From times immemorial man has sought to find the secret of happiness and the art of living. From the Greek philosopher Epictetus to today’s Sri Sri Ravi Shankar, all try to define what should be the ideal life for happiness and fulfillment. In “The art of living”, Epictetus shows that a happy life and a virtuous life are synonymous. Happiness and personal fulfillment, he says, are the natural consequences of doing the right things. His discourses outline the path to happiness, fulfillment and tranquility, no matter what ones circumstances happen to be. His teachings for a happy life may well be encapsulated in the serenity prayer:” grant me the serenity to accept things I cannot change, the courage to change the things I can, and the wisdom to know the difference.”
Unfortunately the “art of dying” has far fewer scribes.
While much has been written about how to live, less has been written about how to die. While “ death hath ten thousand several doors for men to take their exits”, the actual process is less clear. All of us understand that death will come to all of us or as the poet puts it
“ Of all the wonders that I yet have heard,
It seems to me most strange that men should fear;
Seeing that death, a necessary end,
Will come when it will come”. Shakespeare
Yes there is a vast literature on death and dying. But virtually all of it is intended to help people cope with the emotional trauma involved in the process and its aftermath. Some like Diane Athill do venture to write about the end: “There are no lessons to be learnt”, she says in her book “ Somewhere towards the end, “no discoveries to be made, no solutions of offer. I find myself left with nothing but a few random thoughts…although a human life is less than the blink of an eyelid in terms of the universe. it is amazingly capacious. One life can contain serenity and tumult, heartbreak and happiness, coldness and warmth, grabbing and giving.”
But others like Dr Nuland, in his new book “ How we die”, take a different tack. He describes the actual physical processes by which various diseases drain us of our vitality and take away our lives. He chooses six of the most common diseases of our time whose characteristics are the stoppage of circulation, the inadequate transport of oxygen to tissues, the flickering out of the brain function, the failure of organs and the destruction of vital centers. He describes the mechanisms of cancer, heart attack, stroke, AIDS and Alzheimer’s disease with clinical exactness and sometimes with painful but poetic prose. Dr Nuland draws upon his life of thirty years dealing with those who will leave this world as a result of these afflictions. But, he says, for most of us the process of dying may have neither dignity nor the absence of pain.
In the past ‘ ars moriendi ‘ or “the art of dying” was a religious and spiritual endeavor. Those were the times when the only possible attitude to the approaching death was to let it happen and to accept one’s fate with resignation and fortitude. But now we live in an era of the art of saving life. With the advent of modern medicine, doctors are rarely willing to give up their attempts to solve the riddle of life, especially the ending of it. Unfortunately, thus, we rarely go gently into that good night.
But this was not most of us wanted. Most of us hope for a swift death or a death during sleep “so I wont suffer”. We all cling to an image of our final moments that combine grace with a sense of closure; we long for a perfect lapse into agony free unconsciousness. Death has now become enshrined in the modern myth of the longed for ideal of “ death with dignity”.
A major culprit in upsetting this is, paradoxically, the advances in modern medical science. The quest of every doctor in approaching serious disease is to make the diagnosis and design and carry out the cure. It is the fuel that drives clinical engines of medicines most highly trained specialists. Oncologists and others are particularly loath to give up on their attempts to prolong life with all that medicine has to offer. Patients often have substantial reasons for not going further when only a diminishingly small possibility exists that they may survive or lead a modicum of a normal life on recovery. The cost of the procedures may simply not be worth the price they are willing to pay. But in their obsessive search for prolonging life, specialists are rarely willing to admit defeat and to share the dire predictions with the patient.
A second is the hard fact is that the complexity of these cures often requires hospitalization. The intensive care unit becomes a secluded treasure room of high tech hope within the citadel in which the sick are segregated so that they may be better taken care of . However, the isolation among strangers is not what they want and need in their final moments. They are instead abandoned to the good intentions of highly skilled professionals but who barely know them. The hospitals have thus become a place of solitary death. Eighty percent of American deaths now occur in hospitals.
But the dying too bear a responsibility not to be entrapped by a misguided attempt to spare those whose lives are intertwined with theirs. Death belongs to the dying and to those who love them- and not the doctors who attend them and attempt to prolong their lives at all costs. What is needed more than anything else is a restoration of the certainty that when the end is near, our last moments will be guided not by the bioengineers seeking to prolong our life but by those who know who we are and what we want. That should be our hope. The hope, the assurance that there will be no unreasonable efforts, is an affirmation that the dignity to be sought in death is the appreciation by others of what one has been in life. It is a dignity that proceeds from a life well lived and from the acceptance of ones own death as a necessary process of nature that permits our species to continue in the form of our children.
Dr Nulund ends his search with his heartfelt plea about his own life “ When my time comes,” he says, “ I will seek hope in the knowledge that insofar as possible I will not be allowed to suffer or be subjected to needless attempts to maintain life; I will seek it in the certainty that I will not be abandoned to die alone; I am seeking it now in the way I try to live my life so that those who value what I am will have profited by my time on earth and be left with comforting recollections of what we have meant to one another.”
The dignity that we seek in dying must be found in the dignity with which we have lived our lives. The honesty and grace of the years of life that are ending is the real measure of how we die. It is not in the last weeks or days that we compose the message that will be remembered, but in all the decades that preceded them. The greatest dignity to be found in death is thus the dignity of the life that preceded it. This is a form of hope we can all achieve, and it is the most abiding of all.
In the end, the art of dying, it seems to me, is the same as the art of living.
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