Wednesday, February 22, 2012

Ars Moriendi

Ars Moriendi (The Art of Dying) was a medieval book first published around 1415. The author was an unknown Dominican friar, who subsequently became a bestseller for some 200 years. The book gave the lay person instruction in respect to understanding death, how to prepare for it, and how to think and behave at the time of death (whether yours or someone else’s).

‘I have often seen the most difficult cases make a beautiful death’, said the priest in Brideshead Revisited. Evelyn Waugh’s novel of the same name as its later ITV adaptation by John Mortimer gives considerable time to the build-up, preparations for, and subsequent death of Lord Marchmain. The scenes are tender and peaceful, with humour interlaced with religious angst, and ultimately contain a deep poignancy. The messages contained therein are not necessarily for everyone, although it does demonstrate one way to prepare well for death.

Nonetheless, not all of us can have a Chinese drawing room, an antique and regal four-poster bed, an army of servants and a coterie of aristocratic attendants to assist us from this world. Happily, we can still hope to have ‘a beautiful death’, whether it be in the Roman Catholic sense of finding ultimate Grace, or overtly atheistic. For most people in the modern century, death does not come suddenly. In a 2010 essay published in the New Yorker, the author Gawande quotes a doctor working in an American intensive care unit as saying ‘I am running a warehouse for the dying’. For many people death is now, up to the ultimate point, a medically controlled process.

The 16th century philosopher, Francis Bacon, argued that the purpose of medicine was to preserve health, cure disease, and prolong life. The concept of controlling the ultimate process of dying in order to render the inevitable a peaceful and painless process (both physically and psychologically) is, I believe, something to which Bacon would not have demurred. However, he might have been less impressed with the recent publication of the report by the Commission on Assisted Dying, wherein the current laws regarding assisted suicide are debated and challenged.

Many readers will be familiar with the Dignitas Clinic in Switzerland where, in the last few years, 76 Britons are known to have ended their lives. There is sadness in the fact that a few feel forced to travel to a foreign country to die in unfamiliar surroundings and away from family and friends. It is therefore understandable that there is a call for a change in the English law in order to legally allow assisted suicide in Britain. Nevertheless, desirable though such a debate may be for some, it is not a debate many doctors feel ethically or morally able to participate in. Indeed, the British Medical Association refused to attend the Commission’s hearings. Some would argue that doctors should be involved in the debate. However, many feel that would, de facto, give credence to the topic. Medicine may be many things to many people, but most doctors did not train to kill people or assist them in killing themselves; preventing suffering whilst letting nature take its course is a very different process to that which the Commission is now publicly debating. It is a debate which is beyond a ‘right to die’, for we all have no choice in that matter. The difficulties for doctors are manifold and multiple, including the question of how to tell when someone has less than a year to live, and how to be sure of a patient’s true capacity to make such irreversible decisions when depression, fear of the unknown, and family and social pressures may also have an influence in their decision making?

‘Oh build your ship of death, Oh build it! For you will need it. For the voyage of oblivion awaits you’, wrote D. H. Lawrence. Quite so; preparing mentally and physically for death is to be commended and encouraged. Knowledge of the existence of death encourages us to delight in living and savour each waking moment. ‘I’m alive; it’s all that matters,’ were the words of a terminally ill friend. Doctors should be helping people to live with their illness, not to die. We change the law to the ultimate risk of us all.

(First published in the Scunthorpe Telegraph, Thursday 19 January 2012.)

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