A loaded pause interrupts the conversation. I sense that no one here really wants to entertain this difficult subject. Eventually, Liz replies, speaking carefully. ‘Some patients will wish to have conversations with our doctors about that.’ Another pause. ‘Our doctors will have this discussion, but always on the basis that assisted dying is illegal in Britain. The doctors will talk through with the patient what it is that makes them want to take that route.’
Ultimately, many of these discussions at Arthur Rank – indeed, anywhere in the UK – can only ever be about exploring options of pain relief and controlling anxiety. The final decision rests with the patient. Liz Webb says firmly: ‘If our patients choose to seek assisted dying, that’s the point at which they must make their own arrangements.’
‘Meaning?’
‘They will have to go to Switzerland.’
18
THE DYING OF THE LIGHT
‘In vain do individuals hope for immortality, or any patent from oblivion, in preservations below the Moon.’
Sir Thomas Browne, Urn Burial
In his fiction, Terry Pratchett, who was never squeamish about mortality, made ‘Death’ a character. At the end of his life, grappling with Alzheimer’s, he became a passionate advocate of the right to choose, challenging what he saw as the ‘questionable’ assumptions of those who assert that no one need consider a voluntary death of any kind, when better end-of-life care is always available. He condemned the suggestion that ‘affliction is somehow a penance for an unknown transgression’, railed at ‘the choreographed outcry’ against assisted dying, and scorned ‘the British tradition of bullying from the top down: the common people are stupid, and we who know better must make the decisions for them.’ In a fierce, rhetorical peroration to his article, ‘Assisted Dying: It’s time the government gave us the right to end our lives’, Pratchett wrote:
The common people are not stupid. They might watch god-awfully-stupid reality TV, but they are very clever about the politics of blood and bone and pain and suffering. They understand about compassion and they are nothing if not practical about these things.
In preparation for my hospice visit, and the urgent question of the ‘Right to Die’, I had already spent some time with the novelist Salley Vickers, who lives a few miles from Arthur Rank House, on the other side of Cambridge. Her recent novel, Cousins, is set in the university, and is about Will, who suffers locked-in syndrome. Will explores assisted dying, and finally persuades his cousin Cecilia to help him.
This is a subject close to Vickers’ heart. She has always said, quite openly, that if she becomes incapacitated in old age (she is now in her sixties), she will not hesitate to take her own life as expeditiously as possible. ‘Oh yes,’ she exclaims, ‘I would absolutely advocate assisted dying.’
She has good reasons: ‘My family history is rife with Alzheimer’s. My mother had Alzheimer’s; her mother had Alzheimer’s; my mother’s brother had Alzheimer’s; and so on. I have to make sure I can scuttle off. Yes: I definitely have the means – oh most definitely – and, if it comes to it, I’m going to go that way.’ She has no intention of putting her children through the torment of caring for a parent with Alzheimer’s. Indeed, she wrote Cousins partly because she believes that people should have the possibility of dying when they choose.
As our discussion turned to the question of how easy, or difficult, it might be to kill yourself, I recalled my conversation with Henry Marsh, a passionate believer in ‘patient autonomy’ and the kind of ‘doctor assisted suicide’ performed in some parts of the USA. Both Marsh and Andrew Lees have memories of the euthanasia practised in British hospitals up until the 1970s. This involved successive injections of potassium chloride, diacetylmorphine (heroin), and finally suxemethonium. ‘I have no illusions about what dying from a brain tumour might be like,’ said Marsh, at one of our meetings, ‘though whether I’d have the courage to take my own life, I don’t know.’
Dying – the fact of death – is simple enough: we run out of air. Throttled of oxygen, the heart stops; in the subsequent blackout, the brain-stem is murdered with the speed of an expert strangler. In How We Die, Sherwin Nuland gives a succinct description of the universal processes that we’ll all experience as we die: ‘The stoppage of circulation, the inadequate transport of oxygen to tissues, the flickering out of brain function, the failure of organs, the destruction of vital centres – these are the weapons of every horseman of death.’ Now, driving away from Arthur Rank House, I crossed Cambridge to complete my conversation with Salley Vickers, whose resolute coming-to-terms with death and dying I have known for years.
Vickers occupies a Victorian terrace house in a quiet cul-de-sac. We talk at length over cups of coffee in her large light kitchen-diner, hung with paintings and bunched cuttings, from the fine old bay tree you can see through the French windows. ‘How,’ I ask her, sitting by the green Rayburn, ‘how do we reconcile the conflict between medical progress and that necessary friendship with the reality of death and dying?’
As I’d hoped, Vickers has a clear answer: ‘I suspect the concept of “progress” in all areas tends to make a craving to control the terms of life seem more possible and thus more of a right,’ she says. ‘Medical advances are no exception. We are not well trained in the stoicism of our forebears, stoicism being less attractive than hedonism, but none the less a valuable attribute.’ Her voice drops. ‘I have never been afraid of dying (though plenty afeared of ageing). I’ve always regarded death as a tragedy for the survivors rather than the subjects.’ A characteristic flash of irony. ‘Of course that might all change when I am balanced on the edge about to topple off.’
‘Well then,’ I persist, ‘has your family accepted your stated intention of “taking steps” to end it, if there’s no hope? Have you had any argument from them?’
‘I’ve only confided to one of my children,’ Salley replies. ‘He understands about the Alzheimer’s threat but emphatically wants no part in it.’ His mother might secretly have to acknowledge that response. For Vickers, a Christian, there must be something ‘God-given’ about our allotted span of three score years and ten. Meanwhile, as the evening light creeps in across the Fens, I am still wrestling in my mind with this ‘right to die’.
‘So,’ I ask, ‘is it a right?’
A long pause supervenes. Finally, Vickers says, ‘Yes, I think it is a right.’ She hesitates in thought. ‘It’s an odd right, because we don’t have the right to be born. So maybe we don’t have the right to die.’ She sighs at the weight of the question, and comes up with a pragmatic response. ‘This is what you’d call a tricky area, and it’s certainly an individual matter.’
‘Like faith?’
‘I do think that religion does help, though not in the old-fashioned sense,’ she replies. ‘Nowadays no sensible religion (except possibly Islam), and certainly no sensible Christians, really believe in Heaven and Hell. But religion gives you a sense that something will survive, a memory in other people’s eyes.’
I am about to mention ritual, and the benefits of being part of life’s narrative, both its plot and sequence, when Salley adds, ‘Religion gives you a drama in which you play a part, and being part of a drama offers a great compensation. I mean, death is dramatic, and if you have religion it gives the drama of death a place in a theatre of things.’
When I suggest that, at the end, religion supplies an essential narrative, Salley carries the thought forward: ‘It gives you a story, and once you have a story or a drama you become more important. It really doesn’t matter if it’s true or false. It’s much more comforting to have it. I think this is where Pascal is so right. We might as well bet on there being a point to the whole thing. Why not? It makes a better story.’
‘Pascal’s wager’, to which Vickers referred, starts from the assumption that the stakes are infinite if there is even a small probability that God does in fact exist. In that case, Pascal argues that a rational person should live as though God exists, and seek to
believe in God. If God does not actually exist, such a person will have only a finite loss (some pleasures, luxury, etc.), whereas they stand to receive infinite gains (for instance, eternity in Heaven) and avoid infinite losses (for example, eternity in Hell).
The pragmatic outcome of Pascal’s wager is that most people live according to the precepts of a faith they have never believed in. At the end it will be the language of their adopted religion that carries them towards oblivion. For Richard Dawkins, a celebrated atheist, in that extreme condition, many of us will take refuge in a ‘personal’ idea of God. He is, says Dawkins, ‘an imaginary friend’, which links to Salley’s candid assertion that it’s immaterial whether our religion is true or false. It works because we believe it. That, in turn, connects to our fear of the unknown. It’s often said that many people only turn to religion ‘because they are afraid of death’.
From Pascal (1623–1662) it’s a short step back in time to one of my favourite writers on this subject, Montaigne (1533–1592). ‘If I were a writer of books,’ the latter remarks at one point, ‘I would compile a register, with a comment, of the various deaths of men: he who should teach men to die would at the same time teach them to live.’ As a writer of essays, Montaigne has plenty to say about humanity’s approach to death and dying, and especially the fear of death: that most intense of all emotions. He contextualizes his own work by observing that ‘Philosophizing is nothing other than getting ready to die’ and asserting the wholesome nature of his endeavour, ‘one of virtue’s main gifts is a contempt for death’. This must be a good step towards a mature consideration of death and dying. In Grief Works, Julia Samuel, a veteran grief counsellor, explores the necessity of coming to terms with grief and the emotions associated with loss. Samuel writes, in words which echo my own argument, that ‘Our culture is imbued with the belief that we can fix just about anything and make it better; or, if we can’t, that it’s possible to trash what you have and start all over again. Grief is the antithesis of this belief: it requires endurance, and forces us to accept that there are some things in this world that simply cannot be fixed.’
Finally, Montaigne’s advice is practical: ‘We know not where death awaits us: so let us wait for it everywhere. To practise death is to practise freedom. A man who has learned how to die has unlearned how to be a slave.’
19
THE NOWNESS OF EVERYTHING
‘Things are both more trivial than they ever were, and more important than they ever were, and the difference between the trivial and the important doesn’t seem to matter. But the nowness of everything is absolutely wondrous.’
Dennis Potter, Seeing the Blossom
It’s approaching midsummer. There’s a storm thundering overhead; and I am listening to Rachmaninov’s ‘Elegy’, op. 3 no. 1, composed in a frenzy, just days after the death of Tchaikovsky. It is a melancholy, passionate, and thrilling piece whose notes are torn by grief. This music always sounds cathartic, but there are many other composers whose chords will reconcile extremes of feeling. As Terry Pratchett puts it, ‘With Thomas Tallis on my iPod, I would shake hands with Death.’
In the search for narrative, the first motive of all writing, I find classical music especially helpful in establishing a mood for the quest. My soundtrack to Every Third Thought includes: Tallis’s Spem in Alium; Bach’s unaccompanied cello suites; Barber’s Adagio for Strings; Beethoven’s late string quartets; Mozart’s Ave Verum Corpus; and from Purcell, ‘When I am laid in earth’, Dido’s Lament in Dido and Aeneas; or from Rossini, his Petite Messe Solonelle, described by the composer as ‘the last of my sins of old age’ (péchés de vieillesse). Maybe it is fanciful to attribute special insights into the human condition from composers in their final days, but it remains a potent fantasy.
Music offers a language often more powerful than prose, but I cannot read a score. Words are my medium, so I come back to print and paper. Everyone has their favourite literary distraction: poetry, short stories, even crosswords and children’s books. In The Ministry of Fear, Graham Greene acknowledges the potency of the first books to seduce our imaginations: ‘No later books satisfy us like those which were read to us in childhood – for those promised a world of great simplicity of which we knew the rules.’ The need for clarity towards the end might be a reason to return to Alice in Wonderland or Charlotte’s Web. When I was convalescent at the National Hospital in 1995, Sarah used to read aloud to me, after the heat of the day, from her favourite E. B. White, in the dusty gardens of Queen Square during those late summer afternoons I associate so powerfully with the aftermath of my ‘brain attack’.
Twenty-something years ago, on my return from hospital, I found myself reading the King James Bible for the music of its language and the thrilling arrests of its narrative. Here was a cathedral of words whose expression of faith had no meaning for me, but whose sonorous periods can make you weep. I cherish the mystery of that response. The demons of inner dread can inspire a search for friends and allies, while patients can find solace in the strangest juxtapositions of words and music. Some will turn to the potency of musicals; others to Mozart or Wagner. Words can be harlequins or priests, and good words offer their own kind of covert resolution. Next to the childhood classics we love, there are the books which share with the reader an insight into the experience of being in extremis.
I know from the letters and emails I still receive about My Year Off that readers get a thrill from the special intimacy with a book that offers previously unexplored truths about the extremes of life and death, the regular grist to the mill of confessional writing. ‘Life-writing’, observes Blake Morrison, an old master of this genre, ‘turns out to mean death-writing’, which is another way of saying that we want truths about mortality (which we cannot know) more than truths about everyday life (which we know too well).
As much as a craving for morphine, the patients’ need for authenticity in prose becomes a kind of addiction. In hospital, where everything is at stake, the next question becomes: ‘How true is it?’ To which the paradoxical answer is that, while it does not always have to be true in a literal sense, it must be intrinsically honest. That’s to say (because, after all, any memoir is composed), it might be deliberately shocking, or calculatedly confessional, or cynically manipulative, or even self-dramatizing, but it must express a fundamental truth. Rousseau’s Confessions are often provocative, absurd and preposterous, but they speak the man, and we believe them. Without that trust, the contract between the reader and the writer breaks down. When that happens, the words fly up meaninglessly into nothingness. To the agony of the patient’s solitude, as described by Donne in Devotions, there’s no worse cruelty than empty words.
Sometimes, only poetry can speak to such agony: favourite passages from Shakespeare, Wordsworth, Hardy, Yeats, and Eliot. Any selection will depend on the unbidden alchemy of the moment. In certain moods, The Hunting of the Snark can be as consoling as The Waste Land.
Erect and sublime, for one moment of time,
In the next, that wild figure they saw
(As if stung by a spasm) plunge into a chasm,
While they waited and listened in awe.
‘It’s a Snark!’ was the sound that first came to their ears,
And seemed almost too good to be true.
Then followed a torrent of laughter and cheers:
Then the ominous words ‘It’s a Boo—’
Then, silence. Some fancied they heard in the air
A weary and wandering sigh
That sounded like ‘-jum!’ but the others declare
It was only a breeze that went by.
They hunted till darkness came on, but they found
Not a button, or feather, or mark,
By which they could tell that they stood on the ground
Where the Baker had met with the Snark.
In the midst of the word he was trying to say,
In the midst of his laughter and glee,
He had softly and suddenly vanish
ed away—
For the Snark was a Boojum, you see.
Lewis Carroll, on this reading, becomes an existential not a nonsense poet. He and his nomadic contemporary, Edward Lear, illustrate the way in which the music of words, as much as their meaning, might help us in dire straits. But this, finally, is not enough. We need Montaigne, whose conclusion becomes a spirited call to optimism.
Let us disarm Death of his novelty and strangeness, let us converse and be familiar with him, and have nothing so frequent in our thoughts as death. Upon all occasions represent him to our imagination in his every shape; at the stumbling of a horse, at the falling of a tile, at the least prick with a pin, let us presently consider, and say to ourselves, ‘Well, and what if it had been death itself?’ and, thereupon, let us encourage and fortify ourselves.
Thus encouraged and fortified, we might agree that life is a risky business whose outcome is always fatal. For me, the narratives of great literature have a vital role to play in the conduct of the endgame, but we still have to concede that only the living can sustain a narrative beyond the grave.
This mundane reality becomes the meaning of mourning, and the purpose of memory. As the questions multiply, the prospect of death intensifies the enigma of living. When I started to write Every Third Thought, I imagined that, through the putting of words on paper, I would arrive at a conclusion, as if at a well-mapped destination.
Vain hope: in the end, questions of life, death, and consciousness baffle and defeat the search for clarification. With no possible report from beyond the grave, and no other resolution available, we are left with this one basic option: to live in the moment while the moment lasts, and to become reconciled to the acceptance of our fate. Once upon a time, writing My Year Off provided a kind of resolution. This time, my investigation has yielded just one intransigent outcome: that there are only more questions and an ever-deepening mystery.
Every Third Thought Page 16