Catholic Medical Quarterly Volume 72 (4) November 2022

Faith in Medicine

Taking death seriously: why we need philosophy and theology when thinking about dying, death and end-of-life care.

Dr Pia Matthews

Dr Pia MatthewsThis talk is an abridged version of a talk given by Pia at the 2022 Annual Conference of the Catholic Medical Association in St Marys University, Twickenham.

‘Death be not proud, though some have called thee, Mighty and dreadful, for thou art not so’. Thus begins the Holy Sonnet Death Be Not Proud written by the sixteenth century metaphys­ical poet John Donne. What to make of death has been a perennial question for human beings. And the 2022 Lancet Commission report On the value of death: bringing death back to life is one of the latest offerings. The Lancet report takes the perspective that dying is simply a natural part of living, which in one sense it is. Dying and death are part of the natural processes of being human. However, there is a real problem in thinking about being human in purely natural terms, not least that human beings are not simply biological beings or beings only in the natural order of things. To help us think more deeply about what it is to be human we need the aid of philosophy and theology. And philosophy and theology lead us to take death seriously, as Donne himself did.

Changing attitudes

Donne’s concern with death did not end on a dismissive note. In his Meditation XVII Donne wrote the immortal words: ‘no man is an island entire of itself’, continuing, ‘any man’s death di­minishes me because I am involved in mankind’. Donne wrote extensively on death in his poetry and, as Dean of St Paul’s, in his sermons. Given that for people living in the sixteenth century there were high mortality rates, plague, life expectancy at best in the sixties, no vaccines or antibiotics, public executions commonplace and often venues of entertainment, death was a very visible and ever-present reality. Moreover, Donne was not a lone voice: death was in the open.

This open exposure to dying and death has been contrasted to attitudes in the twentieth and twenty first century – at least before the COVID­pandemic – where death has come to be invisible, principally because dying tends to happen out of sight in hospitals. This unfamiliarity with dying and death, and consequent isolation of the dying was noted early on in the 1970s by Paul Ramsey in his highly influential book The Patient As Person. Ramsey moreover observed that dying and death had become medicalised with people thinking that everything that can be done medically for the patient should always be done thus promoting the view that hospitals are best equipped to ‘manage’ death in a way that families and communities are not. In this medicalisation of dying there remain real concerns about dying being out of the person’s control and in the hands of the medical professional, dying not in the place of a person’s choosing, dying dominated by treatment and interventions, undertreatment and overtreatment, and the denial of the reality of death. In many people’s experience families are excluded from the conversation, if indeed there is a conversation given the taboo on talking about death. In this medicalisation of dying death is seen as a failure of medicine.

However, there has been a concerted effort to bring dying and death out of the shadows, out of hospitals, back into communities and back home. The UK government’s 2008 End of Life Care Strategy was the official starting point in the call to tackle the taboo on discussing death and to change attitudes towards dying. A series of sig­nificant initiatives such as the 2009 National Council for Palliative Care’s Dying Matters Coalition designed to raise public awareness of dying, death and bereavement, and surveys of people’s experiences in the last months of life, has brought dying and death more into the public consciousness. Statistics show that most people want to die at home, though in reality most deaths occur in hospitals even when there is no clinical need for the person to be there. Important books, such as Kathryn Mannix’s With the End in Mind have been written to highlight the fact that dying is a bodily process that people can be prepared for, and this can make dying less frightening and more peaceful. In the wake of the Liverpool Care Pathway, the 2013 review of the Pathway, More Care Less Pathway stressed the need for a proper national conversation about dying. The UK government’s 2015 report What’s Important to Me: A Review of Choice in End of Life Care sought the views of the public and professionals on what kind of choices people should be able to make as they neared the end of life, and how they could be supported in these choices with the aim of formu­lating a national choice offer for end-of-life care.

The 2022 Lancet Report points out that because death tends to happen in hospitals under the surveillance of medical professionals, people in general do not have experience of dying and death and so lack confidence, hence the reliance on the medical profession. Moreover, the Report says that to a certain extent this lack of experience also applies to the medical profession as a whole and significantly, the Report encourages all healthcare professionals to be versed in dying. Rather than treatments and interventions, put relationships at the centre; dying, as part of life, should be in all conversations around healthcare from discussing cancer treatment and elderly care to general healthcare. Moreover, the Report says that most care of the dying, hour by hour, is the responsibil­ity of the dying themselves, family, friends, and community.

These publications call for personalised, co-ordi­nated, joined up care, involving individuals, professionals and communities, plus honest conversations about needs and preferences, and advance care planning so that people can die where they choose – in their communities, with their family and friends. Tool kits have been developed for ‘compassionate communities,’ communities that help and support dying people and their families all the way through to grief and bereavement, with the possibility of death ‘doulas’ to build up capacity and skills in the community. Dying and death are being ‘brought home’. Notably, and unlike earlier initiatives, the Lancet Report relegates palliative care to a specialism, only to be accessed in cases of real need.

Dying to save the planet: a shift too far?

Certainly, dying and death are taken seriously in the call for a change in attitude to seeing dying and death as part of living well, and in encourag­ing people to talk about their hopes and wishes. However, it is wise to monitor shifts to ensure the conversation does not tip too far in the other direction. In particular, when we speak about the reality and naturalness of dying and death, we should ensure that we do not lose sight of how we should cherish our life. In the rebalancing of our relationship to death and dying, the Lancet Report is keen to stress that dying is not simply a physiological event, rather it is a relational and spiritual process. Death has a ‘value’ that must be rediscovered. According to the Report, at its simplest expression of value, human beings are merely part of nature and death should be seen in the context of the climate crisis. Dying is the ecologically friendly thing to do – we live in a ‘crowded world’, death frees up space on the planet. Not only can the carbon footprint of healthcare systems be reduced by changing clini­cal practice to avoid treatment at the end of life, we should also rethink the disposal of dead bodies – perhaps composting or dissolving bodies and using the resulting fluid as fertiliser. Given that the best way to combat climate change is to die, we should not try to hold back death. Treatment in the last months of life is costly and often continues for too long. Moreover, in the conse­quentialist framework, the ethical demand not to hasten death amounts to the same as holding back death, and hastening death through assisted dying becomes one potential way of giving people back control over their dying.

Insights from philosophy and theology

Donne’s bringing death down to size may have resonance with some views that death indeed is not mighty or dreadful, but simply a part of life; Donne’s view that death concerns us all chimes with the appreciation that it is a conversation for everyone. However, Donne wrote as a theologian and philosopher. His insights go far deeper than a natural or relational appreciation of death. Death not only has value; death, and dying, matter. We may all agree on the importance of talking more about dying, death and bereavement; involving family, friends and the community; developing compassionate communities; enabling personalised and properly co-ordinated care, that is also appropriately funded. But putting dying back into the community requires more: the hard thinking of philosophy reflecting on reason. Setting aside practicalities like who in the community is providing care, when families are fragmented, carers, more often than not women, are now the ‘sandwhich generation’ caring for grandchildren, children and elderly relatives, and how do we ensure good and ethical care, the shift away from the medicalisation of dying has landed significantly on a philosophical understanding of death as natural, part of life, but also even a good because it is good for the planet when we die, better if there is no sign we were ever here. Investing resources in end-of-life care risks being seen as a waste because in effect this is simply prolonging life. We do not need to fear death, or even care about it. Indeed, some people are better off dead. Apart from the real impact this attitude has on people who are elderly, disabled or vulner­able, what does reason and experience have to say about this? Certainly, there is an art of dying well, and there are good deaths, but that art cares about the reality of dying. It cherishes life and does not rush death. Good palliative care recognises this. And even when death is expected, even when it comes as a relief, death comes as a shock. Death leaves lots of shattered people. Palliative care knows this. On the one hand we cannot treat death as a taboo subject; we cannot simply med­icalise death; but nor can we simply biologise death as if the end of a human life is the same as the end of any other organism, melting back into the ground.

Donne’s insight that ‘no man is an island’, that we are all connected, is not an example of the connectedness of biology in the great circle of life where dead bodies fertilise the earth and give life to the next organisms up the chain. Donne reminds us that every person’s death diminishes every one of us, in part because, as the Church Fathers explain, each human being is unique and irreplaceable. Like a whole world in this world, once I die my unique perspective on life also dies with me. Philosophy reflecting on the common human experience of bereavement reinforces this. This is not to say that we should keep people alive no matter what. Donne’s reflection on the pow­erlessness of death is that death does come in very many different ways, from accident to disease and plague, and death cannot be kept at bay. However, death does not have the last word: ‘One short sleep past, we wake eternally, And death shall be no more; Death thou shalt die’. Deep thinkers like Donne rail against death because philosophically speaking dying is an existential crisis; theologi­cally speaking we are not meant to be dead. We are meant to be alive in Christ. Theology tells us something that a current philosophy of death risks forgetting: death matters. If there is an easy switch from life to death, then neither death nor life matters.

Pia Matthews is a senior lecturer at St Mary’s, a faculty member of the Mater Ecclesiae College, and Director of Quality Assurance and Curriculum Development at Allen Hall Seminary Chelsea. She has a BA/MA in Law from Cambridge University, a BTh (Theology) from St John’s Seminary Wonersh (Surrey University), and an MA in Bioethics from St Mary’s. Her PhD doctorate explored the notion of the person in patristic theology and philosophy, applying insights from Trinitarian theology and Christology to contemporary issues concerning the person in bioethics.