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Death & life

25 October 2023

6 min read

Dealing with death – why the fuss?

“No fuss” cremations are getting more popular. Not giving a formal space or process to say goodbye feels like a seismic cultural shift to Jane Cacouris. Part of the How To Die Well series.

Jane Cacouris

Jane Cacouris is a writer and consultant working in international development on environment, poverty and livelihood issues.

A sculpture shows mourning women raising hands and fists to the sky.

The Tragedy of the Sea memorial in Matosinhos, a Portuguese port.

Prilfish, CC BY 2.0, via Wikimedia Commons.

Widow’s Rip is a notorious swirl of ocean just offshore from Nazaré, a centuries-old fishing village on Portugal’s windy and unpredictable Atlantic coast. Decades ago fishermen used oxen to pull brightly painted boats onto the beach and then rowed into the giant waves. Many lost their lives when the seas were rough. I first visited Nazaré with my Portuguese grandmother as a child and stayed in a fisherwoman’s house with an orange-tiled roof just off the central square. My eyes had to adjust to the gloom every time we went inside as she kept all of the shutters drawn. Even though it was thirty degrees outside, I remember her tanned, crumpled face shrouded in a black shawl that covered her head and shoulders. She wore a black knee length skirt with an array of petticoats and black shoes. As a ten-year-old, I was a little scared. I asked my grandmother when the fisherwoman’s husband had died. “About twenty-five years ago at sea”, she said. She explained it would be a sign that you didn’t love your late husband if you didn’t wear black for the rest of your life.

Nowadays, although fishing is still a livelihood for some who live there, Nazaré is known for its sweeping beach and touristy promenade of restaurants, bars and stalls selling Portuguese wares. But the widows, now very old ladies, who lost their husbands to the sea all those years ago still potter around the town dressed head to toe in black. An ingrained tradition of how to grieve.

No other event in our life brings us closer to facing questions of mortality and eternity than the death of a loved one.

Grief and how we deal with the loss of a loved one is of course deeply personal and expressed differently depending on so many things; culture, beliefs, personality, life experience, to name a few. But in recent years, there has been a defined shift in British society away from some of the traditions that have historically accompanied death.

The growing trend for direct or “no fuss” cremations is an example of this shift, with a rise from 3 per cent of all cremations in 2019 to 18 per cent in 2022 according to a life insurance company’s recent report. A traditional cremation includes a service at the crematorium or place of worship beforehand, whereas a direct cremation does not have a service. Instead, the deceased is taken directly to be cremated with no one in attendance, unless witnesses ask to be present. A simple coffin is used, and the timing of the cremation is determined by the funeral director, usually according to availability.

Why are families choosing to cut out the funeral?

Sources point to a range of reasons. A matter of choice – perhaps a statement of faith that the afterlife is not about funeral rituals, or conversely, that there is no afterlife, and the body will just decompose organically and be subsumed back into the Earth so why make a fuss? It can be for practical reasons such as cost; traditional funeral services are much more expensive than a simple cremation, estimated to be approximately £2,500 cheaper. A “no fuss” cremation can also reduce the likelihood of family division or arguments over the type of ceremony. Or family living in different locations geographically means a memorial service scheduled for a more convenient time can be organised.

All these reasons seem perfectly valid. But not giving a formal space or process to say goodbye does feel like a seismic cultural shift, even for the British, known for our ability to keep our feelings under wraps. Practical reasons aside, are we ducking the emotion that inevitably hits us when we lose someone we love? Or perhaps avoiding the difficult questions that come with death? No other event in our life brings us closer to facing questions of mortality and eternity than the death of a loved one.

On holiday in Nazaré in his youth, my father remembers a fisherman’s death in the house where he was staying. The night before the funeral - with the deceased laid out in the dining room - each of the women in the family took it in turns to sit in the corridor outside, the top skirt of their seven petticoats over their head, wailing in an outpouring of grief so raw that they couldn’t continue for more than a couple of hours. The “wailing process” carried on throughout the night, the role passing from woman to woman until sunrise. Not only was the loss of the fisherman the loss of their beloved, it was also the loss of a working partnership - the women sold the fish that the men brought home – and the loss of the family’s livelihood and income. The wailing was a necessary part of expressing this agony ahead of the funeral service when the rest of the family would come together to support each other.

There are also intensely reverent traditions observed with death in Portugal, particularly within the Catholic church. The burial or cremation is usually no more than three days after the person has died. When my grandmother passed away a few years ago, her body was laid in an open casket in a room of the Catholic church in the mountain village in rural Portugal where she had lived most of her life. The night before the funeral, a procession of people visited her to pay their last respects, including distant family members, whilst my immediate family sat with her all night. People touched her arm or hand, and sat and chatted to one another. After Mass the following day, her coffin lined with lead was sealed and she was taken to the family Mausoleum to be laid beside my grandfather, along with the remains of around thirty of our relatives dating back to the early 1900s.

Brazil, where we lived for several years, has many similarities to Portugal in dealing with death. The time between death and burial or cremation is even faster, usually within twenty-four hours. Family and friends rapidly gather, usually together with the body of the loved one in an open casket. Touching and kissing the body and wailing over it is not uncommon. According to a Brazilian friend, “Bebendo do morto” which means “drinking to the dead” is an old custom where family members raise a final glass of Cachaça, a traditional drink, to the deceased in the presence of their body.

A funeral service is partly about taking a look back at our loved one’s jigsaw of life, at all the pieces that have slotted together to make up their precious and unique time on Earth.

In all these traditions, the funeral service acts as the closure to the first “phase” of grief, and the passing of the deceased into God’s care. The next phase is then the more private continuation of grief for months or years to come.

Christians believe in life after death based on a conviction that as Jesus rose from the dead, so will we. A funeral service is partly about taking a look back at our loved one’s jigsaw of life, at all the pieces that have slotted together to make up their precious and unique time on Earth. Of course, there are damaged and missing pieces, but Christians believe that the jigsaw will be made whole and perfect in Heaven with Jesus. It is also a chance to give thanks for the the life of a human being wonderfully and fearfully made in the image of God.

Regardless of the country, the culture or the tradition, the death of someone we love means that our world will never be the same again. It will continue spinning without them and we have to get used to that. The Book of Ecclesiastes in the Bible says:

“There is a time for everything, and a season for every activity under the heavens: a time to be born and a time to die”.

Death is an entire season; not only the end of the existence of a human on Earth who was created and loved by God, but a prolonged period of growth and change for those of us left behind.

Death deserves us to make a fuss.

Article

Assisted dying

Care

Culture

Death & life

13 November 2024

8 min read

The deceptive appeal of assisted dying changes medical practice

In Canada the moral ethos of medicine has shifted dramatically.

Ewan Goligher

Ewan is a physician practising in Toronto, Canada.

a doctor consults a tablet against the backdrop of a Canadian flag.

Once again, the UK parliament is set to debate the question of legalizing euthanasia (a traditional term for physician-assisted death). Political conditions appear to be conducive to the legalization of this technological approach to managing death. The case for assisted death appears deceptively simple—it’s about compassion, respect, empowerment, freedom from suffering. Who can oppose such positive goals? Yet, writing from Canada, I can only warn of the ways in which the embrace of physician-assisted death will fundamentally change the practice of medicine. Reflecting on the last 10 years of our experience, two themes stick out to me—pressure, and self-deception.

I still remember quite distinctly the day that it dawned on me that the moral ethos of medicine in Canada was shifting dramatically. Traditionally, respect for the sacredness of the patient’s life and a corresponding absolute prohibition on deliberately causing the death of a patient were widely seen as essential hallmarks of a virtuous physician. Suddenly, in a 180 degree ethical turn, a willingness to intentionally cause the death of a patient was now seen as the hallmark of patient-centered doctor. A willingness to cause the patient’s death was a sign of compassion and even purported self-sacrifice in that one would put the patient’s desires and values ahead of their own. Those of us who continued to insist on the wrongness of deliberately causing death would now be seen as moral outliers, barriers to the well-being and dignity of our patients. We were tolerated to some extent, and mainly out of a sense of collegiality. But we were also a source of slight embarrassment. Nobody really wanted to debate the question with us; the question was settled without debate.

Yet there was no denying the way that pressure was brought to bear, in ways subtle and overt, to participate in the new assisted death regime. We humans are unavoidably moral creatures, and when we come to believe that something is good, we see ourselves and others as having an obligation to support it. We have a hard time accepting those who refuse to join us. Such was the case with assisted death. With the loudest and most strident voices in the Canadian medical profession embracing assisted death as a high and unquestioned moral good, refusal to participate in assisted death could not be fully tolerated.

We deceive ourselves if we think that doctors have fully accepted that euthanasia is ethical when only very few are actually willing to administer it.

Regulators in Ontario and Nova Scotia (two Canadian provinces) stipulated that physicians who were unwilling to perform the death procedure must make an effective referral to a willing “provider”. Although the Supreme Court decision made it clear in their decision to strike down the criminal prohibition against physician-assisted death that no particular physician was under any obligation to provide the procedure, the regulators chose to enforce participation by way of this effective referral requirement. After all, this was the only way to normalize this new practice. Doctors don't ordinarily refuse to refer their patients for medically necessary procedures; if assisted death was understood to be a medically necessary good, then an unwillingness to make such referral could not be tolerated.

And this form of pressure brings us to the pattern of deception. First, it is deceptive to suggest that an effective referral to a willing provider confers no moral culpability on the referring physician for the death of the patient. Those of us who objected to referring the patient were told that like Pilate, we could wash our hands of the patient’s death by passing them along to someone else who had the courage to do the deed. Yet the same regulators clearly prohibited referral for female genital mutilation. They therefore seemed to understand the moral responsibility attached to an effective referral. Such glaring inconsistencies about the moral significance of a referral suggests that when they claimed that a referral avoided culpability for death by euthanasia, they were deceiving themselves and us.

The very need for a referral system signifies another self-deception. Doctors normally make referrals only when an assessment or procedure lies outside their technical expertise. In the case of assisted death, every physician has the requisite technical expertise to cause death. There is nothing at all complicated or difficult or specialized about assessing euthanasia eligibility criteria or the sequential administration of toxic doses of midazolam, propofol, rocuronium, and lidocaine. The fact that the vast majority of physicians are unwilling to perform this procedure entails that moral objection to participation in assisted death remains widespread in the medical profession. The referral mechanism is for physicians who are “uncomfortable” in performing the procedure; they can send the patient to someone else more comfortable. But to be comfortable in this case is to be “morally comfortable”, not “technically comfortable”. We deceive ourselves if we think that doctors have fully accepted that euthanasia is ethical when only very few are actually willing to administer it.

We deceived ourselves into thinking that assisted death is a medical therapy for a medical problem, when in fact it is an existential therapy for a spiritual problem.

There is also self-deception with respect to the cause of death. In Canada, when a patient dies by doctor-assisted death, the person completing the death certificate is required to record the cause of death as the reason that the patient requested euthanasia, not the act of euthanasia per se. This must lead to all sorts of moments of absurdity for physicians completing death certificates—do patients really die from advanced osteoarthritis? (one of the many reasons patients have sought and obtained euthanasia). I suspect that this practice is intended to shield those who perform euthanasia from any long-term legal liability should the law be reversed. But if medicine, medical progress, and medical safety are predicated on an honest acknowledgment about causes of death, then this form of self-deception should not be countenanced. We need to be honest with ourselves about why our patients die.

There has also been self-deception about whether physician-assisted death is a form of suicide. Some proponents of assisted death contend that assisted death is not an act of deliberate self-killing, but rather merely a choice over the manner and timing of one's death. It's not clear why one would try to distort language this way and deny that “physician-assisted suicide” is suicide, except perhaps to assuage conscience and minimize stigma. Perhaps we all know that suicide is never really a form of self-respect. To sustain our moral and social affirmation of physician-assisted death, we have to deny what this practice actually represents.

There has been self-deception about the possibility of putting limits around the practice of assisted death. Early on, advocates insisted that euthanasia would be available only to those for whom death was reasonably foreseeable (to use the Canadian legal parlance). But once death comes to be viewed as a therapeutic option, the therapeutic possibilities become nearly limitless. Death was soon viewed as a therapy for severe disability or for health-related consequences of poverty and loneliness (though often poverty and loneliness are the consequence of the health issues). Soon we were talking about death as a therapy for mental illness. If beauty is in the eye of the beholder, then so is grievous and irremediable suffering. Death inevitably becomes therapeutic option for any form of suffering. Efforts to limit the practice to certain populations (e.g. those with disabilities) are inevitably seen as paternalistic and discriminatory.

There has been self-deception about the reasons justifying legalization of assisted death. Before legalization, advocates decry the uncontrolled physical suffering associated with the dying process and claim that prohibiting assisted death dehumanizes patients and leaves them in agony. Once legalized, it rapidly becomes clear that this therapy is not for physical suffering but rather for existential suffering: the loss of autonomy, the sense of being a burden, the despair of seeing any point in going on with life. The desire for death reflects a crisis of meaning. We deceived ourselves into thinking that assisted death is a medical therapy for a medical problem, when in fact it is an existential therapy for a spiritual problem.

We have also deceived ourselves by claiming to know whether some patients are better off dead, when in fact we have no idea what it's like to be dead. The utilitarian calculus underpinning the logic of assisted death relies on the presumption that we know what it is like before we die in comparison to what it is like after we die. In general, the unstated assumption is that there is nothing after death. This is perhaps why the practice is generally promoted by atheists and opposed by theists. But in my experience, it is very rare for people to address this question explicitly. They prefer to let the question of existence beyond death lie dormant, untouched. To think that physicians qua physicians have any expertise on or authority on the question of what it’s like to be dead, or that such medicine can at all comport with a scientific evidence-based approach to medical decision-making, is a profound self-deception.

Finally, we deceive ourselves when we pretend that ending people’s lives at their voluntary request is all about respecting personal autonomy. People seek death when they can see no other way forward with life—they are subject to the constraints of their circumstances, finances, support networks, and even internal spiritual resources. We are not nearly so autonomous as we wish to think. And in the end, the patient does not choose whether to die; the doctor chooses whether the patient should die. The patient requests, the doctor decides. Recent new stories have made clear the challenges for practitioners of euthanasia to pick and choose who should die among their patients. In Canada, you can have death, but only if your doctor agrees that your life is not worth living. However much these doctors might purport to act from compassion, one cannot help see a connection to Nazi physicians labelling the unwanted as “Lebensunwortes leben”—life unworthy of life. In adopting assisted death, we cannot avoid dehumanizing ourselves. Death with dignity is a deception.

These many acts of self-deception in relation to physician-assisted death should not surprise us, for the practice is intrinsically self-deceptive. It claims to be motivated by the value of the patient; it claims to promote the dignity of the patient; it claims to respect the autonomy of the patient. In fact, it directly contravenes all three of those goods.

It degrades the value of the patient by accepting that it doesn't matter whether or not the patient exists.

It denies the dignity of the patient by treating the patient as a mere means to an end—the sufferer is ended in order to end the suffering.

It destroys the autonomy of the patient because it takes away autonomy. The patient might autonomously express a desire for death, but the act of rendering someone dead does not enhance their autonomy; it obliterates it.

Yet the need for self-deception represents the fatal weakness of this practice. In time, truth will win over falsehood, light over darkness, wisdom over folly. So let us ever cling to the truth, and faithfully continue to speak the truth in love to the dying and the living. Truth overcomes pressure. The truth will set us free.