Intended for healthcare professionals

Feature Christmas 2020: House of God

Danse Macabre

BMJ 2020; 371 doi: (Published 14 December 2020) Cite this as: BMJ 2020;371:m4600
  1. Paul Keeley, consultant in palliative medicine
  1. Glasgow Royal Infirmary, Glasgow, UK
  1. Correspondence to: P Keeley, @drcrouchback

Our current predicament should make us think more about death and how we die—but we probably won’t

In an age of social media outrage, it is hardly surprising that hospital staff dressed in full personal protective equipment, posting videos of themselves dancing along to a jaunty track on TikTok, Twitter, or Facebook might be the targets of digital ire. I’m torn. On the one hand I can see the benefit in maintaining morale in difficult times. On the other hand, I am aware that while loved ones are dying alone on wards because their relatives cannot be with them, it might be somewhat galling to see staff twerking around their clinical areas. I doubt staff motives are anything other than benign, but such videos could be considered crass.

Iconography of death

Dancing around death is nothing new. Many English parish churches were adorned with Danses Macabres, until they were whitewashed over during the protestant reformation. In these vivid wall paintings skeletons, representing death, cavorted with all the estates of society—popes, kings, bishops, lords, priests, and peasants—a reminder that death is the great leveller and we should prepare for it.

The modern iconography of death is somewhat different. On the front of the building until recently occupied by the Fulton County Department of Health and Wellness in Atlanta, Georgia, is a bas-relief by the sculptor, Julian Hoke Harris. The sculpture, called Keeping Away Death, shows a muscular man, bearing the Rod of Asclepius and thus an avatar of medicine, holding off skeletal death, robed and holding a scythe. The image is striking, but self-defeating. The ultimate cause of our success in prolonging life is contested. The epidemiologist and historian of medicine Thomas McKeown pointed out more than 50 years ago that the reductions in mortality asserted by medicine might be better claimed by improved nutrition, hygiene, and, only later, by superior physic. In the intervening years, clinical practice can claim more success in increases in longevity from the treatment of cancer, heart disease, and other chronic ailments. We can hold off death, but only for so long. In the process of doing so, we change the mode of death from the short infectious disease of most human history to the prolonged trajectory of degenerative illness and organ failure.

An opportunity in the middle of a drama

A plague, pestilence, or viral pandemic—call it what you please—we are in a drama that has brought illness—potentially life threatening illness, to the forefront and centre of our perception. As we distance ourselves from each other, as did the citizens of Italian city states quarantining themselves from the black death, it might be the moment to contemplate what it all means. As the shielding Israelites in Egypt stayed indoors while the angel of death passed over, we might consider from what we are being shielded.

Mark Taubert, a palliative care consultant, recently praised Albert Camus’ novel, The Plague, as an exemplar of how we might find meaning from such an epidemic.1 Camus’ story is a propagandistic caricature pitting of the noble atheist Dr Rieux in his battle to save his patients from illness against the grotesque, moralising priest, Father Paneloux. Camus’ view was that plague was not a modern way to die. I tend to disagree. Coronavirus and the illness that accompanies it—coronavirus disease 2019 (covid-19)—is both a modern and ancient way to die. For most of human history, death that wasn’t through war, violence, famine, and plague was through a rapid decline due to infectious disease (now largely curable) with a short illness.

We have an opportunity to consider our mortality—the closeness to death seen by many through this crisis should give us pause to relish life and value every day. Yet it also gives us a chance to examine the limits to medical care that we would want if we were to become acutely or gravely ill. What are the civilised limits we put to the interventions we are willing to accept when we are older and more infirm?

The aftermath

In the aftermath of the “Spanish flu” pandemic in 1918-19, the events of the outbreak were quickly consigned to oblivion. The death toll of the pandemic, at an estimated 50 million, far outstripped, at least numerically, the carnage of the first world war. Yet the subsequent events of the early 20th century—the depression (to which it was undoubtedly a contributory factor), the rise of fascism and Nazism in Europe, and Japanese militarism in the East leading to a second world war, left the pandemic largely forgotten. It did not become a subject of academic interest until nearly a century later, perhaps in the aftermath of further pandemics—severe acute respiratory syndrome, Middle East respiratory syndrome, and swine flu. The internet is both a blessing and a curse to memorialisation.

We are unlikely to forget this pandemic—given the electronic footprint it will have, but our attention span seems to have shortened as our use of social media increases. This latest brush with death’s latest manifestation gives us a chance to think about how we deal with death and dying. The sad thing is, when things have settled, we will probably go back to ignoring our own mortality again.


  • This article is dedicated to the memory of Professor John Cash, 1936-2020


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