Danse Macabre

This is the second of three posts on the struggle we have to know what to do about assisted dying. The first addressed the sanctity of life. This one is about death. The third will be on technology.

On the one hand more and more people are being artificially kept alive against their wishes. On the other, whoever is entrusted with the right to say it is time for someone to die, there is the danger of abuse.

When we face a dilemma like this it is worth taking a step back and asking whether we have a blind spot. The spookiness of death is, I believe, one of the blind spots.

The Christian history of death

We struggle to explain what life is, but on the matter of death we prefer not to talk at all.

Philippe Ariès’ The Hour of Our Death (London: Allen Lane, 1981) explores this well. It describes in hair-raising detail the changing Christian attitudes to death until the 1970s when the book was written. Some examples will illustrate the point. The ancients were afraid of the dead and buried them out of the way, but the early medieval Christians, with their commitment to the resurrection of the body and the tombs of the martyrs, kept them close. From the fifth to the eighteenth centuries ‘the dead ceased to frighten the living, and the two groups coexisted in the same places and behind the same walls’. The effect was no more hygienic than one would expect: while in one part of a church a priest would be giving children a lesson in the Catechism, in another gravediggers would be digging up the floor to bury a body. The release of gases from previously buried bodies could cause illness and sometimes even death. Ariès gives examples from as late as the eighteenth century.

Before modern times death was seen as a time of transition. In the later Middle Ages, it was the stage for a supernatural struggle between the forces of good and evil for the dying person’s soul. As Savonarola put it,

Man, the devil plays chess with you, and he does his utmost to capture and checkmate you at this point. Hold yourself in readiness, therefore, and think well on this point, because if you win here, you will win all the rest, but if you lose, all that you have done before will be worthless.

There is a church in Naples where, in the seventeenth century, there began the custom in which

anyone can choose a skull at random in the charnel and take it into a crypt transformed into a mortuary chapel. One visits one’s skull periodically to keep the candles lit and recite prayers. One hopes that the unknown soul thus favored will be promptly delivered from purgatory. And he in turn, from his new celestial abode, may one day repay his benefactor in kind.

Thus Ariès introduces us to one practice after another which would be socially unacceptable to us. Death, and its implications, were acceptable topics of conversation. Together with the danses macabres and the transi (popular artistic representations of rotting corpses) one discovers a different attitude, where they laughed at death just as death laughed at them.

The modern medicalisation of death

Yet the greatest shock comes at the end, when he contrasts all this with the modern medicalisation and hospitalisation of death.

The dying man, who had already formed the habit of confiding to survivors wishes he no longer included in his will, abdicated gradually, abandoning to his family the control of the end of his life, and of his death. The family, in turn, passed this responsibiity on to the scientific miracle worker, who possessed the secrets of health and sickness and who knew better than anyone else what should be done.

This leads to a redefinition:

Death has ceased to be accepted as a natural, necessary phenomenon. Death is a failure, a “business lost”. This is the attitude of the doctor, who claims the control of death as his mission in life. But the doctor is merely a spokesman for society. When death arrives, it is regarded as an accident, a sign of helplessness or clumsiness that must be put out of mind. It must not interrupt the hospital routine, which is more delicate than that of any other professional milieu. It must therefore be discreet.

Medicalisation then redefines expectations. The ‘acceptable style of facing death’ is ‘the death of the man who pretends that he is not going to die’. The bad death

is always the death of a patient who knows. In some cases he is rebellious and aggressive; he screams. In other cases, which are no less feared by the medical team, he accepts his death, concentrates on it, and turns to the wall, loses interest in the world around him, cuts off communication with it. Doctors and nurses reject this rejection, which denies their existence and discourages their efforts. In it they recognize the hated image of death as a phenomenon of nature, whereas they had turned it into an accident of illness that must be brought under control.

To me this brings back memories. While Ariès was writing his book I was a nurse. Often enough the body language of helpless dying patients was clear enough: ‘Go away and leave me to die in peace’. No matter: my job was to take temperature, pulse and blood pressure, make the bed, whatever else. Decades later, when our dying family dog exhibited the same body language, the penny dropped.

Ariès’ judgement is severe. We have lost the codes we used to have for revealing unexpressed feelings – codes for courting, giving birth, dying and consoling the bereaved. Instead the feelings are suppressed: ‘It is quite evident that the suppression of mourning is not due to the frivolity of survivors but to a merciless coercion applied by society.’

Unmentionable death

My point is a limited one. One does not have to accept all Ariès’ strictures to recognise that modern society is far more squeamish about death than our predecessors were. This, I suggest, is one of the blind spots that hinders our current debate. In the past death could be seen as a time of transition. What was to happen next was variously described, but as long as it was a transition to something else, one could reflect on it. Today, for many, it is an absolute end. For the dying person there is no future at all, nothing to reflect on. The institutional ethos of hospitals presupposes this as the default position; doctors who believe in an afterlife should keep their views to themselves while on duty. In this situation it is inevitable that death becomes the great unmentionable. Just as 1930s Germans, aware that nasty things were going on in the gas chambers, knew it would be a faux pas to chat about them at dinner parties, so we today know not to talk about death.

One way to run away from it is to fantasise about postponing it as long as possible. Maybe medical technology will one day enable us to live to 150. When we are young the prospect can seem exciting; by the time we get to 90, the thought of another 60 years is the last thing we want. Because so much medical research is valuable for other reasons we are reluctant to criticise it, but theologians should not collude with those whose real agenda is to avoid facing up to death.

Death happens. We need to rediscover how to talk about it realistically. If we did, perhaps we would become better able to help the terminally ill to die well.