The Way We Die Now (6 page)

It is difficult to categorize Illich: he was a medieval historian, a social theorist, a philosopher, a theologian and an educationalist. His core thesis, which he developed at CIDOC, and which has a whiff of Rousseau, was that industrialization and urbanization had robbed people in developed countries of their freedom and their spirituality. One of his best-known works,
Medical Nemesis
(1975) opens with the famous assertion: ‘The medical establishment has become a major threat to health.’ In this radical polemic, Illich argued that modern medicine had hubristically taken on a mission to eradicate pain, sickness, and even death. These were, he argued, eternal human realities, with which we must learn to cope: in fact, coping with these verities is what it means to be ‘healthy’. Although I don’t think Illich coined the word ‘iatrogenesis’ – meaning the harm done by doctors – he certainly popularized it. He described three types of iatrogenesis: clinical, or the direct harm done by various medical treatments; social, or the medicalization of ordinary life; and cultural, the loss of traditional ways of dealing with suffering: medicine ‘constitutes a prolific bureaucratic program based on the denial of each man’s need to deal with pain, sickness and death’. This medicalization of death, he argued, caused us to lose our ability to accept death and suffering as aspects of life, and to devalue our traditional rituals around death and dying. He went further: medicalization is a form of social control, in which a rejection of ‘patienthood’ is viewed as a form of deviance.

Illich’s prose is dense and difficult; his use of footnotes is greater even than the late David Foster Wallace. His scholarship, however, is unarguable. Illich’s arguments were not taken seriously enough at the time because he overstated his case, and proposed no practical solutions. The medical establishment dismissed him as a crank and moved on. Illich himself became an increasingly marginal figure. Although disowned by the church, he held visiting professorships in several European universities, after closing CIDOC in 1976. Illich himself had something of the ancient Greek philosopher Diogenes about him: he never wore a watch, which he called a ‘gauge’, and which he believed forced an artificial structure on daily life, yet he frequently asked the time from ‘gauge bearers’. He spent most of his later life living in a mud hut just outside Mexico City, ‘aristocratically aloof, austere, absorbed but happy’, according to his obituary
in
The Times.
There was more than a touch of the Old Testament prophet in Illich’s public persona; indeed, he was frequently dismissed by critics in ad hominem attacks as a ‘Jeremiah’.

It is tempting to dismiss Illich as just another historical footnote to the counter-culture of the 1960s and 1970s, and yet, nearly forty years on, much of what he warned against has come to pass. Since the publication of
Medical Nemesis
, US spending on health care as a percentage of GDP has doubled. Illich would have been wryly amused by the invention of new diseases, such as social anxiety disorder (shyness), male-pattern alopecia (baldness) and erectile dysfunction (impotence), all of which can now be medicated. The ever-increasing venality of the pharmaceutical industry would not have surprised him. How he would have loved to attack the sacred cow that is ‘evidence-based medicine’. Illich wrote: ‘Through the medicalization of death, health care has become a monolithic world religion... the struggle against death, which dominates the life-style of the rich, is translated by development agencies into a set of rules by which the poor of the earth shall be forced to conduct themselves.’

Illich believed that there is a profound difference between pain and suffering. Pain, he argued, is a sensation, but suffering is a practice. Pain could be borne with dignity by ‘duty, love, fascination, routines, prayer and compassion’. Cultural iatrogenesis has robbed people in Western countries of their ability to suffer. Medicine, which convinced people that all pain is curable, has made pain unendurable. He predicted that this medicalization might eventually lead to assisted suicide being seen as a human right: ‘The patient’s unwillingness to die on his own makes him pathetically dependent. He has now lost faith in his ability to die, the terminal shape that health can take, and has made the right to be professionally killed into a major issue.’

‘Dying’, wrote Illich, ‘has become the ultimate form of consumer resistance.’

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Ivan Illich, in his fifties, developed a facial cancer, for which he typically refused treatment, or even investigation; he believed in ‘the liberty to die without a diagnosis’. The cancer slowly advanced, causing considerable pain and disfigurement, and eventually killed him in 2002 at the age of seventy-six. His obituary reported:

As the tumour on his cheek became more prominent and painful and subject to epileptic attacks, he refused to accept the diagnosis imposed by the doctors. ‘I am not ill, it’s not an illness’, he declared. ‘It is something completely different – a very complicated relationship.’

All four of these thanatologists are dead now. Ariès died aged sixty-nine; I hope his funeral was traditionally conducted and well attended, and that his family observed a suitable period of mourning. Gorer lived to eighty, and died in his manor house in Sussex, where he had cultivated his prize-winning rhododendrons. His closest friends – Orwell, Auden and Mead – predeceased him. I trust his relatives went into formal mourning.

The bleakest funeral I ever attended was that of my friend, S. He died in Amsterdam in 2000, at the age of only forty-seven. He had lived in Holland for many years, where he worked in construction, and had married a Dutch woman, with whom he had two teenage children. He had become unwell, complaining of pains in his left arm and shoulder. Although he was a smoker with a strong family history of heart disease, his doctor thought these pains were muscular. He died suddenly of a heart attack. I travelled from Leeds (where I was living at the time) to Amsterdam for the funeral. My friend had emigrated from his native west Cork more than twenty-five years before, and left behind all those things about Ireland that he regarded as backward, such as religion. His funeral, therefore, was a singularly secular event.

I got a taxi from the airport to a huge cemetery in the suburbs of Amsterdam, and met my friend’s three brothers at the entrance. They greeted me ruefully and thanked me for travelling. His widowed mother did not travel; the furthest she had ever ventured from their small farm was to the city of Cork. A business-like undertaker took control of the proceedings, and we followed him and the coffin – no ‘open coffin’ here – in the rain to the recently dug grave. The coffin was lowered into the ground and we few mourners simply walked away – without prayers or words of any kind. We gathered in a public room attached to the cemetery and were given coffee. The undertaker asked in a desultory fashion if anyone wanted to say a few words. The three brothers looked at each other and shook their heads: this was a task for a priest. But there was no priest, only the brusque Dutch funeral director. After a long and painful silence, one of my friend’s Dutch workmates stepped shyly forward and gave a short speech – mainly in Dutch – concluding ‘he was a good guy’. A CD of some folk songs that the dead man had loved was played. And that was it.

I got a taxi back to Schiphol airport where I had several hours to think about the importance of ritual in dealing with death. My friend’s three brothers, reared in the Catholic tradition, were literally dumbstruck by this secular event: the banality of it was heart-breaking.

Years later, I was deeply impressed by how Catholic ritual – after the deaths of my great-uncle (March 2013) and father-in-law (October 2013) – guided the bereaved during the days immediately following their deaths. Ritual helps the dying too: in Ireland, the sacrament of anointing the sick carries a powerful significance even for those with little or no religious belief. This is not something a lay hospital chaplain can do. Karen Armstrong, the historian of religion, has argued that religion is about practice, rather than belief; about doing, not dogma. Our ancestors had a communal knowledge of how to mourn, and ritual was at the core of this knowledge.

Alain de Botton has suggested in
Religion for Atheists
that our secular world should cherry-pick some of the good ideas from organized religion and adapt them for our bright, modern secular world, while ditching what he sees as all the superstitious, supernatural nonsense: ‘Many of the problems of the modern soul can successfully be addressed by solutions put forward by religion, once these solutions have been dislodged from the supernatural structure within which they were first conceived.’ De Botton lists many of the positive aspects of organized religion, such as the way it brings people together as a community, the weekly opportunity to simply sit and engage in contemplation, and the comforting rituals around birth, marriage and death.

His case is well argued, but it seems to me that religion has developed and refined these rituals over millennia, so why bother inventing new ones? Why build new Temples to ‘Perspective’ and ‘Reflection’ when we already have the great cathedrals, temples and mosques? De Botton describes one such doomed attempt to invent a godless religion, namely the French philosopher Auguste Comte’s ‘religion for humanity’. I wonder if we should simply be content with belonging, and stop being so worried about believing. Evangelical atheism has accelerated the flight from religion, leaving us even more adrift, more atomized, and unsure of how to behave when faced with the great events of our lives.

So we have to fashion our own
ars moriendi.
It has been said that death hasn’t quite come out of the closet, but its toe is sticking out. Any priest will tell you that funerals have become increasingly informal, and are now more representative of the individual than the community. Up until very recently, traditional Irish Catholics thought it vulgar to talk about the deceased, personally and specifically, from the altar during the funeral mass; now, the eulogy has become a central part of the occasion. Coffins are commonly draped with mementos such as mobile phones and replica sports jerseys. The deceased is celebrated as a wacky individualist. In crematoria, the coffin often disappears to the tune of ‘My Way’ or ‘Always look on the bright side of life’. Ariès’s ‘tame death’ may have been ‘tame’ in the sense that it was acknowledged and accepted, but it was still awesome, terrible and grand. Now, we strive to make death tame again by a kind of studied frivolousness.

I lived in Britain for fourteen years. My wife is Scottish, and my two children were born in Yorkshire. Coming from Ireland and a Catholic upbringing, I found British mourning practices very alien. An English colleague of mine died relatively young – in her early sixties – from cancer. A mutual friend, a senior doctor at the hospital, had been closely associated professionally with the dead woman for more than two decades. I was surprised, therefore, not to see him at the funeral service. I mentioned this a few days later to him, and he told me that unfortunately the funeral had coincided with a professional meeting which he was unable to reschedule. In Ireland, this would have been unthinkable. I was similarly surprised when, after the death of my father-in-law, his next-door neighbours called to the house to commiserate. We invited them in and gave them tea. When asked if they would like to see the dead man, they recoiled, saying they would like to remember him as he was.

The Irish, for all our many failings, still – just – do mourning well. The old ritualistic Catholic sequence – first the rosary, then the removal, and finally the funeral mass and burial, still survives. Rural folk still hold a ‘month’s mind’ mass, a month after the death. The formulaic words – ‘sorry for your trouble’ – are still intact. Since returning to Ireland in 2001, I have been to countless removals. Funeral-going in Ireland can be excessive: I have felt obliged to attend the removals or funerals of people I have never even met − usually the parents and relatives of work colleagues. The queues are sometimes so long that it can take more than an hour to reach the top: queue-jumping at removals is a regular sight.

One of my great-uncles was a notably enthusiastic funeral-goer. Irish funerals are famously sociable events, with much food and drink provided; if the deceased is very old, the atmosphere is light-hearted, almost celebratory. In his retirement, this great-uncle travelled all over County Cork and beyond, to attend the funerals of persons with whom he often had only the most tangential and remote connection. The death notices of the
Cork Examiner
constituted his only reading material. Had he survived into the age of the Internet, he would have been an avid user of the website RIP.ie.

In the cities, however, these rituals and codes are slowly dying; in the space of a single generation, Ireland has gone from a country with near-universal church attendance to a secular society in which weekly worship is now a minority activity.

One of the few books I inherited from my father was
Irish Wake Amusements
by Seán Ó Súilleabháin. This slim volume, originally written in Irish as
Caitheamh Aimsire ar Thórraimh
, is a scholarly account of wake customs in rural Ireland in the eighteenth and nineteenth centuries, with detailed descriptions of the rituals, games and drinking which occurred at these events:

Storytelling; singing; music and dancing; card- playing; riddles, tongue-twisters; versifying and repetition of Jingles... Contests in strength, agility, dexterity, accuracy of aim, endurance and toughness, hardihood and athletics... Taunting and mocking, booby traps, mischief-making, horse- play, rough games, fights... imitative games, catch games, games of hide, seek and guessing.

When this book was first published in 1961, the author (correctly) assumed the religious beliefs of his readership:

As Christians, it is difficult for us to imagine how people in pagan times regarded Death and what might follow it. They knew by experience that Death ended the normal way of life which the deceased had known. Still, they believed that, in some way or another, ‘life’ of some kind continued beyond the grave. Christianity taught them gradually about the existence of the human soul which was not ended by Death; nevertheless, they felt that the dead were still involved in some way in human affairs, still continuing in some kind of human form which was rather like that held during life.