This book’s main objective is to dispel several pernicious myths about death and dying. It’s remit is quite extensive, covering the medical, social, literary, and philosophical dimensions of death. With graphic descriptions, it illustrates how people actually die in hospitals, describing both the rapid and messy, and the slow and painful death (page x). It powerfully rejects the ‘bizarre modern fantasies about immortality‘ which modern medicine and society have entrenched (pages x and xii). The author makes the case that ‘the awareness of death should be a part of the doctor’s everyday life’ (page 4), but he deplored the general ignorance of the medical profession about mortality, asserting that ‘although we see it everyday, doctors do not think very much about death and dying’ (page 12).

The author devotes a major part of the book to his personal experience of witnessing death, bluntly stating that ‘the deaths I see are frequently undignified‘ (page xi). Dying, in his reality, is a process ‘more often marked by pain, fear, boredom, and absurdity than it is by dignity, spirituality, and meaning‘ (page 236). He attributed this to the rising number of people dying in acute hospitals, a situation that he blames on the society which has foisting the responsibility of dying on acute hospitals, and also on the dying for their reluctance to accept their imminent mortality (pages 80-119). He contends that acute hospitals are ‘ill-equipped to meet the needs of the dying’, and any expectations of dying with dignity within them is ‘almost laughable’. He proposes that the ‘care of the dying needs to return to the core of what doctors do’ (page 135), but he did not offer a blueprint on how this will work in practice, outside of a hospital setting.

The book is a powerful critique of current medical practices around death, and the author expressed very strong views against the heroic measures doctors take when they care for the dying. For example, he criticised the liberal use of feeding tubes, a practice he claims symbolises the ‘medicalization of death’, and highlights the failure of moderm medicine to care humanely for those most in need of its help’ (page 15). He was vehemently against the ‘culture of excess‘ in the treatment of cancer whereby patients are offered ‘a toxic combination of false hopes and a bad death…on the naive assumption that there is a treatment for every ill’ (page 171). He was also scathing of the narrative medicine movement which he claims ‘provokes mockery and contempt for its smugness, its pretension and its risible, strangely biblical jargon’ (page 139). His forceful opinions cover many medical practices, from the erosion of the doctor-patient relationship to the unbridled rise of patient autonomy (pages 74-75); from advance directives and do-not-resuscitate orders (page 185-197) to the culture of professional overregulation (page 89).

An interesting concept the book explored in admirable detail is how the fear of death drives our individual and collective irrational behaviours around dying. He blamed ‘much of our contemporary fear of death to ‘the prevailing certainty, for most people, that death means extinction, oblivion’ (page 231). He blamed evangelical atheism for replacing the fear of God with the fear of death (page 231-233), and for leaving us ‘unsure of how to behave when faced with the great events of our lives’ (pages 52-55). The author made no secret of his admiration of how religious rituals help the dying and the bereaved to cope with death. He however contends that the fear of death is also driven by the absence of death in public discourse, and he supports this assertion with reference to historical intellectual figures who have thoroughly examined the subject: Philippe Aries, Geoffrey Gorer, Ernest Becker, and Ivan Illich (pages 31-32).

The book is significantly enhanced by the author’s extensive review of depictions of death in literature, both fictional and real. It referred particularly to Tolstoy’s ‘The Death of Ivan Ilyich‘ as ‘the most powerful, the most true, depiction of dying in fiction’ (page 63). It used the death of past philosophers such as Michel de Montaigne to argue against the idea that ‘we can overcome the dread of (death) by keeping it constantly in our thoughts’ (page 213). The author also extensively critiqued the personal death accounts of more modern celebrities, extracting diverse lessons from each. For example he excoriated Christopher Hitchens for his ‘uncharacteristically optimistic‘ hope of cure from esophageal cancer, and he chided Susan Sontag because she ‘steadfastly refused to even contemplate her mortality’ (pages 146-147 and 161). He also denounced right-to-die campaigner Marie Fleming because she ‘was fighting not for the right to die, but for the right to die on her own, highly individualistic terms’ (pages 205). On the other hand he applauded journalist Nuala O’Faolain because she ‘confronted and acknowledged her mortality’ (page 170).

Opinion

The key lessons of this book are that death should be more open to public discourse, and physicians should play a more active role in the management of the dying. The author’s passion and concern about the subject of death shone throughout the book, and the topics he covers are all relevant to healthcare. The book raises significant and thought provoking questions, and the author seems to have answers for all of them. He expressed his views very strongly, and in many places, rather angrily and perhaps self-righteously. This makes many of his opinions to appear more radical and controversial than they actually are.

Overall assessment

This is a significant contribution to the efforts to bring the subject of death to public discourse. It promotes a healthy and pragmatic attitude to the care of people who are dying. Some of the author’s views are not mainstream and should encourage a healthy debate. The book however makes many sensible suggestions for reforming healthcare and I recommend it to all doctors.