Grief, Loss, Death & Dying

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Dying in the Twenty-First CenturyReview - Dying in the Twenty-First Century
Toward a New Ethical Framework for the Art of Dying Well
by Lydia Dugdale (Editor)
MIT Press, 2015
Review by A. P. Bober
Oct 6th 2015 (Volume 19, Issue 41)

No one wants to die; no one wants to think about it. This work provides material likely unknown to most of us. It helps us to think about whether to have an advance directive and partly what to put in it, whether to donate organs, whether to use hospice and palliative care, and, centrally, how much control to have in a situation in which control increasingly slips out of our hands.

The ten papers span three areas: a. traditional medical, usually hospital, interventions versus HPM (hospice and palliative medicine), philosophical discussion (Hegel, Heidegger) regarding choices about the "good" death within the context of modern versions of the Ars moriendi (late medieval "art of dying"), b. a broadly religious social-ritual approach to dying, a detailed discussion of the life and death of Francis of Assisi—with a part of his famous canticle of connection with nature as sibling, including death itself as a "sister" at the end of life—followed by claims of the importance of community in specifically Christian contexts, though the writers claim applicability beyond that religion, and, c. specific discussions around the emotional topic of the death of children and choices to be made around the death of the child, the mother, or, possibly, both, followed by the relatively new complications of AIDS and dementia.

Some dramatic real-life examples of the process by which people people died according to the various modalities come to view, some as possibly litigable mistakes. The reader might get angry imagining herself in those situations, as Susan Sontag, the writer and "committed atheist" (96, 184-5), did. She screamed at everyone and everything, "and presumably at the universe itself" (96). Outside of her example, the topics of agnosticism and atheism hardly come up. The apparent negative example of the way one atheist died seems to be a panegyric in favor of religiosity, the only meaning given to frequent references to "spirituality." The book presents no equivalent of a peaceful atheist end, like that of David Hume, whose cheerfulness, conversation, and whist-playing, even with the coming of the boatman Charon with whom he bantered, make him the perfect counterpoint to the death of Francis. To the editor's credit much is made of Sontag's son's claim that she died a death that was 'authentically hers.' So much the better for Dylan Thomas's "cry, cry against the dying of the light."

The best paper by far is the one written by Curlin where he argues for maintaining health and consciousness in the face of increased narcotization, even under the hospice regime. "When HPM professionals became involved . . . , their loved ones were put on powerful drugs, became unconscious and unresponsive, and were soon dead." (48) Oh, and let us not forget money.

En passant I note the timid references to suicide where the name of Dr. Kevorkian would otherwise merit mention. Although not explicitly stated, an overall psychiatric deprecation of suicide prevails in the modern era, even against events like Cassius falling on his sword when  told (incorrectly) his forces had lost to Brutus, or old Eskimos, in accord with cultural norms, walling themselves up in their igloo in support of the altruistic suicide described by sociologist Emile Durkheim. The old and unproductive supposedly did not wish to make themselves a burden. The claim is probably poorly understood about ". . . stories of Eskimos' [sic] putting their elderly on ice floes as a way of ridding themselves of an economic burden. . . ." (154) Even movie anthropologists know of Japanese hara-kiri and kamikaze or more recent Buddhist cases in Vietnam.

All the papers support the idea of the community context, especially that of family members. Twice the book lists six points of the bioethics approach (81, 177), two of whose prongs, following in the one case Kant's emphasis on autonomy, are:

  • make the dying the principal directors of their own dying process
  • integrate patients' communities into the dying process

Those two principles, on the practical level, are in direct contradiction. The interests of the "decendent" (Latinically, "the dying one") ultimately clash with those of family members and of doctors. As Jane Brody's Guide to the Great Beyond, not found in the book's bibliographies, points out,  a doctor might walk right past a letter from a judge giving you the power to decide what medical interventions shall and shall not be made. Even with a stalwart champion, the decedent either won't get what she wants or won't know what she's getting or won't be able to communicate discomfort or pain. There is a parallel case with the use of sedation in dentistry. Some of us who grew up on the slow drill with no sedation have all but the most florid cases handled without sedation, notwithstanding dentists who wrongly consider this barbaric. Even there the reality is only the convenience of the dentist to ward off aggression and to get a maximum of work done in the fewest units.

The ideal case for full decedent control of his life is the self-microsedation from a candy dispenser.

This critique, if the prospective reader should find it substantively so, unfortunately makes a good deal of the book seem insufficiently analyzed amidst a writing style that usually gives a fuzzy edge to everything. The text is generally accessible to the educated reader.



© 2015 Anthony P. Bober


A.P. Bober has studied a psychology spanning Skinner and a humanistic-clinical view based on existential phenomenology and had been a PhD candidate in a substantive yet philosophic European-based sociology including the "critical" view. His teaching augmented courses in group theory/"small-group developmental dynamics" (lab) while introducing "sociology of knowledge" and "issues in biological anthropology," with publications in the first two fields. Currently he is writing a book on mystical experience as metaphorically tied to neuroendocrinology.



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