades of our culture being dominated by individualism and consumerism, our respect for other people has diminished? We have witnessed the paradox of rising life expectancy accompanied by a contemporary culture obsessed with youth and beauty, and dismissive of the old. The arid spiritual dwarfishness of materialism and secularism has hardly helped. We see ourselves, in the phrase of Ivan Illich, as ‘bundles of diagnoses’. In Europe, the churches have emptied, and people no longer know how to die, or how to mourn. In my own country, this process has happened so quickly that we are still reeling.

There is a perception – even a consensus – that death is something that medicine should somehow ‘sort out’. But our needs are spiritual, not medical. Medicine’s dominion should be limited and explicitly defined. Medicine, and our culture, would be healthier and happier if we stopped expecting medicine to solve our existential and spiritual problems, if we stopped thinking of our bodies as machines, and if we gave up our fantasies of control and of immortality. Doctors can indeed help the dying, but dying needs to be de-medicalized. I was, in part, prompted to write this book because my limited, strictly medical, expertise was inadequate to meet the demands placed on it by society and by my dying patients and their families. I had no answers, no profound insight. It is as difficult to advise someone how to die, as it is to advise them how to live.

We hope you enjoyed this book!

For more information, click the following links

Maurice Earls read an early draft and persuaded Jonathan Williams to act as my agent. Jonathan’s wisdom and experience were invaluable. My editor Neil Belton championed the book, and gave wise counsel over several revisions. Georgina Blackwell guided me through the publishing process with much common sense and patience. The manuscript was copyedited with great care and attention to detail by Jane Robertson.

Several friends and colleagues helped me to clarify my ideas: I would like to thank particularly Tony O’Brien, Eoin O’Brien and Columba Quigley. I am grateful also to Fr Michael Buckley, Dan Collins, Sheila Lordan, Anne Nagle and Brian O’Brien. My wife Karen provided unstinting moral support, as well as much practical assistance.

I have changed some of the details relating to patients to preserve confidentiality.

Adams, Tim (2013) ‘Sam Parnia – the man who could bring you back from the dead.’
Observer
, 6 April.

Appleyard, Bryan (2007)
How to Live Forever or Die Trying.
London: Simon & Schuster.