A Matter of Life and Death14 min read
There are many epitaphs that reflect a dark sense of humour on the part of the departed. Spike Milligan’s comes to mind: “I told you I was ill.” But my favourite one belongs to Marcel Duchamp, the French master who pretty much wrote the rule book for the plastic arts in the 20th century. Freely translated from the French, the inscription on his tombstone reads: “After all, it’s always the others that die.” This, to my way of thinking, captures the extraordinarily paradoxical nature of the human animal. We all know that everyone must eventually die – and yet, somehow, we don’t think that we ourselves ever will. A doctor I was once talking to about matters deathly expressed the same idea slightly differently. “No patient,” he told me, “ever thinks of themselves as a statistic.”
Following a year in which there have been more excess deaths (those above the annual average) in Britain than in any since 1942, death, along with its supposed opposite, health, has never been far from people’s thoughts. We may be overly cautious in our response to the pandemic, or pretty blasé – both entail that we take up a position in relation to our own mortality, and that of everyone else. When we get angry about this or that aspect of government policy – either cursing “them” for failing to take all necessary measures to stem, palliate, cure and then eradicate the disease; or, damning the lockdown for destroying livelihoods and mental health, while assisting in the production of those mournful statistics quite as much as the coronavirus itself – it’s still the skull beneath our skin that’s animating us, twisting our features into a snarl, or a sneer.
It’s the same when we either defiantly refuse to wear a mask, or rail against others who won’t: 2020 was the year in which personal anxieties and political positions potentiated one another to a mortal degree. To listen to all the verbiage that has been spewed out during a long year of coming to terms with the most serious public health crisis since the Second World War is to hear a sort of collective howl, as if the entire nation were – to adapt a line from Dylan Thomas’s celebrated poem about mortality – raging, raging against the dying of the light. It’s an anger that is in counterpoint to all of the pot-banging and hand-clapping in support of “our” National Health Service. This possessive is now mandatory for any politician who wishes to appear as a man or woman of the people, whatever their affiliation. Put simply, the pandemic has now revealed anew all of those systemic inequalities – between rich and poor, black and white, old and young – that they’ve tried to hide with this sleight of mind: the elision of the commonwealth with common health.
And yet you wouldn’t be reading this magazine – let alone this article – if you weren’t already someone who is acutely conscious of his health. I’d bet quite confidently that the majority of you scanning these words know fine well that the UK’s miserable position at the top of the league table when it comes to the pandemic’s death score is a function of both a long-standing crisis in public health and a long-standing success.
How can we explain this paradox? Well, on the one hand, Britain remains the fat man of Europe, the diabetic man of Europe and one of its hardest-drinking and heaviest-drugging nations. And for all our championing of elite sport – and our successes in it – we also remain predominantly a nation of armchair exercisers. But the success that is most implicated in our high death rate from the virus is that of a socialised health-care system managing to keep so many elderly and infirm people alive; one that’s now doubling down on that conspicuous achievement by enabling Britain to deliver the vaccines faster than most other nations.
True, our elderly may be warehoused in so-called care homes that – in many cases, though not all – their relatives seldom visited even before the pandemic made this impossible. And they may also be suffering from an epidemic of dementia that makes it questionable that they enjoy any meaningful quality of life. But the important thing is that they’re alive; alive in sufficient numbers during the past year to die from the virus.
No individual thinks of themselves as a statistic, but our discussion of these matters revolves entirely around them. Well, here’s a statistic that’s worth considering: it is estimated that the vast majority – perhaps as much as 90% – of health-care resources allocated to an average Briton’s life are spent during their final three months. The conclusion is inescapable: if we were all simply to die suddenly, three months before the heart attack, stroke or carcinoma did its deathly thing, there would be 90% more capacity in “our” NHS, and dealing with a relatively non-lethal virus such as this one (and its variants) would be a metaphorical walk in the park.
It’s been a quarter of a century since, contemplating this frankly bizarre statistic, I renamed our NHS – in my own mind at least – the National Death Service. From this perspective, all of the brouhaha during elections about its continuing funding can be seen more clearly. Political parties are competing to convince the electorate that they’re the ones who will ensure that the people will have a painless death. Another doctor told me recently (and yes, I do often discuss these matters with medical people: I’ve been just as interested in death and dying as in life and health) that the only drug in the pharmacopoeia that there is no upper limit on British doctors prescribing is morphine, in all its variants. That most Britons with metastatic cancer die as junkies is just another of the inconvenient truths surrounding the British way of death that we like to repress. Yes, of course good medicine involves effective pain management, but it must be the greatest serendipity – if the possibility of divine intervention is ruled out – that the drug that does this so effectively also induces a euphoria that masks our fear of death and makes it possible for us to contemplate it without any hope of resurrection or afterlife.
Going with the Flow
Understandably, spiritual questions lie beyond the remit of a magazine that is predominantly focused on physicality. Yet surely death is the great decider in these matters, for when we contemplate our own extinction – to really sit there and think about it in concrete detail – we are forced also to consider what remains once our bodies have returned to dust. Or are we? I see no evidence that the pandemic has made people any more willing to apprehend their own deaths – as opposed to their anxiety about it, or indeed anyone else’s demise. Meanwhile, I’d also argue that it’s this unwillingness that makes it difficult – if not impossible – to address the public health issues that have made the pandemic so devastating for Britain.
Put bluntly: most people consider that leading a healthy life involves the consistent denial of death. Dwelling on matters morbid is bad for mental health and, besides, when you’re in those flow states so intrinsic to health, such as during bodily exercise, death is the last thing on your mind. Mens sana in corpore sano (“a healthy mind in a healthy body”) is perhaps the one Latin maxim that we can all sign up to – no matter that, unlike the Prime Minister, we weren’t all classically educated!
The argument here, perhaps, is that in order to cultivate a healthy mind in a healthy body, it’s best to extend that flow state to the whole of our lives. Much of the way modish “mindfulness” bowdlerises traditional meditational practices seems to aim at this desideratum: a lifelong flow state, in which thoughts of death are, quite literally, unthinkable. The trouble with this approach is, I suspect, that in cultures that have no collective vision of an afterlife, it becomes hard to tell the difference between a deeply fulfilled being-in-the-moment and a painfully frightened state of denial in which we, figuratively speaking, stick our fingers in our ears and hum as loudly as possible to block out the knell that tolls the passing day, and the passing of our lives.
The National Death Service and our frenzied efforts to ensure that it continues to operate at maximum efficiency are stymied by this inescapable fact: the demand for medical care, facilitated by advances in medical science, increases exponentially, while our ability to pay for it inevitably lags behind. Our faith – such as it is – rests in the former, and this is understandable. When I was diagnosed with a myeloid blood condition a decade ago, my life expectancy was around 15 years. If there hadn’t been extraordinary progress in developing drugs able to target the stem cells that cause my bone marrow to overproduce haemoglobin, platelets and so on, I’d be contemplating my imminent demise right now. As it is, my life expectancy is now pretty much the same as for any other 59-year-old British man.
It was Arthur C Clarke who noted that any sufficiently advanced technology is indistinguishable from magic – and this applies not only to my meds, but also to the innovative RNA vaccines that we hope will deliver us from the pandemic. Magic and faith are ways of human thinking that, under optimal conditions, also increase exponentially – by which I mean that, just as those who have religious faith can ward off their fear of death with a vision of everlasting life, so those of us who are rather more materialistically inclined can suppress it with a vision of our lives being infinitely extended by medical science. Yes, yes, I know: you’re not one of those whack jobs who believe in the Singularity – that vision of a human destiny that lies in being uploaded into some sort of computable (rather than celestial) cloud. Yet the incremental nature of medical science’s advances tricks us into our own strange version of one of Zeno’s paradoxes: we advance halfway towards our death, then a medical advance occurs that lengthens the remaining half of our lives. And so on, such that just as the arrow never reaches its target, so we never arrive at that death itself.
A Good Way to Die
Except that we do. I’ve had a deathly couple of years: my ex-wife died of metastasised breast cancer in October 2019, aged 58. Two friends died early in 2020: one aged 58 of cancer, the other in his mid-sixties, ostensibly of COVID but really of cancer, as well. Over the past six months, I’ve been trying to help my brother-in-law, who has been succumbing to lung cancer, aged 54.
My observations of the way these several individuals have died – or are dying – were confirmed by a conversation I had with an acquaintance who has worked as a palliative care nurse for 15 years and seen a great number of people die. “Put bluntly,” she told me, “those who’ve lived a chaotic life have a chaotic death, while those who’ve lived an unfulfilled and unhappy life also have an unhappy death. The reverse is also the case: those who have ordered lives have ordered deaths, and if they’ve been loved and content, they’re more accepting of the inevitable.”
So far, you might say, so predictable. My acquaintance is not the sort of person to treat the ill and dying as statistics; her vocation absolutely demands that she sees everyone as an individual. But while she maintains, “There is no typical death – there are as many different deaths as people dying,” she nonetheless readily put a figure on the percentage of those who arrive at the jumping-off point with at least a partial acceptance of its reality: “85% do resign themselves in the end,” she said, “and often it’s the relatives who are the obstacle to this occurring earlier.” Relatives, who, she said, frequently insist on just those life-extending interventions that are so very costly and deliver very little benefit apart from prolonging the brute fact of someone’s existence.
And while personally having some religious faith, this palliative care nurse is at pains to reject any idea that she was “an angel”, or – worse still – saintly. “I’ve seen plenty of colleagues who fall for that image of themselves,” she says. “We call them ‘glory hunters’.” But really, there’s no glory to be found here. Only, I think, a kind of shameful hypocrisy in the face of a social ethic that insists on the sanctity of life – any life, no matter how painful and diminished – while denying that there’s any afterlife, and so making it almost impossible, psychologically, for people to realise the autonomy that might lead them to a greater acceptance of death.
I would argue that we need to reverse the palliative care nurse’s dictum and admit to ourselves that the meaning of our lives is – at least, in a large part – to have a good death. Perhaps if we keep this objective clearly in view, it will enable us to lead our lives in a healthy and harmonious way. This is, if you like, an appeal for us all to have “healthy deaths”. This isn’t a contradiction in terms, because death and life – let alone death and health – are not opposites but deeply entwined. It was the nurse who also told me a joke that does the rounds among those involved with our modern way of death: “Why do they have nails on coffin lids?” To which the reply is: “To keep the oncologists out.”
But while she concedes that many end-of-life scenarios conform to the picture I’ve painted here, she is assiduous in pointing out that many people – especially the elderly – die with little requirement for either analgesia or drugs to ease anxiety. She also gave me an insight into the scrupulousness with which palliative care specialists consider matters of medication – something not often managed as well by generalists. Overall, talking to her gave me an impression of at least one department of the National Death Service that was faithful to its core principles – but then that’s hardly surprising, given their vocational ethic is not to hasten death, or needlessly and painfully extend life.
Faith and Medicine
Nor, of course, is that the aim of oncology. Yet over the past few months, I have witnessed, up close and personally, just this phenomenon as my brother-in-law has been offered increasingly futile “treatments”. Painful, debilitating and, most importantly, dehumanising interventions, which, by objectifying him, have made it quite impossible for him to reach an acceptance of the fact that he’s dying, and to therefore have a healthy death.
I’ve sat in meetings with my brother-in-law’s oncologists while they’ve spent more time examining their computer screens than they have him. I’m not necessarily criticising these doctors as individuals – I truly believe we’re all in this folly together. The palliative care nurse told me that people from lower socioeconomic backgrounds tend to be more accepting of death than the educated middle classes, who will go mano a mano with doctors, because they see them as professionals, employed to do a job like lawyers or accountants.
Each intervention offered to the moribund who are in denial of their deaths cannot help but be seen by them as clinically effective, even if the doctors administering it are quite clear that it isn’t any more. That this should be so is a function of the faith in medicine I’ve alluded to above. The analogy would be if the priest who had christened you, instructed you for your confirmation – or first communion, or bar mitzvah, or bhrataman, for that matter – married you, and then also christened all your children, were the same person who then told you that you were dying and should prepare to be received by your maker. Oh! But hang on a minute – it is the same person who performs those roles for the religiously faithful, and that’s arguably why they believe in what he or she tells them.
My own disenchantment with the ability of doctors to take on the role of priests goes back a long way. My mother died when she was 66 and I was 26 – and it was, in some ways, the defining event of my adult life. I was close to her, took her to her radiology sessions and was present when the cancer entered her cerebrospinal fluid. Over the course of an afternoon, I saw a lucid, intelligent and cultured woman turn into a mindless creature, thrashing about and screaming incoherently.
I went with her in the ambulance to the hospital where she died a week later – these were the days before the Liverpool Pathway had been established, which sets out practical and ethical protocols for how to treat the dying. As it was, mercifully, the nursing staff upped her dosage of both barbiturates, to keep her unconscious, and opiates, to ensure that she was pain-free, until she succumbed, in all likelihood, to their effects as much as to the cancer. And note this: they made little secret of what they were doing.
But if my experience of my mother’s death made me determined to live life to the full – a not uncommon reaction of those who witness another’s demise up close and highly personally – it was the behaviour of the people around me in its aftermath that made me react so vehemently against the modern British way of dying. I was shocked by the inability of emotionally mature people to even say the D-word, let alone offer adequate condolences. I found myself on numerous occasions with interlocutors who seemed to be trying to finesse the word out of me, so that they could then weigh in with their compassion. I was appalled by this 30 years ago – and yet more appalled when I experienced the same phenomenon in relation to my ex-wife’s death in 2019. People would stand talking to me, their eyes roving the heavens and the ground beneath their feet – looking anywhere but at me and in my eye.
When I braced one or two of these pathologically death-averse types as to why they couldn’t simply say, “Sorry to hear about your ex, it must be very hard for you and the children…” they fell back on the most common English shibboleth of all, lisping, “I didn’t want to say anything in case you thought it was rude.” Rude! As if dying were like burping in the vicar’s face during a genteel tea party – as if, in fact, dying were some sort of social solecism, one of those things that just isn’t done.
I believe it isn’t until we can talk openly about death that we’ll begin to lead truly healthier lives. For me, acceptance of death is what will make it possible for preventative medicine to become the principal kind practised, rather than the sort of “heroic” interventions that are used to prolong life nowadays, often in situations where its quality is, at best, debatable.
And yes: I wouldn’t mind living in a society in which people took the “Roman way” out and committed suicide when it was their time. It’s what I intend to do. Mark well: by this I don’t mean “assisted suicide”, because as I hope I’ve managed to convey to you, our slavish faith in doctoring is one of our most troublesome ills. And arguably worse for our health than those that ostensibly plague us.
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