30 April 2020
The Grim Reaper
‘An unimaginable tragedy’.
By Lynda Goetz
The coronavirus outbreak prompts me to return to a subject I addressed just over a year ago in The Shaw Sheet in Being Mortal and earlier than that in A 21st Century Death.
It is quite clear that, in the West at least, we are increasingly unable to accept the idea of human mortality. Fear of death is nothing new, of course. Most religions have at their heart the idea of some sort of afterlife, to help us cope with the idea that this one does not last for ever. Our own death, like the idea of infinity, is a hard one for the human mind to grasp. (It does not seem to be the case, as far as we are aware at least, that other creatures have the same ability to know of this inevitability). To imagine nothingness, a world in which we no longer exist, is difficult. Add to this the knowledge of the likelihood of accompanying pain as we pass from one state to the other and it is hardly difficult to see why the concept of some form of Paradise on ‘the other side’ has appeal. (Provided we behaved well, that is, which also provided a useful tool for our political masters.)
As the importance of religion for most of us declines, the comfort of religious solutions to the problem of mortality diminishes. The prolongation of human life becomes almost a religion in itself. Each individual death is, of course, for the person concerned and for those who love them, an immense sadness; whether that person is 10 or 100, for those who have known them, who love them and care about them, that death is a loss. In some cases it can truthfully be described as a tragedy. But can the fact that half of European deaths from Covid-19 occurred in nursing homes or care homes honestly be described as ‘an unimaginable tragedy’? These were the words used by Dr Hans Kluge, European Regional Director of the World Health Organisation (WHO) in a press briefing last Thursday. UK charities said the figures were “an appalling indictment” of the failure to protect older and disabled people in the settings in which they should be safe (my italics). How on earth can one be safe from death, particularly in one’s eighties or nineties?
Nursing homes are a modern invention. Before medical advances and the rise of state or community institutions it was the responsibility of families to care for their elderly. Nowadays many find themselves, for different reasons, unable to care for elderly family members and they are, either by their own choice (see Diana Athill’s writings on the subject) or, more usually that of their family, moved into a place where their complex needs can be better met. By the time the retirement home environment has been replaced by the care home environment those elderly citizens are usually suffering from a number of so-called ‘underlying conditions’. These may vary from Alzheimer’s through Type2 diabetes to post-stroke conditions. Thanks to modern medicines and the heroic efforts of their professional carers these elderly people can last for many years. In some cases their quality of life may be reasonably good; in others it may be almost non-existent. It is probably quite fair to say however that in all cases they are still alive because of the dedication of staff and the huge advances in modern medicine. Is the death of such an individual, however many times it is multiplied, really ‘an unimaginable tragedy’? (Where testing has been so patchy, can we indeed be certain that those deaths were directly attributable to Covid-19 and how much does it matter?)
If we have a much-loved pet which is suffering from a serious cancer or some other life-threatening illness, we will in all probability go to the vet and ask for the animal to be ‘put down’ to avoid it suffering. That option is not available to any of us. No doctor, whose entire training is towards the preservation of live and the curing of illness, would readily countenance that possibility. Vets are expected to cope with the fact that they are the instruments of such decision-making with equanimity. ( Few clients even pause to think of the emotional toll that can have on those they use to execute their wishes). The sanctity of human life has in contrast, for a very long time, been all important. It is built into our cultures and our laws. Is it time perhaps to look anew at what prolonging life means and to question our own and society’s attitude to life and death?
Atul Gawande, the physician who wrote Being Mortal: Medicine and What Matters in the End’, (a book I would thoroughly recommend) makes the point that; “Our ultimate goal is not a good death, but a good life to the very end”. ‘A good life to the very end’, surely does not mean living a number of months or years of ‘non-life’? This is a conversation we need to be having. The idea of the ‘Over-70s’ possibly being forced to self-isolate for a further period of time for ‘their own benefit’ raises additional questions. If, in order to live another few months or years you are not allowed to have contact with those you love, what sort of quality of life is that? Would you rather live another year in isolation with a dedicated paid carer or carers or another month during which time you can see your children, grandchildren and remaining friends? Is this choice one the state should be making for you or one you should be allowed to make for yourself?
Unfortunately, in the current climate, these conversations are not really happening. Back in 2016, Joan Bakewell had a series on BBC Radio 4 entitled We Need to Talk about Death. Coronavirus has in many ways made the need for this discussion more urgent. It is not a question of age, but of health. Those particularly susceptible to the coronavirus are those with ‘underlying health conditions’. That applies to pretty much all those in care homes. To describe their deaths as ‘an unimaginable tragedy’ is to diminish the word ‘tragedy’ and elevate ‘unimaginable’. It can be a tragedy for a young person to die. It can be unimaginable for events leading to that death to happen. It is, in all honesty, rarely a tragedy when an old person dies. If they have had their ‘three score years and ten’ (and I am fast approaching that milestone) then any years beyond that should perhaps be viewed as a bonus, not an entitlement; if they are suffering from underlying health conditions then it could even be that their death, however sad, is a release for them and a relief for those who love them. That they should die within the next few weeks, months or years should be eminently imaginable, not to say expected. We should be using our imaginations to envisage such a scenario, not blanking them off in some form of unhealthy denial of the inevitable.
Dignity in Dying has campaigned for years for changes to current legislation in this country. The existence in Switzerland of an organisation like Dignitas only highlights the unimaginable tragedy of so many in care homes unable to live ‘a good life to the very end’. Of course we need to be extremely grateful to the underpaid carers who work in nursing homes and who recently have put their own lives on the line (and in some cases paid the ultimate price) for their vulnerable, elderly inmates. However, to describe the deaths of many of those inmates as an ‘unimaginable tragedy’ is to distort words and ignore reality. Our tragedy is our inability to accept and prepare for the inevitability of the end of life. Death, the Grim Reaper, is here to stay – unlike every one of us. Whether the instrument of our death is heart attack, cancer stroke, pneumonia or Covid-19, it will happen and when it does, it will not be an ‘unimaginable human tragedy’. It will simply be the inevitable end. Certainly we should recognise and be grateful to those ‘unsung heroes’ working in the nursing homes, but we also need to recognise that quantity is no substitute for quality. Who wants to live to 100 in poor health unable to have any contact with friends and family?