Against Death


Death as Commodity

   In every society the dominant image of death determines the prevalent concept of health.1 Such an image, the culturally conditioned anticipation of a certain event at an uncertain date, is shaped by institutional structures, deep-seated myths, and the social character that predominates. A society's image of death reveals the level of independence of its people, their personal relatedness, self-reliance, and aliveness.2 Wherever the metropolitan medical civilization has penetrated, a novel image of death has been imported. Insofar as this image depends on the new techniques and their corresponding ethos, it is supranational in character. But these very techniques are not culturally neutral; they assumed concrete shape within Western cultures and express a Western ethos. The white man's image of death has spread with medical civilization and has been a major force in cultural colonization.

   The image of a "natural death," a death which comes under medical care and finds us in good health and old age, is a quite recent ideal.3 In five hundred years it has evolved through five distinct stages, and is now ready for a sixth. Each stage has found its iconographic expression: (1) the fifteenth-century "dance of the dead"; (2) the Renaissance dance at the bidding of the skeleton man, the so-called "Dance of Death"; (3) the bedroom scene of the aging lecher under the Ancien Régime; (4) the nineteenth-century doctor in his struggle against the roaming phantoms of consumption and pestilence; (5) the mid-twentieth-century doctor who steps between the patient and his death; and (6) death under intensive hospital care. At each stage of its evolution the image of natural death has elicited a new set of responses that increasingly acquired a medical character. The history of natural death is the history of the medicalization of the struggle against death.4

The Devotional Dance of the Dead

   From the fourth century onwards, the Church struggled against a pagan tradition in which crowds, naked, frenzied, and brandishing swords, danced on the tombs in the churchyard. Nevertheless, the frequency of ecclesiastical prohibitions testifies that they were of little avail, and for a thousand years Christian churches and cemeteries remained dance floors. Death was an occasion for the renewal of life. Dancing with the dead on their tombs was an occasion for affirming the joy of being alive and a source of many erotic songs and poems.5 By the late fourteenth century, however, the sense of these dances seems to have changed:6 from an encounter between the living and those who were already dead, it was transformed into a meditative, introspective experience. In 1424 the first Dance of the Dead was painted on a cemetery wall in Paris. The original of the Cimetière des Innocents is lost, but good copies allow us to reconstruct it: king, peasant, pope, scribe, and maiden each dance with a corpse. Each partner is a mirror image of the other in dress and feature. In the shape of his body Everyman carries his own death with him and dances with it through his life. During the late Middle Ages, indwelling death7 faces man; each death comes with the symbol corresponding to his victim's rank: for the king a crown, for the peasant a pitchfork. From dancing with dead ancestors over their graves, people turned to representing a world in which everyone dances through life embracing his own mortality. Death was represented, not as an anthropomorphic figure, but as a macabre self-consciousness, a constant awareness of the gaping grave. It was not yet the skeleton man of the next century to whose music men and women will soon dance through the autumn of the Middle Ages, but rather each one's own aging and rotting self.8 At this time the mirror9 became important in everyday life, and in the grip of the "mirror of death" the "world" 10 acquired a hallucinating poignancy. With Chaucer and Villon, death becomes as intimate and sensual as pleasure and pain.

   Primitive societies conceived of death as the result of an intervention by an alien actor. They did not attribute personality to death. Death is the outcome of someone's evil intention. This somebody who causes death might be a neighbor who, in envy, looks at you with an evil eye, or it might be a witch, an ancestor who comes to pick you up, or the black cat that crosses your path.11 Throughout the Christian and Islamic Middle Ages, death continued to be regarded as the result of a deliberate personal intervention of God. No figure of "a" death appears at the deathbed, just an angel and a devil struggling over the soul escaping from the mouth of the dying. Only during the fifteenth century were the conditions ripe for a change in this image,12 and for the appearance of what would later be called a "natural death." The dance of the dead represents this readiness. Death can now become an inevitable, intrinsic part of human life, rather than the decision of a foreign agent. Death becomes autonomous and for three centuries coexists as a separate agent with the immortal soul, with divine providence, and with angels and demons.

The Danse Macabre

   In the morality plays,13 death appears in a new costume and role. By the end of the fifteenth century, no longer just a mirror image, he assumes the leading role among the "last four things," preceding judgment, heaven, and hell.14 Nor is he any longer just one of the four apocalyptic riders from Romanesque bas-reliefs, or the batlike Maegera who picks up souls from the cemetery of Pisa, or a mere messenger executing the orders of God. Death has become an independent figure who calls each man, woman, and child, first as a messenger from God but soon insisting on his own sovereign rights. By 1538 Hans Holbein the Younger15 had published the first picture-book of death, which was to become a best-seller: woodcuts on the Danse Macabre.16 The dance partners have shed their putrid flesh and turned into naked skeletons. The representation of each man as entwined with his own mortality has now changed to show his frenzied exhaustion in the grip of death painted as a force of nature. The intimate mirror-image of the "self" which had been colored by the "new devotion" of the German mystics has been replaced by a death painted as the egalitarian executioner of a law that whirls everyone along and then mows them down. From a lifelong encounter, death has turned into the event of a moment.

   During the Middle Ages eternity, together with God's presence, had been immanent in history. Now death becomes the point at which linear clock-time ends and eternity meets man. The world has ceased to be a sacrament of this presence; with Luther it became the place of corruption that God saves. The proliferation of clocks symbolizes this change in consciousness. With the predominance of serial time, concern for its exact measurement, and the recognition of the simultaneity of events, a new framework for the recognition of personal identity is manufactured. The identity of the person is sought in reference to a sequence of events rather than in the completeness of one's life span. Death ceases to be the end of a whole and becomes an interruption in the sequence.17

   Skeleton men predominate on the title pages of the first fifty years of the woodcut, as naked women now predominate on magazine covers. Death holds the hourglass or strikes the tower clock.18 Many a bell clapper was shaped like a bone. The new machine, which can make time of equal length, day and night, also puts all people under the same law. By the time of the Reformation, postmortem survival has ceased to be a transfigured continuation of life here below, and has become either a frightful punishment in the form of hell or a totally unmerited gift from God in heaven. Indwelling grace has been turned into justification by faith alone. Thus during the sixteenth century, death ceases to be conceived of primarily as a transition into the next world, and the accent is placed on the end of this life.19 The open grave looms much larger than the doors of heaven or hell and the encounter with death has become more certain than immortality, more just than king, pope, or even God. Rather than life's aim, it has become the end of life.

   The finality, imminence, and intimacy of personal death were not only part of the new sense of time but also of the emergence of a new sense of individuality. On the pilgrim's path from the Church Militant on earth to the Church Triumphant in heaven, death was experienced very much as an event that concerned both communities. Now each man faced his own and final death. Of course, once death had become such a natural force, people wanted to master it by learning the art or the skill of dying. Ars Moriendi, one of the first printed do-it-yourself manuals on the market, remained a best-seller in various versions for the next two hundred years. Many people learned to read by deciphering it. The most widely circulated version was published by Caxton at the Westminster press in 1491: over one hundred incunabula editions were made before 1500 from woodblocks and from movable type, under the title Art and Craft to knowe ye well to dye. The small folio printed in neat Gothic letters was part of a series to instruct the "complete gentleman" in "behaviour, gentle and devout," from manipulating a table knife to conducting a conversation, from the art of weeping and blowing the nose to the art of playing chess, of praying, and of dying.

   This was not a book of remote preparation for death through a virtuous life, nor a reminder to the reader of an inevitable steady decline of physical forces and the constant danger of death. It was a "how-to" book in the modern sense, a complete guide to the business of dying, a method to be learned while one was in good health and to be kept at one's fingertips for use in that inescapable hour. The book is not written for monks and ascetics but for "carnall and secular" men for whom the ministrations of the clergy were not available. It served as a model for similar instructions, often written in much less matter-of-fact spirit, by people like Savonarola, Luther, and Jeremy Taylor. Men felt responsible for the expression their face would show in death.20 Kunstler has shown that about this very time an unprecedented approach was developed in the painting of human faces: the Western portrait of countenance, which tries to represent much more than just the likeness of facial traits. The first portraits, in fact, represent princes and were executed immediately after their death, from memory, in order to render the individual, atemporal personality of the deceased ruler present at his state funeral. Early Renaissance humanists wanted to remember their dead, not as ghouls or ghosts, saints or symbols, but as a continuing, personal, historical presence.21

   In popular devotion a new kind of curiosity about the afterlife developed. Fantastic horror stories about dead bodies and artistic representations of purgatory both multiplied.22 The grotesque concern of the seventeenth century with ghosts and souls underscores the growing anxiety of a culture faced with the call of death rather than the judgment of God.23 In many parts of the Christian world the dance of death became a standard decoration in the entrance of parish churches. The Spaniards brought the skeleton man to America, where he fused with the Aztec idol of death. Their mestizo offspring,24 on its rebound to Europe, influenced the face of death throughout the Hapsburg Empire from Holland to the Tyrol. After the Reformation, European death became and remained macabre.

   Simultaneously, medical folk-practices multiplied, all designed to help people meet their death with dignity as individuals. New superstitious devices were developed so that one might recognize whether one's sickness required the acceptance of approaching death or some kind of treatment. If the flower thrown into the fountain of the sanctuary drowned, it was useless to spend money on remedies. People tried to be ready when death came, to have the steps well learned for the last dance. Remedies against a painful agony multiplied, but most of them were still to be performed under the conscious direction of the dying, who played a new role and played it consciously. Children could help a mother or father to die, but only if they did not hold them back by crying. A person was supposed to indicate when he wanted to be lowered from his bed onto the earth which would soon engulf him, and when the prayers were to start. But bystanders knew that they were to keep the doors open to make it easy for death to come, to avoid noise so as not to frighten death away, and finally to turn their eyes respectfully away from the dying man in order to leave him alone during this most personal event.25

   Neither priest nor doctor was expected to assist the poor man in typical fifteenth- and sixteenth-century death.26 In principle, medical writers recognized two opposite services the physician could perform. He could either assist healing or help the coming of an easy and speedy death. It was his duty to recognize the facies hippocratica,27 the special traits which indicated that the patient was already in the grip of death. In healing as in withdrawal, the doctor was anxious to work hand-in-glove with nature. The question whether medicine ever could "prolong" life was heatedly disputed in the medical schools of Palermo, Fez, and even Paris. Many Arab and Jewish doctors denied this power outright, and declared such an attempt to interfere with the order of nature to be blasphemous.28

   Vocational zeal tempered by philosophical resignation comes through clearly in the writings of Paracelsus.29 "Nature knows the boundaries of her course. According to her own appointed term, she confers upon each of her creatures its proper life span, so that its energies are consumed during the time that elapses between the moment of its birth and its predestined end. . . . A man's death is nothing but the end of his daily work, an expiration of air, the consummation of his innate balsamic self-curing power, the extinction of the rational light of nature, and a great separation of the three: body, soul, and spirit. Death is a return to the womb." Without excluding transcendence, death has become a natural phenomenon, no longer requiring that blame be placed on some evil agent.

   The new image of death helped to reduce the human body to an object. Up to this time, the corpse had been considered something quite unlike other things: it was treated almost like a person. The law recognized its standing: the dead could sue and be sued by the living, and criminal proceedings against the dead were common. Pope Urban VIII, who had been poisoned by his successor, was dug up, solemnly judged a simonist, had his right hand cut off, and was thrown into the Tiber. After being hanged as a thief, a man might still have his head cut off for being a traitor. The dead could also be called to witness. The widow could still repudiate her husband by putting the keys and his purse on his casket. Even today the executor acts in the name of the dead, and we still speak of the "desecration" of a grave or the secularization of a public cemetery when it is turned into a park. The appearance of natural death was necessary for the corpse to be deprived of much of its legal standing.30

   The arrival of natural death also prepared the way for new attitudes towards death and disease which became common in the late seventeenth century. During the Middle Ages, the human body had been sacred; now the physician's scalpel had access to the corpse itself.31 Its dissection had been considered by the humanist Gerson to be "a sacrilegious profanation, a useless cruelty exercised by the living against the dead."32 But at the same time that Everyman's Death began to emerge in person in the morality plays, the corpse first appeared as a teaching object in the amphitheater of the Renaissance university. When the first authorized public dissection took place in Montpellier in 1375, this new learned activity was declared obscene, and the performance could not be repeated for several years. A generation later, permission was given for one corpse a year to be dissected within the borders of the German Empire. At the University of Bologna, also, one body was dissected each year just before Christmas, and the ceremony was inaugurated by a procession, accompanied by exorcisms, and took three days. During the fifteenth century, the University of Lerida in Spain was entitled to the corpse of one criminal every three years, to be dissected in the presence of a notary assigned by the Inquisition. In England in 1540, the faculties of the universities were authorized to claim four corpses a year from the hangman. Attitudes changed so rapidly that by 1561 the Venetian Senate ordered the hangman to take instruction from Dr. Fallopius in order to provide him with corpses well suited for "anatomizing." Rembrandt painted "Dr. Tulp's Lesson" in 1632. Public dissection became a favored subject for paintings and, in the Netherlands, a common event at carnivals. The first step towards surgery on television and in the movies had been taken. The physician had advanced his knowledge of anatomy and his power to exhibit his skill, but both were disproportionate to an advance in his ability to heal. Medical rituals helped to orient, repress, or allay the fear and anguish generated by a death that had become macabre. The anatomy of Vesalius rivaled Holbein's Danse Macabre somewhat as scientific sex-guides now rival Playboy and Penthouse magazines.

Bourgeois Death

   Baroque death counterpointed an aristocratically organized heaven.33 The church vault might depict a last judgment with separate spaces reserved for savages, commoners, and nobles, but the Dance of Death beneath depicted the mower who used his scythe regardless of post or rank. Precisely because macabre equality belittled worldly privilege, it also made it more legitimate.34 However, with the rise of the bourgeois family,35 equality in death came to an end: those who could afford it began to pay to keep death away.

   Francis Bacon was the first to speak about the prolongation of life as a new task for physicians. He divided medicine into three offices: "First, the preservation of health, second, the cure of disease, and third, the prolongation of life," and extolled the "third part of medicine, regarding the prolongation of life: this is a new part, and deficient, although the most noble of all." The medical profession did not even consider facing this task, until, some one hundred and fifty years later, there appeared a host of clients who were anxious to pay for the attempt. This was a new type of rich man who refused to die in retirement and insisted on being carried away by death from natural exhaustion while still on the job. He refused to accept death unless he was in good health in an active old age. Montaigne had already ridiculed such people as exceptionally conceited: " 'Tis the last and extreme form of dying . . . what an idle conceit is it to expect to die of a decay of strength which is the effect of the extremest age, and to propose to ourselves no shorter lease on life . . . as if it were contrary to nature to see a man break his neck with a fall, be drowned by shipwreck, be snatched away with pleurisy or the plague . . . we ought to call natural death that which is general, common and universal."36 Such people were few in his time; soon their numbers would increase. The preacher expecting to go to heaven, the philosopher denying the existence of the soul, and the merchant wanting to see his capital double once more were all in agreement that the only death that accorded with nature was one which would overtake them at their desks.37

   There is no evidence to show that the age-specific life expectancy of most people in their sixties had increased by the middle of the eighteenth century, but there is no doubt that new technology had made it possible for the old and rich to hang on while doing what they had done in middle age. The pampered could stay on the job because their living and working conditions had eased. The Industrial Revolution had begun to create employment opportunities for the weak, sickly, and old. Sedentary work, hitherto rare, had come into its own.38 Rising entrepreneurship and capitalism favored the boss who had had the time to accumulate capital and experience. Roads had improved: a general affected by gout could now command a battle from his wagon, and decrepit diplomats could travel from London to Vienna or Moscow. Centralized nation-states increased the need for scribes and an enlarged bourgeoisie. The new and small class of old men had a greater chance of survival because their lives at home, on the street, and at work had become physically less demanding. Aging had become a way of capitalizing life. Years at the desk, either at the counter or the school bench, began to bear interest on the market. The young of the middle class, whether gifted or not, were now for the first time sent to school, thus allowing the old to stay on the job. The bourgeoisie who could afford to eliminate "social death" by avoiding retirement, created "childhood" to keep their young under control.39

   Along with the economic status of the old, the value of their bodily functions increased. In the sixteenth century "a young wife is death to an old man," and in the seventeenth, "old men who play with young maids dance with death." At the court of Louis XIV the old lecher was a laughingstock; by the time of the Congress of Vienna he had turned into an object of envy. To die while courting one's grandson's mistress became the symbol of a desirable end.

   A new myth about the social value of the old was developed. Primitive hunters, gatherers, and nomads had usually killed them, and peasants had put them into the back room,40 but now the patriarch appeared as a literary ideal. Wisdom was attributed to him just because of his age. It first became tolerable and then appropriate that the elderly should attend with solicitude to the rituals deemed necessary to keep up their tottering bodies. No physician was yet in attendance to take on this task, which lay beyond the competence claimed by apothecary or herbalist, barber or surgeon, university-trained doctor or traveling quack. But it was this peculiar demand that helped to create a new kind of self-styled healer.41

   Formerly, only king or pope had been under an obligation to remain in command until the day of his death. They alone consulted the faculties: the Arabs from Salerno in the Middle Ages, or the Renaissance men from Padua or Montpellier. Kings, however, kept court physicians to do what barbers did for the commoner: bleed them and purge them, and in addition, protect them from poisons. Kings neither set out to live longer than others, nor expected their personal physicians to give special dignity to their declining years. In contrast, the new class of old men saw in death the absolute price for absolute economic value.42 The aging accountant wanted a doctor who would drive away death; when the end approached, he wanted to be formally "given up" by his doctor and to be served his last repast with the special bottle reserved for the occasion. The role of the "valetudinarian" was thereby created, and with genteel decrepitude, the eighteenth-century groundwork was laid for the economic power of the contemporary physician.

   The ability to survive longer, the refusal to retire before death, and the demand for medical assistance in an incurable condition had joined forces to give rise to a new concept of sickness: the type of health to which old age could aspire. In the years just before the French Revolution this had become the health of the rich and the powerful; within a generation chronic disease became fashionable for the young and pretentious, consumptive features43 the sign of premature wisdom, and the need for travel into warm climates a claim to genius. Medical care for protracted ailments, even though they might lead to untimely death, had become a mark of distinction.

   By contrast, a reverse judgment now could be made on the ailments of the poor, and the ills from which they had always died could be defined as untreated sickness. It did not matter at all if the treatment doctors could provide for these ills had any effect on the progress of the sickness; the lack of such treatment began to mean that they were condemned to die an unnatural death, an idea that fitted the bourgeois image of the poor as uneducated and unproductive. From now on the ability to die a "natural" death was reserved to one social class: those who could afford to die as patients.

   Health became the privilege of waiting for timely death, no matter what medical service was needed for this purpose. In an earlier epoch, death had carried the hourglass. In woodcuts, both skeleton and onlooker grin when the victim refuses death. Now the middle class seized the clock and employed doctors to tell death when to strike.44 The Enlightenment attributed a new power to the doctor, without being able to verify whether or not he had acquired any new influence over the outcome of dangerous sickness.

Clinical Death

   The French Revolution marked a short interruption in the medicalization of death. Its ideologues believed that untimely death would not strike in a society built on its triple ideal. But the doctor's newly acquired clinical eyeglasses made him look at death in a new perspective. Whereas the merchants of the eighteenth century had determined the outlook on death with the help of the charlatans they employed and paid, now the clinicians began to shape the public's vision. We have seen death turn from God's call into a "natural" event and later into a "force of nature"; in a further mutation it had turned into an "untimely" event when it came to those who were not both healthy and old. Now it had become the outcome of specific diseases certified by the doctor.45

   Death had paled into a metaphorical figure, and killer diseases had taken his place. The general force of nature that had been celebrated as "death" had turned into a host of specific causations of clinical demise. Many "deaths" now roamed the world. A number of book plates from private libraries of late nineteenth-century physicians show the doctor battling with personified diseases at the bedside of his patient. The hope of doctors to control the outcome of specific diseases gave rise to the myth that they had power over death. The new powers attributed to the profession gave rise to the new status of the clinician.46

   While the city physician became a clinician, the country physician became first sedentary and then a member of the local elite. At the time of the French Revolution he had still belonged to the traveling folk. The surplus of army surgeons from the Napoleonic wars came home with a vast experience, looking for a living. Military men trained on the battlefield, they soon became the first resident healers in France, Italy, and Germany. The simple people did not quite trust their techniques and staid burghers were shocked by their rough ways, but still they found clients because of their reputation among veterans of the Napoleonic wars. They sent their sons to the new medical schools springing up in the cities, and these upon their return created the role of the country doctor, which remained unchanged up to the time of World War II. They derived a steady income from playing the family doctor to the middle class who could well afford them. A few of the city or town rich acquired prestige by living as patients of famous clinicians, but in the early nineteenth century a much more serious competition for the town doctor still came from the medical technicians of old—the midwife, the tooth-puller, the veterinarian, the barber, and sometimes the public nurse. Notwithstanding the newness of his role and resistance to it from above and below, the European country doctor, by mid-century, had become a member of the middle class. He earned enough from playing lackey to a squire, was family friend to other notables, paid occasional visits to the lowly sick, and sent his complicated cases to his clinical colleague in town. While "timely" death had originated in the emerging class consciousness of the bourgeois, "clinical" death originated in the emerging professional consciousness of the new, scientifically trained doctor. Henceforth, a timely death with clinical symptoms became the ideal of middle-class doctors,47 and it was soon to become incorporated into the aspirations of trade unions.

Trade Union Claims to a Natural Death

   In our century a valetudinarian's death while undergoing treatment by clinically trained doctors came to be perceived, for the first time, as a civil right. Old-age medical care was written into union contracts. The capitalist privilege of natural extinction from exhaustion in a director's chair gave way to the proletarian demand for health services during retirement. The bourgeois hope of continuing as a dirty old man in the office was ousted by the dream of an active sex life on social security in a retirement village. Lifelong care for every clinical condition soon became a peremptory demand for access to a natural death. Lifelong institutional medical care had become a service that society owed all its members.

   "Natural death" now appeared in dictionaries. One major German encyclopedia published in 1909 defines it by means of contrast: "Abnormal death is opposed to natural death because it results from sickness, violence, or mechanical and chronic disturbances." A reputable dictionary of philosophical concepts states that "natural death comes without previous sickness, without definable specific cause." It was this macabre hallucinatory death-concept that became intertwined with the concept of social progress. Legally valid claims to equality in clinical death spread the contradictions of bourgeois individualism among the working class. The right to a natural death was formulated as a claim to equal consumption of medical services, rather than as a freedom from the evils of industrial work or as a new liberty and power for self-care. This unionized concept of an "equal clinical death" is thus the inverse of the ideal proposed in the National Assembly of Paris in 1792: it is a deeply medicalized ideal.

   First of all, this new image of death endorses new levels of social control. Society has become responsible for preventing each man's death: treatment, effective or not, can be made into a duty. Any fatality occurring without medical treatment is liable to become a coroner's case. The encounter with a doctor becomes almost as inexorable as the encounter with death. I know of a woman who tried, unsuccessfully, to kill herself. She was brought to the hospital in a coma, with a bullet lodged in her spine. Using heroic measures the surgeon kept her alive, and he considers her case a success: she lives, but she is totally paralyzed; he no longer has to worry about her ever attempting suicide again.

   Our new image of death also befits the industrial ethos.48 The good death has irrevocably become that of the standard consumer of medical care. Just as at the turn of the century all men were defined as pupils, born into original stupidity and standing in need of eight years of schooling before they could enter productive life, today they are stamped from birth as patients who need all kinds of treatment if they want to lead life the right way. Just as compulsory educational consumption came to be used as a device to obviate concern about work, so medical consumption became a device to alleviate unhealthy work, dirty cities, and nerve-racking transportation.49 What need is there to worry about a murderous environment when doctors are industrially equipped to act as life-savers!

   Finally, "death under compulsory care" encourages the re-emergence of the most primitive delusions about the causes of death. As we have seen, primitive people do not die of their own death, they do not carry finitude in their bones, and they are still close to the subjective immortality of the beast. Among them, death always requires a supernatural explanation, somebody to blame: the curse of an enemy, the spell of a magician, the breaking of the yarn in the hands of the Parcae, or God dispatching his angel of death. In the dance with his or her mirror-image, European death emerged as an agent independent of another's will, an inexorable force of nature that men and women had to face on their own. The imminence of death was an exquisite and constant reminder of the fragility and tenderness of life. During the late Middle Ages, the discovery of "natural" death became one of the mainsprings of European lyric and drama. But the same imminence of death, once perceived as an extrinsic threat coming from nature, became a major challenge for the emerging engineer. If the civil engineer had learned to manage earth, and the pedagogue-become-educator to manage knowledge, why should the biologist-physician not manage death? 50 When the doctor contrived to step between humanity and death, the latter lost the immediacy and intimacy gained four hundred years earlier. Death that had lost face and shape had lost its dignity.

   The change in the doctor-death relationship can be well illustrated by following the iconographic treatment of this theme.51 In the age of the Dance of Death, the physician is rare. In the only picture I have located in which death treats the doctor as a colleague, he has taken an old man by one hand, while in the other he carries a glass of urine, and seems to be asking the physician to confirm his diagnosis. In the age of the Dance of Death, the skeleton man makes the doctor the main butt of his jokes. In the earlier period, while death still wore some flesh, he asks the doctor to confirm in the latter's own mirror-image what he thought he knew about man's innards. Later, as a fleshless skeleton, he teases the doctor about his impotence, jokes about or rejects his honoraria, offers medicine as pernicious as that the physician dispensed, and treats the doctor as just one more common mortal by snatching him into the dance. Baroque death seems to intrude constantly into the doctor's activities, making fun of him while he sells his wares at a fair, interrupting his consultation, transforming his medicine bottles into hourglasses, or taking the doctor's place on a visit to the pesthouse. In the eighteenth century a new motif appears: death seems to enjoy teasing the physician about his pessimistic diagnoses, abandoning those sick persons whom the doctor has condemned, and dragging the doctor off to the tomb while leaving the patient alive. Until the nineteenth century, death deals always with the doctor or with the sick, usually taking the initiative in the action. The contestants are at opposite ends of the sickbed. Only after clinical sickness and clinical death had developed considerably do we find the first pictures in which the doctor assumes the initiative and interposes himself between his patient and death. We have to wait until after World War I before we see physicians wrangling with the skeleton, tearing a young woman from its embrace, and wresting the scythe from death's hand. By 1930 a smiling white-coated man is rushing against a whimpering skeleton and crushing it like a fly with two volumes of Marle's Lexicon of Therapy. In other pictures, the doctor raises one hand and wards off death while holding up the arms of a young woman whom death grips by the feet. Max Klinger represents the physician clipping the feathers of a winged giant. Others show the physician locking the skeleton into prison or even kicking its bony bottom. Now the doctor rather than the patient struggles with death. As in primitive cultures, somebody can again be blamed when death triumphs. This somebody is no longer a person with the face of a witch, an ancestor, or a god, but the enemy in the shape of a social force.52 Today, when defense against death is included in social security, the culprit lurks within society. The culprit might be the class enemy who deprives the worker of sufficient medical care, the doctor who refuses to make a night visit, the multinational concern that raises the price of medicine, the capitalist or revisionist government that has lost control over its medicine men, or the administrator who partly trains physicians at the University of Delhi and then drains them off to London. The witch-hunt that was traditional at the death of a tribal chief is being modernized. For every premature or clinically unnecessary death, somebody or some body can be found who irresponsibly delayed or prevented a medical intervention.

   Much of the progress of social legislation during the first half of the twentieth century would have been impossible without the revolutionary use of such an industrially graven death-image. Neither the support necessary to agitate for such legislation nor guilt feelings strong enough to enforce its enactment could have been aroused. But the claim to equal medical nurturing towards an equal kind of death has also served to consolidate the dependence of our contemporaries on a limitlessly expanding industrial system.

Death Under Intensive Care

   We cannot fully understand the deeply rooted structure of our social organization unless we see in it a multifaceted exorcism of all forms of evil death. Our major institutions constitute a gigantic defense program waging war on behalf of "humanity" against death-dealing agencies and classes.53 This is a total war. Not only medicine but also welfare, international relief, and development programs are enlisted in this struggle. Ideological bureaucracies of all colors join the crusade. Revolution, repression, and even civil and international wars are justified in order to defeat the dictators or capitalists who can be blamed for the wanton creation and tolerance of sickness and death.54

   Curiously, death became the enemy to be defeated at precisely the moment at which megadeath came upon the scene. Not only the image of "unnecessary" death is new, but also our image of the end of the world.55 Death, the end of my world, and apocalypse, the end of the world, are intimately related; our attitude towards both has clearly been deeply affected by the atomic situation. The apocalypse has ceased to be just a mythological conjecture and has become a real contingency. Instead of being due to the will of God, or man's guilt, or the laws of nature, Armageddon has become a possible consequence of man's direct decision. Cobalt, like hydrogen bombs, creates an illusion of control over death. Medicalized social rituals represent one aspect of social control by means of the self-frustrating war against death.

   Malinowski56 has argued that death among primitive people threatens the cohesion and therefore the survival of the whole group. It triggers an explosion of fear and irrational expressions of defense. Group solidarity is saved by making out of the natural event a social ritual. The death of a member thereby becomes an occasion for an exceptional celebration. The dominance of industry has disrupted and often dissolved most traditional bonds of solidarity. The impersonal rituals of industrialized medicine create an ersatz unity of mankind. They tie all its members into a pattern of "desirable" death by proposing hospital death as the goal of economic development. The myth of progress of all people towards the same kind of death diminishes the feeling of guilt on the part of the "haves" by transforming the ugly deaths that the "have-nots" die into the result of present underdevelopment, which ought to be remedied by further expansion of medical institutions.

   Of course, medicalized 57 death has a different function in highly industrialized societies than it has in mainly rural nations. Within an industrial society, medical intervention in everyday life does not change the prevailing image of health and death, but rather caters to it. It diffuses the death-image of the medicalized elite among the masses and reproduces it for future generations. But when "death prevention" is applied outside of a cultural context in which consumers religiously prepare themselves for hospital deaths, the growth of hospital-based medicine inevitably constitutes a form of imperialist intervention. A sociopolitical image of death is imposed; people are deprived of their traditional vision of what constitutes health and death. The self-image that gives cohesion to their culture is dissolved, and atomized individuals can now be incorporated into an international mass of highly "socialized" health consumers. The expectation of medicalized death hooks the rich on unlimited insurance payments and lures the poor into a gilded deathtrap. The contradictions of bourgeois individualism are corroborated by the inability of people to die with any possibility of a realistic attitude towards death.58 The customs man guarding the frontier between Upper Volta and Mali explained to me this importance of death in relation to health. I wanted to know from him how people along the Niger could understand each other, though almost every village spoke a different tongue. For him this had nothing to do with language: "As long as people cut the prepuce of their boys the way we do, and die our death, we can understand them well."

   In many a village in Mexico I have seen what happens when social security arrives. For a generation people continue in their traditional beliefs; they know how to deal with death, dying, and grief.59 The new nurse and the doctor, thinking they know better, teach them about an evil pantheon of clinical deaths, each one of which can be banned, at a price. Instead of modernizing people's skills for self-care, they preach the ideal of hospital death. By their ministration they urge the peasants to an unending search for the good death of international description, a search that will keep them consumers forever.

   Like all other major rituals of industrial society, medicine in practice takes the form of a game. The chief function of the physician becomes that of an umpire. He is the agent or representative of the social body, with the duty to make sure that everyone plays the game according to the rules.60 The rules, of course, forbid leaving the game and dying in any fashion that has not been specified by the umpire. Death no longer occurs except as the self-fulfilling prophecy of the medicine man.61

   Through the medicalization of death, health care has become a monolithic world religion62 whose tenets are taught in compulsory schools and whose ethical rules are applied to a bureaucratic restructuring of the environment: sex has become a subject in the syllabus and sharing one's spoon is discouraged for the sake of hygiene. The struggle against death, which dominates the life-style of the rich, is translated by development agencies into a set of rules by which the poor of the earth shall be forced to conduct themselves.

   Only a culture that evolved in highly industrialized societies could possibly have called forth the commercialization of the death-image that I have just described. In its extreme form, "natural death" is now that point at which the human organism refuses any further input of treatment. People63 die when the electroencephalogram indicates that their brain waves have flattened out: they do not take a last breath, or die because their heart stops. Socially approved death happens when man has become useless not only as a producer but also as a consumer. It is the point at which a consumer, trained at great expense, must finally be written off as a total loss. Dying has become the ultimate form of consumer resistance.64

   Traditionally the person best protected from death was the one whom society had condemned to die. Society felt threatened that the man on Death Row might use his tie to hang himself. Authority might be challenged if he took his life before the appointed hour. Today, the man best protected against setting the stage for his own dying is the sick person in critical condition. Society, acting through the medical system, decides when and after what indignities and mutilations he shall die.65 The medicalization of society has brought the epoch of natural death to an end. Western man has lost the right to preside at his act of dying. Health, or the autonomous power to cope, has been expropriated down to the last breath. Technical death has won its victory over dying.66 Mechanical death has conquered and destroyed all other deaths.