How to die?

“It takes the whole of life to learn how to live, and – what will perhaps make you wonder more – it takes the whole of life to learn how to die.”

– Seneca, 65 CE

The quest to defy death is as old as humanity itself, perhaps older. In the Abrahamic scriptures, including the Quran, the first human, Adam, is deceived by Iblis (Satan) into eating the forbidden fruit of paradise to acquire immortality (Quran 20:120). The avoidance of death and the quest to prolong life is a pattern repeatedly woven into the tapestry of human stories. In a Greek myth,^[1] Eos, the goddess of dawn, asks Zeus to grant her lover Tithonus (the prince of Troy) immortality but forgets to mention eternal youth along with it. A tragic end follows when Tithonus reaches a “hateful old age,” getting to a point where he is not able to even lift his limbs. Finally, Eos locks him into a chamber where he babbles endlessly. In another Greek myth, the Cumaean Sibyl (a Greek priestess) asks the god Apollo for a thousand-year life, but forgets to mention enduring youth. In the end, she too becomes the “prey of a long old age” and shrinks until she is confined to a jar, whispering, “I wish to die.”

The Roman Stoic philosopher Seneca remarked that it is not only difficult to learn how to live but that “it takes the whole of life to learn how to die.” A few thousand years down the road, humans have not yet succeeded in evading death but medical advancements in the last century are pushing back the boundaries, raising new questions about what kind of life is worth living and what it means to die well. In one of Plato’s dialogues (The Republic, Book III), Socrates says that Herodicus, regarded as the tutor of the Greek physician Hippocrates, tormented himself as well as others “by the invention of lingering death.” Herodicus, who had a chronic disease, spent his life trying to cure himself. Since recovering from that disease was impossible, he used his skills in medicine and therapy to keep himself going till he reached old age. Plato criticizes Herodicus for practicing such coddling medicine and argues that Aesculapius (the god of medicine) did not teach such medical practices – not out of ignorance but because Aesculapius was concerned about society’s functionality. In a well-governed society, according to Plato, there is a function specific to each member of that society, and no one has “leisure to be sick” and doctor himself all his days.

Whether we agree with Plato’s rather stern viewpoint about a useful life or not, it is hard to deny that medical advancements that are making it possible to live longer, are changing the ways in which we die. In traditional narratives of death in many societies, an old parent would die in his bed after having distributed inheritance and attended to his responsibilities. Death in a familiar environment, surrounded by loved ones, fulfilled the dying person’s psychological and emotional needs without involving many healthcare professionals. Death was deemed imminent and faced with patience and confidence. This was a constant in history across cultures. Prophet Muhammad’s companion Bilal bin Rabah on his death bed, sang, “Tomorrow we shall meet with our beloved ones, Muhammad (peace be upon him) and his companions.” The Sufi ascetics embraced death gladly, viewing it as a means of union with God. Ibn Qayyim al-Jawziyya explained that death was a way of union with God, saying, “Every lover yearns for the meeting with his beloved.”^[2]

In fifteenth century Europe, Christian texts titled Ars moriendi (the art of dying) were well known. These texts provided guidance on the proper rules and procedures for facing death in the best way. For those who gladly accepted it, death was not only a natural process but also had a spiritual and ‘other-worldly’ aspect. Dreams and the presentiment of death were common, even among ordinary people. French historian, Philippe Ariès, quotes from the history of Europe, the last words of kings, knights, saints, common people – even children – calmly facing death. “I shall not live two days,” “I see, and I know that my end has come,” “I feel that death is near,” “My death is at hand, that’s what it is,” were common phrases near death.

Despite the fact that people in earlier times prepared themselves for dying well, death did not ask before coming – nor could it be turned away. With the rapid scientific advancement in the last century, death has become less adventitious, at least, in technologically advanced societies where a large cohort of the population dies after going through the regular phases of life (education, marriage, career, and children) and reaching old age. Death no longer seems as unpredictable as before, but something has been lost: The presentiment of death has become rarer.

According to a well-known quote by Ivan Illich, “In every society, the dominant image of death determines the prevalent concept of health.” Death in our times has been medicalized. From an inevitable natural phenomenon or a call by God, death has transformed into the effect of an identifiable cause (disease) which it is possible to get the better of. The categorization of death into natural and unnatural/abnormal/accidental supplements this perception. Along with this, the idea of ‘savior’, formerly invested in the physician’s persona, has now materialized in the form of the healthcare institution and we turn to the hospital to save us from death. The resultant medicalization of society elevates the ‘power over death’ perception to a new level. Death feels optional. Consequently, people spend massive amounts of money on healthcare in the last few days of life. While this does not eliminate death it does create the most rational and normal form of death – a hospitalized death under the supervision of medical experts.

Some contemporary writers, especially from the medical fraternity, have also started focusing on this topic. Atul Gawande, in his essay, ‘Letting Go’, writes that anxiety about death is increasing in modern society. According to Gawande, until the actual declaration of death, there is often a state of denial regarding impending death by both the patient and the family. Possibly, the denial stems from this relatively new, institutionalized image of death as something that can be controlled, circumvented, defeated – or even chosen. As a result, the modern, hospitalized death often follows extraordinary efforts to ‘do everything’ to prolong life – regardless of the quality of that life. For those who are engaged in healthcare provision, a BMJ editorial asks a thought provoking question: “Would you like to die the way your patients do, doctor?”^[3] As Seneca wrote, the question of how to die is perhaps connected to the question of how to live –  the other side of the same coin.

[1] Homeric Hymn to Aphrodite

[2] Ibn Qayyim Al Jawziyya, Madarij Al Salikeen (Ranks of the Divine Seekers: A Parallel English-Arabic Text) Trans. Ovamir Anjum (Brill, 2020), Vol 2, 620.

[3] Enkin, Murray, Alejandro R. Jadad, and Richard Smith. “Death can be our friend” (2011). BMJ; 343.