Book Review

Facing Death

N Engl J Med 1997; 336:970March 27, 1997

Article

Facing Death
Edited by Howard M. Spiro, Mary G. McCrea Curnen, and Lee Palmer Wandel. 205 pp., illustrated. New Haven, Conn., Yale University Press, 1996. $27.50. ISBN: 0-300-06349-0

One sentence in this book fairly leaps off the page. In one of several short essays depicting the responses of people in various cultures to death, historian John Demos reproduces a description of the dying days of Sarah Lippet, an 18th-century New Jersey woman. Close to the end Mrs. Lippet drifted in and out of sleep. Waking at one point, she turned to those assembled at her bedside and said, “Don't let me go asleep again, for I want to know when I die.”

How startling to the modern reader! How unusual for us, with our crash carts, defibrillators, and morphine drips, to come upon a woman who is eager to be thoroughly present in the moment of her dying, for whom dying is a sacred event, full of transcendent meaning.

Precisely. The perception that the modern world has lost the sense of death's sacredness and meaning — and replaced it with medicine's all-out battle against death — occasioned a multidisciplinary colloquium on ars moriendi (the art, or way, of dying) in 1994 at Yale University. This book contains the papers presented at the colloquium, grouped into two sections. The first consists of narratives and reflections by physicians on the experience of caring for the dying. Many of these essays are emotionally charged and confessional in tone. Their message is that care of the dying is difficult and demanding but potentially rewarding work, made more difficult than it needs to be by professional, institutional, and cultural denial. As historian William J. Bouwsma observes in his superb conclusion to the book, “Death requires, from those assisting it, a wisdom, a capacity for reassurance and comfort, an intimate acquaintance with the dying, a priestly role, if you please, which in the absence of priests doctors are now called upon to perform and which had never been expected of them in the past. No wonder they feel uncomfortable.”

The second section includes short essays by cultural historians, anthropologists, ministers, and theologians. It intends to contrast what the editors believe is the dominant motif of modern medicine — that death is utterly without meaning except as loss and failure — with the investment of death by various societies with meaning as a significant part of human experience. The contrast itself is instructive, even though many of these chapters are disappointingly dry and abstract, all the more so because they follow the vivid personal accounts in the previous section. Captivating exceptions are the essays by Valerie Hansen (on 11th- and 12th-century Chinese popular culture), Peter S. Hawkins (on the NAMES Project AIDS Quilt), and John Demos. These three stick to concrete and particular experiences and legends and convey the living flavor of actual societies and cultures.

An underlying assumption of the book is that our impoverished cultural framework for interpreting death is part of the reason so many of us die the “technologically attenuated” deaths of modern medicine (to borrow a phrase from Daniel Callahan, who wrote the foreword to this book). I agree with the editors about this. Nevertheless, I am not as optimistic as they are that increasing our knowledge of responses to death in other cultures will help us. Bouwsma seems right on the mark: “Cultures are something like natural growths,” he writes in his concluding chapter. “They are not sets of interchangeable parts such that one culture can borrow from another, and they change only very gradually. Little can be done deliberately to change them, although the disintegration of traditional cultures in the modern world suggests that they can be destroyed.”

Nor is it enough to encourage modern physicians to get in touch with their feelings and fears about death and loss, as editor Howard Spiro exhorts them to do in his preface — though I certainly agree with Spiro that this is an important step toward improving medical care. Exactly 50 years ago a dying patient told social worker Cicely Saunders, “I only want what is in your mind and in your heart.” The operative word here is mind. Excellent palliative care depends on more than insight and sentiment. It is a demanding technical skill as well as an empathic meeting of persons. Yet there is an alarming gap between the state of the art in the management of pain and symptoms and the level of competence (and funding) for palliative care in the general medical community. Only recently have professional and educational efforts begun to close this gap. The public deserves better.

David Barnard, Ph.D.
Pennsylvania State University College of Medicine, Hershey, PA 17033