“This is not a book of consolation: death is simply affliction and the end of our days. We are frail and vulnerable animals.” Seamus O’Mahony
One of my earliest memories is my grandfather dying. Neither I, nor he for that matter, were very old at the time; I wasn’t yet four and he had just reached sixty. Given that I was barely out of infancy I don’t remember much; he was a big man, a painter and decorator, and in my memories is always dressed in capacious white overalls curiously free of paint stains. I loved being tormented by him and he would lunge and grab me as I sidled past him, half in fear, half eager to be caught and folded into acres of white cotton drill from where it was impossible to escape. Once I was a prisoner he placed a chin bristling with stubble and abrasive as sandpaper next to my soft and defenceless cheek and rubbed until the side of my face was aflame and I squealed for mercy. When he became ill he wasn’t, as he would be today, admitted to hospital. Instead he took to his bed where I was only allowed to see him once, after much pestering, ushered in by my grandmother when he was asleep, an elephantine bulk to my three year old eyes, swathed in white linen sheets and frighteningly immobile beneath the bed clothes. I didn’t ask him to see him again. My mother told me, much later, that she had been shocked when he told her that he was tired of living and wanted to die. “When our time comes, let us say our goodbyes and die as creatures,” says Seamus O’Mahoney, “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 Isiah.” That is how I think of my grandfather dying, metaphorically turning to the wall and relinquishing life. He may well not have escaped so easily these days; “the default setting of modern medicine is full intervention,” says O’Mahony, keeping people alive in acute hospitals, intubated and on ventilator if necessary, for as long as medical science makes possible.
|The Kansas-based pathologist Dr Ed Friedlander proudly sports a tattoo on his chest saying ‘no CPR’|
Seamus O’Mahony, a Gastroenterologist with a literary and philosophical bent, has experience of both the Irish and the British health services. His day job is a Consultant at Cork University Hospital and with whatever spare time he has he contributes to the Dublin Review of Books. His first book challenges the medicalisation of death, expressing a deep frustration with notions like “death is something that medicine should somehow ‘sort out’”. He writes “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.” He seems a deeply humane and caring man, exasperated with the system and with the expectations of patients and relatives that he should somehow be able to indefinitely defer the inevitable, the dying that comes to us all. It seems that however hopeless the situation most of us prefer to be deceived when a diagnosis or a medical crisis forces us to ask a doctor if our condition is terminal. We want to be told that there is a new treatment in America, or hear about a doctor who is getting extraordinary results with a new drug or even about people cured by quackery like homeopathy when all the doctors had given up on them. “There is little reward, professionally or emotionally, for doctors who tell patients the truth,” says O’Mahony, “but the Lie is heavily incentivized. Nearly all families, and many patients, prefer the Lie. I try to engage with the dying patient with the intention of being honest, but the path of the Lie often looks so much more inviting. And no one has ever complained to me for taking the path of the Lie. Doctors, like their patients, are human and flawed, and the easy path of the Lie is the road commonly taken.”
Being dead is easy but dying is hard. O’Mahony’s sobering book is about the process of dying, when we have to cope not only with the existential anguish of our imminent demise but with the physical pain and suffering that accompanies it. He is attracted by Philippe Ariès notion of tame death as described in the French historian’s 1975 magnum opus Essais sur l'histoire de la mort en Occident: du Moyen Âge à nos jou (published in English as Western Attitudes Toward Death from the Middle Ages to the Present). Ariès argued that before the 17th century people were acutely aware and accepting of their own deaths. Death was a public event and people rarely died alone without the comfort of friends, relatives and religion. Excessive expressions of emotion were avoided in the presence of the dying; these only became normal when death became feared and shunned from the 17th century onwards. Today, O’Mahony observes, “death has become fashionable as a topic of public discussion, but, despite all the celebrity memoirs and earnest newspaper articles, it is still largely hidden. In Europe, the process of secularization has advanced so far that we will never see a return to Philippe Ariès's 'tame death'. Could we fashion a secular version of tame death? I doubt it: death is tamed by ritual, and ritual is primarily a religious phenomenon. We will never go back to a pre-Enlightenment Christianity in Europe, and secular rituals will not emerge.”
|Seamus O'Mahony, the literary gastroenterologist|
O’Mahoney points out that most medical practitioners, who after all should know what they are talking about, are deeply sceptical about the value of excessive and aggressive intervention of dying patients. He cites a 2003 study carried out by John Hopkins University which “examined doctors’ preferences for their own care at the end of life. Most had an advance directive. The overwhelming majority did not want cardio-pulmonary resuscitation, dialysis, major surgery or tube feeding. They were unanimous in their enthusiasm for analgesic drugs. The uncomfortable conclusion of this study is that doctors routinely subject their patients to treatments they wouldn’t dream of having themselves. The Kansas-based pathologist Dr Ed Friedlander proudly sports a tattoo on his chest saying ‘no CPR’.” He thinks 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.”
Seamus O’Mahony’s excellent book makes uncomfortable reading. Highly recommended.