The late American comedian George Carlin didn’t worry about getting old. “Thanks to our fear of death in this country,” he said, “I won’t have to die: I’ll ‘pass away’.”
Our contemporary refusal to confront death forms the centrepiece of The Way We Die Now by Seamus O’Mahony, a consultant gastroenterologist at Cork University Hospital.
Many of the patients O’Mahony sees on his hospital wards fail to die with dignity because they are in denial about – and consequently unprepared for – death.
This brave, timely, and uncompromising book is an attempt to prise open the conversation about death and to remind us that it is an inevitable part of life.
In Ireland, people are 10 times more likely to die in an acute hospital than in a hospice.
O’Mahony suggests this discrepancy is, in part, a symptom of our inability to deal with death: many patients who die in acute hospitals refuse to accept that their condition is incurable.
Yet the picture he paints of dying in an acute hospital is stark.
“The culture, the ambience, the tone,” he writes, “is of haste, bustle, frayed tempers and a strange kind of giddiness.”
O’Mahony evokes a chaotic environment of frail, elderly patients lying on trolleys in emergency departments – passed between doctors – and of overcrowded wards with meals left uneaten by patients who cannot feed themselves.
Trying to find a quiet room to speak to a dying patient and their family can prove almost impossible and O’Mahony recalls, at key moments in such difficult conversations, being disturbed by cleaners determined to complete their work.
In contrast to the idea of a ‘good death’, the reality is that we are likely to die after a long, chronic illness in the care of strangers – doctors and nurses we have known for, at best, a few weeks – after a series of painful, excessive, and, ultimately, futile medical interventions.
Crucially, we often won’t know that we are dying – the truth hidden from us by loving relatives and well-intentioned doctors complicit in the kindly lie that there is still hope.
This tacit contract – between patients, their families, and doctors – to elude death is a cornerstone of The Way We Die Now.
O’Mahony acknowledges that patients’ fear of death and the demands placed on doctors conspire against an open discussion.
“The relatives will be content and the dying will soon be dead,” he writes of the prevailing attitude.
“Why give yourself the grief?” But he regards this approach contributes to a dishonest and excessive medical culture.
Doctors, he argues, must tell patients the truth, even when this is not what patients want to hear.
O’Mahony’s diagnosis is a significant cultural shift: with the decline of religious belief, we have pushed death almost exclusively into the medical realm.
He regards dying patients’ clamour to pursue futile medical procedures, and, more broadly, society’s neurosis about mortality as a “spiritual, not medical” problem and insists that dying must be “de-medicalied”.
As a corollary, the book, in part, stems from the gap between O’Mahony’s medical expertise and the expectations placed on him by his dying patients and their families.
The Way We Die Now is frequently combative and unstintingly candid.
While criticising the care of the dying provided by acute hospitals, O’Mahony asserts that society is culpable by outsourcing this vital responsibility to these very same hospitals and designating them as “dustbins” for a cocktail of non-medical problems.
Likewise, he is disdainful of oncology (it has “more than a touch of primitive shamanic ritual about it”) and acerbic about the sentimentality of families who, after receiving a cancer diagnosis, respond that their relative is a ‘fighter’ (“by which they mean that the known biological statistics appropriate to other, lesser known souls, do not apply in this particular case”).
The most controversial aspect of the book relates to advance directives and assisted suicide.
O’Mahony scathingly dismisses both ideas, and the complex arguments that surround them, as misguided attempts to exert control.
His primary opposition to advance directives (a statement specifying the medical treatment you want to receive in the event that you are incapable of expressing informed consent) is that you can’t anticipate your reaction to a medical diagnosis until you receive it.
O’Mahony’s argument about assisted suicide is presented largely through the prism of Marie Fleming, the right-to- die campaigner who died from multiple sclerosis in 2013, shortly after losing her challenge to the ban on assisted suicide in the Supreme Court.
Fleming was not, O’Mahony claims, fighting for the right to die: she was fighting for the right to die “on her own, highly individualistic, terms” that, had she won her court case, would have irrevocably changed how the author practices medicine and his responsibilities to his patients.
O’Mahony is adamant: “We cannot, as a society, alter our laws to indulge in fanciful notions, held by a single individual, of a special death”.
An important device in O’Mahony’s examination of our anxiety about death is his exploration of the attitude of public figures to their terminal illnesses.
In contrast to our private reluctance to broach the subject, celebrity memoirs charting cancer ‘battles’ have never been more popular.
This book offers an incisive comparison of the responses of Christopher Hitchens, Susan Sontag, and Nuala Ó Faoláin to their respective cancer diagnoses.
Where Hitchens and Sontag pointedly persisted in seeking medical intervention despite their incurable diagnoses, Ó Faoláin brokenheartedly acknowledged her mortality, earning O’Mahony’s admiration for her “vivid acceptance”.
Distilling over 30 years’ experience, The Way We Die Now offers the rare angle of a medical doctor’s perspective on treating the dying and handling death.
Drawing on case studies and personal experience, commissioned reports and novels, O’Mahony expresses his unfailingly frank arguments in reasoned, unfussy prose.
Although it questions whether medical schools can teach empathy, the book would have benefited from O’Mahony’s accounts of striking a balance between showing compassion to his patients with terminal illnesses while maintaining professional detachment.
Similarly, the author recalls, to illustrate particular ideas, a variety of encounters with dying patients, but these episodes are characterised by an aloofness that precludes the presumed intimacy of the situations.
Speculating on whether his medical knowledge will help him deal with his own death when the time comes, O’Mahony is uncertain and cites an intriguing US study examining doctors’ instructions for treatment at the end of their own lives.
It found that most had an advance directive and, of these, the majority specified that they did not want the types of treatments – such as cardio-pulmonary resuscitation (CPR), tube feeding, or major surgery – that they typically administer to their patients.
Ultimately, The Way We Die Now is a considered plea for a more honest and courageous approach to death.
While we cling desperately to the notion of ‘death with dignity’, many of us will refute a fundamental prerequisite of this concept: a recognition and acceptance that we are dying.
Death “cannot be sanitised, work-shopped or managed,” O’Mahony concludes in this sobering study.
“In death, there is only affliction. When our time comes, let us say our goodbyes and die as creatures. If we choose to turn to the wall, to withdraw from our families and the world, then there is no shame in that.”