Death and dying in literature

Death and dying in literature

John Skelton APT 2003, 9:211-217. Access the most recent version at DOI: 10.1192/apt.9.3.211

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Advances in Psychiatric Treatment (2003), vol. 211–220 Death and dying in9,literature

Death and dying in literature John Skelton Abstract This paper considers how death and dying are presented in literature. A wide range of texts, principally but not exclusively from the English language tradition, is used to illustrate themes. Broad categories are suggested for the study of death: some authors give personal accounts of their impending death or their sense of bereavement; some use literature to structure and order our thoughts about death; and some treat death as a literary device, using it, for example, as a symbolic representation of the decay of society. It concludes that the biggest obstacles that health professionals and patients face as they attempt to understand death in literature are concerned not with a lack of appropriate emotional depth, but with difficulties either in understanding the conventions of literature or in coming to terms with the cultural gaps imposed by time and place.

This is the third in a series of papers on literature and psychiatry. Previous papers introduced cognitive linguistics and metaphor (Eynon, 2002) and literature and substance misuse (Day & Smith, 2003). Future papers will consider, among other things, how dementia is described in fiction and biography, and the value of autobiographical narrative to psychiatry.

How do people write about death and dying? At one end of the scale there are the sometimes embarrassing but often deeply personal and profoundly felt lines of doggerel on tombstones or ‘In Memoriam’ columns (‘She faltered by the wayside and the angels took her home’). The internet is a great source of these, although some are, no doubt, apocryphal. At the other end of the scale, there is death in literature, for example King Lear’s lament over his dead daughter, Cordelia. This extraordinary scene concludes: ‘” No, no, no life! Why should a dog, a horse, a rat, have life, And thou no breath at all? Thou’lt come no more, Never, never, never, never, never! Pray you, undo this button: thank you, sir. Do you see this? Look on her, look, her lips, Look there, look there!”’ (King Lear: Act V, scene iii)

And Lear himself dies, perhaps under the delusion that Cordelia still lives. As an interesting sidelight on death and its meanings, the play was 1. Books are not necessarily referenced to their first editions.

rewritten in the 18th century with a happy ending to reflect the more optimistic ethos of an age which believed this was, in Voltaire’s famous phrase, the ‘best of all possible worlds’. In the 20th century, Edward Bond wrote a version of the Lear story which was bleaker than Shakespeare’s original, precisely on the grounds that Shakespeare was too optimistic. One of the central things of which literature can make us more aware is that death means different things at different times. But these two kinds of text – the banal and the sublime – clearly have things in common. They attempt to express some of the emotions of bereavement and they attempt to give shape to our thoughts about death. The first affirms a belief in the final, Christian, order of the universe; and it is the question of order that Shakespeare, too, addresses: Where is justice if the good people die? Great literature – ‘Literature’ with a capital ‘L’ – makes use of death for its own purposes. The death of Cordelia, however moving we may find it on stage, is a functional device. In fact, many fictional deaths are not terribly moving or true to our personal or professional experiences of bereavement and death. In other words, literature is not just an attack on the emotions. Nor do we only find emotions expressed in great literature. In this paper, I therefore try to separate out, although in a fairly loose and fluid manner, a number of different ways in which death and dying are presented in writing. First, I look at personal accounts of death and dying, then I consider how writing is used to structure and order our

John Skelton is a senior lecturer in medical communication skills at the Department of Primary Care and General Practice (University of Birmingham, Edgbaston B15 2TT, UK. Tel: 0121 414 3767/8534; e-mail: [email protected]) and Director of the Interactive Skills Unit, which runs courses in communication and interactive management skills in the West Midlands and beyond. His first degree is in English literature and, before his career in medical education, he worked in applied linguistics. He has published widely in both applied linguistics and medical communication. With colleagues, he has run a special study module in literature and medicine for medical students at Birmingham.

Advances in Psychiatric Treatment (2003), vol. 9. http://apt.rcpsych.org/

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experience of death. Finally, I discuss some of the functional uses writers make of death and dying. I have quoted as extensively as space permits, partly to let authors speak for themselves and partly in the hope that readers will enjoy the contact with perhaps unfamiliar names and be encouraged to dig more deeply. In order to dispense with distracting inverted commas, let me say that although the word ‘literature’ has many uses, I use it here in the traditional sense, familiar to A-level students of English literature; thus Shakespeare is literature, but this paper is not.

Personal accounts Literature touches our emotions and perhaps this is what people consider to be its greatest characteristic. Yet the power of the arts is ambivalent. It can blind the reader to sentimental trash. Who has not cried at the death of Bambi’s mother in the Walt Disney cartoon? Which girl – it seems only girls read it – has not wept over the demise of Beth in Louisa M. Alcott’s Little Women? Who, in other words, would disagree with the sense of Noel Coward’s famous bon mot: ‘It is extraordinary how potent cheap music is’? Dickens was one of the greatest of all writers but, like many Victorians, he was very susceptible to sentimentality. Here, he describes the death of the impoverished child, Little Nell, in The Old Curiosity Shop. Dickens owed a great and direct debt to Shakespeare in his work. Note the similarities between this death and that of Cordelia, above. The first speaker is the old man whom Nell has befriended. ‘” She is still asleep,” he whispered. “You were right. She did not call – unless she did so in her slumber.” ‘“ She has called to me in her sleep before now, Sir; as I have sat by, watching, I have seen her lips move, and have known, though no sound came from them, that she spoke of me. I feared the light might dazzle her eyes and wake her, so I brought it here …” ‘ “ …She is sleeping soundly,” he said; “but no wonder. Angel hands have strewn the ground deep with snow, that the lightest footstep may be lighter yet; and the very birds are dead, that they may not wake her. She used to feed them, Sir. Though never so cold and hungry, the timid things would fly from us. They never flew from her!”’ (Dickens, 2001: pp. 534–535)

But, like Lear, the old man is mistaken: ‘For she was dead. There, upon her little bed, she lay at rest. The solemn stillness was no marvel now. ‘She was dead. No sleep so beautiful and calm, so free from trace of pain, so fair to look upon. She seemed a creature fresh from the hand of God, and waiting for the breath of life; not one who had lived and suffered death.

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‘Her couch was dressed with here and there some winter berries and green leaves, gathered in a spot she had been used to favour. “When I die, put near me something that has loved the light, and had the sky above it always.” Those were her words. ‘… She was dead. Dear, gentle, patient, noble Nell was dead… ‘And still her former self lay there, unaltered in this change. Yes. The old fireside had smiled upon that same sweet face; it had passed, like a dream, through haunts of misery and care; at the door of the poor schoolmaster on the summer evening, before the furnace fire upon the cold wet night, at the still bedside of the dying boy, there had been the same mild lovely look. So shall we know the angels in their majesty, after death.’ (Dickens, 2001: p. 540)

If this does not move us to abject surrender and sentimental tears, the emotions evoked might be more complex and less forgiving. ‘Who’, as Oscar Wilde once remarked, ‘can read the death of Little Nell without laughing?’ Perhaps. And it is the mix of complex embarrassment, humour and dismay that colours our response to both this and amateur verse, or the attempts of the poorly equipped to strike a formal note of gravity. The inscriptions on headstones in a typical graveyard can move the most earnest person to giggles. This does not mean that poverty of expression is the same as poverty of feeling. One of the lessons of King Lear, after all, is that true feelings lie too deep for words: beware those who, like Lear’s wicked daughters, can articulate their love. Trust rather the saintly Cordelia, the daughter whose love is deep beyond expression. By extension, for just this reason a dying patient or a bereaved relative may welcome the release that literature brings. They may feel that their own power to express themselves has failed and that there is relief in the words of others and the possibility of saying, ‘This is what I mean’. This makes for an ambivalence in much of the writing about death and dying. Sometimes it is profoundly felt, sometimes it is profoundly expressed, but not often is it both. This is exemplified in an excellent anthology of poems on bereavement, The Long Pale Corridor (Benson & Falk, 1996). The range of poems, in terms of quality, is from the adequate to the outstanding, but nobody could describe the book as easy reading. This example is by the American poet, Jack Hirschman, whose son died of leukaemia when in his twenties. ‘It was a happy day when he was born 34 years ago my blonde son. How golden the sun in the park today, how happy the birds and flying balls.



I sit in golden light almost forgetting he’s eight years gone because the sun is so like his hair and the air like the golden laughter of his love. Eight years old and into a radiant windup. Here comes a perfect strike of light upon an old old glove.’ (Jack Hirschman, ‘October 11th 1990’. Reprinted with permission from Hirschman, J. (1992) Endless Threshold. Willimantic, CT: Curbstone Press.)

There is a good deal to respond to in this poem. The idea that love is laughter is a particular delight – and if the poem lacks immediacy to a UK reader, it is partly because it is North American; the glove is a baseball glove and the central image is that most American of rituals, a father and son playing baseball. A non-American audience may miss the references altogether and, even if they do pick them up, may catch only a glimmer of the rich network of associations conjured up by the sport, and thus the poem about the sport. The point here is that literature does not deal with facts, things which are true at all times for all conditions and every reader. Clinicians and patients alike evidently share the greatest difficulty when they turn to literature as a way of sharing experience. Barriers of context can impose themselves more or less completely between the most well-intentioned reader and the text. This means that we turn most easily to writing where the barriers effectively vanish, because the culture is our own and the kind of reading the text demands of us is the kind of reading we do anyway. For examples, we turn to accounts of their illness by contemporary, articulate people. Sometimes, as with the journalists John Diamond and Oscar Moore, victims of throat cancer and AIDS, respectively, an easy sophistication hangs over their work (Moore, 1996; Diamond, 1999). But this is a game whose rules many of us understand, and the writing – essentially very clever versions of the volubility of the chattering classes – therefore has an immediate power, closely linked to our confidence that we know what is going on. This is Moore, talking about going blind: ‘Dwindling in weight and morale, I fled to out-oftown friends and spent two days sitting in a garden on Long Island recuperating … i.e. napping. So it should have been easy to blame my foggy vision and guerrilla headbangs on a combination of red-eye flight and nap overdose. Unfortunately not. ‘You see (I hate sight verbs!) the fog wasn’t unseasonal bonfires or post-night-flight blur, and the

headaches weren’t random flares. We were at war, and losing it. The CMV had woken up with a hunger, and I now had so little retina left on the left that my vision was getting to be like US television – hardly enough pixels to make a picture.’ (Moore, 1996: p. 166)

The writing is self-consciously able and literate. Moore effortlessly strings his war metaphors together, for example. At the same time, the issue of quality, whether this is ‘good writing’, seems to be beside the point and a text like this is perhaps, above all, a way of putting sufferers and their relatives in touch with another experience; of relieving the burden of loneliness. It is not unkind to observe that Moore actually says little which is very insightful – nothing there the healthy could not have guessed about what the dying feel. In the end, it is not for the quality of his thoughts or feelings that we read this, but for their authenticity and the sense of the person which shines through. In that respect, it matters less what is said than who says it. This is writing at its most immediate. One is granted permission to watch as the writer dies and there is no doubt that this contributes to its impact. Even more immediate, perhaps, are the possibilities that the internet gives us to write interactively. Here is a posting from an HIV bulletin board: ‘Not sure what I am looking for, just very lonely and kind of lost. My partner of 15 years died 2 weeks ago here at home with me after a long but very courageous fight. I do have friends and people around who do care, but I still feel so lonely and sometimes feel as if I will never feel happy again. We did so much together. Three years ago we opened, and still have, a restaurant that I am very proud of. He was a remarkable person who never let the disease stop him or myself from doing things that would make us happier, or better as people and a couple. It’s just so hard, because everything here at home reminds me of him, and everything at work does too. Of course, there are so many good memories, but now that’s all I have. I just miss him so much!’ (http://www.thebody.com/bbs/forums.html)

The expression of sentiment is commonplace yet profound in a way that we can easily understand.

Making sense of death One of the central tasks of literature is to impose a structure on life and death, giving meaning to both. Indeed, literature as a discipline aims just as certainly as science does to understand the world in which we live and to interpret our own role as participants in the human condition. The difficulty for the non-specialist is understanding the various ways in which literature works and, once more, this is particularly true when it comes to the question of understanding across time and space.


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Here is one example, which is fairly well-known and relatively approachable. Perhaps it also corresponds to a certain idea of what poetry is in its effortless rhythmical dexterity and command of sound: ‘Dark house, by which once more I stand Here in the long unlovely street, Doors, where my heart was used to beat So quickly, waiting for a hand, A hand that can be clasp’d no more – Behold me, for I cannot sleep, And like a guilty thing I creep At earliest morning to the door.

(John Donne, Holy Sonnet X: ‘Death, Be Not Proud’)

He is not here; but far away The noise of life begins again, And ghastly thro’ the drizzling rain On the bald street breaks the blank day.’ (Alfred Lord Tennyson, In Memoriam, VII)

Tennyson wrote this long – very long – series of short poems (published in 1850) following the death, at just 22, of his close friend, Arthur Hallam. Hallam was a brilliant young man in his own right and it seems clear that Tennyson expected to spend the rest of his life in close contact with him. The deeply felt grief makes it a personal account, but deep feeling refined into literature. A little more cynically, it could be seen as an instance of the French poet and man of letters Paul Valery’s description, ‘A poem is a machine for reproducing an emotion’. Note, in particular, a much-quoted example of Tennyson’s genius in the way that the easy, gentle rhythms are subverted in the last line by the sudden abruptness of ‘bald’ and ‘blank’. In a sense, the poem is held together by poetic technique; the feelings behind it are so bleak that it is hard to see how they found expression at all. Behind the sadness, hovering off-stage for much of the time in the poems of In Memoriam, and entirely absent in this one, is the apparatus of Victorian life and, in particular, the solace of the Christian faith. This, of course, has been the backdrop to a great deal of Western literature about death and dying. Christianity has offered a way of understanding grief and our own death in the context of eternity. At its literary best, faith lends a power and conviction to writing which speaks clearly to those of other faiths, or none. This is John Donne, who became a cleric in later life. He is often regarded as one of the greatest of all English poets. The poem is perhaps best read aloud, with passion and speed, to reveal the power of that triumph over death it celebrates: ‘Death be not proud, though some have called thee Mighty and dreadful, for, thou art not so, For, those, whom thou thinks’t, thou dost overthrow, Die not, poor death, nor yet canst thou kill me; From rest and sleep, which but thy pictures be, Much pleasure, then from thee, much more must flow,

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And soonest our best men with thee do go, Rest of their bones, and soul’s delivery. Thou art slave to fate, chance, kings and desperate men, And dost with poison, war and sickness dwell, And poppy, or charms can make us sleep as well, And better than thy stroke; why swells’t thou then? One short sleep past, we wake eternally, And death shall be no more, Death thou shalt die.’

This poem also works through the force of its sounds – for example, by the way the sounds ‘p’, ‘b’ and ‘d’ are deployed in the opening lines (phonetically these are ‘stops’, because the passage of air is stopped then suddenly released by either the lips or tongue). Here, the effect is of passion and a kind of driven commitment, one might say, reinforced by the tight verse form of the sonnet, which is handled effortlessly and compacts a great deal of meaning into a short space. The poem works because of technique. What guarantees the value of the writing is not who is writing but what is said and how. It also works because of the shared understanding that most readers will have of the cultural and religious context, even if they do not actually share the belief system. In other words, cultural familiarity is of substantial importance. Contrast this with, for example, inscriptions from other cultures, whose social value is now lost to us. The Ancient Egyptians set great store by the account of themselves written on their tombs, but these texts, sometimes called ‘autobiographies’, have no real meaning to us now, unless we are archaeologists or historians. The following is a poem written by Basho, the great Japanese writer of haiku, as death approached. It is extremely famous, much translated and, without a knowledge of Japanese culture, fairly vacuous: ‘Ill on a journey, My dreams still wandering round Over withered fields.’ (Oseko, 1990: p. 329)

What do such things mean? – very little without the shared culture; without, for example, a sense of the resonance of the word ‘dream’ (‘yume’, in the original), which pervades the short Japanese poem and has been picked up, played with and enriched by author after author over centuries.

Symbolic deaths Clearly, much of what is quoted above is literature striving to demonstrate that particular deaths fit into some kind of overall scheme. This may be an



eschatological account of the world or merely a matter of taking death seriously because we, in turn, hope that our death will be taken seriously. At any rate, what matters is the context in which death is placed. But literature itself is such that death has many functions. In other words, the context of literature gives death and dying many roles to play. At one end of the scale is one of the most common types of death in all fiction, the discovery of the body in the ‘whodunnit’ or murder mystery. This may require us to expend no deeper emotion than we do on a crossword puzzle, or it may, as in the next example, aim to do more. This is from Smiley’s People by the great novelist of the spy-story, John le Carré (2000). His hero, Smiley, has just discovered a second body: ‘Slowly, [Smiley] returned his gaze to Leipzig’s face. Some dead faces, he reflected, have the dull, even stupid look of a patient under anaesthetic. Others preserve a single mood of the once varied nature – the dead man as lover, as father, as car driver, bridge player, tyrant. And some, like Leipzig’s, have ceased to preserve anything. But Leipzig’s face, even without the ropes across it, had a mood, and it was anger: anger intensified by pain, turned to fury by it; anger that had increased and become the whole man as the body lost its strength’ (p. 243).

This is almost a meditation on the nature of death. However, the focus immediately changes to death as a puzzle: ‘Methodically, Smiley peered about him, thinking as slowly as he could manage, trying, by his examination of the debris, to reconstruct their progress. First the fight before they overpowered him, which he deduced from the smashed table-legs and chairs and lamps and shelves … Then the search, which took place after they had trussed him and in the intervals while they had questioned him’ (p. 243).

One stage further on is the kind of book, often called a ‘whydunnit’, in which the identity of the killer is not as important as his or her motivation. Bear in mind here that the greatest of all constraints on the writers of whodunnits is that they cannot describe the motivations of their characters well, or it will be at once clear who is the killer. The complete blandness of Agatha Christie characters is necessary, in this respect, to fulfil the genre’s requirements – or at least it is a happy accident. Contrast this with Charles Dickens’ The Mystery of Edwin Drood, which is, among other things, a whodunnit. Famously, Dickens died before revealing the identity of the killer, but it can be determined with near certainty from the imagery and symbolism with which Dickens surrounds him throughout the book. The greatest master of the whydunnit is probably Dostoevsky, whose Crime and Punishment is sometimes described as one of the first detective novels.

The function of the hero’s death in tragedy and epic is one of the oldest literary conventions. We have looked at King Lear but it is worth reminding ourselves of the way the idea of the good death varies from society to society. This is the death of the Trojan hero, Sarpedon. Homer’s text is here translated by Alexander Pope, whose urbane 18th-century style puts a neo-classical veneer on Homer’s more direct original: The towering chiefs to fiercer fight advance: And first Sarpedon whirl’d his weighty lance, Which o’er the warrior’s shoulder took its course, And spent in empty air its dying force. Not so Patroclus’ never-erring dart; Aim’d at his breast it pierced a mortal part, Where the strong fibres bind the solid heart. Then as the mountain oak, or poplar tall, Or pine (fit mast for some great admiral) Nods to the axe, till with a groaning sound It sinks, and spreads its honours on the ground, Thus fell the king; and laid on earth supine, Before his chariot stretch’d his form divine: He grasp’d the dust distain’d with streaming gore, And, pale in death, lay groaning on the shore. So lies a bull beneath the lion’s paws, While the grim savage grinds with foamy jaws The trembling limbs, and sucks the smoking blood; Deep groans, and hollow roars, rebellow through the wood. (Pope, 1715–1720)

The ‘pity of war ’, in Wilfred Owen’s famous phrase, was seldom mentioned until this century and its principle exponent is Owen himself, who gave death a new kind of meaning. ‘Strange Meeting’ is linked to the conventions associated with the literature of dreams and ghosts. It begins: ‘It seemed that out of battle I escaped Down some profound dull tunnel, long since scooped Through granites which titanic wars had groined. Yet also there encumbered sleepers groaned, Too fast in thought or death to be bestirred. Then, as I probed them, one sprang up, and stared With piteous recognition in fixed eyes, Lifting distressful hands, as if to bless. And by his smile, I knew that sullen hall, By his dead smile I knew we stood in Hell.’ (Wilfred Owen, ‘Strange Meeting’)

Indeed, the death scene in literature is just as much a convention as is the finding of the body. Among the finest death scenes in fiction are the death of Joachim in Thomas Mann’s Magic Mountain and the death of Paul Dombey in Dickens’ Dombey and Son. The following, however, is part of the death scene of the consumptive Ralph Touchett, in Henry James’s exquisite novel, The Portrait of a Lady. When his close friend, Isabel, visits him, she finds at first that his


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face on his deathbed is, in an astonishing phrase, ‘as still as the lid on a box’. Then, after some days, he is briefly well enough to talk: ‘”What does it matter if I’m tired when I’ve all eternity to rest? There’s no harm in making an effort when it’s the very last of all. Don’t people always feel better just before the end? I’ve often heard of that; it’s what I was waiting for. Ever since you’ve been here I thought it would come. I tried two or three times; I was afraid you’d get tired of sitting there.” … “It was very good of you to come,” he went on. “I thought you would; but I wasn’t sure.” ‘”I was not sure either till I came,” said Isabel. ‘”You’ve been like an angel beside my bed. You know they talk about the angel of death. It’s the most beautiful of all. You’ve been like that; as if you were waiting for me.” ‘”I was not waiting for your death; I was waiting for – for this. This is not death, dear Ralph.” ‘”Not for you – no. There’s nothing makes us feel so much alive as to see others die. That’s the sensation of life – the sense that we remain. I’ve had it – even I. But now I’m of no use but to give it to others. With me it’s all over.” And then he paused. Isabel bowed her head further, till it rested on the two hands that were clasped upon his own. She couldn’t see him now; but his faraway voice was close to her ear. “Isabel,” he went on suddenly, “I wish it were over for you.”’ (James, 2003: p. 260)

A few mornings later, Ralph is dead. Isabel tries to comfort Ralph’s mother, a cold and patrician lady, but is rebuffed as follows – again, a sudden, piercing moment, quietly stated: ‘”Go and thank God you’ve no child,” said Mrs Touchett, disengaging herself’. To make the obvious point: even without the context of knowing precisely who these characters are, the generosity of spirit is clear, as is a kind of maturity of feeling which is missing in the case of Little Nell. Note how different the angels are in this novel compared with those that hover around the deathbed in Dickens’ tale. Sometimes, however, the conventions take us away from death itself entirely. Novels are full of deaths which symbolise the death of some good thing in society, and there are times when references to death are so casual or mannered that they have no real power at all – from the love songs of the Renaissance to those of the present day. An excellent, brief and extremely clever example of this kind of mannerism is Samuel Beckett’s poem from the Dieppe series: ‘I would like my love to die and the rain to be falling on the graveyard and on me walking the streets mourning the first and last to love me.’ (Samuel Beckett, 1984. With permission from Calder Publications.)

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The desire to pose as a person experiencing grief is itself a kind of posturing we all recognise, no doubt.

Selected reading An excellent starting point for anyone interested in medical humanities is a website at New York University (http://endeavor.med.nyu.edu/lit-med/ medhum.html). A number of journals discuss issues relevant to health care, notably Literature and Medicine and Medical Humanities (although their papers can sometimes be a little precious for some tastes). JAMA regularly includes poetry, often of a high order. These days, all the great writers – and some of the not-so-great – are represented on the internet and this is a good starting place for those who, faced with the thousands and thousands of books on Shakespeare, for example, do not know where to start. One example is the website ‘Mr William Shakespeare and the Internet’ (http://shakespeare. palomar.edu) which is a place where most of us could happily lose ourselves for an hour or two.

Conclusions Death in literature is a varied thing, just as is death in society. Death is also an inescapable destiny for each of us as individuals and, for this reason, has always permeated our thoughts at all levels, from the immediate sense of devastation that personal bereavement gives us to the ways in which we manage the fact of death by pushing it onto the surface, as familiarly and comfortably spooky as the deaths in Hammer horror films. One of the uses of literature in the health professions is to help people to become more articulate about their concerns and their worries: to help them to ‘talk about their feelings’. It is often said that reading literature will help health professionals as well, perhaps particularly when they are young and lack experience; or perhaps when they are older and crusted over with the cynicism of experience. These are valuable functions, of course, but they tend to pull us away from a real sense of what literature is and can do if we actually repay it with study and read repeatedly. The fact of the matter is that literature is difficult and, if we fail to understand it, this may be because we know too little about the cultures that have brought it into being or cannot recognise or appreciate the techniques through which it is realised, rather than because we lack the finer sentiments. It follows from this that the role of literature as part of the growing movement in ‘medical humanities’ can be interpreted too narrowly. Literature, if we trust its strength and accept that to become its



student is to undertake something always rich and often difficult, is a way of understanding what it is to be human. One central gift it can give to those with a scientific training is that, because it is not reductive, it can bring home the fact that there are ways of understanding which cannot be tested by MCQ. It is the role of literature to observe that the world as we experience it is irreducibly complex. An abstract of a scientific paper is one thing; an abstract of Hamlet is quite another, and certainly is not Hamlet.

References Beckett, S. (1984) Collected Poems 1930–78. London: Calder. Benson, J. & Falk, A. (eds) (1996) The Long Pale Corridor Newcastle: Bloodaxe Books. Day, E. & Smith, I. (2003) Literary and biographical perspectives on substance use. Advances in Psychiatric Treatment, 9, 62–68. Diamond, J. (1999) Because Cowards Get Cancer Too. London: Vermillion. Dickens, C. (2000) The Old Curiosity Shop. London: Penguin Classics. Eynon, T. (2002) Cognitive linguistics. Advances in Psychiatric Treatment, 8, 399–407. James, H. (2003) The Portrait of a Lady. London: Penguin Classics. Le Carré, J. (2000) Smiley’s People. London: Hodder & Stoughton. Moore, O. (1996) PWA. Looking Aids in the Face. London: Picador. Oseko, T. (1990) Basho’s Haiku: Literal Translations for those who Wish to Read the Japanese Text, with Grammatical Analysis and Explanatory Notes. Tokyo: Chuoh Printing.

2 a b c d e

Literature is easier to understand when: it is well-written it is unsentimental it is written from within a familiar culture it expresses deep feelings it is read quickly.

3 a b c d e

Literature exists: only as a way of expressing feelings as a way of helping us make sense of the world primarily as a form of entertainment because sometimes words fail us to pass the time.

4 We make sense of literature if: a we read it expecting to find precise answers to precise questions b we make no effort to understand the context in which it was written c we believe that only science gives us understanding d none of the above is true e it is simply and straightforwardly written. 5 Because literature is not reductionist, both literary texts and commentaries on them: a make little sense b are inferior kinds of knowledge c run the risk of being muddled d need to be read several times to be fully appreciated e are often confused.

Multiple choice questions

MCQ answers

(Choose the answer most relevant in the context of this

1 a b c d e

paper) 1 a b c d e

MCQs are very bad for testing: a knowledge of fact an understanding of literature a student’s ability to memorise lists clinical information most things.

F T F F F

2 a b c d e

F F T F F

3 a b c d e

F T F F F

4 a b c d e

F F F T F

5 a b c d e

F F F T F

It follows from 5d that you should read this paper again!

INVITED COMMENTARY ON Death and dying in literature Why? … because. This commentary to John Skelton’s paper (Skelton, 2003, this issue) addresses the question, ‘Why should I, a busy consultant serving a population of 40 000 in north Lincolnshire and having considerable difficulty in keeping up with

the latest developments about antipsychotic drugs, use my precious time for CPD reading about death and dying in literature?’ The answer is two-fold: death and dying is intrinsically an important and relevant subject for psychiatrists; and literature gives


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useful opportunities for modelling, comparing, contrasting and experimenting with circumstances removed from the patient’s immediate situation but still recognised as ‘real life’. Great literature demonstrates authenticity. If the experiences described are true to life, perhaps the strategies that were used in this literary work, or are suggested through their absence, may be effective in your patient’s (or even your own) predicament. Literature, or ‘the humanities’, can enhance good practice in medicine (Evans & Greaves, 1999). East of the Mountains, a gritty story by David Guterson (1999), concerns a recently retired and widowed cardiologist. He knows that he is dying from carcinoma of the colon, which has metastasised to the liver, and he does not like what he knows. He leaves his home in Seattle to return to the applegrowing countryside where he had been a child, taking his dogs, his gun and a more than half-formed intention of turning the gun on himself. The story is of his journey, both geographical and psychological, and of his intimate involvement on the way with many people, all totally different from himself. To write more would spoil the story for you, but the themes are the inevitability of, and also the potential for nobility in, the process of dying. In his editorial in Advances in Psychiatric Treatment, Powell (2001) reminds us that our patients do not share our embarrassment and incredulity concerning matters of the spirit or soul: ‘Fifty per cent of service users hold religious or spiritual beliefs that they see as important in helping them cope with mental illness, yet do not feel free, as they would wish, to discuss these beliefs with the psychiatrist’. In none of our work as psychiatrists, is recognition of, and appreciation for, the spiritual needs of our patients greater than when dealing with concerns over death and dying. In this context, one uses the word spiritual for any or all of the following meanings: • aims and goals, meaning in life; • the interrelatedness of all human beings; • dealing with whole people – body, mind and

spirit; • the moral aspect – good, beautiful and

enjoyable; • awareness of the connection between God and

man. Such ideas are clearly of importance for both patients and their doctors (Sims, 1994). For most people in the world, their notion of spirituality is closely linked to their religious beliefs. The great religions are all intimately concerned with matters of life and death. Usually, this implies something of what death means, both to the individual and for all humanity, and also makes

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comment on what follows death. For this reason, when the process of dying has been observed in committed believers, it has been possible to see their calm conviction that they are moving on to something else and not just to oblivion. Some people who have come close to death have reported a profound experience in which they believed that they had left their physical bodies and transcended the normal boundaries of time and space (Greyson, 2000). This gives an opportunity to explore the links between the spiritual and the psychological in the context of death and dying. Unfortunately, in medical investigations of this phenomenon, there has often been a failure to record the religious beliefs of those reporting near-death experiences, and so this opportunity has been missed. It is self-evident that the psychiatrist should not try to impose his or her beliefs on the patient. Neither, however, should the psychiatrist ignore and exclude areas from discussion that may be of crucial concern to the patient. A psychiatrist once said, ‘Patients never talk about religion to me’. He had not considered whether he was seeing a selected group of patients who had no interest in religion or, alternatively, that his patients knew what sort of response they would get if they volunteered any sort of religious interest. Patients can benefit considerably when the psychiatrist encourages them to use their own religious beliefs to help them through the difficult life crises associated with death and dying in the same way that they are helped to use other resources of their individual personality in therapy. When individuals know that they are dying or are faced with the risk of death, they will almost inevitably consider their spiritual situation; this is universal human experience. Psychiatrists pride themselves on their holistic approach to illness; disease is seen as not solely a biochemical upset in a localised organ or system within the body. This concentration of attention on all aspects of the person – body, mind and spirit – becomes acutely relevant when concerned with death. The hospice movement originally arose out of spiritual concerns for the dying patient. Literature sometimes helps people to resolve the spiritual issues of death. It can be both objective and personal and it can give inspiration. Reading how someone else did or did not cope with this, the ultimate life crisis, helps us to order our thoughts, refine our beliefs and decide for ourselves where we can place our trust for the future. When I was faced with quite a high risk of death within the next few hours, it was the reassuring cadences of the 23rd Psalm that gave me strength through the long hours of the night: ‘Even though I walk through the valley



of the shadow of death, I will fear no evil, for you are with me’. Some writing is of value in objectifying and articulating our thoughts and feelings. This is particularly true when our patients are concerned with matters of life and death. If the psychiatrist’s concern and tolerance for the patient’s spiritual and religious position is added to this, the usefulness of literature is given another dimension. We all, ultimately, have to face our own death and the process leading to it. Whatever spiritual resources we have, that is when we will call upon them. Eventually, we all become patients. Much in literature helps us and our patients prepare for and integrate our thinking about the deaths of those close to us and of ourselves.

References Evans, M. & Greaves, D. (1999) Exploring the medical humanities. BMJ, 319, 1216. Greyson, B. (2000) Dissociation in people who have neardeath experiences: out of their bodies or out of their minds? Lancet, 355, 460–463. Guterson, D. (1999) East of the Mountains. London: Bloomsbury. Powell, A. (2001) Spirituality and science: a personal view (editorial). Advances in Psychiatric Treatment, 7, 319–321. Sims, A. (1994) Psyche – spirit as well as mind? British Journal of Psychiatry, 165, 441–446. Skelton, J. (2003) Death and dying in literature. Advances in Psychiatric Treatment, 9, 211–217. Andrew Sims Editor of Advances in Psychiatric Treatment (1993–2003). Past-President of the Royal College of Psychiatrists (1990–1993) and Emeritus Professor of Psychiatry in the University of Leeds (correspondence: Church Farm House, Alveley, Bridgnorth, Shropshire WV15 6ND, UK).

INVITED COMMENTARY ON Death and dying in literature John Skelton’s paper (2003, this issue) reminds us that literature can put into words thoughts and feelings which we might otherwise be unable to think or articulate. This is an important attribute and one which we can make use of in our attempts to help patients and families faced with lifethreatening illness. It might also help those who have been bereaved to find meaning in what seems like a meaningless experience. Such literature is a fruitful source of quotations that can be used to bring comfort and reassurance at funeral and memorial services. A useful review of these is Ned Sherrin’s (1996) anthology Remembrance. One of the most popular quotations is from Henry Scott Holland:

Most find this helpful, but some have criticised its failure to accept the need for grief. Whatever faith we may have in the prospect of reunion in the hereafter, many would agree with the widow who insisted to me, ‘I want him now’. It is this urgent necessity which makes parting so painful. Singing and laughter both enable expression of intense emotion in ways that make it tolerable. It is no coincidence that death has provided humorists with ways of helping us to think the unthinkable. Woody Allen is a rich source,

‘Death is nothing at all… I have only slipped away into the next room. I am I and you are you. Whatever we were to each other that we are still. Call me by my old familiar name, speak to me in the easy way which you always used. Put no difference in your tone; wear no forced air of solemnity or sorrow. Laugh as we always laughed at the little jokes we enjoyed together. Play, smile, think of me, pray for me. Let my name be the household word that it always was. Let it be spoken without effort, without the ghost of a shadow on it. Life means all that it ever meant. It is the same as it ever was; there is an unbroken continuity. Why should I be out of mind because I am out of sight? I am waiting for you for an interval, somewhere just around the corner. All is well.’

‘I don’t want to achieve immortality through my work, … I want to achieve it through not dying’

‘when you’re dead, its hard to find the light switch’; ‘Death is an acquired trait’ ;

as is Dorothy Parker: ‘Time doth flit, Oh shit!’

and ‘Drink and dance and laugh and lie Love, the reeling midnight through, For tomorrow we shall die! (But, alas, we never do).’

Missives such as these are both cathartic and an antidote to the pomp and solemnity of death.


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Bibliotherapy is the use of books as therapy and there are several that can be recommended to people faced with death or bereavement. Some, such as Charlotte’s Web by E.B. White (1952), aim to educate children about death. Lists of such books, for children of various ages, can be obtained from Winston’s Wish booklists for children aged 0–6 years, 7–12 years and 13–18 years (available from Winston’s Wish, The Clara Burgess Centre, Gloucester Road Hospital, Great Western Road, Gloucester GL1 3NN). For helping bereaved adults, Alida Gersie’s book Storymaking in Bereavement (1991) contains 50 folk tales and suggests ways in which they can be used. It also cites many other literary treatments of death-related issues. More systematic is The Oxford Book of Death (Enright, 1983) and an anthology for those who grieve, All in the End is Harvest (Whitaker, 1984). I conclude with an extract from one of my favourites, a work of fiction which carries the reader on a journey through grief. This is Susan Hill’s In the Springtime of the Year (1977: p. 135). ‘Without any warning, the tears rose up and broke out of her, and Potter sat on his chair saying nothing,

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and yet being a comfort to her, taking some of the grief on to himself. She wept as she had never wept before in front of another human being, and it was a good thing to do; it was more value than all the months of solitary mourning. It brought something to an end.’

References Enright, D. J. (ed.) (1983) The Oxford Book of Death. Oxford: Oxford University Press. Gersie, A. (1991) Storymaking in Bereavement. London: Jessica Kingsley. Hill, S. (1977) In the Springtime of the Year. Harmondsworth: Penguin. Holland, H. S. (1919) Sermon delivered at St Paul’s on 15 May 1910. Fact of Faith. London: Longmans. Sherrin, N. (ed.) (1996) Remembrance. London: Michael Joseph. Skelton, J. (2003) Death and dying in literature. Advances in Psychiatric Treatment, 9, 211–217. Whitaker, A. (ed.) (1984) All in the End is Harvest. London: Darton, Longman & Todd. White, E. B. (1952) Charlotte’s Web. New York: Dell. Colin Murray Parkes Consultant Psychiatrist at St Christopher’s Hospice, Sydenham, and St Joseph’s Hospice, Hackney (correspondence: 21 South Road, Chorleywood, Hertfordshire WD3 5AS, UK). Life President of Cruse – Bereavement Care; author of many articles and books on bereavement, including Bereavement: Studies of Grief in Adult Life (Harmondsworth: Pelican).
