As I Was Dying: An Examination of Classic Literature and Dying

Medical training rarely deals with helping the dying patient find peace and comfort. In fact, most physicians are uncomfortable with the entire subject. I believe it is one of the most neglected aspects of medical care. I have spent my career as a pulmonary and critical care physician, and I have cared for thousands of dying patients. In many cases, both the patients and I knew that they were dying. After I provided clinical and supportive care, I would walk away from their bedside and go on with my work and go home to my family.

Now the world has turned around for me. I have widespread metastatic disease to my lungs and bones.

When the diagnosis of metastatic disease was made, I found myself unprepared to deal with my own mortality. I tried many avenues in an attempt to come to grips with my disease. I threw myself into work and writing. I contacted old friends for solace. My friends contacted me. I discussed all possibilities of cure with many physicians across the United States and the world and chose what I believe is the most hopeful course. And, I decided to examine the classics to see how great writers dealt with death in their poetry, drama, and philosophical and fictional writings.

I was searching for peace. I hoped I might find it either in literature or in the accounts of how great writers dealt with their own mortality. But largely, literature dealt with life rather than death. No great insights appeared. Actually, the most fascinating revelation was how rarely literature does provide insight into death. One notable exception was the poetry of Emily Dickinson, who wrote frequently about death. For me, some of her most revealing lines include the following.

After great pain, a formal feeling comes—

… … .

This is the Hour of Lead—

Remembered, if outlived,

As Freezing persons, recollect the Snow—

First—Chill-then Stupor—then the letting go—

(#341)

I've seen a Dying Eye

Run round and round a Room—

In search of Something—as it seemed—

Then Cloudier become—

And then—obscure with Fog—

And then—be soldered down

Without disclosing what it be

'Twere blessed to have seen—

(#547)

Because I could not stop for Death—

He kindly stopped for me—

The Carriage held but just Ourselves—

And Immortality.

(#712)

I found another rare exception in Louisa May Alcott's Little Women. The description of Beth's death is one of literature's few accounts of a character's experience at the moment of death:

Seldom except in books do the dying utter memorable words, see visions, or depart with beatified countenances, and those who have sped many parting souls know that to most the end comes as naturally and simply as sleep. As Beth had hoped, the “tide went out easily,” and in the dark hour before the dawn, on the bosom where she had drawn her first breath, she quietly drew her last, with no farewell but one loving look, one little sigh.

With tears and prayers and tender hands, mother and sisters made her ready for the long sleep that pain would never mar again, seeing with grateful eyes the beautiful serenity that soon replaced the pathetic patience that had wrung their hearts so long, and feeling with reverent joy that to their darling death was a benignant angel, not a phantom full of dread.

The words “Please come here and help me” are uttered by Ivan Ilych Golovin near the end of his life in Leo Tolstoy's short novel The Death of Ivan Ilych. This profound work of literature is one of the greatest explorations of life and death ever written. Ivan Ilych, an ordinary man living in late 19th century Russia, has a family, is educated, and serves as a judge. He is also faced with an incurable disease. He travels a physical and psychological path both tortuous and painful, the same path those of us who are terminally ill must face. He consistently resists asking for help, believing that by doing so, he is resisting his disease. But he eventually comes to understand that his family and friends are there to help him. Only then can he say the words, “Please come here and help me.”

In As I Lay Dying, William Faulkner writes about a woman named Addie, who is dying, and her son Cash, who is building her coffin. Addie's daughter stands by her mother, fanning her. Addie wants to be buried near relatives in another town. The novel is a parody of the distinction between being and not-being. The family is afflicted on the way by flooding, the loss of a horse that pulled the wagon, and buzzards. Faulkner makes reference to the family madness: “In sunset we fall into furious attitudes, dead gestures of dolls.” Faulkner portrays the gesture of pathos of this poor family with a dead body that used to be their mother.

In Hemingway's For Whom the Bell Tolls, we learn that “Any man's death diminishes me,” and in his The Old Man and the Sea, that the virility and courage of youth extends to “old age.” The latter novel was Hemingway's last and, in my opinion, his finest work. The book focuses on a Cuban fisherman, Santiago, who squares off with the forces of death and emerges victorious. The reader feels that even if a man dies he can obtain a spiritual victory from the battle and emerge victorious—that life is a struggle, but the value of life lies in how we deal with it.

One of the most perceptive plays that I examined was Our Town, by Thornton Wilder. This is a contemporary play set in a mythical small town in America, Grover's Corners, New Hampshire, about ordinary people—ordinary people who allow life to pass them by without even recognizing it. Wilder makes the point that, as human beings, we often are blind to the daily wonders of the world. He shows that life can end quickly, without warning. He shows us that we should not be caught up in the everyday rat race. In sum, his message is: Life is short. Take time to smell the roses.

In Walden, by Henry David Thoreau, Wilder's theme is revisited. “Man becomes like machines whose sole purpose is to make a living,” Thoreau tells us. “This mass of man lead lives of quiet desperation.” Thoreau goes to Walden Pond to search for his soul. He is seeking serenity and fulfillment. Thoreau says, “The better part of the man is soon ploughed into soil for compost. They become employed for what they call necessity, and then gather up treasures which moths and dust will eventually destroy and which thieves can break through and steal. …” He counsels that men should commune with nature. If he takes himself to the woods he can learn more about himself than in the rest of the world. (One wonderful quotation attributed to Thoreau seems to show his inner peace near the time of his death. When Thoreau was asked “Have you made peace with God,” he humorously remarked, “I didn't know we quarreled.”)

The return to Nature as Answer was also provided by Ralph Waldo Emerson in “Nature.” He felt that the best kind of solitude was the sort that encouraged meditation, best accomplished when man was alone with nature. Emerson believed that the soul existed before birth. He felt the spiritual world to be more important than the material world. He explained that when man's conduct was moral, he was aligned with nature and therefore with the spirit, or Godliness, which pervades nature.

In metaphysics as well, I found some answers. In Meditations, Rene Descartes searches for truth. He tells us that one should doubt all previous conclusions, accept no conclusions based only on assumptions, and subject all knowledge to the analysis of individual thought processes. According to his conclusions, any perfect being would be imperfect without existence. Therefore, God must exist. He thus provides an argument for the existence of God using scientific method.

The most important controversy was the challenge offered to organized religions. After proclaiming the dogma of papal infallibility in 1870, the pope declared that evolution was untrue. The greatest challenge came to the account of creation in Genesis. If Darwin was correct, how could God's creation of the earth in 7 days be compatible with evolution? Benjamin Disraeli asked in 1864, “Is man ape or an angel?” In 1925, the debate continued with the famous Scopes Monkey Trial, which was resolved in favor of evolution.

Aristotle, in his Nicomachean Ethics, described in the 4th century that true happiness is found in the virtuous life. He said that happiness comes from virtuous activities that result from intense intellectual pursuits. With these pursuits, man can endure hardship and sorrow and maintain virtue and dignity. He states that no one can really be happy until death.

In Age of Reason, Thomas Paine attacked institutionalized religion. He attacked the Christian Church by stating, “I do not believe in the creed professed … by any church I know of. My own mind is my own church.” He felt the church “… appears as a human invention, set up to terrify and enslave mankind, and monopolize power and profit.” He then tried to strip away the false doctrine of Christianity. He describes the Bible as hearsay, not revelation. He said that the Old Testament stories were mostly reworked ancient pagan tales. He felt that the New Testament was not as brutal as the Old Testament but was even more absurd. He felt Jesus was a good man who was killed because he posed a threat to greedy priests and power-hungry Romans. He stated that church leaders settled by majority vote what would make up the Bible. If the vote had been different, Christian beliefs would be different.

After all of this, Paine asserts his belief in God. He says that “The Word of God is the Creation we behold and it is in this word, which no human invention can counterfeit or alter, that God speaketh universally to man.” We see God's wisdom, power, mercy, and munificence in the creation of the universe. He thus returns to a thesis described earlier in the work by Rene Descartes, Meditations, that used the scientific method to conclude that God must exist. He simply said he believed in his own personal revelations, not those that were transmitted by organized religion. Paine's central message was that man could find God by looking at his creation, using reason.

The classics may at first be troubling. How could I find comfort in them? I felt, and feel, that the Bible and the church help one communicate with God—in contrast, today, to the terror found in the greed and power of the early organized religions. The church, synagogue, and Bible, in my view, are accounts that can help us find hope and comfort. The church of today exists to provide a vehicle to study God. The ministers of today are neither wealthy nor powerful. They are in the main articulate, merciful, poor persons dedicated to the concept of helping man find God.

Sidney Carton found Him. In A Tale of Two Cities, Charles Dickens describes a tragic romance, both timely and universal. Carton is caught up in the maelstrom of social change just before and during the French Revolution. Before he dies, he utters his famous passage, “It is a far, far better thing I do than I have ever done. It is a far, far better place of rest I go to than I have ever known.”

In summary, the great classics, the most significant works in literary history, have had a seminal effect on the behavior and attitudes of our world today, concerning themselves as they do with the issues of love, tragedy, seduction, pride, intrigue, suspense, murder, vanity, fantasy, evil, cruelty, greed, adultery, deceit, depression, fear, brutality, hypocrisy, pride, chivalry, heroism, romance, honor, loyalty, and friendship. But only rarely do they deal with an understanding of death. Notable exceptions include the passages visited above, most memorable in the scene of Beth's death in Little Women, Emily's death in Our Town, and Thoreau's observations in Walden. I examined the classics closely for answers and was left with the conclusion that if you have limited time, read Thoreau, Alcott, and Wilder.

At the end of my search, I felt like Thoreau as he left Walden Pond: “I left the woods for as good a reason as I went there. Perhaps it seemed to me that I had several lives to lead, and I could not spend any more time for that one.”

Editor's Note: Dr. Bone, in preparing this essay, examined the following classics: The Complete Poems of Emily Dickinson, Little Women, On the Death of a Young Lady, As I Lay Dying, Death of a Salesman, The Great Gatsby, A Farewell to Arms, For Whom the Bell Tolls, The Old Man and the Sea, Our Town, Walden, “Nature,” Critique of Pure Reason, Meditations, Origin of the Species, Nicomachean Ethics, Age of Reason, A Tale of Two Cities, The Divine Comedy, Faust, War and Peace, Far From the Madding Crowd, Fathers and Sons, Anna Karenina, The Prince and the Pauper, The Adventures of Tom Sawyer, A Connecticut Yankee in King Arthur's Court, “How We Think,” “Self-Reliance,” The World as Will and Idea, The Cherry Orchard, The Brothers Karamazov, Crime and Punishment, Great Expectations, Camille, The Scarlet Letter, Moby Dick, Madame Bovary, The Idylls of the King, Middlemarch, and Silas Marner.

That effort speaks for itself.

• Copyright ©2004 by the American College of Physicians