A SOCIAL HISTORY OF DYING
By Allan Kellehear

Cambridge University Press, 310 pages, $21.99

Time was when death, like the savage, was noble. In A Social History of Dying, Allan Kellehear, a sociologist at England's University of Bath, extols the "good" peasant death, in which the dying are surrounded by friends and family at home. Some of us, Kellehear notes, might still long for the realization of this Dickensian fantasy at our own leave-taking.

The "well-managed" death might once have enjoyed some faint basis in reality, though not in the 14th century, when the Black Death ravaged Europe, and not in the 19th century, when infections diseases such as cholera, typhoid and tuberculosis swept cities in the Old World and the New. Kellehear's brief survey of thanatology chronicles four major epochs of dying. The first, the Stone Age, was marked by sudden, violent death from human and animal predation (this much is reasonably certain). In Kellehear's view, the Stone Age heralded the dawn of mortal awareness in which shamans choreographed our transition to the land of the happy shades.

The second, "the pastoral age," dated from the beginnings of agriculture 12,000 years ago. In the Old World, but not the New, the pastoral age saw humans living in proximity with domestic animals (cows, chickens, horses) and acquiring some of their diseases, "the main reason," Kellehear claims, "why Old World diseases went rampant during Old World colonial expansion into the New."

The third epoch, "the age of the city," witnessed the transition from the good death to the managed death. And the fourth, which Kellehear calls the Cosmopolitan Age, "has turned dying on its head." Paradoxically, it is in this Cosmopolitan Age of the 20th and 21st centuries rather than some more mythic age that "dying is full of tests, demons and hazards. The otherworld journey [of the Stone Age], by comparison, seems like sweet reunion or mere nothingness."

Much of this is conjectural; much of it is marked by political correctness (Kellehear's "sic-ing" of authors who use the noun "man" in their texts or titles irritated me); much of it also is marked by a sparseness of individual stories. Some of Kellehear's judgments are quite unhistorical. I do not know, for example, how he can he write of "the historical record of our dying behaviour ... moving in opposite directions over the last two million years," when our species is at most a quarter of a million years old and historiography occupies but a few thousand years of that. Perhaps some sweet Australopithecines have magically conveyed their insights into dying to the University of Bath.

So what soured the honeyed waters of the Lethe? A Social History of Dying offers technology as the sacrificial villain, "along with a moral and social failure to provide satisfactory models of social care for dying people at the margins of our society."

One in five people today will die what Kellehear calls a "shameful" death: alone, fevered, demented. In contrast to those allegedly "well-managed" deaths of yore, the shameful death is exacerbated by aging, poverty and "social exclusion." A quarter of the population will endure nursing-home deaths preceded by multiple organ failures, pneumonia and/or protracted drug-resistant infections. More than half will suffer "managed" deaths after prolonged hospitalization. Never has the Grim Reaper enjoyed such a ripe - or overripe - harvest.

Timing is all, Kellehear asserts, the only component of death over which the elderly can hope to have any control. In Kellehear's view, suicide constitutes a kind of anti-heroic resistance to the shameful death. Small wonder then that of the approximately one million suicides per year worldwide, the largest age-related grouping is for those over 80.

The data tend to confirm this: The World Health Organization gives 50 suicides per 100,000 males over 75, 15.8 per 100,000 females. If the gender discrepancy in suicide rates demands an explanation, A Social History of Dying does not give it. Another caveat: Such statistics, skewed because of underreporting, must be treated with caution. However, although the elderly constitute the largest grouping of suicides, the rate of suicide among the aged has fallen in recent years, and no one seems to have a good explanation for this.

Nevertheless, the trend is depressingly clear. In the Cosmopolitan Age, "suicide represents 1.4 per cent of the burden of mortality. The annual global toll of suicide is greater than all world homicides, war, and in some countries even car accidents." The suicide rate among elderly men, more than double that of younger age cohorts, has witnessed a growth paralleling the incidence of Alzheimer's disease, which Kellehear calls an epidemic. The contemporary response, warehousing more and more of the elderly in more and more nursing homes, which some critics have taken to calling the "final solution," leads Kellehear to aver that "the act of dying now appears to be disintegrating."

Those involved in geriatric medicine may take exception to Kellehear's concept of the "shameful death." Staffers at long-term care facilities will not be happy to find themselves implicitly compared to extermination-camp guards. Yet anyone who has cared for an aged or dying relative, or who has had to consign a demented loved one to a long-term care facility - indeed, anyone who has walked the corridors and visited the lounges of such facilities - will have considerable sympathy with Kellehear's conclusion: "For increasing numbers of people in wealthy countries their bodies now have the capacity to take them way past the time that they wish to live [Kellehear's italics]."

Is this an argument for euthanasia? No, because Kellehear is correct to remind us that "dying is not, and never was, solely a medical challenge." Even if it were, "People who request death with the help of doctors ... simply prefer assisted sudden death to assisted slow dying."

If death seems like a secular age's final amendment to the pursuit of happiness, the question of the "right" time to die - given the demographic of aging baby-boomers - will, Kellehear predicts, increasingly preoccupy the 21st century. This, of course, brings up the question of whether there is a right time to die. Nietzsche thought so, and Kellehear quotes Zarathustra's urging that we should all die at the right time. But perhaps it does not matter so much how or when we die as how we live.

Unlike Elisabeth Kübler-Ross, whose On Death and Dying influenced the formation of the hospice movement, Kellehear gives no indication that he has ever worked with the dying. A Social History of Dying may disappoint non-academic readers in search of original insights into dying, which is part of life, after all. But I am sure the book will take its place worldwide in university library stacks, where sociology, too, is part of life.

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