How the Victorians could help us to die well

Victorians welcomed the angel of death, rather than fearing it. Ian Bradley explores their changing attitudes towards death. Part of the How to Die Well series.

Ian Bradley

Ian Bradley is Emeritus Professor of Cultural and Spiritual History at the University of St Andrews.

A bronze statue of a resting angel sits atop a low stone grave.

A grave in a Dresden cemetery.

Veit Hammer on Unsplash.

When it comes to dying well, there is much that we can learn from our Victorian forebears. Experiencing death more frequently and directly than most of us do, they were not frightened by it but regarded it rather as part of the natural order and, thanks to the pervasive influence of the Christian faith, as the gateway to eternal life.

In his widely read epic poem, ‘In Memoriam’, inspired by the death of his close friend Arthur Hallam at the age of 22 and published in 1851, Alfred Tennyson posed the rhetorical question: ‘How fares it with the happy dead?’. It struck a deep chord with his readers, as did his answer that they are ‘the breathers of an ampler day for ever nobler ends’.

The Victorians thought, wrote, preached, and sang about death and what follows it far more than we do today. Novels were judged by the power and pathos of their death bed scenes. Ninety hymns in the 1889 edition of Hymns Ancient and Modern deal primarily with the experience of death and dying. By contrast, there is not a single hymn on this subject in its current successor, the 2013 Ancient & Modern: Hymns and Songs for Refreshing Worship. Death and heaven featured prominently in popular poems, none more so than those by Adelaide Procter, a devout Catholic and the second most read Victorian poet after Tennyson. For her, ‘the beautiful angel, Death, waiting at the portals of the skies’ is to be welcomed rather than dreaded. Her verses about a ‘lost chord’ that an organist realises he may only hear again in heaven, set to music by Arthur Sullivan, who also had no fear of death, became the best-selling song in Britain throughout the last quarter of the nineteenth century.

To our modern taste, such sentiments may seem maudlin and morbid. We have done our best to sweep death under the carpet and we think little about what may follow it.

For most Victorian Christians death was something to be looked forward to rather than dreaded. Frederick William Faber, who converted from Anglicanism to Roman Catholicism, was typical in his enthusiastic evocation of its joyful and liberating character:

O grave and pleasant cheer of death! How it softens our hearts and without pain kills the spirit of the world within our hearts! It draws us towards God, filling us with strength and banishing our fears, and sanctifying us by the pathos of its sweetness. When we are weary and hemmed in by life, close and hot and crowded, when we are in strife and self-dissatisfied, we have only to look out in our imagination over wood and hill, and sunny earth and starlit mountains, and the broad seas whose blue waters are jewelled with bright islands, and rest ourselves on the sweet thought of the diligent, ubiquitous benignity of death.

To our modern taste, such sentiments may seem maudlin and morbid. We have done our best to sweep death under the carpet and we think little about what may follow it. For the Victorians, by contrast, it was an ever-present reality, mostly happening at home rather than out of sight in a curtained-off hospital bed or care home, and directly affecting the young as well as the old. The average life expectancy of someone born in Britain in 1837, the year of Victoria’s accession, was just 39 years, less than half the current figure of 81. Infant mortality stood at 150 per 1,000 births and actually rose through the century, reaching 160 per 1,000 births in 1899 – the current level is just over three per 1,000.

It was in this context that Victorian clergy sought to dispel anxious fears about death and help people to die well by expounding the Christian doctrine of eternal life. There was a pastoral imperative to do so when seeking to minister to so many who were dying or grieving.

Their focus was on the promise of heaven rather than the fear of hell. There was still a continuing adherence within the churches to the doctrine of eternal punishment for the wicked in the aftermath of a final and terrible Day of Judgment. However, the latter half of the nineteenth century saw a marked decline of belief in hell, prompted partly by the impact of the new German school of biblical criticism which challenged Biblical literalism and by moral revulsion at the idea that a basically benevolent and good God could consign people who had not led particularly bad lives to eternal torment.

Increasing missionary endeavour and contact with those of other faiths, or of no faith, also made many Christians uneasy with the idea that a large proportion of the human race were condemned to everlasting punishment simply because they had never encountered the Christian Gospel.

As fear of hell subsided, so hope of heaven came to occupy a much more prominent place in Victorian thought and imagination. This can be clearly seen in the language of hymns. Heaven receives over 100 explicit mentions in the seminal 1889 edition of Hymns Ancient and Modern, and there are a further 43 references to Paradise. Hell is mentioned in just 15 of the 638 hymns and only in four of those is it conceived of primarily as a place of pain and punishment.

Hymns are, indeed, a good place to gain an insight into Victorian views of death and heaven. Two popular ones written at the very beginning of Victoria’s reign set the tone for those that followed. ‘I’m but a stranger here, heaven is my home’ by Thomas Taylor, a Bradford Congregational minister, and ‘There is a happy land, far, far away’ by Edinburgh schoolmaster Andrew Young, emphasize the idea of death as a home-coming and reinforce the conviction, increasingly common among Victorian clergy, that friends and family will be reunited in heaven.

As mortality rates rise in the wake of Covid and as a consequence of an ever-older population and death comes out of the closet, we are at last beginning to talk and think about it more. Through their poems and hymns, the Victorians can help us to be less fearful and to die well.

Ian's new book Breathers of an Ampler Day: Victorian Views of Heaven is published by Sacristy Press.

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.