1.4.2 Concepts of a good death
The concept of a ‘good death’ is highly contentious. Definitions vary according to different historical and cultural contexts. At certain points in history there has existed formal teaching about the proper conduct of death and dying, perhaps the most noteworthy being the medieval books on ‘the art of dying well’. These were often illustrated with woodcuts showing angels and devils at the deathbed competing for the dying person’s soul. The accompanying inscriptions explain that God and his court are there to observe what happens when the dying person is presented with his or her whole life. The crucial question is whether or not the person yields to despair over his or her sins (Ariès, 1976). The concept of a good death at this time was one in which the dying person was given the opportunity to review his or her life and was able to face this. Accordingly, people regularly prayed for delivery from sudden death which would deprive them of this opportunity, whereas now some people pray for a sudden death.
At the back of our minds many of us have some ideas about the kinds of circumstances and situations that make a death more or less acceptable. Perhaps the most obvious factor we take into account is the age at which someone dies: the death of an 80-year-old neighbour is much more acceptable than that of one who is only 18. We may also find ourselves considering how much pain the person suffered, whether the death was expected or not and, if it was, whether the dying person and the family in some sense felt ready for death. Before looking in more depth at your own values and views, read the following brief extracts from interviews with Hindu people living in Britain:
My father had a hernia at 60 … Three days before he knew he was going to die, so he called all the family members to come ‘so we can all live together’. They put Ganga [holy] water in his mouth and when he died his forehead was bright. He said he was happy because all his family were there.
My mother never said ‘I want to live, I want to live’. She said everything is well settled. She was a very religious person, at night she used to sing bhajans and she said ‘If anything happens now I'll not be worried, I'll go in peace’. That way her death was a very good death.
The second speaker uses the term ‘good’ to describe her mother’s death. Some of you may feel uneasy with this adjective. If you feel that the existence of death is something always to be protested against, then clearly you will not want to describe a death as good, whatever the circumstances surrounding it. In Britain the hospice movement has exerted a powerful influence on the way in which a ‘good death’ is constructed. There is a move towards alternative ways of dying which are, in part, a rejection of this prescribed ‘ideal death’ (Seymour and Clark, 1998). One example of this is the ‘natural death movement’, which reflects many of the values inherent in the natural birth movement, by rejecting the professional management and control of death and dying, be it in a hospital or hospice. But, as Field and Jones (1993) point out, the ability to choose the way in which we die is dependent upon knowing that we are dying. Many people do not die in a state of awareness. Patients may die in intensive care units, and people die from Alzheimer’s disease.
Suggest three further examples of situations in which being able to choose the manner of one’s death is not possible, or at least very difficult. Record these and add a few words of explanation.
One of our course testers suggested the following examples: murder, accidental death and suicide as a result of mental illness. Another tester suggested neurological disorders which result in someone being aware of their imminent death and unable to communicate. She went on to suggest that people might want to die at home, but that for many reasons their carers may not be able to care for them.
You may also feel wary of the way in which ‘good’ can so easily come to mean ‘well-behaved': the sort of death that causes the least possible upset to carers. This is a very important area of concern. The concept of a ‘good death’ is widely used in literature and so we refer to it in this course, but we ask you to think critically about the way in which it is being used and always to ask the question, ‘good for whom?’ In a complex, plural and even divided society such as ours there are likely to be competing and conflicting notions. Hospital staff, for example, may take the view that providing the best medical attention and maintaining a calm ordered atmosphere are the primary ingredients of a good death, but this is only one point of view and may not suit patients and relatives.
The two extracts above indicate that for the Hindu community there is a definite concept of a ‘good death’ which means one occurring in the presence of family members and involving the opportunity to make ritual and spiritual preparations for death. Most religions (and, more recently, secular psychotherapeutic approaches to the care of dying people) share such an emphasis on the importance of allowing people to prepare for death. For Hindus this ideally means dying with the name of God on the lips and in the mind, or at least being surrounded by people chanting the name of God. It is also thought that death should take place on the floor with the dying person’s head to the North and that Ganges water be placed in the mouth. If a hospital fails to notify a family that death may be imminent the dead person’s relatives and friends are likely to experience strong feelings of anger and frustration; not only have they been prevented from fulfilling their obligations, but they may also believe they have in some way impeded the progress of the dead person’s soul, a view found in many cultures. (A similar belief that the actions of the living can influence the fate of the dead was a strong feature of medieval Christianity.)
Compare this emphasis on the need for preparation with the view frequently expressed in our own society that a ‘good’ death is one in which death gives no warning: ‘He died tonight in his sleep. He just didn’t wake up. It was the best possible way to die.’ There seem to be two main kinds of reason why such a death might be regarded as good. The first has to do with levels of suffering and for many of us this is perhaps the major consideration. To die in one’s sleep indicates an absence of pain and fear (both of which would preclude sleep) or, at least, their effective suppression by drugs. A second kind of reasoning is more concerned with the desire of the living for a well-balanced and well-managed death that does not cause too much practical or emotional trouble, and this is the one of which we should perhaps be more wary.
Because of the danger of identifying the concept of a ‘good death’ with the notion of a well-managed, well-behaved death you may conclude, as did some of our course testers, that the term should not be used. An alternative is Weisman’s term, an ‘appropriate death’ (Weisman, 1972).
Weisman’s ‘appropriate death’ has four aims:
Reducing but not necessarily eliminating conflict.
Making dying people’s dying compatible with their own views of themselves and their achievements.
Preserving or restoring relationships as much as possible.
Fulfilling some of the dying person’s expressed aims.
In a variety of ways this section has explored cultural and ideological issues that affect the quality of dying. But these are only part of the picture. The extent to which people are able to die in the way they would prefer depends greatly on who is looking after them and where they die. The next section looks directly at these questions.