Animation isn’t only for children. This short made by Pixar has been described by some as dark, but it seems to accurately capture some of what we learned about in my last class about life through death: the cost of love, the pain of loss, and that we all become familiar with grief.
Paul wrote in an early part of his book about how quickly the medical students changed and that the, “Cadavers reverse the polarity. The mannequins you pretend are real; the cadavers you pretend are fake… to take one good look at our cadaver’s face and then to leave it covered; it makes the work easier.” (Kalanithi, 45) It’s facelessness quickly allowed what was once a person in whom life dwelled, a person who may have loved deeply and been deeply loved, to become instead pieces of a body. Although in this paper we look at Paul’s life as he approaches death to understand what has been learned both about living and the process of dying, let us not forget that Paul was real and his loss was deep. Loved by his wife, family and friends, he also left behind a future in his words, the lives he impacted and his young daughter newly created. It is in his words to his daughter, who will remember him only through others, that we see the title of our class captured so clearly:
When you come to one of the many moments in life where you must give an account of yourself, provide a ledger of what you have been, and done, and meant to the world, do not, I pray, discount that that you filled a dying man’s days with a sated joy, a joy unknown to me in all my prior years, a joy that does not hunger for more and more but rests, satisfied. In this time, right now, that is an enormous thing. (Kalanithi, 199)
This kind of response to one’s own death might seem extraordinary to many, but it was sculpted by a lifetime of influences. His Christian father and Hindu mother had eloped from the south of India to New York City where he had been raised for a while before being moved to Arizona with his family. His mother’s concern about his education caused her to emphasize reading heavily at a very young age. Meanwhile, his father was deeply committed to his medical practice which meant that he was not frequently around, making Paul view the personal cost of medicine as too high early on in his life. However, these things would remain important threads throughout the story of Paul.
“Brave New World founded my nascent moral philosophy and became the subject of my college admissions essay, in which I argued happiness was not the point of life.” (Kalanithi, 27) After starting college he consumed literature courses in a search for human meaning but soon began to look into biology to understand the mechanisms that made creatures creators, ultimately moving over to the pursuit of a medical degree. And yet literature continued to shape how he tried to understand his patient’s experiences and, ultimately his own. “Neurosurgery attracted me as much for its intertwining of brain and consciousness as for its intertwining life and death… being so close to the fiery light of such moments only blinded me to their nature, like trying to learn astronomy by staring directly at the sun.” (Kalanithi, 81) The medical culture he was now immersing himself in caused him to struggle to respond as a person dying instead of as a doctor and yet his lifetime of seeking served him well in expressing his experience through the book he ended up writing and scoping out his purpose towards the end.
“It is the differences in meaning, far more than mere differences in vocabulary, that isolate cultures and that cause them to regard each other as strange or even barbaric. It is not too surprising that many cultures refer to themselves as “The People,” relegating all other human beings to a subhuman form of life.” (Barland, 39) This division by culture is easily identified when there are language barriers, differences in dress, or other ethnic markers that turn a comparison between people into a study in contrasts. Maybe it is just as likely that cultural misunderstandings occur when we are almost the same. There is so much to relate to Paul on that when I struggle to understand him, it is hard to remind myself of the cultural nuances. For instance, in a culture that requires 100 hours a week when you’re dedicating yourself to the care of other’s, perhaps a reduction of empathy is a means of survival whereas I, having never had such demands put on me, see only callousness. Paul, upon hearing that a friend died from a car accident after an attempt to save her life, wrote: “In that moment, all my occasions of failed empathy came rushing back to me: the times I had pushed discharges over patient worries, ignored patients’ pain when other demands pressed. The people whose suffering I saw, noted, and neatly packaged in various diagnoses…” (Kalanithi, 85)
Additionally, I wonder if I would have chosen to have a child before I died, leaving my spouse with a permanent reminder of myself and the possible burden of being both in mourning and a single parent simultaneously. His wife also asked him, “Don’t you think saying goodbye to your child will make your death more painful?” (Kalanithi, 143) It wouldn’t only be hard on her; they both struggled with the decision. It’s clear as you read that family is a strong value for him from the very beginning. If I had been his wife I think I would have wanted to have the baby. He writes in reply to her question regarding it being more painful, “’Wouldn’t it be great if it did?’ I said. Lucy and I both felt that life wasn’t about avoiding suffering.” (Kalanithi, 143) Indeed, loss is the cost of our commitment to one another sometimes; the price we pay for love. If loving someone more deeply was what made this death harder, perhaps that is the best way one could exit this world.
Another perspective would be that having the child was a form a denial that death was as imminent as he was being told. In fact, he wrote, “We would carry on living, instead of dying.” (Kalanithi, 144) Paul manifested denial differently than many of us might. He could not intellectually deny that he had cancer, or that he understood to at least some extent the severity. He had become the patient for the very things he treated. He writes: “After the diagnosis, I knew that someday I would die, but I didn’t know when. But now I knew it acutely.” (Kalanithi, 132) He undoubtedly felt it profoundly. But his denial was found in his actions. He stated that if he had a sense of the time he had left it would determine what he would do. Two years versus ten years mattered, but he knew she couldn’t give him what he was asking. It appears he was able to exist in a place where he was more acutely aware of his mortality while generally operating in denial until the birth of his daughter. “Yet there is a dynamism in our house. Day to day, week to week, Cady blossoms: a first grasp, a first smile, a first laugh… Time for me is now double-edged: every day brings me further from the low of my last relapse but closer to the next recurrence-and eventually, death.” (Kalanithi, 196)
Paul writes that he believes he went through the five steps of grief in reverse; that because he knew he was going to die but at the time was unable to know the when, instead of experiencing denial first, he experienced it last. Due to his vast medical experience in the field, he saw the stage of acceptance as being at the very beginning because he understood his prognosis. I would say that while Paul and Lucy certainly experienced that stages of grief, acceptance for them was at the end. “One of the most important aspects of Nearing Death Awareness is the need for reconciliation. Dying people develop an awareness that they need to be at peace.” (Callanan, 137) Before his diagnosis, his marriage was in danger of ending. In a way, the cancer brought healing. “Our relationship was still deep in meaning, a shared and evolving vocabulary about what mattered. If human relationality formed the bedrock of meaning, it seemed to us that rearing children added another dimension to that meaning.” (Kalanithi, 142) To that end, the other important part is legacy, that we have defeated death through our ability to continue on even after we have died. Paul and Lucy managed this aspect of their grief through their child and completing the book together.
These aren’t the only things that changed for Paul towards the end of his life. Voirst writes that “our dying may sometimes provide a new opportunity, that dying may sometime permit… growth and change, that dying may precipitate a further stage of emotional development that had – until now—been well beyond our capacities.” (Voirst, 318) At first he had thought that he could never do surgery again. In the end he realized that his doctor had done what he himself had strived to do with his patients: protect the attributes which they value and empower them to discover what they wanted to do with their remaining time. As he practiced surgery, he learned more about how his illness transformed him: “The tricky part of illness is that, as you go through it, your values are constantly changing. You try to figure out what matters to you, and then you keep figuring it out… Death may be a one-time event, but living with terminal illness is a process.” (Kalanithi, 160-161) In other words, dying is a process that at its best has you discovering who you are until the very end.
We come at last to consider the role that religious beliefs played in how Paul dealt with both being diagnosed and dying. Although certainly approached in a scientific and academic manner, Paul was not devoid of a relationship with God; he wrote that if he had known God sooner he would have perhaps pursued a pastoral role instead of the one he ended up in. The fact that he saw no proof of God left him in a place where believing in God seemed unreasonable and so he didn’t. It wasn’t that he didn’t have the foundation; he was familiar with Scripture and his family raised him Christian. After searching through much of his twenties, he reached the following conclusion:
“The problem, however, eventually became evident: to make science the arbiter of metaphysics is to banish not only God from the world but also love, hate, meaning-to consider a world that is self-evidently not the world we live in. That’s not to say that if you believe in meaning you also believe in God. It is to say, though, that if you believe that science provides no basis for God, then you must also be obligated to conclude that science provides no basis for meaning and, therefore, life itself doesn’t have any.” (Kalanithi, 169)
Paul reaches this conclusion and saw sacrifice, forgiveness and redemption as the foundational principles of Christianity. This was crucial to helping him deal with his situation, even if he doesn’t appear to lean on it very heavily. This is true also of his lens of seeing Jesus as delivering a message of mercy over justice. Christians understand that sacrifice is a part of their story; Paul responds to his loss of life, time and experience less with anger and more with a zeal to squeeze what he can out of what is left. While he strives, he is full of forgiveness and we see redemption is his relationships time and again.
Christian’s often define faith with language like “assurance of things hoped for, the evidence of things unseen,” similar to Hebrews 11:1. To this end, I don’t believe this is a struggle of Paul’s. The way he is built makes supernatural faith hard, but he sees evidence in the world around him that speaks to a Creator who wants our lives to have meaning and purpose. So while his faith might look different, that doesn’t make it any less deep. This is a man who, dying, chooses to create life. To write of his experience dying in order to help others. I do not see a struggle of faith in Paul; I see a man being faithful in his struggle, much like the man after which he was likely named.
Barlund, Dean. “Communication in a Global Village.” Basic Concepts of Intercultural Communication: Selected Readings (1998): 35-48. Print.
Callanan, Maggie and Kelley, Patricia. Final Gifts: Understanding the Special Awareness, Needs, and Communications of the Dying. New York: Simon & Schuster Paperbacks, 2012. Print.
Kalanithi, Paul. When Breath Becomes Air. New York: Random House, 2016. Print.
Viorst, Judith. “The ABC of Dying.” Necessary Losses (Unknown): 305-327. Print.
I thought that this class on death would better equip me, but more often then not it highlights how ill-equipped we are to deal with death. How inadequate words are. How necessary the feeling are as you experience grief when you are the one dying or when you are the one who lives on after they’ve passed.
As I look back on past experiences with death, anger is so frequent and so stifled. Our professor says it is okay to be angry at God; that pastors or ministers often discourage it but it’s sometimes a place people have to move through.
I thought quite a bit about it and as I reflect on God’s character, I think my professor is right. As long as we take it TO God. As long as we have a dialogue with Him about what this loss means and what we do with how we are feeling and where His place in that is. Because ignoring anger doesn’t make it go away and stifling it doesn’t put out fires of that kind. However, if we tell people they can’t take their anger at God TO God, they end up taking it out on others.
Yet if we take what we are feeling TOWARDS God, TO God, how differently might things turn out? We get to pour out what we are feeling and maybe God will respond. Maybe your relationship with Him, like many that weather a storm, will be deepened. Take for example what Mary says, which sounds like there might be a little accusation mixed in with her mourning. Yet she takes it to Jesus:
When Mary reached the place where Jesus was and saw him, she fell at his feet and said, “Lord, if you had been here, my brother would not have died.” John 11:32
How about grief? Psalm 102 is a prayer of an afflicted person who then laments to God. Here’s just a tiny peak at what that looks like:
“Hear my prayer, Lord; let my cry for help come to you. Do not hide your face from me when I am in distress. Turn your ear to me; when I call, answer me quickly. For my days vanish like smoke; my bones burn like glowing embers. My heart is blighted and withered like grass; I forget to eat my food.” Psalm 102:1-4
See, I think what we see in that Bible is not that we aren’t supposed to feel the things that we feel when we mourn, but that we are supposed to feel it with God. Furthermore, I think that God is there with us in this mourning, whether we acknowledge Him or not (like the theologians I wrote about when looking at the Holocaust). I was at a lecture by Cath Livesay where she made the point that God doesn’t lose His voice, but we sometimes lose our ability or willingness to listen. You might call out for God while your heart still isn’t ready to hear what He has to say to you; just because you aren’t hearing from God doesn’t mean He isn’t with you.
As I walk through this class and the death I am surrounded by I realize how ill equipped the average Christian is for those who are dying and those who have lost someone to death. They might even experience shame over their own experience with grief. Perhaps we should consider Jesus’ response to the death of his friend as well as those in mourning:
When Mary reached the place where Jesus was and saw him, she fell at his feet and said, “Lord, if you had been here, my brother would not have died.” When Jesus saw her weeping, and the Jews who had come along with her also weeping, he was deeply moved in spirit and troubled. “Where have you laid him?” he asked. “Come and see, Lord,” they replied. Jesus wept.” John 11:32-35
Are some of us not able to relate to Mary in times of loss, going to God and saying, “Lord, if you had been here, this person I had love would not have died.” While it is true that Jesus later, because he was moved again, raised Lazarus from the dead, this was not his first response. Jesus’ first response was to weep with them. He mourned with them. He did not try to get them to skip over the natural state of broken heartedness at the loss of the person no longer sharing this life with them, or ignore the fact that their day to day life would be radically transformed by his absence. He wept with them.
“Blessed are those who mourn, for they will be comforted.” Matthew 5:4
I found Final Gifts by Maggie Callanan and Patricia Kelley to be a powerful insight into the lives of three different groups of people: nurses for the dying, the family and friends of the dying and the dying themselves. It looks at “Nearing Death Awareness,” or the increasing awareness one has when one is dying over a long period of time, the actual experience of it and what they need in order to die peacefully. Three concepts I felt really stood out to me and that I feel I can apply immediately in the future were the idea that the dying often need permission to die, the relationship between birth and death and the value of reconciliation and the role we can play in it.
It was helpful for me to acknowledge the truth that dying people often need permission to die; receiving it can provide a great amount of relief and the withholding of it can make the process of death longer and more challenging. This is likely due to what they are trying to communicate and why: “The dying often use the metaphor of travel to alert those around them that it is time for them to die. They also have a deep concern about the welfare of those they love, asking themselves, ‘Do they understand? Are they going to be alright?’ In the example of Ellen, her family struggled at first to understand that she was trying to communicate that she was dying to them. This increased the level of stress and anxiety for both Ellen and her family. Once they realized that she was likely referring to heaven, they went in and comforted and affirmed her. “Ellen’s family provided what she needed by letting her know they understood the messages she was so desperately trying to give them-‘I am dying, it is time for my journey from this life, I need to know you understand and are ready; I need your permission to go.’” While I have never witnessed this, I have heard stories from people about someone they love “constantly agitated towards the end.” I’ve also encountered people in homes who didn’t seem to make any sense and they were generally dismissed. This idea encourages me to approach people not only with a heart of compassion but with a belief that there is, perhaps, an understanding that can be reached.
Another idea I found helpful was the analogy between birth and death. As one nurse described, “I also feel strongly that, like birthing, dying can be an opportunity for the whole family to share positive experiences, rather than only sadness, pain and loss. That is the challenge of the work…” In fact, both birth and death used to happen in the home until industrialization and the twentieth century hit; then birth became a procedure and death a failure at successful treatment. Recently there has been some headway made in both these areas, and both birth and death are now often possible in the comfort of one’s home rather than in the often isolating and unfamiliar hospital. Consider the difference that this has made for births: “Family members present at delivery share a special bond with mother and child-a closeness born of sharing that powerful moment. The deeper their involvement and understanding, the likelier they are to come away with a sense of learning and growth.” This same thing could be said for those who experience death alongside loved ones. Their deeper involvement leaves them with a sense that there were fully participatory in the end and the person dying is less lonely and fearful because they are surrounded by those who care for them. When I consider the growth and community that comes from birth I have to believe that the same is true for death and I see the value of community in times where people are facing a terminal illness.
I also learned that many times the most important thing for a person as they are nearing death is reconciliation. “As death nears, people often realize some things feel unfinished or incomplete-perhaps issues that once seemed insignificant or that happened long ago. Now the dying person realizes their importance and wants to settle them.” If this is request is understood people will often do what they can to assist the person but there are also times when the request is unclear, leaving the person upset or appearing in pain when they aren’t physically pained; rather they are suffering psychologically or emotionally. They desire peace, and to die peacefully they need either healing or reconciliation to occur in the relationship (often in the form of an apology or expression of gratitude). “Most dying people begin by listing their accomplishments, but they also will consider their disappointments-tasks not completed, opportunities missed, relationships broken or left to wither. As caregivers or friends, if we can help dying people conduct such reviews and heal damaged relationships, we can help them find peace.” I saw this with my Father’s mother as she was nearing her own end. It was clear she wanted reconciliation with my mother and I tried to provide the best reassurances I could. That seemed to be a great comfort to her in those moments, as she was very fearful of death.
Callanan, Maggie & Kelley, Patricia. (2012) Final Gifts: Understanding the Special Awareness, Needs, and Communications of the Dying. United States of America: Simon & Schuster Paperbacks. Pg. 74
 Callanan & Kelley. Pg. 75
 Callanan & Kelley. Pg. 130
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In “The ABC of Dying” Judith Viorst writes, “For how can we live as fully conscious animals, the only creatures on earth that know they will die? How can we, in the chilling words of Ernest Becker’s great book The Denial of Death, endure the awareness that we are “food for worms”?” It is a provoking question and one that philosophers, theologians, psychologists, doctors, artists, and many others have searched for answers to over the millennia.
The theory of unconscious denial of death that Freud proposed, making the yawning unknown that awaits us on the other side of death possible to be ignored, is a popular choice by many. We distract ourselves with other more “manageable” anxieties and block off parts of life in an effort to convince ourselves that we can exert some sort of control over the future. Yet it is only in the juxtaposition to death, as she points out through the words of poets, physicists and theologians, that we fully see and experience life. The character from Memento Mori probably best summed up the sentiment in this, “If I had my life over again…I would practice, as it were, the remembrance of death. There is no other practice which so intensifies life. Death… should be part of the full expectancy of life. Without an ever-present sense of death life is insipid. You might as well live on the whites of eggs.”
Viorst was forced to face her own mortality when she lost three women she was close to in the span of six weeks. Although she had once feared flying; it was no longer an issue. She realized staying off airplanes wouldn’t guarantee her immortality. Certainly, the best course of action in her mind would be to learn how best to die, if one must go through the experience of doing so. Perhaps this was her mechanism for coping with death.
She examines death in the abstract and the applied, using the example of Ivan Ilych. “The syllogism he had learnt from Kiesewetter’s Logic: “Caius is a man, men are mortal, therefore Caius is mortal,” had always seemed to him correct as applied to Caius, but certainly not as applied to himself…” Full of memories, experiences, emotions, joys and grief. And in the example, Ivan is further isolated because his community won’t acknowledge his impending death. Viorst writes that this mindset against speaking of death is being challenged in more modern times through individuals like Elisabeth Kubler-Ross who wrote on the five stages she sees people pass through towards death.
The first stage is said to be denial, followed by the anger/envy stage. Commonly asked within this second stage is, “Why me?” The third is bargaining, something offered if they can have just a little bit more time. The fourth is depression over present and future losses. A need for others to be present and sit with them in this time is called out. Last is acceptance; this is not a hallelujah moment but an absence of emotion and struggle. Instead of resisting their end they meet it “with a certain degree of quiet expectation.” Not everyone makes it to this phase, or should, according to Kubler-Ross. Dr. Edwin Shneidman disagreed strongly based on his own substantial experiences with the dead and dying, saying: “…I reject the notion that human beings, as they die, are somehow marched in lock step through a series of stages of the dying process. On the contrary… the emotional states, the psychological mechanisms of defense, the needs and drives, are as variegated in the dying as they are in the nondying…” Whereas Kubler-Ross felt that acceptance was often the implied end of the journey, Shneidman pointed out more often than not life was abandoned to death without any real readying, leaving loose ends. I have yet to have the breadth of experience with those in the midst of dying to be to discern for myself whose theory might be more accurate but I certainly think the knowledge of both helps me to be better equipped for whatever state I might identify a dying person to be in.
Viorst reflected on the ways three of her close friends chose to handle their death, and on the increasing interest in assisted suicide in society today, or even those like her friend who spend their time with the people they love the way they want to and then end it on their own terms. “The wish not to suffer, to stay in charge, to be remembered by loved ones the way they were motivates some to choose the hour of their death.” While I understand our society’s propensity to run from suffering, it softly rings of the warnings I heard in the book A Brave New World, in which there is a society that avoids any pain, suffering or discomfort at the cost of maturity, intimacy, faith and intellectual depth. Interestingly, she points out later that Philippe Aries studied the history of death and “the concept of the ‘good death’ has been redefined, so that instead of its being a conscious, expected, ritualized departure, as once it was, a good death today ‘corresponds exactly to what used to be the accursed death’: Sudden death.” Why, as a society, do we fear the death our ancestors hoped for and long for a death that was once viewed as a curse?
There’s another section of the dying population who wouldn’t take their lives yet also don’t view death as an enemy. “Death becomes a friend. It offers the chance to lay their burden down, whether the burden they yearn to lay down is the agony of a last illness; the helplessness, uselessness, loneliness of old age; the sufferings, at any age, attendant upon an unendurable loss…” There are endless reasons why one might be ready to hand over the endless drudgery of their current existence for the hope of whatever death might offer. They don’t flee life, but recognize its inevitable end. One thing that Kaufmann postulates might make this easier is that we have a project of our own that we’ve seen to fruition; that we’ve in essence beat death in one place if we cannot beat it at retaining life.
This may be why some people experience such transformation near their death. Eissler even proposes: “The full awareness of each step that leads closer to death, the unconscious experience of one’s own death up to the last second which permits awareness and consciousness, would be the crowning triumph of an individually lived life.” This is where we see the meek demonstrate courage and bravery or the shy become forward and outspoken. Their final moments are their last chance to be the person that they perhaps always saw themselves as becoming but were never brave enough to allow themselves to actualize within their day to day lives.
Immortality is the only way to counteract death, and this can be done through several ways. One is religion, which “Freud argues that such religious beliefs are illusions built up by man to make his helplessness in this world endurable. He writes that just as children depend on their parents to protect them, so anxious adults depend on gods and God.” Another option is through nature, through the fact that we are part of an earth that continues on long after we do. We are made up of that ancient material and will merge back with it when we are dust. A third option would be through works or acts that influence future humanity; we see things like this in the great structures built, sculptures, works of art and literature, the rise and fall of nations, etc. Lastly, there is the biological continuation through progeny or even just humanity in general. While I can’t agree with Freud in that God is an illusion, I certainly see the drive for immortality in the behaviors of people daily. They want to leave a legacy, to be remembered, to have impacted the world. Perhaps this goes back to what Kauffman was saying. If a person has the sense they’ve achieved one of these levels of immortality, perhaps it makes it easier to go with death, feeling like they’ve already defeated it.
 Viorst, Judith. Necessary Losses. “The ABC of Dying,” pg. 306
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