O’Mahony, Seamus. The Way We Die Now. St Martin’s, New York, 2016. NF;9/17.

Stephen Pinker tells us that when we read we are looking for the author. We want that is to know who this person is and what we think about him/her. Well, I really like this guy. But that probably has to do with my sharing many of his negative, curmudgeonly views of our profession. And O’Mahony sees (and I think fancies) himself as a sort of a male Cassandra, telling the world things it doesn’t want to hear and probably won’t believe. That, in my mind, is me as well. So you will understand I’m positively disposed going in.

This is a book about death (see also Kalanithi’s When Breath Becomes Air, and Barnes’s Nothing to be Frightened of). But really it’s a book about the medical profession’s abandonment of kindness, ritual, and common sense (see also Gawande’s Being Mortal). Which amounts to abandonment of its patients, especially when they are dying. O’Mahony tells us physicians’ pieties about dying are false; kindness is replaced by “cowardice, evasion, and humbug.” Physicians, he says, think we can tame nature, but end up trying to make it look like we can. Good doctoring as it is generally understood is compatible with charlatanism. Medical conferences feature an atmosphere of “pomposity and hubris”. He quotes Ivan Ilich: “The medical establishment has become a major threat to health”.

All this makes hair stand up on the back of my neck. In my mind he’s absolutely right. Trying to support the impossible claim that medicine made… I guess sometime between 1850 and 1950… that we can tame and control nature, we have robbed death (and the other great events of life) “of (their) awesome grandeur”. And most of us don’t even know we’re doing it.

O’Mahony has a gift for characterizing medicine’s falsehood in respect of dying. He compares the way we have taken over the “management” of death to his own experience of childbirth classes in the 1990s. It was as if we were the first ones to ever have children. Or to die. We are teaching students “how to give bad news” and how to be compassionate with dying people, when the truth is people in trouble can detect false empathy in a second and its cheapness can only deepen their despair. I remember seeing in a cemetery a section marked “Babyland”. I couldn’t believe my eyes. O’Mahony refers to medicine’s attempt to get control of the “procedure” of talking to dying people as “studied frivolousness”. Babyland was a posthumous version of that ridiculous attempt to trivialize and deny something hideous, something so bad it can’t be named. But something real. We tear away the opportunity (in the past the inescapable necessity) to be responsible for what happens to us, in the service of convincing everyone including ourselves that we are in control.

We are told in this book that as a result of this type of falsehood people no longer know how to behave when confronted with the “great events of our lives”. Faced with what ends up being brute existential reality, we default to the acute-care hospital as the sorting-house for what’s wrong.

This (I imagine originally Catholic but now perhaps agnostic) author suggests “cherrypicking” good ideas from religion. Forget the “superstition”, but take the serious emotional solace we can from its music, solemnity, and ritual. I like that (see also De Botton’s Religion for Atheists ). I also liked his idea that you can’t teach kindness in a lecture theatre. It’s a “private mystery that only many years of practice teaches.”

Dr. O’Mahony isn’t perfect and neither is his book. He prevaricates about palliative comfort measures: wants them for himself but is convinced that there is something noble about the agony of death as it was experienced in the past with its “pain, terror, and horror”. He spends for me too much time quoting famous authors who have developed specific philosophies of dying. He hasn’t gathered his criticisms and his proposed solutions together in a coherent systematic way. But his fundamental message of honesty in the face of terrible realities is unavoidable. And – I agree with him – very very necessary now.

I thought I went into medicine to help people, but that was a childish idea. I really wanted to be what my parents and the rest of their generation thought doctors were: the new high priests who relied on, not superstitious mumbo-jumbo, but science. Dear and glorious physicians all therefore were loved and respected and I’m sorry to say I wanted that. These days of course it exists pretty well noplace except in the imaginations of narcissistic American doctors and all too many of their patients. Fortunately the UK and (I hope) Canada still contain a few people like Seamus O’Mahony (I should say in fairness that I know American MDs who share this author’s worries about the way we all do business). I was shocked once I started practice, and still am after 40 years, at the things we do and don’t do.

I’m humbled every day by colleagues who are capable almost beyond imagining, kind and patient, deeply troubled by patients’ suffering, and fundamentally bright and lovely human beings. But I also see arrogance, excuses and cover-ups for incompetence, and moral laziness that replaces telling a poor sad person something they will be horrified to hear, but need to hear, with ordering another scan.

Dr. O’Mahony, you’ve seen it and told it as it is. Bravo. 9.5/8.5