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Death and dying in literature

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Death and dying in literature
John Skelton
APT 2003, 9:211-217.
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 Advances in Psychiatric Treatment (2003),
Death and vol.
dying in9,literature
211–220

Death and dying in literature

John Skelton

Abstract This paper considers how death and dying are presented in literature. A wide range of texts, principally
but not exclusively from the English language tradition, is used to illustrate themes. Broad categories
are suggested for the study of death: some authors give personal accounts of their impending death
or their sense of bereavement; some use literature to structure and order our thoughts about death;
and some treat death as a literary device, using it, for example, as a symbolic representation of the
decay of society. It concludes that the biggest obstacles that health professionals and patients face as
they attempt to understand death in literature are concerned not with a lack of appropriate emotional
depth, but with difficulties either in understanding the conventions of literature or in coming to terms
with the cultural gaps imposed by time and place.

This is the third in a series of papers on literature and psychiatry.
Previous papers introduced cognitive linguistics and metaphor
(Eynon, 2002) and literature and substance misuse (Day & Smith,
2003). Future papers will consider, among other things, how
dementia is described in fiction and biography, and the value of
autobiographical narrative to psychiatry.
How do people write about death and dying? At
one end of the scale there are the sometimes
embarrassing but often deeply personal and
profoundly felt lines of doggerel on tombstones or
‘In Memoriam’ columns (‘She faltered by the
wayside and the angels took her home’). The internet
is a great source of these, although some are, no
doubt, apocryphal. At the other end of the scale,
there is death in literature, for example King Lear’s
lament over his dead daughter, Cordelia. This
extraordinary scene concludes:
‘” No, no, no life!
Why should a dog, a horse, a rat, have life,
And thou no breath at all? Thou’lt come no more,
Never, never, never, never, never!
Pray you, undo this button: thank you, sir.
Do you see this? Look on her, look, her lips,
Look there, look there!”’
(King Lear: Act V, scene iii)
And Lear himself dies, perhaps under the
delusion that Cordelia still lives. As an interesting
sidelight on death and its meanings, the play was
1. Books are not necessarily referenced to their first
editions.
rewritten in the 18th century with a happy ending
to reflect the more optimistic ethos of an age which
believed this was, in Voltaire’s famous phrase, the
‘best of all possible worlds’. In the 20th century,
Edward Bond wrote a version of the Lear story which
was bleaker than Shakespeare’s original, precisely
on the grounds that Shakespeare was too optimistic.
One of the central things of which literature can
make us more aware is that death means different
things at different times.
But these two kinds of text – the banal and the
sublime – clearly have things in common. They
attempt to express some of the emotions of bereave-
ment and they attempt to give shape to our thoughts
about death. The first affirms a belief in the final,
Christian, order of the universe; and it is the question
of order that Shakespeare, too, addresses: Where is
justice if the good people die?
Great literature – ‘Literature’ with a capital ‘L’ –
makes use of death for its own purposes. The death
of Cordelia, however moving we may find it on stage,
is a functional device. In fact, many fictional deaths
are not terribly moving or true to our personal or
professional experiences of bereavement and death.
In other words, literature is not just an attack on the
emotions. Nor do we only find emotions expressed
in great literature. In this paper, I therefore try to
separate out, although in a fairly loose and fluid
manner, a number of different ways in which death
and dying are presented in writing. First, I look at
personal accounts of death and dying, then I consider
how writing is used to structure and order our

John Skelton is a senior lecturer in medical communication skills at the Department of Primary Care and General Practice
(University of Birmingham, Edgbaston B15 2TT, UK. Tel: 0121 414 3767/8534; e-mail: j.r.skelton@bham.ac.uk) and Director
of the Interactive Skills Unit, which runs courses in communication and interactive management skills in the West Midlands
and beyond. His first degree is in English literature and, before his career in medical education, he worked in applied linguistics.
He has published widely in both applied linguistics and medical communication. With colleagues, he has run a special study
module in literature and medicine for medical students at Birmingham.

Advances in Psychiatric Treatment (2003), vol. 9. http://apt.rcpsych.org/ 211

Skelton/Sims/Parkes
experience of death. Finally, I discuss some of the
functional uses writers make of death and dying.
I have quoted as extensively as space permits,
partly to let authors speak for themselves and partly
in the hope that readers will enjoy the contact with
perhaps unfamiliar names and be encouraged to
dig more deeply. In order to dispense with distrac-
ting inverted commas, let me say that although the
word ‘literature’ has many uses, I use it here in the
traditional sense, familiar to A-level students of
English literature; thus Shakespeare is literature, but
this paper is not.
Personal accounts
Literature touches our emotions and perhaps this is
what people consider to be its greatest characteristic.
Yet the power of the arts is ambivalent. It can blind
the reader to sentimental trash. Who has not cried
at the death of Bambi’s mother in the Walt Disney
cartoon? Which girl – it seems only girls read it –
has not wept over the demise of Beth in Louisa M.
Alcott’s Little Women? Who, in other words, would
disagree with the sense of Noel Coward’s famous
bon mot: ‘It is extraordinary how potent cheap music
is’? Dickens was one of the greatest of all writers
but, like many Victorians, he was very susceptible
to sentimentality. Here, he describes the death of the
impoverished child, Little Nell, in The Old Curiosity
Shop. Dickens owed a great and direct debt to
Shakespeare in his work. Note the similarities
between this death and that of Cordelia, above. The
first speaker is the old man whom Nell has
befriended.
‘” She is still asleep,” he whispered. “You were right.
She did not call – unless she did so in her slumber.”
‘“ She has called to me in her sleep before now, Sir;
as I have sat by, watching, I have seen her lips move,
and have known, though no sound came from them,
that she spoke of me. I feared the light might dazzle
her eyes and wake her, so I brought it here …”
‘ “ …She is sleeping soundly,” he said; “but no
wonder. Angel hands have strewn the ground deep
with snow, that the lightest footstep may be lighter
yet; and the very birds are dead, that they may not
wake her. She used to feed them, Sir. Though never
so cold and hungry, the timid things would fly from
us. They never flew from her!”’
(Dickens, 2001: pp. 534–535)
But, like Lear, the old man is mistaken:
‘For she was dead. There, upon her little bed, she lay
at rest. The solemn stillness was no marvel now.
‘She was dead. No sleep so beautiful and calm, so
free from trace of pain, so fair to look upon. She
seemed a creature fresh from the hand of God, and
waiting for the breath of life; not one who had lived
and suffered death.
212 Advances in Psychiatric Treatment (2003), vol. 9. http://apt.rcpsych.org/
‘Her couch was dressed with here and there some
winter berries and green leaves, gathered in a spot she
had been used to favour. “When I die, put near me
something that has loved the light, and had the sky
above it always.” Those were her words.
‘… She was dead. Dear, gentle, patient, noble Nell
was dead…
‘And still her former self lay there, unaltered in this
change. Yes. The old fireside had smiled upon that same
sweet face; it had passed, like a dream, through haunts
of misery and care; at the door of the poor schoolmaster
on the summer evening, before the furnace fire upon
the cold wet night, at the still bedside of the dying boy,
there had been the same mild lovely look. So shall we
know the angels in their majesty, after death.’
(Dickens, 2001: p. 540)
If this does not move us to abject surrender and
sentimental tears, the emotions evoked might be more
complex and less forgiving. ‘Who’, as Oscar Wilde
once remarked, ‘can read the death of Little Nell
without laughing?’ Perhaps. And it is the mix of
complex embarrassment, humour and dismay that
colours our response to both this and amateur verse,
or the attempts of the poorly equipped to strike a
formal note of gravity. The inscriptions on head-
stones in a typical graveyard can move the most
earnest person to giggles.
This does not mean that poverty of expression is
the same as poverty of feeling. One of the lessons of
King Lear, after all, is that true feelings lie too deep
for words: beware those who, like Lear’s wicked
daughters, can articulate their love. Trust rather the
saintly Cordelia, the daughter whose love is deep
beyond expression. By extension, for just this reason
a dying patient or a bereaved relative may welcome
the release that literature brings. They may feel that
their own power to express themselves has failed
and that there is relief in the words of others and the
possibility of saying, ‘This is what I mean’.
This makes for an ambivalence in much of the
writing about death and dying. Sometimes it is pro-
foundly felt, sometimes it is profoundly expressed,
but not often is it both. This is exemplified in an
excellent anthology of poems on bereavement, The
Long Pale Corridor (Benson & Falk, 1996). The range
of poems, in terms of quality, is from the adequate to
the outstanding, but nobody could describe the book
as easy reading. This example is by the American
poet, Jack Hirschman, whose son died of leukaemia
when in his twenties.
‘It was a happy day
when he was born
34 years ago
my blonde son.
How golden the sun
in the park today,
how happy the birds
and flying balls.

I sit in golden light
almost forgetting
he’s eight years gone
because the sun
is so like his hair
and the air like
the golden laughter
of his love.
Eight years old and
into a radiant windup.
Here comes a perfect
strike of light
upon an old old glove.’
(Jack Hirschman, ‘October 11th 1990’. Reprinted
with permission from Hirschman, J. (1992) Endless
Threshold. Willimantic, CT: Curbstone Press.)
There is a good deal to respond to in this poem.
The idea that love is laughter is a particular delight
– and if the poem lacks immediacy to a UK reader, it
is partly because it is North American; the glove is a
baseball glove and the central image is that most
American of rituals, a father and son playing base-
ball. A non-American audience may miss the
references altogether and, even if they do pick them
up, may catch only a glimmer of the rich network of
associations conjured up by the sport, and thus the
poem about the sport. The point here is that literature
does not deal with facts, things which are true at all
times for all conditions and every reader.
Clinicians and patients alike evidently share the
greatest difficulty when they turn to literature as a
way of sharing experience. Barriers of context can
impose themselves more or less completely between
the most well-intentioned reader and the text.
This means that we turn most easily to writing
where the barriers effectively vanish, because the
culture is our own and the kind of reading the text
demands of us is the kind of reading we do anyway.
For examples, we turn to accounts of their illness
by contemporary, articulate people. Sometimes, as
with the journalists John Diamond and Oscar Moore,
victims of throat cancer and AIDS, respectively, an
easy sophistication hangs over their work (Moore,
1996; Diamond, 1999). But this is a game whose rules
many of us understand, and the writing – essentially
very clever versions of the volubility of the chattering
classes – therefore has an immediate power, closely
linked to our confidence that we know what is going
on. This is Moore, talking about going blind:
‘Dwindling in weight and morale, I fled to out-of-
town friends and spent two days sitting in a garden
on Long Island recuperating … i.e. napping. So it
should have been easy to blame my foggy vision and
guerrilla headbangs on a combination of red-eye flight
and nap overdose. Unfortunately not.
‘You see (I hate sight verbs!) the fog wasn’t
unseasonal bonfires or post-night-flight blur, and the
Advances in Psychiatric Treatment (2003), vol. 9. http://apt.rcpsych.org/
Death and dying in literature
headaches weren’t random flares. We were at war,
and losing it. The CMV had woken up with a hunger,
and I now had so little retina left on the left that my
vision was getting to be like US television – hardly
enough pixels to make a picture.’
(Moore, 1996: p. 166)
The writing is self-consciously able and literate.
Moore effortlessly strings his war metaphors
together, for example. At the same time, the issue of
quality, whether this is ‘good writing’, seems to be
beside the point and a text like this is perhaps, above
all, a way of putting sufferers and their relatives in
touch with another experience; of relieving the
burden of loneliness. It is not unkind to observe that
Moore actually says little which is very insightful –
nothing there the healthy could not have guessed
about what the dying feel. In the end, it is not for the
quality of his thoughts or feelings that we read this,
but for their authenticity and the sense of the person
which shines through. In that respect, it matters less
what is said than who says it.
This is writing at its most immediate. One is
granted permission to watch as the writer dies and
there is no doubt that this contributes to its impact.
Even more immediate, perhaps, are the possibilities
that the internet gives us to write interactively. Here
is a posting from an HIV bulletin board:
‘Not sure what I am looking for, just very lonely and
kind of lost. My partner of 15 years died 2 weeks ago
here at home with me after a long but very courageous
fight. I do have friends and people around who do care,
but I still feel so lonely and sometimes feel as if I will
never feel happy again. We did so much together. Three
years ago we opened, and still have, a restaurant that I
am very proud of. He was a remarkable person who
never let the disease stop him or myself from doing
things that would make us happier, or better as people
and a couple. It’s just so hard, because everything here
at home reminds me of him, and everything at work
does too. Of course, there are so many good memories,
but now that’s all I have. I just miss him so much!’
(http://www.thebody.com/bbs/forums.html)
The expression of sentiment is commonplace yet
profound in a way that we can easily understand.
Making sense of death
One of the central tasks of literature is to impose a
structure on life and death, giving meaning to both.
Indeed, literature as a discipline aims just as
certainly as science does to understand the world
in which we live and to interpret our own role as
participants in the human condition. The difficulty
for the non-specialist is understanding the various
ways in which literature works and, once more, this
is particularly true when it comes to the question of
understanding across time and space.
213
Skelton/Sims/Parkes
Here is one example, which is fairly well-known
and relatively approachable. Perhaps it also corres-
ponds to a certain idea of what poetry is in its effort-
less rhythmical dexterity and command of sound:
‘Dark house, by which once more I stand
Here in the long unlovely street,
Doors, where my heart was used to beat
So quickly, waiting for a hand,
A hand that can be clasp’d no more –
Behold me, for I cannot sleep,
And like a guilty thing I creep
At earliest morning to the door.
He is not here; but far away
The noise of life begins again,
And ghastly thro’ the drizzling rain
On the bald street breaks the blank day.’
(Alfred Lord Tennyson, In Memoriam, VII)
Tennyson wrote this long – very long – series of
short poems (published in 1850) following the death,
at just 22, of his close friend, Arthur Hallam. Hallam
was a brilliant young man in his own right and it
seems clear that Tennyson expected to spend the
rest of his life in close contact with him. The deeply
felt grief makes it a personal account, but deep feeling
refined into literature. A little more cynically, it could
be seen as an instance of the French poet and man of
letters Paul Valery’s description, ‘A poem is a machine
for reproducing an emotion’. Note, in particular, a
much-quoted example of Tennyson’s genius in the
way that the easy, gentle rhythms are subverted in
the last line by the sudden abruptness of ‘bald’ and
‘blank’. In a sense, the poem is held together by
poetic technique; the feelings behind it are so bleak
that it is hard to see how they found expression at all.
Behind the sadness, hovering off-stage for much
of the time in the poems of In Memoriam, and entirely
absent in this one, is the apparatus of Victorian life
and, in particular, the solace of the Christian faith.
This, of course, has been the backdrop to a great
deal of Western literature about death and dying.
Christianity has offered a way of understanding grief
and our own death in the context of eternity.
At its literary best, faith lends a power and convic-
tion to writing which speaks clearly to those of other
faiths, or none. This is John Donne, who became a
cleric in later life. He is often regarded as one of the
greatest of all English poets. The poem is perhaps
best read aloud, with passion and speed, to reveal
the power of that triumph over death it celebrates:
‘Death be not proud, though some have called thee
Mighty and dreadful, for, thou art not so,
For, those, whom thou thinks’t, thou dost overthrow,
Die not, poor death, nor yet canst thou kill me;
From rest and sleep, which but thy pictures be,
Much pleasure, then from thee, much more must
flow,
214 Advances in Psychiatric Treatment (2003), vol. 9. http://apt.rcpsych.org/
And soonest our best men with thee do go,
Rest of their bones, and soul’s delivery.
Thou art slave to fate, chance, kings and desperate
men,
And dost with poison, war and sickness dwell,
And poppy, or charms can make us sleep as well,
And better than thy stroke; why swells’t thou
then?
One short sleep past, we wake eternally,
And death shall be no more, Death thou shalt die.’
(John Donne, Holy Sonnet X:
‘Death, Be Not Proud’)
This poem also works through the force of its
sounds – for example, by the way the sounds ‘p’, ‘b’
and ‘d’ are deployed in the opening lines (phoneti-
cally these are ‘stops’, because the passage of air is
stopped then suddenly released by either the lips or
tongue). Here, the effect is of passion and a kind of
driven commitment, one might say, reinforced by
the tight verse form of the sonnet, which is handled
effortlessly and compacts a great deal of meaning
into a short space. The poem works because of
technique. What guarantees the value of the writing
is not who is writing but what is said and how.
It also works because of the shared understanding
that most readers will have of the cultural and
religious context, even if they do not actually share
the belief system. In other words, cultural familiarity
is of substantial importance.
Contrast this with, for example, inscriptions from
other cultures, whose social value is now lost to us.
The Ancient Egyptians set great store by the account
of themselves written on their tombs, but these texts,
sometimes called ‘autobiographies’, have no real
meaning to us now, unless we are archaeologists or
historians. The following is a poem written by
Basho, the great Japanese writer of haiku, as death
approached. It is extremely famous, much translated
and, without a knowledge of Japanese culture, fairly
vacuous:
‘Ill on a journey,
My dreams still wandering round
Over withered fields.’
(Oseko, 1990: p. 329)
What do such things mean? – very little without
the shared culture; without, for example, a sense of
the resonance of the word ‘dream’ (‘yume’, in the
original), which pervades the short Japanese poem
and has been picked up, played with and enriched
by author after author over centuries.
Symbolic deaths
Clearly, much of what is quoted above is literature
striving to demonstrate that particular deaths fit into
some kind of overall scheme. This may be an

eschatological account of the world or merely a
matter of taking death seriously because we, in turn,
hope that our death will be taken seriously. At any
rate, what matters is the context in which death is
placed. But literature itself is such that death has
many functions. In other words, the context of
literature gives death and dying many roles to play.
At one end of the scale is one of the most common
types of death in all fiction, the discovery of the body
in the ‘whodunnit’ or murder mystery. This may
require us to expend no deeper emotion than we do
on a crossword puzzle, or it may, as in the next
example, aim to do more. This is from Smiley’s People
by the great novelist of the spy-story, John le Carré
(2000). His hero, Smiley, has just discovered a second
body:
‘Slowly, [Smiley] returned his gaze to Leipzig’s face.
Some dead faces, he reflected, have the dull, even
stupid look of a patient under anaesthetic. Others
preserve a single mood of the once varied nature –
the dead man as lover, as father, as car driver, bridge
player, tyrant. And some, like Leipzig’s, have ceased
to preserve anything. But Leipzig’s face, even without
the ropes across it, had a mood, and it was anger:
anger intensified by pain, turned to fury by it; anger
that had increased and become the whole man as the
body lost its strength’ (p. 243).
This is almost a meditation on the nature of death.
However, the focus immediately changes to death
as a puzzle:
‘Methodically, Smiley peered about him, thinking as
slowly as he could manage, trying, by his examination
of the debris, to reconstruct their progress. First the
fight before they overpowered him, which he
deduced from the smashed table-legs and chairs and
lamps and shelves … Then the search, which took
place after they had trussed him and in the intervals
while they had questioned him’ (p. 243).
One stage further on is the kind of book, often
called a ‘whydunnit’, in which the identity of the
killer is not as important as his or her motivation.
Bear in mind here that the greatest of all constraints
on the writers of whodunnits is that they cannot
describe the motivations of their characters well, or
it will be at once clear who is the killer. The complete
blandness of Agatha Christie characters is neces-
sary, in this respect, to fulfil the genre’s requirements
– or at least it is a happy accident. Contrast this
with Charles Dickens’ The Mystery of Edwin Drood,
which is, among other things, a whodunnit.
Famously, Dickens died before revealing the identity
of the killer, but it can be determined with near
certainty from the imagery and symbolism with
which Dickens surrounds him throughout the book.
The greatest master of the whydunnit is probably
Dostoevsky, whose Crime and Punishment is some-
times described as one of the first detective novels.
Advances in Psychiatric Treatment (2003), vol. 9. http://apt.rcpsych.org/
Death and dying in literature
The function of the hero’s death in tragedy and
epic is one of the oldest literary conventions. We
have looked at King Lear but it is worth reminding
ourselves of the way the idea of the good death
varies from society to society. This is the death of the
Trojan hero, Sarpedon. Homer’s text is here trans-
lated by Alexander Pope, whose urbane 18th-century
style puts a neo-classical veneer on Homer’s more
direct original:
The towering chiefs to fiercer fight advance:
And first Sarpedon whirl’d his weighty lance,
Which o’er the warrior’s shoulder took its course,
And spent in empty air its dying force.
Not so Patroclus’ never-erring dart;
Aim’d at his breast it pierced a mortal part,
Where the strong fibres bind the solid heart.
Then as the mountain oak, or poplar tall,
Or pine (fit mast for some great admiral)
Nods to the axe, till with a groaning sound
It sinks, and spreads its honours on the ground,
Thus fell the king; and laid on earth supine,
Before his chariot stretch’d his form divine:
He grasp’d the dust distain’d with streaming gore,
And, pale in death, lay groaning on the shore.
So lies a bull beneath the lion’s paws,
While the grim savage grinds with foamy jaws
The trembling limbs, and sucks the smoking
blood;
Deep groans, and hollow roars, rebellow through
the wood.
(Pope, 1715–1720)
The ‘pity of war ’, in Wilfred Owen’s famous
phrase, was seldom mentioned until this century
and its principle exponent is Owen himself, who
gave death a new kind of meaning. ‘Strange Meeting’
is linked to the conventions associated with the
literature of dreams and ghosts. It begins:
‘It seemed that out of battle I escaped
Down some profound dull tunnel, long since
scooped
Through granites which titanic wars had groined.
Yet also there encumbered sleepers groaned,
Too fast in thought or death to be bestirred.
Then, as I probed them, one sprang up, and stared
With piteous recognition in fixed eyes,
Lifting distressful hands, as if to bless.
And by his smile, I knew that sullen hall,
By his dead smile I knew we stood in Hell.’
(Wilfred Owen, ‘Strange Meeting’)
Indeed, the death scene in literature is just as much
a convention as is the finding of the body. Among
the finest death scenes in fiction are the death of
Joachim in Thomas Mann’s Magic Mountain and the
death of Paul Dombey in Dickens’ Dombey and Son.
The following, however, is part of the death scene of
the consumptive Ralph Touchett, in Henry James’s
exquisite novel, The Portrait of a Lady. When his close
friend, Isabel, visits him, she finds at first that his
215
Skelton/Sims/Parkes

face on his deathbed is, in an astonishing phrase,
‘as still as the lid on a box’. Then, after some days,
he is briefly well enough to talk:
‘”What does it matter if I’m tired when I’ve all eternity
to rest? There’s no harm in making an effort when it’s
the very last of all. Don’t people always feel better
just before the end? I’ve often heard of that; it’s what
I was waiting for. Ever since you’ve been here I
thought it would come. I tried two or three times; I
was afraid you’d get tired of sitting there.” … “It was
very good of you to come,” he went on. “I thought
you would; but I wasn’t sure.”
‘”I was not sure either till I came,” said Isabel.
‘”You’ve been like an angel beside my bed. You know
they talk about the angel of death. It’s the most
beautiful of all. You’ve been like that; as if you were
waiting for me.”
‘”I was not waiting for your death; I was waiting for
– for this. This is not death, dear Ralph.”
‘”Not for you – no. There’s nothing makes us feel so
much alive as to see others die. That’s the sensation of
life – the sense that we remain. I’ve had it – even I. But
now I’m of no use but to give it to others. With me it’s
all over.” And then he paused. Isabel bowed her head
further, till it rested on the two hands that were clasped
upon his own. She couldn’t see him now; but his far-
away voice was close to her ear. “Isabel,” he went on
suddenly, “I wish it were over for you.”’
(James, 2003: p. 260)
A few mornings later, Ralph is dead. Isabel tries
to comfort Ralph’s mother, a cold and patrician lady,
but is rebuffed as follows – again, a sudden, piercing
moment, quietly stated: ‘”Go and thank God you’ve
no child,” said Mrs Touchett, disengaging herself’.
To make the obvious point: even without the
context of knowing precisely who these characters
are, the generosity of spirit is clear, as is a kind of
maturity of feeling which is missing in the case of
Little Nell. Note how different the angels are in this
novel compared with those that hover around the
deathbed in Dickens’ tale.
Sometimes, however, the conventions take us
away from death itself entirely. Novels are full of
deaths which symbolise the death of some good
thing in society, and there are times when references
to death are so casual or mannered that they have
no real power at all – from the love songs of
the Renaissance to those of the present day. An
excellent, brief and extremely clever example of this
kind of mannerism is Samuel Beckett’s poem from
the Dieppe series:
‘I would like my love to die
and the rain to be falling on the graveyard
and on me walking the streets
mourning the first and last to love me.’
(Samuel Beckett, 1984.
With permission from Calder Publications.)
The desire to pose as a person experiencing grief
is itself a kind of posturing we all recognise, no doubt.
Selected reading
An excellent starting point for anyone interested in
medical humanities is a website at New York
University (http://endeavor.med.nyu.edu/lit-med/
medhum.html). A number of journals discuss issues
relevant to health care, notably Literature and Medicine
and Medical Humanities (although their papers can
sometimes be a little precious for some tastes). JAMA
regularly includes poetry, often of a high order.
These days, all the great writers – and some of the
not-so-great – are represented on the internet and
this is a good starting place for those who, faced
with the thousands and thousands of books on
Shakespeare, for example, do not know where to
start. One example is the website ‘Mr William
Shakespeare and the Internet’ (http://shakespeare.
palomar.edu) which is a place where most of us
could happily lose ourselves for an hour or two.
Conclusions
Death in literature is a varied thing, just as is death
in society. Death is also an inescapable destiny for
each of us as individuals and, for this reason, has
always permeated our thoughts at all levels, from
the immediate sense of devastation that personal
bereavement gives us to the ways in which we
manage the fact of death by pushing it onto the
surface, as familiarly and comfortably spooky as the
deaths in Hammer horror films.
One of the uses of literature in the health
professions is to help people to become more
articulate about their concerns and their worries: to
help them to ‘talk about their feelings’. It is often
said that reading literature will help health profes-
sionals as well, perhaps particularly when they are
young and lack experience; or perhaps when they
are older and crusted over with the cynicism of
experience. These are valuable functions, of course,
but they tend to pull us away from a real sense of
what literature is and can do if we actually repay it
with study and read repeatedly. The fact of the matter
is that literature is difficult and, if we fail to under-
stand it, this may be because we know too little about
the cultures that have brought it into being or cannot
recognise or appreciate the techniques through
which it is realised, rather than because we lack the
finer sentiments.
It follows from this that the role of literature
as part of the growing movement in ‘medical human-
ities’ can be interpreted too narrowly. Literature, if
we trust its strength and accept that to become its

216 Advances in Psychiatric Treatment (2003), vol. 9. http://apt.rcpsych.org/

 Death and dying in literature

student is to undertake something always rich and 2 Literature is easier to understand when:
often difficult, is a way of understanding what it is a it is well-written
to be human. One central gift it can give to those b it is unsentimental
with a scientific training is that, because it is not c it is written from within a familiar culture
d it expresses deep feelings
reductive, it can bring home the fact that there are
e it is read quickly.
ways of understanding which cannot be tested by
MCQ. It is the role of literature to observe that the 3 Literature exists:
world as we experience it is irreducibly complex. a only as a way of expressing feelings
An abstract of a scientific paper is one thing; an b as a way of helping us make sense of the world
abstract of Hamlet is quite another, and certainly c primarily as a form of entertainment
is not Hamlet. d because sometimes words fail us
e to pass the time.
References 4 We make sense of literature if:
Beckett, S. (1984) Collected Poems 1930–78. London: Calder. a we read it expecting to find precise answers to precise
Benson, J. & Falk, A. (eds) (1996) The Long Pale Corridor questions
Newcastle: Bloodaxe Books. b we make no effort to understand the context in which
Day, E. & Smith, I. (2003) Literary and biographical perspec- it was written
tives on substance use. Advances in Psychiatric Treatment,
c we believe that only science gives us understanding
9, 62–68.
Diamond, J. (1999) Because Cowards Get Cancer Too. London: d none of the above is true
Vermillion. e it is simply and straightforwardly written.
Dickens, C. (2000) The Old Curiosity Shop. London: Penguin
Classics. 5 Because literature is not reductionist, both literary
Eynon, T. (2002) Cognitive linguistics. Advances in Psychiatric texts and commentaries on them:
Treatment, 8, 399–407.
James, H. (2003) The Portrait of a Lady. London: Penguin
a make little sense
Classics. b are inferior kinds of knowledge
Le Carré, J. (2000) Smiley’s People. London: Hodder & c run the risk of being muddled
Stoughton. d need to be read several times to be fully appreciated
Moore, O. (1996) PWA. Looking Aids in the Face. London: Picador. e are often confused.
Oseko, T. (1990) Basho’s Haiku: Literal Translations for those
who Wish to Read the Japanese Text, with Grammatical
Analysis and Explanatory Notes. Tokyo: Chuoh Printing.

Multiple choice questions MCQ answers

(Choose the answer most relevant in the context of this 1 2 3 4 5

paper) a F a F a F a F a F
b T b F b T b F b F
1 MCQs are very bad for testing: c F c T c F c F c F
a a knowledge of fact d F d F d F d T d T
b an understanding of literature
e F e F e F e F e F
c a student’s ability to memorise lists
d clinical information
e most things. It follows from 5d that you should read this paper again!

INVITED COMMENTARY ON
Death and dying in literature

Why? … because. This commentary to John Skelton’s
paper (Skelton, 2003, this issue) addresses the
question, ‘Why should I, a busy consultant serving
a population of 40 000 in north Lincolnshire and
having considerable difficulty in keeping up with
the latest developments about antipsychotic drugs,
use my precious time for CPD reading about death
and dying in literature?’ The answer is two-fold:
death and dying is intrinsically an important and
relevant subject for psychiatrists; and literature gives

Advances in Psychiatric Treatment (2003), vol. 9. http://apt.rcpsych.org/ 217

Skelton/Sims/Parkes
useful opportunities for modelling, comparing,
contrasting and experimenting with circumstances
removed from the patient’s immediate situation
but still recognised as ‘real life’. Great literature
demonstrates authenticity. If the experiences
described are true to life, perhaps the strategies that
were used in this literary work, or are suggested
through their absence, may be effective in your
patient’s (or even your own) predicament. Litera-
ture, or ‘the humanities’, can enhance good practice
in medicine (Evans & Greaves, 1999).
East of the Mountains, a gritty story by David
Guterson (1999), concerns a recently retired and
widowed cardiologist. He knows that he is dying
from carcinoma of the colon, which has metastasised
to the liver, and he does not like what he knows.
He leaves his home in Seattle to return to the apple-
growing countryside where he had been a child,
taking his dogs, his gun and a more than half-formed
intention of turning the gun on himself. The story is
of his journey, both geographical and psychological,
and of his intimate involvement on the way with
many people, all totally different from himself. To
write more would spoil the story for you, but the
themes are the inevitability of, and also the potential
for nobility in, the process of dying.
In his editorial in Advances in Psychiatric Treatment,
Powell (2001) reminds us that our patients do not
share our embarrassment and incredulity concern-
ing matters of the spirit or soul: ‘Fifty per cent of
service users hold religious or spiritual beliefs that
they see as important in helping them cope with
mental illness, yet do not feel free, as they would
wish, to discuss these beliefs with the psychiatrist’.
In none of our work as psychiatrists, is recognition
of, and appreciation for, the spiritual needs of our
patients greater than when dealing with concerns
over death and dying. In this context, one uses the
word spiritual for any or all of the following
meanings:
• aims and goals, meaning in life;
• the interrelatedness of all human beings;
• dealing with whole people – body, mind and
spirit;
• the moral aspect – good, beautiful and
enjoyable;
• awareness of the connection between God and
man.
Such ideas are clearly of importance for both
patients and their doctors (Sims, 1994).
For most people in the world, their notion of
spirituality is closely linked to their religious beliefs.
The great religions are all intimately concerned with
matters of life and death. Usually, this implies
something of what death means, both to the
individual and for all humanity, and also makes
218 Advances in Psychiatric Treatment (2003), vol. 9. http://apt.rcpsych.org/
comment on what follows death. For this reason,
when the process of dying has been observed in
committed believers, it has been possible to see their
calm conviction that they are moving on to some-
thing else and not just to oblivion.
Some people who have come close to death have
reported a profound experience in which they
believed that they had left their physical bodies and
transcended the normal boundaries of time and
space (Greyson, 2000). This gives an opportunity to
explore the links between the spiritual and the
psychological in the context of death and dying.
Unfortunately, in medical investigations of this
phenomenon, there has often been a failure to record
the religious beliefs of those reporting near-death
experiences, and so this opportunity has been
missed.
It is self-evident that the psychiatrist should
not try to impose his or her beliefs on the patient.
Neither, however, should the psychiatrist ignore
and exclude areas from discussion that may be of
crucial concern to the patient. A psychiatrist once
said, ‘Patients never talk about religion to me’. He
had not considered whether he was seeing a selected
group of patients who had no interest in religion
or, alternatively, that his patients knew what sort
of response they would get if they volunteered any
sort of religious interest. Patients can benefit
considerably when the psychiatrist encourages them
to use their own religious beliefs to help them
through the difficult life crises associated with death
and dying in the same way that they are helped to
use other resources of their individual personality
in therapy.
When individuals know that they are dying or
are faced with the risk of death, they will almost
inevitably consider their spiritual situation; this is
universal human experience. Psychiatrists pride
themselves on their holistic approach to illness;
disease is seen as not solely a biochemical upset in
a localised organ or system within the body. This
concentration of attention on all aspects of the
person – body, mind and spirit – becomes acutely
relevant when concerned with death. The hospice
movement originally arose out of spiritual concerns
for the dying patient.
Literature sometimes helps people to resolve the
spiritual issues of death. It can be both objective and
personal and it can give inspiration. Reading how
someone else did or did not cope with this, the
ultimate life crisis, helps us to order our thoughts,
refine our beliefs and decide for ourselves where we
can place our trust for the future. When I was faced
with quite a high risk of death within the next few
hours, it was the reassuring cadences of the 23rd
Psalm that gave me strength through the long hours
of the night: ‘Even though I walk through the valley

of the shadow of death, I will fear no evil, for you are
with me’.
Some writing is of value in objectifying and
articulating our thoughts and feelings. This is
particularly true when our patients are concerned
with matters of life and death. If the psychiatrist’s
concern and tolerance for the patient’s spiritual and
religious position is added to this, the usefulness of
literature is given another dimension. We all,
ultimately, have to face our own death and the
process leading to it. Whatever spiritual resources
we have, that is when we will call upon them.
Eventually, we all become patients. Much in litera-
ture helps us and our patients prepare for and
integrate our thinking about the deaths of those close
to us and of ourselves.
INVITED COMMENTARY ON
Death and dying in literature
John Skelton’s paper (2003, this issue) reminds us
that literature can put into words thoughts and
feelings which we might otherwise be unable to
think or articulate. This is an important attribute
and one which we can make use of in our attempts
to help patients and families faced with life-
threatening illness. It might also help those who
have been bereaved to find meaning in what seems
like a meaningless experience.
Such literature is a fruitful source of quotations
that can be used to bring comfort and reassurance
at funeral and memorial services. A useful review of
these is Ned Sherrin’s (1996) anthology Remembrance.
One of the most popular quotations is from Henry
Scott Holland:
‘Death is nothing at all… I have only slipped away
into the next room. I am I and you are you. Whatever
we were to each other that we are still. Call me by my
old familiar name, speak to me in the easy way which
you always used. Put no difference in your tone; wear
no forced air of solemnity or sorrow. Laugh as we
always laughed at the little jokes we enjoyed together.
Play, smile, think of me, pray for me. Let my name be
the household word that it always was. Let it be
spoken without effort, without the ghost of a shadow
on it. Life means all that it ever meant. It is the same
as it ever was; there is an unbroken continuity. Why
should I be out of mind because I am out of sight? I
am waiting for you for an interval, somewhere just
around the corner. All is well.’
Advances in Psychiatric Treatment (2003), vol. 9. http://apt.rcpsych.org/
Death and dying in literature
References
Evans, M. & Greaves, D. (1999) Exploring the medical
humanities. BMJ, 319, 1216.
Greyson, B. (2000) Dissociation in people who have near-
death experiences: out of their bodies or out of their minds?
Lancet, 355, 460–463.
Guterson, D. (1999) East of the Mountains. London:
Bloomsbury.
Powell, A. (2001) Spirituality and science: a personal view
(editorial). Advances in Psychiatric Treatment, 7, 319–321.
Sims, A. (1994) Psyche – spirit as well as mind? British
Journal of Psychiatry, 165, 441–446.
Skelton, J. (2003) Death and dying in literature. Advances in
Psychiatric Treatment, 9, 211–217.
Andrew Sims Editor of Advances in Psychiatric Treatment
(1993–2003). Past-President of the Royal College of Psy-
chiatrists (1990–1993) and Emeritus Professor of Psychiatry
in the University of Leeds (correspondence: Church Farm
House, Alveley, Bridgnorth, Shropshire WV15 6ND, UK).
Most find this helpful, but some have criticised
its failure to accept the need for grief. Whatever
faith we may have in the prospect of reunion in
the hereafter, many would agree with the widow
who insisted to me, ‘I want him now’. It is
this urgent necessity which makes parting so
painful.
Singing and laughter both enable expression of
intense emotion in ways that make it tolerable. It is
no coincidence that death has provided humorists
with ways of helping us to think the unthinkable.
Woody Allen is a rich source,
‘when you’re dead, its hard to find the light switch’;
‘Death is an acquired trait’ ;
‘I don’t want to achieve immortality through my
work, … I want to achieve it through not dying’
as is Dorothy Parker:
‘Time doth flit,
Oh shit!’
and
‘Drink and dance and laugh and lie
Love, the reeling midnight through,
For tomorrow we shall die!
(But, alas, we never do).’
Missives such as these are both cathartic and an
antidote to the pomp and solemnity of death.
219
 Skelton/Sims/Parkes
Bibliotherapy is the use of books as therapy and
there are several that can be recommended to people
faced with death or bereavement. Some, such as
Charlotte’s Web by E.B. White (1952), aim to educate
children about death. Lists of such books, for child-
ren of various ages, can be obtained from Winston’s
Wish booklists for children aged 0–6 years, 7–12
years and 13–18 years (available from Winston’s
Wish, The Clara Burgess Centre, Gloucester Road
Hospital, Great Western Road, Gloucester GL1
3NN). For helping bereaved adults, Alida Gersie’s
book Storymaking in Bereavement (1991) contains 50
folk tales and suggests ways in which they can be
used. It also cites many other literary treatments of
death-related issues. More systematic is The Oxford
Book of Death (Enright, 1983) and an anthology for
those who grieve, All in the End is Harvest (Whitaker,
1984).
I conclude with an extract from one of my
favourites, a work of fiction which carries the reader
on a journey through grief. This is Susan Hill’s In
the Springtime of the Year (1977: p. 135).
‘Without any warning, the tears rose up and broke
out of her, and Potter sat on his chair saying nothing,
220 Advances in Psychiatric Treatment (2003), vol. 9. http://apt.rcpsych.org/
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and yet being a comfort to her, taking some of the
grief on to himself. She wept as she had never wept
before in front of another human being, and it was a
good thing to do; it was more value than all the months
of solitary mourning. It brought something to an end.’
References
Enright, D. J. (ed.) (1983) The Oxford Book of Death. Oxford:
Oxford University Press.
Gersie, A. (1991) Storymaking in Bereavement. London: Jessica
Kingsley.
Hill, S. (1977) In the Springtime of the Year. Harmondsworth:
Penguin.
Holland, H. S. (1919) Sermon delivered at St Paul’s on 15
May 1910. Fact of Faith. London: Longmans.
Sherrin, N. (ed.) (1996) Remembrance. London: Michael Joseph.
Skelton, J. (2003) Death and dying in literature. Advances in
Psychiatric Treatment, 9, 211–217.
Whitaker, A. (ed.) (1984) All in the End is Harvest. London:
Darton, Longman & Todd.
White, E. B. (1952) Charlotte’s Web. New York: Dell.
Colin Murray Parkes Consultant Psychiatrist at St
Christopher’s Hospice, Sydenham, and St Joseph’s Hospice,
Hackney (correspondence: 21 South Road, Chorleywood,
Hertfordshire WD3 5AS, UK). Life President of Cruse –
Bereavement Care; author of many articles and books on
bereavement, including Bereavement: Studies of Grief in Adult
Life (Harmondsworth: Pelican).