Death and dying are unexceptional. Everyone who ever was, and all of us now will succumb, counted among death’s conquests. Literature, good and bad, abounds with death; it is the staple of the thriller, the dark edge to stories for children, and the shocking denouement of many a tale. Death is central to much of literature; as a device it can summon up and help explain many of the tangled and complex emotions that make us human. Within medicine, death is an equally pivotal player, but its presence is something generally felt, not articulated. Death may well be there in the subconscious of all the players of real hospital dramas unfolding around us, it will be in the minds of the patients as they prepare themselves for admission, and of their loved ones left behind to worry; and it will be a dark fear for many of the doctors who care for them.

Yet despite death’s ubiquity and the certainty of its arrival, it remains a mystery, our fears left unspoken. In many ways, death can be seen as the last taboo. Elisabeth Kübler-Ross writes of it as ‘a dreaded and unspeakable issue to be avoided by every means possible in our modern society’. This can be most striking of all in the doctor-patient setting, and there are many reasons why this is sometimes the hardest place to confront death. This essay explores some aspects of death and the dying faced by doctors in caring for the sick and looks at ways in which literature may illuminate the nature of death, as it provokes some of humanity’s darkest thoughts and profoundly difficult questions.  As John Skelton notes, ‘literature as a discipline aims just as certainly as science does to understand the worlds in which we live and to interpret our own role as participants in the human condition’. So, though they may initially seem an unlikely pairing, we discover that medicine and literature offer perhaps the most profound gaze of all into the human condition.

‘By the Deathbed’, by Edvard Munch, 1896

‘rage, rage against the dying of the light’

In both literature and medicine, much of the drama surrounding death lies in the conflict between fighting against death and reaching an acceptance of the inevitable. When we talk about illness and death, we often speak in metaphors of war, conjuring up battles against disease, and the fight to survive; on learning that death may arrive sooner than anticipated, acceptance is hard, and anger and denial are the norm. In Somerset Maugham’s ‘Sanatorium’, Mr Chester resents the unfairness of it all: he is, we are told, a very ordinary man, with very ordinary ambitions, who has to come to terms with the fact that he is dying. 

‘It seemed to him a cruel and unjust trick that fate had played upon him. He could have understood it if he had led a wild life, if he had drunk too much, played around with women or kept late hours. He would have deserved it. But he had done none of these things. It was monstrously unfair.’

The random nature of terminal disease of course has no logic, and doesn’t restrict itself to the same moral guidelines that we may follow. Mr Chester is bitterly angry that he is to die, denial and anger being familiar elements of the distinct stages experienced by those exposed to terminal illness and death. Having finally realised that his premature death is certain, Mr Chester is unable to bear contact with those not under threat of death. Visits from his wife cause him suffering, as she represents the life he has had to leave behind, and reminds him of the life that will go on beyond his own death. His wife understands this, ‘You see, he resents it so terribly that he’s ill and I’m well. He’s afraid he’s going to die and he hates me because I’m gong to live’. This dispute with death is seen many times in literature, when Mr Chester contests the unfairness of his death sentence we are reminded of Lear’s outraged protest at the death of Cordelia,

‘Why should a dog, a horse, a rat, have life,
And thou no breath at all? Thou’lt come no more,
Never, never, never, never, never!’

In Chekov’s short story ‘Misery’, the coachman laments the fallibility of death, ‘Here my son’s dead and I am alive….It’s a strange thing, death has come in at the wrong door…Instead of coming for me it went for my son…’ The premature death of the young, shortened lives left unfulfilled, is an unbearable tragedy that can only be seen as a terrible mistake; there can be no other reasoning that offers any solace.
 
In many ways, resisting death is what defines medicine - the popular perception of the doctor is of someone manning the frontline between the patient and the disease, saving lives and curing ills. This constant striving to put off the inescapable is in many ways a laudable effort, and the rejection of death can also be seen as a celebration of life. Nothing is appreciated so much as in the moment of its taking away, and so death and the fear of death are a potent reminder to us all of the joy of life. We see Dylan Thomas’ angry extolling of his father, demanding that he should fight to the last,                                                                                                         

‘Do not go gentle into that good night,
Old age should burn and rave at close of day;
Rage, rage against the dying of the light.’

By engaging in the struggle against death, we acknowledge that life is precious, and worth holding on to. William Carlos Williams’ direct and brutal writing style matches the unsentimental view he has of his patients and, in some cases, of their deaths. He too, appreciates the fighter; we see in his short story ‘Jean Beicke’: ‘I hated to see the kid go. She was such a scrawny, misshapen, worthless piece of humanity that I had said many times that somebody ought to chuck her in the garbage chute – but after a month watching her suck up her milk and thrive on it – and to see those alert blue eyes in that face – well, it wasn’t pleasant’. This little scrap of a human being, against all odds, showed a lust for life and a tenacity that couldn’t fail to impress her case-hardened doctor.

And yet, this battle against death is one we shall inevitably lose, if not this time, then another. In an age when it feels as if the scope for scientific advancement is limitless, it is unsettling to come across patients with inoperable tumours, end-stage renal failure, or any other terminal disease that may have nothing to do with age. The journey toward acceptance of death can be a difficult one for patients, their family and also the doctors who care for them. For the patient, this passage is made all the more difficult if they are unable to express their concerns to their doctor, who may also be struggling on a different level to come to terms with the dying patient. For the doctor, difficulties arise from several sources; from being unable to find an understanding of the patient’s fear and pain, to the uneasy feeling of perhaps having ‘failed’ the patient. At the moment death truly becomes inevitable, reaching an acceptance is vital: literature may show doctors ways to help our patients achieve this, and indeed help us to be better doctors at a time when our patients need special understanding and skill.

‘unresting death’

Most people have close experience of death only rarely, and their impression of it will be formed by media such as literature, music and other arts. We may all wish to follow Maugham’s advice and have ‘nothing whatsoever to do with death’, but this is hardly an option for those who care for the sick and the dying. It would perhaps do all medical students well to consider the advice of Irish physician and writer Oliver St Gogarty’s professor of medicine to his own medical students:

‘Turn back now if you are not prepared and resigned to devote your lives to the contemplation of pain, suffering and squalor…Your outlook on life will have none of the deception that is the unconscious support of the layman; to you all life will appear in transit…You will see…the pull of the grave that never lets up for one moment, draw down the cheeks and the corners of the mouth and bend the back until you behold beauty abashed and life itself caricatured in the spectacle of the living, looking down on the sod as if to find a grave.’

 

The ‘unconscious support’ of denial is a luxury that Philip Larkin never allowed himself either. In his poem, ‘Aubade’, death harries him relentlessly, permitting no repose; life is only another step in the journey toward death.

‘Till then I see what’s really always there:
Unresting death, a whole day nearer now,
Making all thought impossible but how
And where and when I myself shall die’

In another of Larkin’s poems, ‘Next, Please’, Larkin wonders how it is that we spend our lives expecting the arrival of some ‘Sparkling Armada of promises’, and yet,

‘Only one ship is seeking us, a black-
Sailed unfamiliar, towing at her back
A huge and birdless silence.
In her wake
No waters breed or break’

There are no glittering prizes for Larkin, a life well lived will end in the same manner as any other. The only constant is death, sailing toward us on her steady and unfaltering course. In the short story, ‘Ward No.6’, Chekov’s doctor Andrey Yefimitch seems to share this view, ‘People will suffer pain, grow old, and die just as they do now. However magnificent a dawn lighted up your life, you would yet in the end be nailed up in a coffin and thrown into a hole’. This cynical outlook is parodied by the doctor’s schizophrenic patient, Ivan Dimitritch, ‘A peasant woman comes with toothache…well, what of it? Pain is the idea of pain, and besides, “there is no living in this world without illness; we shall all die, and so, go away, woman, and don’t hinder me from thinking and drinking vodka”’. 

He remonstrates with the doctor for his derisive understanding of death and pain; for the doctor it is nothing, because he has no empathy for those who suffer. From his detached point of view he can observe that suffering is just another fact of life that should be borne without complaint, that those who endure pain and death are perhaps all the better for it. However, in the story’s grim conclusion, it is only when he comes to suffer pain and powerlessness himself that he begins to understand its true meaning, that there is nothing ennobling about enduring this wretched experience. In ‘Sanatorium’, Maugham makes the same point, ‘There are people who say that suffering ennobles. It is not true. As a general rule it makes man petty, querulous and selfish’.

‘Full of sound and fury, signifying nothing’

Coming to an acceptance of death is perhaps a greater problem for our modern secular world. Mikhail Bulgakov writes:

‘It is the tragedy of our day that these humble souls have lost their faith in God, in whom lay hope, and their belief in a resurrection that may bring them the happiness that has been denied them on earth; and have found nothing to put in their place’.

For those who believe in the afterlife, death represents a transition. Yet, as Maeir notes:

‘for the secular, death represents annihilation. Death is no longer an event for which one wishes to prepare. It is a reality which people wish to deny. It is approached psychologically in the very same manner as we deal with the unpleasant and unacceptable. We deny their existence.’

 

Without the comfort of religious belief, death can only be experienced as loss, best ignored and not given due serious thought. This creates an alienating experience for the dying patient, isolated and unable to discuss their impending death with even their physician, they are unable to put basic affairs in order, or even to say goodbye.

Like Larkin, John Donne also saw death as a constant, a feature of humanity, never to be ignored. Yet, his view is informed by his Christian belief, and so for him, death represents a cyclical, life-giving force, ’all mankind is of one author, and is one volume; when one man dies, one chapter is not torn out of the book, but translated into a better language; and every chapter must be so translated’. The Reverend John McManners, Professor of Ecclesiastical History at Oxford describes the unique significance death has in reaching an understanding of the human condition: ‘The knowledge that we must die gives us our perspective for living, our sense of finitude, our conviction of the value of every moment, our determination to live in such a fashion that we transcend our tragic limitation’.

For Larkin, religion represents nothing more than a trick, ‘created to pretend we never die’. The anticipation of annihilation, of nothingness, and the rejection of the ‘specious’ nature of Christian promise shape Larkin’s ‘Aubade’,

‘That this is what we fear – no sight, no sound,
No touch or taste or smell, nothing to think with,
Nothing to love or link with,
The anaesthetic from which none come round.’

The sure knowledge that oblivion awaits makes any hope of quiet acceptance of death impossible, in its place Larkin instead describes a slow terror,

‘And so it stays just on the edge of vision,
A small unfocused blur, a standing chill
That slows each impulse down to indecision
Most things may never happen: this one will,
And realisation of it rages out
In furnace fear when we are caught without
People or drink. Courage is no good:
It means not scaring others. Being brave
Lets no-one off the grave.
Death is no different whined at than withstood.’

The bleak outlook found in ‘Aubade’, is tempered somewhat in Larkin’s celebrated poem, ‘An Arundel Tomb’,

‘Time has transfigured them into
Untruth. The stone fidelity
They hardly meant has come to be
Their final blazon, and to prove
Our almost-instinct almost true:
What will survive of us is love’.

If anything survives of a human existence, then death is not just absence, and if what survives of us all is love, then this offers some comfort. Larkin’s supposition that love in some way conquers death is echoed by Major Templeton in Somerset Maugham’s ‘Sanatorium’, ‘I don’t mind dying anymore. I don’t think death’s very important, not so important as love’. In this short story, the lovers are warned that if they pursue their wish to be married and leave the sanctity of the sanatorium, their life expectancy could be reduced to just a few months.

In a wonderfully hopeful move, Major Templeton and Miss Bishop defy the recommendations of their doctor and leave the institution to get married; ‘A cheer was raised as they drove away, as they drove away to love and death’. By choosing the route that leads to early death, they are actually choosing life. For the other residents, life no longer has real meaning, we are told that McLeod has given up on outside life, and so he describes his daily existence in this way, ‘having TB is a whole time job, my boy’. The Major and Miss Bishop will not be living out their days waiting in grim anticipation of death, instead they embark on the adventure of living life as it should be lived, with love and joy. For those without faith in the after-life, hope is to be found in living life to the full in the here and now.

‘never send to know for whom the bell tolls; it tolls for thee’

The dying patient is a stark reminder of our own transience. One of the most important elements that distinguishes us as humans is the ability we all have to imagine ourselves in another’s place; we can empathise, understanding something of other people’s suffering. This ability to see the world from another’s perspective means that when we see a dying patient, we can perhaps also imagine ourselves or our loved ones in that position. This means that for the doctor, confronting a patient’s death can be a painful experience, and the self-protective barriers doctors sometimes erect can hinder empathy. As the sole doctor in the cold Russian countryside, Bulgakov probably saw more than his fair share of death, and yet he was never able to overcome the upset it caused him, ‘I felt the customary stab of cold in the pit of my stomach as I always do when I see death face to face. I hate it’.

For the doctor, the dying patient strikes many different chords. Common human compassion means doctors may recognise their patients’ fear and pain, though how they choose to respond to it depends on many other factors. The response will be informed by the doctor’s own subjective view of death, on time pressures – a busy house officer may well do their best to avoid the family of seriously ill patients, because compassion takes time. Returning to ‘Jean Beicke’, Carlos Williams describes his reluctance to talk to the dying infant’s mother, ‘I expected her to begin to ask me questions with that look on her face that all doctors hate’.

One way doctors have found to deal with the death is to form a professional detachment, and there is some benefit to this; it would be very difficult to continue functioning as a doctor if full emotional impact was experienced with the death of each patient. As Donohoe states, this air of ‘detached concern’ not only gives emotional self protection, but also enables doctors to make ‘clear-headed judgements’. However, this distance, exemplified by the formal medical language we are taught to use when we enter the wards as medical students, may, as Abraham Verghese warns mean that ‘in such translation we might lose our ability to imagine the patient’s suffering’. We continually create barriers in our clinical practice; when we are doing things, we are busy maintaining life, not available to discuss its sometimes all too apparent ebbing away. Death is hidden away from view, we are all involved in the collusion that pretends it never happens.

MacLeod is one of the residents who had been at the institution the longest in ‘Sanatorium’, and yet when he dies, he is not given the fond farewells one might expect but instead, ‘was buried two days later, early in the morning so that the patients should not be disturbed by the sight of a funeral’. George Orwell, in his short story, ‘How the Poor Die’, commends the English nurses, who know how to treat death with discretion, ‘I remember that once in a cottage hospital in England a man died while we were at tea, and though there were only six of us in the ward the nurses managed things so adroitly that the man was dead and his body removed without our even hearing of it till tea was over.’ It is worth asking the question, are we maintaining this deception for our patient’s sake, or perhaps to save ourselves from being asked questions with the look that ‘all doctors hate’?

Elisabeth Kübler-Ross describes it thus:

‘Is the reason for this increasingly mechanical, depersonalised approach our own defensiveness? Is this approach our own way to cope with and repress the anxieties that a terminally or critically ill patient evokes in us? Is our concentration on equipment, on blood pressure, our desperate attempt to deny the impending end, which is so frightening and discomforting to us that we displace all our knowledge onto machines, since they are less close to us than the suffering face of another human being, which would remind us once more of our lack of omnipotence, our own limitations and fallibility and last, but not least perhaps, our own mortality?’ (p8)

     

‘how can I save him?’

Meanwhile, all the time there is also the perhaps inevitable sense of failure. There are many circumstances where it is difficult for patient and their family and the medical profession itself not to feel that perhaps something more could have been done that would have made the crucial difference between life and death. Carlos Williams expresses this succinctly, ‘Well, Jean didn’t get well. We did everything we knew how to do except the right thing.’ For Bulgakov, saving his patient is everything, in ‘The Blizzard’ his desperation is palpable,

‘I would examine his pupils, tap his ribs, listen to the deep-down, mysterious beat of the heart, all the while obsessed by one thought – how can I save him? And how can I save the next patient – and the next…? All of them!’

Bulgakov takes the death of his patients as a sign of professional incompetence and his own lack of skill. After travelling through the blizzard to make an unsuccessful attempt to save the life of his patient, he is offered a room for the night, ‘I confess I omitted to say that the mere thought of staying in that house of misfortune, where I was impotent and useless, was intolerable’. Again, in ‘The Vanishing Eye’, he is unable to leave behind the horror of failure, ‘I had been made to suffer unbelievable rigours…I had had to set my unshaven face squarely to it and conquer it. And if I failed, as now, I was… tormented by the thought of the dead baby and the mother I had left behind’.

This self doubt creates a terror in him, and he is tortured by the fear that he will be exposed as a fraud. If we consider the purpose of medicine to be the resistance of death, then the dying patient is the most abject reminder of our failure. Kaspar explains the sense of outrage that can result, ‘the ungrateful effrontery of one who dies despite our most skilful ministrations…the deep wounds to omnipotence when we are shown to be quite impotent…we are busy denying death, and here’s a person doing his level best to demonstrate its reality’.

In some instances, medical advancement has meant that the distinction between life and death has become blurred, life may be prolonged on life support machines until the point when it becomes untenable and death occurs through just the flick of a switch. In our fight to the end to save our patients from death, we may leave them with no opportunity for the quiet contemplation of the end of their lives.

‘the underground stream’

So, what is it that literature offers us as doctors? What else can we take from literature that is not already present in the rich histories of our patients’ lives, offered before us at every consultation? Medicine, by its very nature, seeks problems, and the causes of problems with the goal of solving them. As such, when taking our patient’s history, it can become a means to an end, and we may find that the nuances that shape a person’s life become lost in the search for answers; as Charon points out, ‘analytic forms cannot contain the ambiguities and subtleties of meaning that arise in the moral life; literature is better able to capture the complex resonance of human choice and human desire’.

As both writer and physician, William Carlos Williams reveals to us that there is no great separation between the subject matter of great works of literature and the stories that patients confide in us every day as we care for them. It is all there before us in our patient’s stories, we need to know where to look and how to listen.

‘Day in day out, when the inarticulate patient struggles to lay himself bare for you, or with nothing more than a boil on his back is so caught off balance that he reveals some secret twist of a whole community’s pathetic way of thought, a man is suddenly seized again with a desire to speak of the underground stream which for a moment has come up just under the surface.’

Great literature helps us to understand and to articulate thoughts and feelings that otherwise may be impossible to put into words. Literature and medicine both strive in different ways to illuminate and make sense of what it is to be human, offering insight on the human condition. We know that there is no evading death, not for us and not for our patients; as such we all must endeavour to find ways of preparing for death that benefits both patient and doctor. Great literature can illuminate that path for us.

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Related event: Contemporary attitudes to ageing and dying: Intimations of mortality 
A Battle of Ideas satellite event
7pm, Tuesday 28 October 2008
Foyles Charing Cross Road, London

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