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  The Dying Human Being - How We Can Understand And Be With Him
  

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By: Johannes W. Schneider, M.D.
 (Original Title: Der sterbende Mensch - Wie koennen wir ihn verstehen und begleiten. Merkurstab 1995; 48:494-507. English by A. R. Meuss, FIL, MTA.

A new field of research developed in medicine and psychology during the second half of this century is thanatology, the study of the dying process. This concerns not the moment of death but a process that often takes a long time. Previously, death was only seen in negative terms, as the extinction of life. Now people are asking if there are characteristic stages which form a distinct entity and which have to be understood not only in the light of preceding life but also of impending death.

Phases in the process
Dr. Elisabeth Kubler-Ross's book On Death and Dying was a pioneering effort in this direction. She found the dying process to be in five typical stages. It begins when the sick individual is, for the first time, seriously considering that death may be the outcome of his illness. The idea may still be suppressed, but deep down the individual knows what is coming. The second stage comes when knowledge of approaching death can no longer be suppressed but keeps coming to conscious awareness. The dying person then wants to prove to himself and others that he still exists. He tyrannizes family and nursing staff and refuses to see visitors. At the third stage the individual realizes that he must die - but not yet. He begins to negotiate with his physician, with God. Yes, he has not lived a good life until now, but if he could only be given a few more months he would make better use of them. At the fourth stage, it becomes clear that death is approaching not just in general terms, but now. This causes depression, and self-reproach until, at the fifth stage, the sick individual fully accepts death. He grows peaceful and may even be able to comfort those who must remain behind. Evidently the five stages will not be equally well developed in every case, and patients may even go back to an earlier stage if their condition improves. The above progression is, however, typical, and experience shows it to be so, with many variations.

Elisabeth Kubler-Ross made careful observations not only of the symptoms of dying but of the dying individual himself. It is most fortunate that the beginning of modern research into dying was marked not by cool, objective interest in the subject but a caring attitude toward the human being. Concepts developed in the human sciences are only in accord with reality if they come from such a caring attitude.

Modern research into dying has another important precondition. To understand dying, we must think in terms of processes. It is not enough to describe facts, but we must see them as steps along a road. The scientist must follow the road taken by the dying individual with understanding. It is a great help to the dying individual if a caregiver understands the dying process. Then he does not feel left on his own. The dying individual is not the object of pity but is accompanied with insight and understanding.

Finally, there is a third precondition for the study of the dying process. It is that the evolution has to be considered in light of its ultimate goal, which is death. Death influences and shapes the final part of life. The depression seen in the fourth stage of dying can thus be seen as a preparation for the approaching separation. Coming closer to the threshold of death the sick individual abandons his egotistical attitude and gradually develops a new, sovereign view of the value of life. It is part of the characteristic nature of human development that new capabilities often appear first as their negative counter image. Values that have applied until now are destroyed, making room for a new stage in individual development. Just as the independent thinking and insight which develops in our young years tends to present first as the negative counter image of a critical attitude to society, so the peace of dying first shows itself as depressed feelings about the life lived so far. This depression can only be understood if we know it will be followed by the stage when life coming to its close is contemplated in peace.

Elisabeth Kubler-Ross distinguishes five stages in the dying process, noting above all the changes in the dying individual's relation to the world around him. If we consider the changes in conscious awareness, four stages may be discerned in the process.

The first signs may be characteristic dreams as the individual approaches the threshold of death. The dream images will rarely show openly what they imply: a funeral, a coffin, a grave stone, or seeing one's own dead body. (It may be noted in passing that images of death in dreams do not usually refer to actual death but more often to the dreamer's state of exhaustion or separation from someone near and dear.) A student dreams he is walking through the local cemetery and looking at the beautiful grave stones. He is about to turn and leave when his eye catches a stone with his own name; the date of birth is correctly stated, the date of death partly obscured by some moss covering the last digit for the year. Wanting to scrape off the moss, the dreamer wakes up in a state of agitation but, in the process of waking up, has the feeling that it is the current year. These are two of the themes that come in genuine death dreams. The dreamer wants to escape before the essential theme of the dream, his own grave stone, appears and yet feels drawn to this dream content. He also wants to know the year of his death, but the dream stops, and on waking up the student merely has a feeling that it is the current year. The other typical feature of a genuine death dream is that it casts a veil over an essential element which the dreamer would really like to know once he has awakened. It would be tremendously important to him to know the year and day of his death. A third typical theme did not appear in this dream: knowledge of one's own death brings peace and, sometimes, even happiness.

Generally speaking, however, the theme of death is hidden, presenting in symbolic form. The 19th Century German dramatist, Friedrich Hebbel, described such a dream dreamt of a friend, von Engelhofen, an official at the imperial court in Vienna. He was walking through a landscape he had never seen before, finally coming to a large river, the opposite bank of which was shrouded in mist. He offered money to a ferryman to take him across but was refused. The dream returned for eight more nights. The ninth night, however, the dreamer was allowed to enter the boat and was taken across the river "swiftly as an arrow". There he saw a palace, and his father (who had died earlier) standing in front of it to welcome him. Mr. von Engelhofen knew his dream to have been a true one when he awoke but interpreted it as predicting a diplomatic mission to be undertaken that might earn him an decoration or promotion. We note that wishful thinking came in, drowning out the subtle language of the dream. The river is the image of the border between the realm of the living and the dead not only in dreams but also in mythology. The dead father represented the world beyond the threshold of death which awaited the dreamer. Symbolic dreams of death almost always leave the individual free to interpret them in another way and so may easily be misinterpreted.

When we are close to death, symbolic images appear not only in our dreams but also in waking consciousness, interspersed with the images we gain from sensory perception. The inner image will often fill the center of our field of perception, with optical perceptions remaining in the margins. The dying individual sees himself in a dark, damp cave. A crevice appears in the rock, opening out onto a magnificent wide landscape in bright sunlight. The eye is drawn to the rich green of the meadows. The dark cave is clearly one's own sick body; the landscape outside is the world after death which seeks to draw the dying individual to it. The fact that the eye is drawn to the landscape indicates that an activity is already coming in from outside.

The same theme may appear in a completely different image. The dying individual may feel himself to be sitting in a train that is rushing faster and faster through a tunnel. The light illumining the landscape outside is already visible on the tunnel walls. The tunnel corresponds to the cave in the other dream, the light to the green landscape, and the accelerating speed of the train to the eye being drawn from outside.

For the dying individual, the inner image often has the same inner reality as the optical perception. Together they are the reality in which he lives. Thus a dying man might ask the niece sitting at his bedside: "Where did you get on, and where are you going?" The niece, having no idea of train or tunnel, sees this as the beginning of the mental confusion that is often said to precede death. But the dying individual knows very well that his niece arrived yesterday to nurse him and has asked neighbors to look after her two children. He merely does not realize that the tunnel and the train are inner images that others do not share. Thinking based on memory is quite intact but grows uncertain when it comes to observation of natural laws. The person fails to realize that a rock will not open up to reveal a landscape.

During this first stage of changing consciousness, thinking begins to let go of its bonds with the physical world (which also happens in the transition to dreaming) but does not abandon the logical sequence of life's memories, whereas dreams may link different remembered elements in a quite arbitrary way. The individual continues to identify with his physical body, remaining in the cave, but a view opens up on existence outside the physical body. The inner image is already more powerful than the optical image, pushing it aside and taking up the center itself.

The individual is beginning to let go of the body; the endeavor to do so is apparent in the behavior of a dying person. He'll kick the bedclothes aside or want to leave the room, perhaps even by the window. Yet it is not really the room he wants to leave but his body. He still experiences himself in his body but this has become a burden. If the patient still has sufficient physical energy, he has to be watched at this stage, for he distinguishes as little between the soul leaving the body behind and getting out of bed as he does between inner and outer image.

A second stage in the change of consciousness begins when the dying individual no longer identifies with his body but sees it from outside. In a car crash, the passenger is thrown out into the road where he lies motionless and seemingly unconscious. He is looking at his own body from a point about two meters above his neck. He knows himself to be severely injured but not dead. He sees other cars stopping, people standing around him, and hears one of them say: "He's dead." The "unconscious" person is afraid that people will not consider his injuries but treat the body as a corpse. Incidents such as this show how much unconscious or dying people take in of what happens around them. I know a physician who always tells an unconscious patient what he is doing: "I am giving you an injection. I am taking your temperature. .." This shows great wisdom in caring. Maybe those words do not reach the unconscious mind, but they may equally well help the patient not to become estranged from his body as he lies unconscious. In any case, the physician is taking him seriously as a human being, and this in itself is sufficient justification.

In the accident case just mentioned, the injured individual experiences himself at a particular point in space that remains the same, close to his body. The conscious mind has separated from the body, but the familiar, point-centered concentration of the conscious mind continues. Separation progresses when the feeling of being close to the body ceases and the dying individual feels himself to be sitting in a plane, for instance, looking down at his home town. Now the point in space is in motion, and attention is no longer focused only on the body but on the whole life sphere. It is still focused on a particular point on earth, however. This final limitation of the conscious mind disappears when the dying individual feels himself to be floating freely in cosmic space, now fully free of the burden of body and earth. Now, the content of consciousness is no longer determined by the physical body but by the buoyancy of the excarnating human being.

Growing beyond the confines of the body may also be experienced in another form that is less buoyant. It is the experience of getting bigger. Even an overtired person may feel the head growing larger than the skull. The familiar experience of one's physical form is overlaid with perception of the life organism, with the physical body no longer able to keep it within its boundaries. Close to death the experience may grow stronger and extend to the whole body.

There is another way of experiencing the body from outside that belongs to the same stage. The dying person thinks he hears a cracking, crashing or groaning sound, either from unknown far away places or, if it is localized, usually from below. He will say the people in the flat below are hammering or that a bed spring must have creaked. These sound images reflect him bumping into his own body, touching it from outside. Optically, this may take the form of a dark shadow suddenly cast on a beautiful landscape prospect. This image also occurs in dreams, shortly before waking up.

In the two above stages, the dying person's conscious mind is still directed to the world he is about to leave. In the third phase, the earthly world has vanished, and he meets figures from another world. The simplest way in which this may happen is that the individual feels called by name. It may be the voice of his mother or some other familiar person, but it may also be a chorus of voices. Nor does it have to be his name; it may be something like "Come and join us". The experience may condense into the vision of a loved person who has died; the eyes of that person make the strongest impression with a seeking, asking look that draws the other to it.

A young child comes to be at home on earth on eye contact with its mother. In the same way the dying individual finds his new home as he feels someone is looking at him. This theme also comes in dreams when someone is close to death. The individual is walking through a beautiful meadow where the plants have eyes instead of flowers, big eyes that look at him unblinkingly, hundreds of eyes. Or the individual is in a domed hall, the
vault above him a blue mosaic. The keystone is a huge eye looking down on him. Or he is walking in a misty park and sees a rock in the distance; as he comes closer this assumes the form of someone dear to him who has died and now gives him a penetrating look.

Close to the threshold of death the perception of being looked at also occurs in waking consciousness. The 19th Century Swiss poet and novelist, Gottfried Keller, said the night before his death that he saw two knights in golden armor next to a cupboard in his room who looked at him unwaveringly for a long time. The eyes do not merely rest on the dying individual but enter deeply into him. They do not look but see through the person and judge him. Not the way one person might look at another and form a judgment, but in such a way that the look already is the judgment. There is nothing alien about this judgment, however, and the dying individual feels: if I were completely honest with myself, I would have to feel the way those eyes do.

The strangest experience of this kind is the appearance of the "Mongolian" who comes to the dying individual as a totally alien figure, his features immobile, giving no indication of a particular age. This unapproachable expression is in striking contrast to the look in the eyes which is like the dying individual meeting himself, reflecting his own judgment on himself. Keller's two golden knights showed, in an almost mythical way, that they did not belong to the earth world - we don't wear armor any more, and only heavenly beings wear garments of gold - but with the "Mongolian" the supernatural character is almost hidden. The strangeness and unapproachability show that on and beyond the threshold the human being no longer sees himself the way he does in life. We are often quite surprised to find out what others think of us. This might, of course, be because they do not judge us rightly. We can evade this. But the experience on the threshold of death is inexorable, with all self-justification dying on our lips. The human being comes to see: This is I.

People who are dead may also appear, and the dying person may have a conversation with them; or figures of pure light appear, their glory drawing the dying individual to them. Dying people often give a name to those figures of light, calling them Christ or angels. Caution is indicated here, for they often merely indicate that the dying person always imagined Christ or an angel to look like the figure he now meets. The one thing that is certain is that this is not one of the dead but a more-than-human spirit. This will usually be all one is able to find out. If the dying individual returns once more to a quiet reflective mood, he may get a feeling for whether this figure of light came to meet him as a very personal gesture related to his own inherent nature, perhaps protectively enveloping him in light, which would suggest an angelic encounter; or, if the gesture is more than personal, addressing his human nature and he was simply being received as a human being in the throes of death, which suggests one of the less frequent Christ
encounters. We should not always think immediately of the most sublime that may happen to man.

These encounters show characteristic differences in dying children compared to older people. Even when long illness or advanced age has made the individual's thoughts turn to death for some time, perception of the figure of light comes as a surprise. The contrast to life on earth is clearly felt, and yet this new experience is usually taken as a matter of fact, confirming something the individual has always known deep down, even if it went against accepted opinion. When an older person who is dying is finding his way into this world of light, the eyes often show a delicate luster which is perceived by those around him. The other world does not come as a surprise to dying children. For them, it is like returning to a familiar home from a journey. Knowledge of the spiritual reality does not come from the depths but is like something not far away that is remembered and will provide immediate orientation.

In the fourth stage of changing consciousness, the dying individual already feels at home in the new world. Not only does he grow calm but he is able to radiate peace and calm, and to comfort or bless those around him. It used to be very important to people to reach a deathbed in time to receive the dying person's blessing. Why is it that the power of this is so rarely experienced today? Is this only due to the dying person or perhaps also those who have to stay behind and do not dare face the reality of death?

The individual gesture of dying
The four stages of changing consciousness were described as part of a typical dying process, as were Elisabeth Kubler Ross's stages. Typical does not mean that every individual has all the experiences. Some stages may be particularly marked, others only hinted at or not even percephble. The time sequence of the steps is typical.

Every human life shows the typical stages of development and also a highly individual form of biography. This also holds true for dying. There is an ancient saying that we really only know someone if we know how he died. This individual note cannot be described as a process, a sequence in time; it is a gesture revealing the person's individual nature.

The gesture of dying may be wholly in accord with the gesture of the biography or it may give new emphasis to something. Social individuals may die in isolation. Recluses may gather their friends around their deathbed, perhaps even reconciling them. Some depart suddenly in the midst of an active life; others gradually prepare themselves and their families for the parting. A man in his late eighties, fit and always active, is working in his beloved garden when he suddenly feels weak and sits down for a moment, never to get up again. Death coming swiftly is not bringing a new note to the biography in this case but is letting the person die the way he lived, performing the work he has been given.

Another, also in his late eighties, has never been seriously ill, except for being wounded in the war. Having to depend on others was not a feature in his biography. He suffers a myocardial infarction and is taken to an intensive care unit, where death is imminent a few days later. The machines have been turned off, a "Do not disturb" sign hangs on the door, and the family is quietly waiting for what has to come. Suddenly, the patient feels better, wants to eat something, and has two more weeks during which he experiences the dying of his body very consciously; previously irritated at any medical intervention, he now shows great patience as he allows himself to be nursed and treated. Something has been added to a life that had run its full course, something he can take with him. Not a ripe fruit, but a seed for future development.

Another aspect of the individual gesture of dying is the ordering of one's affairs. Before a sudden and unexpected death, one makes arrangements to make life secure for the family or for the dying person himself the sense of which only shows itself later. A woman in an old people's home wanted to visit a friend. She canceled her meals, said good-bye to everyone in the home, and asked the caretaker to repair a lamp in her room while she was away. No one noticed that no taxi arrived to collect her. When the caretaker had repaired the lamp the next day and was about to leave the flat, he got a feeling that something was not right in the bathroom. He opened the door and saw the dead woman lying there. Here, we see quite clearly a woman unknowingly seeking solitude to die unobtrusively - also making sure that she will be found.

A physician had an incurable disease for a long time. He continued his medical practice in his flat, though with some effort, feeling responsible for his patients. Shortly before his death, he went into his consulting room where he sat quietly at his desk for some time; he then went to his wife and children, looking at them long and hard before withdrawing to his waiting room where he sat down in a chair and died. Saying goodbye to something that meant much is a common element in the gesture of dying, especially the deep gaze, as though to take it in once more, lest one forget.

Of course, people are not usually aware of this individual gesture of dying, and we only perceive it in looking back. Characteristically, those who are left behind will hardly note these images or forget them, only realizing their significance when death has ensued. This applies particularly to acts that are like symbols of making farewells, a few hours before his death, a man who had had many appointments in his life and had to organize his time most carefully, took off the watch he had so often looked at. A member of the family reached out quickly to prevent it falling to the floor and put it on the table. When the room was tidied after the man died, the watch was seen lying there. Suddenly it became clear that the symbolic gesture intended to say: time has come to an end - no more appointments.

Acts such as these, indicating a farewell to life, may sometimes be observed quite a long time before death. For many years my father and I had given lecture courses during the summer holidays. I was only there for some of the time when my father was lecturing, leaving early to go on holiday. Planning the program for the following year, my father unexpectedly and for no apparent reason asked: "Will you be there the whole time?" Taken aback, I felt for a moment that there was more behind those words than appeared. I planned a shorter holiday but forgot those words again. The next year, my father had a stroke the day after his first lecture. The 86-year-old, fit and active until then, went down rapidly and died within a few months. It was only after he had his stroke that I remembered his earlier words.

In the encounter with people who will soon be dying one often has extraordinary premonitions of death. I remember visiting a friend. We said good-bye at the door of his flat, and as I walked down the stairs I suddenly asked myself: could this have been our last parting? I rejected the idea immediately, for neither of us was old, and we were both fit. I did not think of the situation again until the news of his sudden and unexpected death reached me a few days later.

When the threshold of death is nearing people often feel the need to speak of death and what comes after it. They will sometimes initiate the subject themselves, perhaps in very general terms. We always feel our way at first, to see if the other person is ready to talk about the subject. We also know very well whom we can talk to and whom not. We may feel we'd rather leave it to someone else, who may know better how to handle it if we are thus approached, but we must not evade it for it is addressed to us. Someone who is close to death is not usually looking for new knowledge concerning death but for assurance concerning something he has "known" for a long time. Of course, we really only know things from direct experience. We shall only know death for what it is when it reaches out for us. Then, however, it will no longer be a question of knowing about death, but of knowing its reality. The latest scientific discoveries will, therefore, be of little use to a dying person, he does not need expert opinions but what the person he has asked truly believes. We are addressed as human beings here, not as people with special knowledge.

The question concerning death is often not put in words but asked with the eyes. We enter the room of someone who is dying and become aware of an expectant look. Will you also say: "You'll be all right", which is what my physician, my colleague and my niece have said, or will you admit to something you know, something I also know? Are you going to chat, to meet your own need, or will you talk to me, the person I am now? Not only old people may look for such openness, but children, too. Someone who has been touched by approaching death no longer needs to be diverted, entertained, the daily routine; he is asking about something that really matters.

People who have as yet no awareness of the approaching threshold, even though close to death, usually also have no desire to talk about death. The thought of what is to come is then not truth to set them free but an alien power that may even destroy their last vital resources. It does not matter at all if that person has said at some earlier time that he would want to know when the end was coming, wanting to die in full conscious awareness. The thought of distant death and the reality of approaching death are two very different things.

Letting go of life
A man of advanced age who had been expected to die any moment for two weeks, was taking difficult breaths; it was as though he was already far away from his body. A member of the family sitting beside him and holding his hand addressed him by name. The dying man was all there again at that moment, turning his eyes to those he was leaving behind - eyes from which spoke profound knowledge of the world after death - and he closed his eyes forever. Destiny is favoring someone by enabling them to die like this. To lay the body aside in full conscious awareness, inwardly accepting the end of life on earth and turning to a new world.

A woman of advanced age who had already got in step with the world on the other side of the threshold was able to say calmly and as a matter of fact, as though to reaffirm the facts for herself: "Now I die." In her last hour her thoughts went once more to what had been the essence of her life.

For many who die peacefully it is nevertheless important to hold the hand of someone near to them. Often with quite unexpected strength. For the moment the body slips away from the dying individual he feels himself to be above an abyss that separates him from the world after death. At that moment the clasp of a hand is a kind of substitute for living experience of one's own body which had given experience of self until now. Holding the hand of a dying person is often the last act of love we can perform for them. For those of us who remain behind, it is a tangible experience of the reality of death.

People find it easier to let go of life if they feel it has been fulfilled. It is, therefore, a help for the dying to be told once more what they have meant to others. Fulsome phrases won't serve the purpose, but a simple thank-you does. People often will not have achieved what they had originally thought life should be. It is all the more important then to be assured that much has been achieved that may not have been originally intended, life simply demanding that it be done. Many a task has remained half done, and it is a relief to know that others will take it on. This applies above all to a dying mother who is concerned for her children's future. A single sentence making things clear can mean a great deal to her.

Those who are close to death will sometimes be afraid that people will forget them. This is not as surprising as it may seem at first. For as the physical body increasingly becomes less significant for experience of self, memory content and, therefore, being remembered by others gains in importance. The reassuring words, "We'll never forget you, gran", do not help much when death is near. Only experiences of reality will serve. Someone about to die knows whether and how the family has so far remembered others who have gone before, on the day of their death, at the grave or in daily conversation. This, we hope, makes the dying individual feel sure that he, too, will be one of those remembered. The "month of the dead" was an old tradition; it came in the Fall in some countries and in Winter in others. People believed or felt that the dead took part in the life of those left behind during those weeks. Some would set a place at table for them, and care would be taken to avoid noise, lest they be frightened. Thrashing of grain and the big family wash day would have to wait until the dead had returned to their own world. In the Swedish calendar, 12 January was called the "day of the angels' departure" well into this century, the "angels" being the dead who had visited their old abode from 13 December.

It is advisable to put down in writing at an early stage who should have the few things with which one has a special inner connection such a piece of jewelry, the handsome vase that was a wedding present, the family Bible, etc. after one's death. Objects that are not really general goods and chattels but like a piece of oneself can become something of a bridge when those who are left behind and to whom they have been given pick them up. Knowledge of such provisions can give a feeling of security when words no longer have much effect. The dying individual likes to think of being remembered in very real terms.

A key element in letting go of the body is the question: has life been fulfilled? We might say that every human being has the arc of his life span as part of himself, and some are sensitively aware of this. Younger people in particular will often have a sense for whether they are going to grow old or die young. This deep-down knowledge may emerge clearly at special movements. The German poet, Ernst Amdt, was asked by a friend if he had considered his age when he started on a major project at age 86. Amdt told him of a dream he had had 20 years earlier. Walking through a cemetery he had seen his grave stone. It did not give the date of death but clearly stated "at the age of 91." He therefore said he had another 5 years to go, and this proved to be true.

You would think that someone dying at the age of 91 would have satisfied his longing for life on earth to the full. That may be so. Quite a few people, however, will say as death approaches: "Surely that can't be it. I had imagined life to be something else." Or: "I have not really lived my life." This does not mean they have not enjoyed life to the full. A life may have been hard and yet the individual may feel it was his very own. People may have lived only for others and yet, or perhaps exactly because of this, feel their own life to have been truly fulfilled.

What about those who die young? Can a life be meaningful and fulfilled if it ends in childhood or youth? Looking back, one will often find that such individuals had a real hunger for experiences, as if they "knew" that they had not much time on this earth. Sometimes a strange melancholy clouds such children's experience of the world, or their remarkably active will matures. I remember a pupil of mine who died a violent death before reaching the age of 14. She had a mature, serious facial expression through which a bright pleasure in life would also show again and again. After the long holidays she always made one big effort and quickly caught up in any subject where she was weak; this was done with a persistence one normally would expect to see only in an adult who is really working on herself. We might say that, in her case, biographic elements that normally come later in life appeared in childhood. She lived life in condensed form.

When life has been fulfilled and death is part of destiny, is there any justification in medical intervention - using all means at our disposal? Every human being has the right to live and to shape his own life. Does he not also have the right to die? This question often leads to demands that incurably sick or extremely old people should be given the freedom to choose active assistance with death, that is, an injection that will quickly and painlessly terminate life. People who think like this fail to consider how easily seriously ill or very old people's will to live is influenced by others around them. Many simply no longer want to live because they feel they are a burden to others. If justification should ever be found for the termination of unwanted life this would open the floodgates, undermining respect for life altogether. It will then be necessary for governments to establish "objective" standards for the value of a life. We know this has happened before. It is a complete illusion to think people who are in such borderline situations can freely decide for life or death, quite apart from the question of whether we actually have the right to decide. It would be brutal to make someone who is discouraged, hopeless, isolated and despairing make the decision over life or death. It would be a mockery of freedom and self-determination, not respect. The lethal injection would deprive the person of the individual gesture of dying; death would not be his own but something imposed by the will of the family, physicians, or another.

A totally different question is whether life should be maintained at all costs. A physician is obliged to do everything in his power for his patients, including those terminally ill, and it is right to call him to account if he fails to meet his obligations for the patient is the weaker one in this case, is at his mercy, and has to be protected. The question is, what does "everything" in his power mean? Knowing that he may be called to account, the physician must secure himself. Because of this, means are sometimes used which the physician really no longer considers appropriate, not in the patient's interest, but to meet legal requirements. This is not individual, and cannot be so, but takes account of general regulations in clinical medicine. The doctor-patient relationship is, however, a personal one, or should be. As a patient, I claim the right to chose my own physician and the medical approach he uses. The more effective and real the relationship, the greater the individual and therefore human nature of healing - and of dying. The more sophisticated medical technology becomes, the more sensitive must we be to the individual character of disease and of dying. Medicine clearly needs reform in this respect, and this calls for initiative not only from physicians but also from patients.

Is it intervention in destiny to extend life with an organ transplant? Undoubtedly. This applies even to blood transfusions. It is also destiny to live in the 20th Century when such aid is available. When people such as Jehovah's Witnesses refuse a blood transfusion and prefer to face death instead, this is a personal decision and physicians usually respect it. The problem is that the decision is made in advance, the person concerned (understandably) wanting to make sure his wishes are met even when he is no longer able to decide for himself. It is a decision one does not like to leave to others because it is so very important. Yet in the face of death the situation often looks very different and it may be that a completely different decision is made (not only from fear). If there is a possibility of being unable to decide at a later point, it is generally advisable to ask someone one trusts - his physician or perhaps a member of the family - to take the responsibility. It is far from easy to be involved in deciding on the life or death of someone close to you, but it is one of the responsibilities one has to accept.

What is the situation regarding resuscitation? It is justifiable to fetch someone back across the threshold of death? Isn't it that a decision has been made which the family has to accept, however hard this may be? Looking at the life people have had after resuscitation, one finds again and again that it held important elements which one would not like to see missing from the biography, and that these people really wanted to live, to work on themselves and on the world, something only made possible by the difficult intervention by the physician.

An extreme example is the following. I knew a child who had been in a coma for nine months after a road accident. The child had been clinically dead and resuscitated ten times. When I was told this before seeing the child I thought: surely this child wanted to die and has been prevented from doing so. Yet the impression I gained from observing the child at play was different. The child was still somewhat hesitant and, indeed, clumsy in its movements, but had a marked will to be creative in its play. It was actively making itself part of the world. Seeing this, I have become very cautious in saying that even repeated clinical death is a definite statement on the part of the human I that it wants to leave the earthly world.

Another child was taken to hospital after an accident. The physician later said to the parents: "The injuries were severe but need not have been fatal. The child did not give us time, however." These words, spoken by a sensitive individual, show that the child wanted to depart and did not want treatment. Considering the circumstances attending the accident, it is remarkable that the mother, who always took such great care, was not on the spot at just that moment but was as if tied to her housework, which created the space for the accident to happen. Even during her pregnancy the mother had had a strong feeling that this child would need special care and attention. Talking to her, one felt she had had a premonition of the child's early death.

With children who have died, one often has the impression that they have taken the world in deeply and intensely. Looking back one gets the feeling that the purpose of this life had been to experience the world with great intensity. Other children's fates cannot be understood at all unless one looks at their environment. They may have been quiet, perhaps attracting no particular attention, but achieved much with their short life and especially their death. They transformed the people among whom they lived. Close observation may show that these children remain close to their families, that they are waiting. If their families do not drown themselves in pain but let the pain be a gate opening up to deeper insight into the world, the dead children are happy, for their waiting has not been in vain. Their life gains meaning after death.

Death may come early or late, suddenly or after long preparation, due to illness or accident, but it may be that "the time has come". Looking back on the last weeks or months of a life that ended unexpectedly you often recall words or acts that clearly announced the coming departure, though this was not understood at the time. One often finds that important affairs are put in order or a relationship put to rights. Often a word is said, quite casually, that will only later prove vital in understanding that individual's life. The interesting thing is that such words and acts will effortlessly come to mind after the individual's death and then appear highly significant. It seems incredible that no note was taken of them at the time, for seen in retrospect they are so obvious.

Clearly, death does not always come when a life span has reached completion, and "the time has come." An early Christian prayer carved over the gate to the city of Miletus addressed seven archangels, asking them to protect the city and its inhabitants from an "untimely death" - not death as such for that is part of human existence, and even angels cannot change this. However, they may be able to avert a danger when life has not yet run its course.

It is quite unthinkable that millions of people actually sought an early and violent death in concentration camps or from starvation. As 20th Century people we cannot reject our share of responsibility that easily. Those terrible events show that human beings can powerfully intervene in destiny, both their own and that of others. Human beings depend on one another today across all borders. The individual is more and more becoming a member of the human race, and this determines destiny in a way that goes beyond the intention brought with us at birth.

People who feel their life has run its course often feel that others are waiting for them beyond the threshold of death. They may speak frequently of long-dead friends. This is entirely natural in the old, for they often live more intensely in their memories than in the here and now. Their memories are an important affirmation of self for them when the capacities grow less. Relationships with the living may become fewer, and those to the dead grow more important and real.

Living one's memories may condense to a feeling that some of the dead are expecting one. There is a popular tradition that someone who has recently died draws someone who has been close after him. Married people often follow each other quickly. But the simpler and more obvious explanation for this is probably that the one left behind has lost a major purpose in life and may, indeed, long for death, and this loosens the bonds with life on earth. This is not what we are speaking of, however. We are concerned with people who died long ago and come back to mind again as the individual approaches the threshold of death.

When the dead actually "appear in person" to the inner eye, how can we tell if these are memory pictures or a present encounter? Memory pictures take us back into a familiar world, perhaps our childhood or youth. Being thus familiar, they give security, self-affirmation and orientation in a world that may have grown alien. Old people are, above all, happy in their memories. Images reflecting a present encounter with the dead almost always come as a surprise. The dead do not look the way one last knew them but have changed, usually being younger and inwardly illumined. People who speak of such experiences are often unable to say what clothes the dead person wore, even if they have had him clearly before the inner eye for a long time. The question is, what made them recognize him? This is the wrong question to ask, for in a real encounter we do not recognize the dead by something (which is the case with memories), but we know inwardly who it is. Similarly, we may wake still hearing words we know for sure were spoken by someone dead, perhaps even knowing exactly who it was, though actual sound was not involved. This certainty is an unmistakable characteristic of present encounters with the dead. Any doubts as to the reality of the event vanish in the face of that certainty, just as there is no doubt as to the reality of the event when we perceive someone clearly with the senses.

In earlier centuries, death was still experienced within a wider context. In medieval times and the early part of our present age, believers knew they had come from the hand of God to enter into life on earth and would return to God on their death. The term "blessed" was used as an attribute in some languages to indicate that the individual continued to exist and was experiencing a happier existence, unless he had committed grievous sins. It is understandable that in recent centuries, when certainty of life after death had vanished, people wanted to banish the image of death from their lives. This, however, increased the feeling of death's alien and, indeed, sinister nature. Death was made into a nothing, and so were the dead. They would, of course, be remembered and honored; the question is why, since they no longer existed? Probably because this enabled people to do justice to a deep, inner knowledge of the reality of the world after death without getting into conflict with materialistic ways of thinking.

Modern people are more aware again that birth and death are not absolute boundaries to existence. Wanting to understand their true nature, to express in thoughts what they know deep down in their hearts, they have to take account in a new way of the reality of existence before birth and after death, not with theories or creeds, but from experience. Attention and understanding must be given not only to the dying individual but also to the dead. It is true, however, that the further away they go in dying and death, the more subtle and intimate their observation has to be if it is still to reach them. Fixed habits of thinking must not impose themselves on observation, and the observer must grow increasingly still. Active stillness is a faculty of the soul that allows access to the intimate experiences we have spoken of in this chapter.

If birth and death are no longer absolute boundaries to existence, the unborn and the dead become real to us. They are part of humanity just as much as the living are. The living shape the world and carry responsibility today. But those who are waiting to enter into life have their eye on them. Raphael showed this in his Sistine Madonna. The clouds behind Mary condense into heads, into the unborn, whose eyes follow the one who has now found his mother. In the same way the eyes of the dead are on those who approach the gate of death. To think in truly human terms we have to include all human beings, those who are visible and those not visible to the eye.

Johannes W. Schneider, MD
Mergelteichstr. 41
D-44225 Dortmund
Germany





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