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Andrew Grey reviews ‘With the End in Mind: Dying, Death and Wisdom in an Age of Denial’ by Kathryn Mannix 12/10/2018
‘It is as natural to die as to be born’, wrote Francis Bacon. Yet while people love to talk about babies and birth, we do everything we can to avoid talking about death. Most of us fear death, so somehow we think that if we don’t acknowledge it, it won’t really happen.
This is the main reason Kathryn Mannix, a palliative care physician and therapist, wrote With the end in mind. She wants to ‘reclaim public understanding of dying’. She could’ve chosen to do this by explaining the ins and outs of dying and death, or giving us the key facts and statistics. Instead, however, she chose to challenge us through stories – around 30 stories of people’s deaths, each based on her real–life experience as a physician.
Thirty stories of death could easily become relentlessly sad or macabre. There’s also a risk that by about the sixth or seventh they start to feel broadly similar. But Mannix skillfully avoids all of these hazards. The stories are consistently enthralling. A big reason for this is that Mannix sets up each story by telling us about the people at the centre of them – she purposefully introduces each person’s life before narrating their death. In a few short pages you rapidly discover sometimes deep elements of their personalities and mentalities. This means you care about each and every person and their story. It makes the story of each death that much more heartbreaking – but it’s essential for enabling us to see death in its proper context: the life that precedes it and gives it meaning.
The stories have other key elements that keep the reader interested, too – suspense, shock, humour. This is in part due to Mannix’s skillful narration, but also testament to the reality that death, like life, is neither consistent nor predictable.
Through these stories we learn about the realities of dying – a process that, as Dame Cicely Saunders (founder of the modern hospice movement) observed – has physical, psychological, social and spiritual dimensions. These stories include sometimes vivid and uncomfortable descriptions of the physical realities of terminal illnesses – symptoms that can sometimes be greatly alleviated by medicine and at other times are much harder to manage. Importantly, the author doesn’t shy away from these but narrates them sensitively and honestly.
But even more gripping and thought–provoking are the stories of mental anguish, of people wrestling with what their deaths mean for them and those they leave behind. Reading about a terminally ill young man feeling suicidal because he thinks his life is meaningless, or a young mum working out how her kids will go on without her, is of course heartbreaking. (I read this book on my commutes and more than once feared that tears would start streaming down my face in the middle of a packed train carriage).
But with each of these stories there came a significant ray of hope, through Mannix’s practice of cognitive behavioural therapy (CBT). Mannix developed the first ever palliative–care dedicated CBT service in the UK. This fascinating dimension of her career renders it truly unique and leaves a significant impact both on the people she has supported and those reading her stories. If you’ve ever wondered if dying will make you feel depressed, anxious or hopeless, reading these stories is a must.
However, Mannix’s disposition as a psychotherapist, while being a huge strength, also leads to the biggest limitation of this book – that it stops short of bold challenges. As a therapist she is inclined to ask questions for the reader to ponder – ranging from how we cope with difficulties to whether we’ve made any plans for our deaths. But she is rarely explicit about her true convictions. Throughout the book she points to the importance of planning for the ends of our lives, and suggests we consider having conversations now. Yet she does not do what she is both justified and qualified to: press upon us firmly that we really need to start having these conversations and grappling with the hard reality that death awaits us all, and there are consequences for not doing so.
This lack of bold challenge is also evident with one of the most powerful stories in the book – of Ujjal, a terminally ill man who chose to move from the Netherlands, where assisted dying is legal, to the UK, where it is against the law. This story sounds counterintuitive – we hear often about how an assisted dying law would liberate and empower dying people by giving them a choice. But for Ujjal it had the opposite effect – he had to endure frequent reminders from Dutch doctors that he could choose to end his life when he had no interest in it. Well–intentioned professionals made him feel that his life was over when he was still living.
Mannix is absolutely right to let this story do the talking rather than engaging in dogmatic claims or lengthy argument about assisted dying. But there is surely room for some challenge before and after this story. Yes, she poses a couple of questions and raises the possibility that such a law can have unintended consequences. But she would be justified in articulating much more strongly that such a law can have serious implications for people’s experiences of dying, and change the dynamic between a doctor and the person they’re caring for at the most vulnerable time of their life.
However, this should not detract from the fact that Mannix’s extremely powerful collection is a must–read. It will challenge you by exposing you to the experience of dying, which should be as natural as birth but is rarely viewed as such. For many readers it will do more than that – it will challenge and change their conception of death, what it means, and how to ensure that it’s as good as it can be. If enough people read it, Mannix will achieve her ambition of reclaiming public understanding of dying. She will have opened up a conversation about, and brought to the forefront of people’s minds, the central importance of dying to all our lives.
With the end in Mind by Kathryn Mannix is published by William Collins
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