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The End

Bridget English

The Way We Die Now by Seamus O’Mahony, Head of Zeus, 292 pp, £14.99, ISBN: 978-1784974268

Nothing is as certain in life as death. Despite this certainty and the various kinds of death on offer, humans have little choice as to how or when their deaths will occur. Rational thought tells us that death is both natural and uncontrollable, yet humans have nevertheless attempted to master or outwit it for centuries. Until recently, these attempts to make sense of death or to keep it at bay rested on folklore, myth, religion, and superstitions now largely seen as out of step with modern lifestyles. We now find it ridiculous that someone might wear an amulet against evil spirits or that a person might speak of seeing a wailing banshee, foretelling the death of a family member, or that any kind of tarot reading or tea leaf prediction might be taken as a serious warning of imminent death. Instead we put our trust in medicine and believe that technological advances and experimental procedures will save us, while preventative medicine and healthy living will provide us with the key to eternal life.

Our faith in medicine is so strong that even dying patients remain under its spell, and, sometimes unaware that they are dying, pass into oblivion under the influence of morphine or subjected to the pain and stress of ineffective medical procedures which leave behind a bruised, battered and bloody corpse. This is not how it was supposed to happen, we might think, but we cannot quite envision how death was supposed to go, in part because we are unwilling to confront our mortality or that of our loved ones. Older societies had a plan for death and how to attend the dying: the ars moriendi or the “art of dying well”, traceable back to the early fifteenth century, provided steps and instructions for Christians on how to die a “good death” and was largely focused on the redemption of the soul. In our increasingly secular modern society dying has become strictly a physical process, one that the conscious mind is often unprepared for or even unaware of. In our efforts to prolong life for as long as possible, have we lost the ability to die? What constitutes a good death in the twenty-first century and is such a thing even possible?

These are some of the questions that Irish physician Seamus O’Mahony grapples with in his bold new book The Way We Die Now, which addresses the ways that modern Western society denies death in a prose style that is direct and almost clinical in its detachment from emotive language. The result is a book that is unclouded by sentimentality, provoking its readers to consider the practicalities of physical demise. O’Mahony, a gastroenterologist at Cork University Hospital, brings a fresh perspective to the topic of death and dying, one that combines medical experience and expertise with personal anecdotes and research into cultural histories of death. One text that O’Mahony draws heavily on is Philippe Ariès’s classic study of death in Western society, The Hour of Our Death (1981), but he also demonstrates a wider-ranging knowledge of philosophical and literary treatments of death, particularly Leo Tolstoy’s great novella, The Death of Ivan Ilyich.

The Way We Die Now offers no easy answers to the difficult questions surrounding end-of-life care or suggestions as to how to ritualise death in an increasingly secular world, but O’Mahony does expose the delusion and denial that characterises Western attitudes towards the event. He is quick to note in the preface to his book: “This is not a book of consolation: death is simply affliction and the end of our days. We are frail and vulnerable animals.” In other words, this is not a book for those seeing comfort or an optimistic view of the end of life. Indeed, what distinguishes The Way We Die Now from other recent books written by medical professionals, such as Atul Gawande’s humanitarian Being Mortal: Medicine and What Matters in the End (2014), or terminally ill neurosurgeon Paul Kalathini’s lyrical When Breath Becomes Air, is its unadorned style and resistance to the sentimentalising, new age spiritualism or false optimism of other accounts. Still, many of the conclusions that O’Mahony comes to are not vastly different from those reached by other medical professionals or cultural historians.

O’Mahony writes in the prologue: “The language used about death and dying tends to have a quality of cloying earnestness: nobody ‘dies’ anymore; they ‘pass over’, they ‘pass on’, or they simply ‘pass’; The book I wanted to read about death and dying didn’t exist.” His goal is then, as stated, not only to “reclaim the conversation about death and dying” which he views as “too important to be left to the death specialists” but to write a book that offers a realistic portrait of the ways that the dying are treated by medical practitioners and society more generally, without obscuring the topic with any kind of spiritual lessons or metaphysical meditations.

For the most part The Way We Die Know sticks to this programme, offering a refreshingly honest description of the ways that some medical procedures are often employed unnecessarily to make it look as if the doctors have not “given up” despite the futility of such efforts. However, the space given to literary and philosophical treatments of death and dying and mourning rituals, while interesting, seems in some ways to go against the very argument that O’Mahony is trying to make: that doctors should concern themselves with the dying person’s physical needs, offering relief of pain and an honest prognosis rather than engaging with spiritual or metaphysical questions. In one sense, the inclusion of this material seems to imply that perhaps literature or philosophical writing meet the needs of the dying, or at least the mortal desire for meaning, in a way that medicine cannot, while in another, he seems to suggest that these too are merely futile attempts to do the impossible: teach us how to die. While many questions surrounding death and mortality are obviously unanswerable, The Way We Die now at times seems too ready to dismiss difficult questions as hopeless conundrums. In part, this is due to the unmanageability of a topic like death, but at times it seems to stem from the spiritual and metaphysical questions which O’Mahony, as a physician, claims to have no business discussing ‑ but brings up nonetheless.

One instance occurs in the first chapter, which discusses how death has been robbed of its mystery and grandeur, in part because modern society lacks a “common script for dying”. This common script is part of what Ariès called “tame death”, referring to the ways that death was handled in Europe prior to the Industrial Revolution, when it was feared but accepted and impacted the entire community rather than just the individual. O’Mahony argues that in contrast to the tame death of earlier times:

We have been forced to write our own script. Illness memoirs and blogs written by the dying have a popular appeal because people want to know how to compose this script. There is however, something studied and self-congratulatory ‑ even narcissistic ‑ about all this, as there is with the modern clamour for ‘death with dignity’.

O’Mahony is right to point out modern society’s lack of ritual or other cultural support structures for making sense of death and in his assertion that these communal responses have been replaced by a kind of anthropocentric narcissism that fails to see the wider picture beyond individual suffering. The problem is that, as he notes, in the past these older customs were tied to larger religious belief systems and they therefore cannot be easily replaced by some secular version of hollowed-out rituals. The criticism he levels at people who lecture about having a “good death” or “dying with dignity” is that they are attempting to reduce death to a formula or something than can be managed or workshopped. Yet, one wonders if the ars moriendi or the tame death are not also examples of what he calls “trite formulas”? What seems to distinguish older death practices is not the fact that they were spontaneous or lacked a formula but rather that they did not attempt to abolish death or control it. Instead, they recognised, and in some instances even celebrated, its power. O’Mahony argues that modern attempts to control death rob it of its grandeur. However, it does seem problematic to argue that this control is a result of reducing it to a formula, as this was true of earlier practices as well.

Similarly, O’Mahony’s discussion of the rituals surrounding death and mourning, particularly his description of the Irish Catholic funeral ceremony and the Irish wake seem to point to an idealised past in which societies knew how to deal with death, suggesting that secularisation is to blame for modern society’s lack of a “script” for dying. While this may be true, he does not offer many suggestions for alternative rituals even as he recognises that the older rituals cannot be redeployed. He indicates that the Irish still know how to “do” death but like religion more generally, these Catholic and folk rituals are also fading out:

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 […] 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 a minority activity.

While suggesting that the Irish Catholic death ceremony is a kind of ideal or exemplary way of coping with loss, O’Mahony he doesn’t entertain much hope that this ritual will persist once the vestiges of religious practice fully disappear. In fact, he indicates that the so-called “tame death” cannot exist in secular society given that it is so closely tied to ritual which is “primarily a religious phenomenon”. This idea that death rituals must be tied to one particular religion is somewhat perplexing considering O’Mahony’s familiarity with the Irish wake and in particular with Seán Ó Súilleabháin’s Irish Wake Amusements (1967) a book that offers a lively account of the traditional folklore and customs of the Irish wake, which are primarily pagan in origin. In fact, the “ritualistic Catholic sequence” that O’Mahony describes is strikingly similar to the requirements that Thomas Long and Thomas Lynch argue are necessary for a “good funeral” in their co-authored book The Good Funeral: Death, Grief and the Community of Care (2013). Long and Lynch indicate that the only elements required for a good funeral are the presence of the corpse, the bereaved who loved the deceased, some way of registering the change in status, and the narrative created by transporting the corpse to their final resting place, enacting a ritual story that has a beginning, middle, and end. Certainly, this kind of ritualised way of disposing of the dead does not necessarily require religious elements, as much as it may have its origins in those earlier rituals.

The central argument that O’Mahony puts forth in The Way We Die Now ‑ that Western society has lost the ability to deal with death (an idea baldly stated on the book jacket) and that modern medicine’s culture of “excess and dishonesty” disrespects the dying and makes it increasingly difficult to attain a “good death” ‑ is not a particularly original observation (Ariès argued something very similar in 1981), but it is a necessary and vital one. Indeed, many of the recent publications on death and dying from medical humanities perspectives such as Brandy Schillace’s Death’s Summer Coat (2016) or hospice volunteer and journalist Ann Neumann’s The Good Death, and those penned by doctors such as Gawande and Kalathini mentioned above, would concur with the main thrust of O’Mahony’s argument about Western culture’s avoidance of the basic truth of human mortality and the ways in which the medical community has further hidden or obscured death’s harsh realities from both the living and the dying.

O’Mahony’s book is notable for its resistance to tying up loose ends or offering lessons in how to die. However, at times this tendency to not offer tidy conclusions can make for somewhat frustrating reading, as the transitions between paragraphs can often be choppy, lending the narrative a disconnected quality. The fact that the book’s ten chapters are divided into several sub-sections, each of which can range in length from one page or less to several pages or more, does little to smooth over this disjointedness and one often wonders if it would have been better to leave the subheadings out entirely. One particularly irksome example is when O’Mahony references the death of American cultural anthropologist Ernest Becker, who won the Pulitzer Prize posthumously for his book The Denial of Death (1973). Earlier in the book we are told that Becker died of cancer, but the quotation that appears from Becker here, more than a hundred pages later, where he writes that his own death is a chance “to show how one dies, what attitude one takes” is offered without much commentary, leaving readers wondering how Becker died or whether he did indeed succeed in demonstrating to others how to approach the end of life. At other times the lack of explication offered after examples of the death of loved ones or patients can seem true to life, leaving the interpretation of such events up to the reader.

The Way We Die Now offers extensive references to philosophers such as Albert Camus, David Hume, and Ludwig Wittgenstein and writers such as Leo Tolstoy, Samuel Beckett, John McGahern, Philip Larkin and George Orwell, yet O’Mahony claims to find little consolation or illumination in any of these thinkers’ work. In fact, he seems to conclude merely that in spite of that great work they cannot teach us how to die: “Do philosophers, and those writers (such as Tolstoy) who write about death, die any better than their less contemplative brethren? My rather banal conclusion is this: some philosophers die well, some die badly; they appear to have no particular advantage over non-philosophers.” He also faults Beckett in particular for writing about death but not having the courage to be honest with his brother Frank about the fact that Frank was dying of lung cancer: “Mortality was arguably the main theme of Samuel Beckett’s work, but even he found himself powerless to resist the Lie.” Similarly O’Mahony asserts that “Montaigne has left us with many well-polished phrases about not fearing death, but his philosophizing did not prevent him from having the type of death he expressly wished to avoid” while “Tolstoy (1828-1910) showed unique psychological and spiritual understanding of dying in his fiction, but his own death was undignified and unedifying.”

The examples quoted are rare instances where O’Mahony seems to miss the point of literary or philosophical works that deal with death. Regardless of whether these writers and thinkers died a “good” or “ideal” death, their work offers insight into how to live with death rather than instructions on how to die. The point of literature and narrative more generally is not to provide real world solutions to the problem of death but to offer a fictional space that allows us to understand human temporality ‑ from the beginning to the end of life ‑ from our place in medias res or in the midst of life’s action, and thereby provide a way of confronting our own mortality rather than evading it.

Perhaps this misunderstanding of the function of narrative is part of the reason why O’Mahony is resistant to the idea that medical professionals should engage with patient narratives of their personal and medical history. In his 2013 article “Against Narrative Medicine”, O’Mahony criticises this branch of the medical humanities which encourages viewing clinical consultation as a story and which encourages students and doctors to write narratives about their patients and jobs, viewing it as “spiritually arrogant and potentially harmful”. While this may indeed be true of the way narrative medicine is currently practised, O’Mahony runs the risk of dismissing all narratives as failed attempts to offer insights into how to deal with illness or with death, ending his article with a quotation from Oscar Wilde: “All Art is quite useless.” It is curious then that O’Mahony cites so many literary and philosophical examples in his text. Even more curiously, he does not credit medicine or religion with providing any answers to the problem of death either, despite the fact that people increasingly seek a cure for their spiritual turmoil from their doctors. This is where points of his argument seem to get confused, leaving its readers in a Beckettian state of aporia in which neither narrative nor medicine can provide us with a satisfactory way of approaching death.

The emergence of narrative medicine and dignity therapy, O’Mahony argues, has caused doctors to take on a “quasisacerdotal role”, forcing them to “stray from their professional duties into uncharted waters, to take on roles such as spiritual advisor, social worker, life-coach, friend”. Later in the book he asserts: “We have, as a profession, come to a pretty pass when our patients stop trusting their doctors, and see us as an obstacle to a peaceful death.” It is unclear how these two ideas mesh, how patients now see their doctors as shamanic or priest-like figures who are supposed to provide them with spiritual counsel, while at the same time being distrustful of them and seeing them as obstacles to a good death. Presumably this has something to do with what O’Mahony identifies as the “schism within medicine”, with palliative care specialists on the one hand attempting to get patients to acknowledge and accept death and oncologists on the other offering them false hope in the form of additional procedures or experimental treatments. O’Mahony’s larger point, that doctors need to start treating patients in a more compassionate, humane way rather than indulging in wishful thinking, is an important one and it forms the basis for one of the book’s main proposals for how we can avoid over-medicalising death.

The most original and convincing sections of O’Mahony’s book are those that deal directly with what he calls the “culture and excess and dishonesty” that characterises modern medicine’s treatment of the dying. These sections are striking not only for their honesty but also for their practicality for anyone considering end-of-life care. O’Mahony is firm in his assertion that new hospital rituals have robbed death of its significance, with most of his patients dying after “days of syringe-driver-induced oblivion”. Yet when push comes to shove he admits that when his time to die comes he “will not be slow in asking for morphine”, since having witnessed the death of patients who were fully conscious and awake, he would not wish that kind of death on anyone. Thus, while some medicalisation of death is necessary, these procedures should not be employed as a desperate attempt to conquer nature. Medicine’s great sin, according to O’Mahony, is offering patients false hope and performing unnecessary medical procedures that result in a “bad death”. Again, O’Mahony sees oncologists as particularly blameworthy in this regard and in his chapter on celebrity cancer patients, he faults both Christopher Hitchens and Susan Sontag for refusing their own mortality and buying into oncology’s misleading optimism. Hitchens, famous for his scepticism, approached his cancer treatment with a “radical childlike hope” whereas Sontag’s research into experimental treatments for her cancer became what O’Mahony calls “magical thinking disguised as practical research”. Only Irish writer and journalist Nuala O’Faolain escapes O’Mahony’s scorn, rejecting both religious consolation and cancer treatment and refusing to cast her fatal diagnosis in a more positive light.

Though the bulk of The Way We Die Now is dedicated to highlighting the problems with Western medical approaches to death and the perpetuation of death-denial in the media, it does offer several proposals for how we can improve the treatment of the dying. The first step in this process is the recognition and acceptance of death by the dying person and his or her loved ones, as well as by the doctor. Rather than polarising discussions about death and dying by dividing them into groups for and against major issues such as assisted suicide and advance directives, O’Mahony argues in favour of treating the patient with respect and teaching the public, politicians and the media that patients cannot be offered every conceivable option of treatment.

Most importantly of all, the book ends with the argument that medicine should not be wholly dominant in matters relating to death and dying and that its role should be limited and explicitly defined. Medicine cannot advise someone on how to live or how to die, but it can provide some relief for bodily pain. The Way We Die Now offers an unflinching assessment of modern medicine and what it offers or fails to offer the dying. We may not be able to choose how or when we die, but we can choose how we approach the end of life and whether, when our time comes, we will deny death or accept it graciously. O’Mahony provides us with no answers about how to live or how to die but he does offer us insight into how to begin to accept the limits of our own bodies and how to treat our fellow creatures when their time comes. Despite his insistent reminder that we are “frail and vulnerable animals”, O’Mahony’s The Way We Die Now indicates that we are far more complex than other animals in the ways that we approach death. As creatures we must accept our physical mortality, but as humans we cannot rid ourselves of the desire for consolation or meaning.

1/7/2016

Bridget English teaches in the Department of English at Maynooth University. She is currently writing a book on death and dying in the modern Irish novel. 

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