Death Symposium – The Revd Dr Charlie Bell

Death, be not proud’: Dying, Death & Destiny

A record of the Symposium held in The Abbey Centre, 34 Great Smith Street, London SW1P 3BU on Saturday 18 November 2023, organised by The Society of the Faith.

The Revd Dr Charlie Bell: Death and contemporary medicine.

The Revd Dr Charlie Bell is an assistant curate in the parish of St John the Divine Kennington, in the diocese of Southwark, having previously read for a degree and doctorate in medicine at Cambridge, and is now a forensic psychiatrist with a research interest in psychopathy. He is a Fellow of Girton College, Cambridge and also a Tutor at St Augustine’s College of Theology. His main theological research interests concern the interface of science, medicine and theology, focussing at present on the concept of culpability, and he has published books on sex and death.

Thank you very much indeed. I am hoping that this talk follows on from the talks and discussions of this morning, in a way which is fortunate but not planned.

“Death is nothing at all”, as the famous poem goes, except of course it is, as those of us who deal with it on a frequent basis know all too well, and indeed the author of that all too beloved poem Henry Scott Holland knew, too. Death is very much something. And if it were not something, then rather less fuss would be made of pretending it out of the way in modern life. If death were nothing at all, we would not perhaps spend our lives running away from it and hiding those experiencing it from the rest of society. If death were nothing at all, then those of us in the medical profession would not exert quite so much time and effort trying to ward it off, and in the process pretending that none of our patients ever succumb to it.

 

Today I would like to talk about death in medicine, something very few doctors want to admit really happens. I would like to think about the role of the hospice movement in trying to tackle some of the stigma that continues to attach itself to death and to dying, and indeed to the dying themselves; and in particular, the work of Dame Cicely Saunders. We will explore how her concept of “total pain” has revolutionised the landscape in palliative care, and remind ourselves not only of the deep Christian foundations on which that was built, but also the huge possibilities that it offers for us, both as Christian doctors but also as clergy and Catholic Christians more widely, to meditate on death and dying. In the process, I would like to spend a little time asking ourselves what role we think our doctrine should play in our engagement with this most central of Christian questions, and explore what role our doctrine really has been playing.

A quick note on that doctrine before we turn to Dr Saunders. We have heard some of that doctrine earlier today. As Catholic Anglicans, we have the most extraordinary treasure trove of gifts to offer, not only to the wider world but to the wider Church, yet, whether in our own temerity in speaking, or our deafness in hearing (or both), we find ourselves making less of an impact on how the Church does “being the Church” than we might hope. That will be news to nobody here, for when we turn to death and dying it is incontrovertibly the case that, all too often the Church is either playing catch‑up, colluding with wider culture in the denial of death, or simply absent.

During the coronavirus pandemic I will admit I found it scandalous, at least as someone looking on from the secular political world, where I found myself at the beginning of the pandemic, and from the medical world, where I found myself at the end of the pandemic, to see quite how little the Church corporate appeared to feel it had to offer on the great existential questions that the pandemic raised.

The arguments around the Church’s practical role in keeping buildings open or otherwise have themselves been done to death, including by me in a previous Society of the Faith lecture, so we will not allow them to detain us here. But alongside this, and perhaps even more important, was the Church’s apparent willingness to vacate the public sphere in matters of death, which were all too prevalent and yet hidden in plain sight. We heard much about the fabled church scientific advice on the transmissibility or otherwise of coronavirus particles, the importance of door knobs and the great danger of singing the Sursum Corda, but there was a deafening silence when it came to facing up to the reality that, despite all the medical advances, the lockdowns and the vaccinations, people were dying in quite extraordinary numbers: often unprepared, alone and unexpectedly. Our willingness to collude in society’s public dishonesty about this very simple fact felt somewhat instinctual, which is perhaps indicative of our increasing willingness as a church to separate our doctrine from our lived-out experience as human creatures. The Church, of course, was not absent during the pandemic, at least not in the crematoria, at the gravesides, in the funeral parlours of this land and in the front rooms. Although there were plenty of clergy and licensed ministers offering this essential service to their parishes, often day in and day out, the lack of the wider public ecclesial narrative on death meant that these actions felt entirely divorced from anything we corporately believe or believed as a Church. As clergy we deal with death rather more than the average person in the street. Yet as a Church we chose to keep our counsel.

There are perhaps a few reasons why this might have happened. Amongst them, of course, is our wider decline in public life, and with it a lack of belief, not only from the wider world, but, as we heard, from many within the Church too, that we might have anything useful to say to the world frankly, about anything. In recent years, while we have had many of our bishops speaking out on this and that, in actuality, we appear to have not much to say about rather too many things, and almost none of those things is actually based on the doctrines of the Church. We see in our own internal wranglings over doctrine that we are all too frequently skimming the surface and addressing the peripheral and are all too infrequently engaging with the meat of the issue at hand. Death is by no means the only example.

Challenging, too, are our internal struggles in which the Catholic voice appears to be less and less respected as part of the Anglican heritage. Lip service is given to the bishop of a church when it comes to matters of credal importance, like for example the doctrine of the Communion of Saints, to which we will turn in one moment, and to which many of us turn to twice a day in our recitation of the Daily Office; yet the reality is that such doctrines are often seen or portrayed as more of a hindrance than a help, and most certainly as something that can be comfortably ignored if necessary.

Thirdly, our reticence springs perhaps from the fact that, in a world that wants both less dogmatic certainty and more of the workings out to be shown, the Christian proclamation that death is not the end suddenly feels a little less easy to defend.

Many of us feel, or at least I hope feel perfectly comfortable in expressing our confidence in the resurrection of the Lord, and its implications for our eternal future, yet the mechanics of all that, as we heard this morning, (answering questions of where and how and what, and all the rest of it) are somewhat hazier.

The Easter Anthems, for example, are a fantastic way, in my mind at least, of expressing the eternal truths at the heart of the Resurrection, yet they equip us rather less well for questions which contemporary minds tend to pose. ‘What specifically, Father, does the resurrection body look like then?’ Our society is not only uncomfortable with, but positively scorns, the mystical and the scientifically irreducible. And yet many who genuinely believe in our doctrine see us apparently caught in a place where we have something very important to say and yet have lost confidence in the way we used to say it. And this failure is deeply relevant for our ministry and our mission. In my view, this is an error and one which Cicely Saunders’s work can help us to correct.

Cicely Saunders was a quite remarkable woman. It never ceases to amaze me how many people I meet who have, or at least claim to have, worked with her in her pioneering work in the hospice movement. Born as the first world war was in its own death throes, Saunders started her professional life as a nurse, and as an evangelical, yet throughout her career neither of those things really stuck. Qualifying both as a social worker and as a doctor, Saunders began her work at St Luke’s Home for the Dying Poor and then moved on to St Joseph’s Hospice in Hackney, and during these early days of her career herself experienced grief to such a degree that she called it “pathological”. A few years later having meditated on Psalm 37, “Commit thy way unto the Lord; trust also in him; and he shall bring it to pass”, she established St Christopher’s Hospice in Sydenham as the first purpose-built hospice, which remains to this day and at which I am privileged to work as a volunteer chaplain.

Saunders developed an idea, as she worked with the dying and their families, which has stood the test of time, and continues to influence the hospice movement: that of “total pain”. In Saunders’ understanding, pain was not only about physical symptoms but also mental distress and social or spiritual problems. And she saw her own role in the hospice movement as, to quote her, “Providing space for freedom of spirit in facing the mystery of death”. Saunders fundamentally rejected the idea that there is nothing more to be done for people edging towards the end of life, sadly, a phrase we continue to hear all too often in medicine, and instead developed an emergent medicine of terminal care, central to which is a multi-faceted understanding of pain; a medicine concerned also for the “meaning of pain”, as Professor David Clark of the University of Glasgow says. Clark suggests that this conceptual shift allowed the finest human sentiments to shine through in the closing lives of those she was caring for, and enabled her to avoid searching after the clean death: “Death that does not disturb too much”, in the words of Stanley Hauerwas, but instead allowed her to meet her patients as full holistic individuals whose lives were more than the sum of their parts, and whose personhood mattered.

One of Saunders’ earliest descriptions of total pain was taken from a patient who simply stated, “All of me is wrong”, and while she did not shy away from the use of pain medication, nonetheless, she recognised that the pain people were experiencing was not something that could be simplistically categorised or neatly separated into the physical or the psychological. In many ways, Saunders was seeing pain not merely as the output of the firing or misfiring neurons, but rather as an experience for the person in their entirety, something whose cause and effect might not be found in the same modality. In other words, total pain was a recognition that suffering, particularly in those towards the end of their lives, encompassed all of an individual’s experience of the world, be that mental, physical, social, or spiritual, and this suffering’s social and spiritual import could not be overstated.

One’s pain did not start and end with pain receptors. It spread outwards to the family and the community and it spread inwards from them as well, each element contributing to a wider and often overwhelming subjective experience of suffering: what we might otherwise call existential dread, marked by a sense of helplessness, a fear of dependency, anxiety, physical decline and, ultimately, hopelessness. Whilst doctors at the time might have tried to treat each of those modalities on their own, for example with opioids for physical pain, and anti‑depressant medication for low mood, and ignore or neatly side step those they could not treat in that way, or indeed those symptoms that they could not treat such as family separation, or spiritual despair, Saunders fundamentally refused to do so, and in such a refusal created a model of palliative care which remains remarkably relevant and applicable today. It is a matter of deep regret of course that this model has so infrequently been seen outside of palliative care.

Central to Saunders’ vision of total pain was her deep and enduring Christian faith. She treated people as entire people, not only because of her medical training and experience on the wards, but because of her seeing her patients as, in her words, beloved children of God. Her recognition that loss formed a part in patients’ lives was fundamental, and deserves a little more exploration here because of its pertinence to the way we address matters of death and dying as a Church, and as a wider society.

Following Saunders’s thoughts, such loss is very much real for the patients, in that their experience and dread of this loss, of this aloneness, is not simplistically removed at only a mention of the glories of the Kingdom of Heaven. Yet that is not to say that such loss gets to have the final word. These two are held in creative tension with any Christian world view, yet it is far too easy to obscure or over-emphasise one of these, and then do serious damage to either the reality of human experience or fundamental Christian theological vision in the process. As Saunders recognised, and as we too must surely recognise and learn to enunciate, it is possible for loss to be very real in a human sense and yet when viewed in the light of the resurrection to be very unreal as well. It is addressing this tension that we must find a way for our pastoral practice to express our doctrine.

To my mind, Saunders’s concept of total pain sits comfortably and helpfully within the Church’s doctrine of the Communion of Saints. So much of what she speaks of when she speaks of the components of total pain ‑ the loneliness, loss, fear ‑ speak of an individual whose experience of the world is one of an atomised community or society in which each is on their own and the sense of community and continuity is broken.

Describing her ideas for her hospice, Saunders speaks of it as “a community united by a strong sense of vocation, with a great diversity of outlook, in a spirit freedom”. In Allan Verhey’s words, not a contract between self‑interested individuals, but a covenant and a community, within a mantra of Matthew 25:40.

Within her hospice (explicitly embodying Christianity), the dignity of each patient was explicitly recognised, and notably, proselytising forbidden, with patients seen as autonomous and yet welcomed into the community. Her hospice’s aim was to: “express the love of God, to all who come, in every possible way, in the use of every scientific means of relieving suffering and distress, in understanding personal sympathy, with respect for the dignity of each patient as a human being precious to God and man.”

Hospice care then, at least according to Saunders’s perception of it, might be one of the few places in the medical world where human lives are primarily seen in narrative form, and where questions of purpose, loss, meaning and despair are seen, not as awkward and frustrating blips on an uneasy biomedical canvas, but rather, as integral parts of the human person who enters the consultation room.

Yet before I am too unkind on my medical colleagues, let us remember, too, the refusal to meet people as whole, entire, connected, beloved ‑ indeed as individuals in communion ‑ is not merely something of the medical world; and all too often such a refusal infuses not only wider societal understandings of the human person but those of our own understandings in the Church. Our increasing focus on the salvation of the individual as an individual within Church of England polity may be a helpful correction to the perceived slovenliness of modern-day Christian discipleship, yet we run the risk of forgetting our ultimate interconnectedness and belief that each play a part in the life of the Church that ultimately points towards salvation.

It is important to note though that Saunders’s ideas around death and dying are by no means the only ones that exist within our current medical landscape, and as budgets tighten, and as the so‑called “extras” of medical care become more and more difficult to justify, and as hospice care increasingly loses touch with its Christian roots, it may be that this model itself is at risk of being diluted or lost.

To return to the coronavirus pandemic, it is curious, to say the least, that there was so little outcry when thousands upon thousands of people met their deaths without human touch and without even the opportunity to say farewell to family and friends. If we are looking for an example of the medicalisation of death, here we find it writ large. That is not for one second minimising the challenges that existed in hospitals during the pandemic, but it is to note that the dying were placed at a lower priority than those who were sure to live: understandable perhaps in light of our society’s wish that death was nothing at all. One diocese indeed forbad its clerics from taking communion to the dying in case they gave them coronavirus. A plainly absurd directive and yet one which unintentionally gives good insight into the priorities of those diocesan officials.

Our complicity as a Church in the medicalisation of death is no small thing, and must surely be resisted, yet this will only happen if we are willing to look the dying in the face and see Christ there as much as in those who are “lusty and strong”, to quote one of the Psalms.

In my experience of death and dying in the National Health Service, the sad reality is that if a patient’s religion is described as “Church of England” or “Anglican”, this is as good as writing “no religion”, and more often than not, a chaplain is either nowhere to be seen or declined on the patient’s behalf by well-meaning staff, who appear to have heard what little we have to say about death and concur that our presence really is not required.

I am convinced that a return to Cicely Saunders and her concept of total pain, her willingness to recognise and talk about and address despair and hopelessness in the dying, can help us hugely as a Church to regain the initiative. Saunders met those in the valley of the shadow of death whose existential questions often included a recognition of the loss of meaning and purpose, the loss of connectedness to others, thoughts about the dying process, struggles about their state of being, difficulty in finding a sense of self, and a loss of hope. Rather than casting this aside, condemning it as either too difficult, or ungodly – and perhaps Aquinas, or perhaps our interpretation of him, has a little to answer for in his own engagement with the reality of despair – she looked to provide a holy space. This space was one in which such people might be first and foremost recognised as people who despite their own sense of loss and hopelessness were held within the palm and within the hope of Jesus Christ – expressed in community, expressed in communion.

I have made a number of allusions to the Communion of Saints, and I want to finish by focusing a little more on why that doctrine is so helpful to us: a doctrine which offers so much and yet one in which we seem to have lost confidence. I have lost count of the number of churches who, when offering an All Souls’ Day commemoration focus entirely on those left behind, to coin a phrase, with ‘remembering’ being a mere bringing to mind in regret and sorrow ‑ and little more. Even for those who struggle to pray for the dead, such a pedestrian understanding of remembering really does little credit to the meaning of re-membering in the Christian faith. and I think this belies a surprising lack of lived out belief in the real existence of the Church Triumphant, let alone the Church Penitent.

When we gather around the altar, either we do join with angels and archangels and with all the company of heaven in proclaiming the great and the glorious name of the Lord, or we do not. There are no half measures. They are either there or they are not, and the Christian faith is pretty clear that they are. Yet it is perhaps because proclaiming an actual belief in the Communion of Saints requires us to re-situate and re-orientate ourselves to a new world view, that we remain so reticent to do so, in a world so often shaped by scientific reductionism. Of course, as we have heard, not all scientists take a reductionist view and it is clear Saunders is among those who refuse to do so, but it remains tempting to try to fit our doctrines into the parameters set by the wider world rather than by defining our own. If we accept the existence of the Communion of Saints then we situate the life of the Christian within a wider narrative of creation, redemption and resurrection, offering a profound challenge to death itself, and all that it means. It requires us to name ourselves as firstly being in fellowship with others, this being necessary for us to form a part of the body of Christ: a community in which resurrection is a lived reality. In doing so, we find ourselves surrounded by companions and friends even when we find them hard to grasp. In doing so indeed, we find ourselves born for and in lives lived in relationship.

There is not time today to fully explore the pastoral and real-world implications of our really believing in the Communion of Saints which I expound in my book “Total Pain and the Body of Christ”, but it is worth drawing out a few themes as we draw to a close. First, it seems increasingly important for us to recognise that how we conceptualise ourselves as created entire beings really matters. This might sound a truism, but as a Church we need to be consistently called back to remembering that it is in those whom Christ appointed that we will often find new insights in our faith. In the contemporary world those in despair, and those dying, are far too often pushed to the margins and covered with a cloak of invisible respectability, with the hope that they, and all they signify might be kept at a safe distance, or even better, just go away.

A failure to recognise the inherent marginalisation and often scapegoating that dying imbues people with, is a risky business. As the Hiroshima Report puts it, Koinonia (communion) is not an expression of charity from the powerful to the powerless, but a manifestation of solidarity, if you like, of communion with God, humanity and all creation. It goes on: “In contrast to prevailing social patterns, in life together in koinonia the experiences and perspectives of people on the margins are valued, lifted up and considered transformational for the whole.”

This is a profoundly important theological insight. It is not simply an incorporation of marginalised people into existing systems and structures; those at the margins indeed become witnessing agents of life-transforming koinonia. The dying, standing in the hinterland of this world and at the portico of the next, are signs and symbols of the importance of this koinonia in our life together. Our attitudes and behaviours towards the dying as a society, and as a Church, really matter, not just for them but for us. too. In a sense, it is for us to take Saunders’ lived-out reflections on death and dying and make them our own, in the whole of our Christian life, restating that we are not simply the sum of our parts but that our existence has Communion implications, and that the Communion of Saints has similar implications for us, too.

Secondly, let us not shy away from the reality that whilst we in the Church may grapple with the tension of death being both enemy and friend, in wider society there are tensions, too, about how and when death might be permitted, welcomed or even enabled. For a world ultimately terrified by the idea of death, we, nonetheless, want to have some kind of ownership over it, and conversations about euthanasia, assisted dying, suicide and so on, are never far from the surface. On suicide in particular, the Church’s pastoral response has been sadly and frequently lacking in basic charity, yet we must also be careful that this charity is carefully balanced with other theological imperatives, to say the least, when considering the further medicalisation of death through assisted means.

Of particular concern to me as a clinician is what appears to be an increasing acceptance of despair as a reason for death in and of itself, whether in choices being made for euthanasia in some jurisdictions in Europe, or in our tacit acceptance of decisions that life simply is not worth living any more. There is much more to say here of course, but while there may indeed be times when it is entirely within the bounds of Christian charity to demur from further aggressive treatment for a condition, or to choose a palliative route, if these decisions are based on hopelessness or despair then this hints at a failure of the community in helping to resituate the individual concerned. Despair may not be alleviable, but I fear we are far too infrequently open to conversations about it, that we may not be doing all we can as a koinonia to stand in solidarity with those who might need our genuine support, rather than our somewhat detached sympathy.

The dying have much to teach us about our life together and our doctrine can be life-giving in the settled different meanings of the word. Standing at the interface of medicine and the Church, we have much to offer one another, and openness to the reality of death, the existential questions and even the despair it might bring, can only lead us to a healthier and better Church. If we are not willing to talk about it, who will? And talking about it seems to me to be something we need much more of, if we are to truly see the dying as the beloved children of God as Cicely Saunders reminds us that they are. (Applause)

THE CHAIR: Thank you, Fr Charlie. I would like to comment that I think you are somebody who really encourages us all to consider that the Church should be the Church Militant, and actually do it in a kind way, as your militancy is so generous and so kind.

REVD DR CHARLIE BELL: At times.

THE CHAIR: How you think the Church of England, but not only the Church of England, could really get back into delivering chaplaincy in the NHS.

REVD DR CHARLIE BELL: I think that is an excellent question. With all of these questions on chaplaincy, the proviso is some excellent chaplains are available; but the reality is that across too much of our health system chaplaincy has moved towards a model of spiritual care which then often moves towards pastoral care – which then puts God outside. That may be because there are many people who do not particularly want God inside, but for those who do not want God inside, it means we end up with many hospitals which are generally empty of genuine chaplaincy. I think it is a big, big challenge because to persuade the National Health Service that this is something they need, and indeed something they need to pay for, is never going to be an easy sell. I do wonder if one thing which really improves the chaplaincy provision in hospitals is when clergy go and visit their own people, because it reminds other people they are perfectly entitled to have someone visit them. Once you have Father whoever, or Mother whoever, down the road coming to see the person in bed number 8. the person in bed number 7, who has been a churchgoer for their whole life, gets pretty frustrated when the chaplain says they are too busy doing paperwork. I think there is something about encouraging the good practice which encourages more good practice. but also something about the Church saying, “God is back”. In many parts of the wider world we are recognising more and more that God is part and parcel of human life, and other religions are ahead of us in naming that, I think, in the context of NHS chaplaincy.

REVD DR JONG: I cannot tell if it is the same question but I will ask it anyway. I was struck by what you said about chaplains not being called or being turned away on behalf of people who say that they are Anglicans. It reminds me of a programme where they interviewed people on their preferences and also interviewed staff members and family members, and one of the things they found was that family members over‑estimated the extent to which the dying wanted them around, and everybody under‑estimated the extent to which the dying wanted some kind of religious care. So, there was a gap between assumption and reality here. In the system as you understand it, how does one get around that misconception, or is your answer for parish priests to go up to see their people more and therefore people get more used to having a priest around?

REVD DR BELL: I think there are two parts. I think of the nation we have become, particularly as cultural Christians, for want of a better phrase, where, nonetheless, those rites remain important. You will find a large number of people who say they would like the last rites, having no idea what the last rites are, but nonetheless they would like them. I do not have much of a problem. I am very happy to give them. If someone wants them, they can have them, depending on the situation, but so many people, I think, fail to have the language to talk about these things, the things of God, the things of existential life: questioning which previously they may have been more able to speak about in Christian terms. We definitely find people want to talk to somebody but they do not know who it is they want to talk to. But, in many ways, if they had had the language to be able to describe it, and it is the language of their childhood in terms of Christianity, they would have been able to speak to a chaplain. I think they do not know how to talk about it and families do not know how to talk to them about the fact they do not know how to talk about it. And so we are failing, in a sense, and I do not know the answer to this, to give people the language to be able to have those conversations in the first place.

I had a death in the service that I am working at. I work in a mental health facility and it is very rare for us to have an expected death in the mental health inpatient service. First, the staff did not know what to do. There was a terrifying, “I have no idea what to do here, we’re mental health, we don’t deal with this kind of thing”, but there were two things that were really interesting to me. One was the response by members of staff ‑‑ the person who had died had a long criminal history, which is basically everyone I treat, and the response by the staff was uniformly: “May he rest in peace and may he rise in glory”. And the forgiveness, albeit not directly from the victims, which ran through was very, very strong. I really did notice that.

The other thing was the number of patients of other traditions as in non‑Christians, saying, “Did he get to see a priest?” They said this when I know that a lot of families say no on patients’ behalf never having asked them. I think there is also something about equipping our folk to say if you want to see a priest in hospital, you need to not just say I am from the Church of England but I want to see a priest and if I get sick, I want to see a priest. That is no longer the cultural norm now and partly it is about equipping people to say those words.

REVD DR JONG: That is helpful, thank you.

REVD DR ANTHONY: I was wondering if you might say a few words about the connection between death and dying and deathbeds and reconciliation, particularly rooted in that notion of the Communion of Saints? As I think of some of the deathbeds I have witnessed, they are either catastrophically awful or they are miraculously grace filled. One of the things I have noticed, as well, is the capacity of a deathbed to bring about reconciliation. People aren’t sitting there chatting or worrying about the will, or whatever, they are having conversations in which reconciliation is taking place. I can think of parishioners who have put large amounts of energy, time and effort into hating each other who are then reconciled at a deathbed. I wonder if recognising the human dignity in the person that is dying, triggers off in you the capacity to see your own imperfections and the grace of God, in that you have spent a large amount of time hating and now recognise you must be reconciling. There must be a connection between reconciliation and the notion of the Communion of Saints at those occasions when they go well and when God is really at the centre of them in an acknowledged way.

REVD DR BELL: There are three things I want to mention. I hope I remember all three. One of them is the importance that Cicely Saunders puts on that process, so the fact that you can alleviate people’s spiritual distress by naming it and dealing with it. That includes engaging with families and engaging with people with whom there is genuine discomfort and anger and hurt. Too often, particularly in hospitals, that simply does not happen. You treat symptoms and then give someone more Midazolam because they are very disturbed, and they are probably very disturbed because they have not dealt with the things they wanted to deal with, but we keep whacking them with Midazolam, and it is too late and off they go. I think we need to bring attention to this in terms of the general provision of healthcare, and hospices do this really well.

I agree that you see remarkable examples of reconciliation. There are various reasons for that, one of which is time at the end is gifted. I was just talking to someone over lunch and saying I have seen very few patients who have life‑limiting illnesses, ask to die. I see most of them wishing they had a bit longer in order to get things done. There is a kairos moment in this when time, for some reason, has a different symbolism and holds a different meaning than otherwise it does. I think people do see in the dying person their own mortality but you can also see elements of reconciliation at bedsides without that. You see it in individuals who find a sense of peace as they face their own mortality and come to terms with difficulties in their lives, not just with those who are alive but with those who have gone before as well.

I think we have to recognise that there is something metaphysical which is certainly present in that process of dying. You are right, you can feel the grace pouring out of that particular moment. I have sent several people on their way, by which I mean give people the last rites rather than anything else, in the last year, and it seems that the Lord always sends it to me when I have had a really, really, really bad church day. And I get that call and think, “You’re joking “ and then turn up the hospice and it is extraordinary. You leave with a sense of peace and grace which you simply do not find in many other places ‑ you certainly do not find it at weddings! You really do find it there. There is something happening there and it is beautiful and it is definitely a privileged moment, but it is something more. There is something about grace being almost close enough to touch as you are wishing someone well on their way on their journey. It really feels like you are waving someone off on a journey and going home slightly topped more up with grace and kindness and holiness than you were when you turned up. .

REVD CANON TILBY: There are some interesting exceptions too. When I was a parish priest I remember being summonsed to a place where somebody was said to be dying and I was halfway through my recitation of the Psalms and she was very unconscious and suddenly, to my horror, she sat up in bed and said, “Who the hell are you?” after which she lived for another three weeks. It was quite a moment of grace in its own way.

REVD DR JONG: It worked.

REVD CANON TILBY: Also just anecdotally I am interested in this question of asking for the presence of a priest. I have a friend in Portsmouth who is a lay hospice visitor and is very, very sensitive to the fact that she does not go in with a dog collar or any kind of obvious religious covering, but is very adept at simply asking people where they are in terms of their spirituality and what they need. She will frequently, and this is to people who have no church, say, “Would you like me to say a prayer?” I do not think she is supposed to do this, but she does because she is like that; she is fine if someone says no, but if the answer is yes, she can speak afterwards of the often enormous gratitude and warmth that comes back in response to the offer of prayer. And that makes me think that, actually, this is ministry which all kinds of people could become involved in if they were willing to.

Lastly Charlie, and this stayed running with me through the whole of your talk: the dying have much to teach us. Could you expand?

REVD DR BELL: Yes, we often think what we can do for the dying, but, actually, it is partly what they have to say in terms of grace, it is partly in terms of reminding us who we are as whole individuals, it is partly about reminding us how we react with one another and what the key things in life are: to be very blunt about it, what matters and what does not matter. I think it is also partly, as Saunders herself talks about, the dying being on the margins. When we engage with people who are in these last stages of life, we far too often, (and I think this probably includes clergy, it certainly includes doctors) meet them as a problem to be solved rather than as an encounter to be graced by and blessed by. We often also do not allow people to die. They die at the end of not dying. We are so keen for people to remain alive and looking great as long as possible. You often hear people say someone died very quickly, and you think he or she didn’t actually, they took the same amount of time, but you did not want to let them go, prolonging that farewell process, so that sometimes actually the dying do not want their families there. Actually, we can learn a lot about who we are as human beings from people who are different to us but the same as us and further along the journey than us -those who are dying and also those who are dead. Reflecting and meditating on their journeys towards the end can help us become better when we are a bit further on the journey.

REVD CANON TILBY: That very odd phenomenon that the person often dies when the relative is out of the room.

REVD DR BELL: They always do ‑ almost always – and it is very distressing for relatives, but it is almost always the case and you have to sit with someone and say, “I’m really sorry that is usually what happens.” It does not make it any better and people say, “That’s no good for me.” It is true and there is something about the fact that you die alone whether there are people in the room with you or not, because there is no one else dying with you. Even if there is someone else dying at the same time as you, they are not dying with you. You are baptised alone into the Communion and something happens when you enter that portico of death alone, or rather at least with the Lord. I think we think that we can do more than we can in those circumstances.

THE CHAIR: We are at the open question session now so if anybody would like to ask something.

REVD STEPHEN TUCKER: I was once doing a visit and I asked someone, “Would you like me to give you a blessing?” and the response was, “Does it have side effects?”

In hospitals and hospices, I do not know how long ago it was, but at one stage chaplains were able to go round the wards. Then that was stopped. Hospices are increasingly not reappointing chaplains and sometimes you get the sense, or the reason is sometimes given that we don’t want people who are vulnerable to be faced by someone who is trying to convert them. How widespread is that view and what has the Church done, actually, to contribute towards that suspicion?

REVD DR BELL: Well, I think it depends on the location. Saunders and most hospices are anti‑proselytizing – clearly anti‑proselytizing – and the chaplain will poke their head in and say, “Would you like to be seen?” and if they say no, they say, “Goodbye”, and that is it. Of course, no doesn’t always mean no, but in the general sense that is what will happen. In hospitals there is mixed practice and I think that is part of the problem and there is some truth underlying the fear that you will be proselytised. The thing is I am not sure it is the chaplains who have done it. It is often other clergy who have come in, seen someone and think, “I’ll just do a mass for the whole ward”. That does not happen generally from our situation, but you definitely will have it or they will say, “I’ll do a prayer and worship service” or “We will wheel people down to the chapel”, and it is very infrequently the chaplains themselves who do that, and it is often badly behaved clergy who do it, who see it as being a missional opportunity. I do not think the hospital is a missional opportunity primarily. I think it is a ministerial opportunity and if through one’s ministry you show something of the love of God that other people then ask, “What’s going on here?” and you do the Lord’s ‘Come and See’, that is fine. But I think there has been bad practice and the problem is there is a suspicion against religion, against Christian religion. I sound terribly like one of those people on Radio 4 I do not want to listen to, but there is some truth to it: that the established Church comes off pretty badly in all this.

REVD STEPHEN TUCKER: And is that a question of the inadequacy of training for this ministry in ministerial preparation?

REVD DR BELL: I would be intrigued if there is any training for this ministry in ministerial prep. There is some but not much and it depends where you have gone. I think it is also just a societal thing. I think it is part of the cultural shift against established religion and against the Church of England, and I think the Church of England takes most of the cultural hit for opposition to religion in general. I think it is a bit of both. I have definitely seen poor practice where people come in and go, “I’ll give out some leaflets”. “No, you won’t, sunshine.”

REVD DR JONG: I had a nurse tell me something very interesting not long after Covid restrictions were lifted. I would walk into wards and visit parishioners in my cassock and I noticed they let me in even outside of visiting hours. I thought this was very interesting and peculiar, and how generous, and the head nurse said to me, actually, we started doing this not long after Covid restrictions were lifted because we wondered where the priests went because no one came, and when I was invited, it was come whenever you like. Over time that has become stricter and now it is 2 pm to 4 pm, or whatever it is, but in the early days of Covid restrictions being lifted, there was an appetite for clergy to visit. Even though I agree with you there is the suspicion, on the other hand, there is also some recognition that there is a need to be fulfilled, which we really failed to do during Covid.

REVD DR BELL: One final thing. One of the other things I think makes a big impact on whether the chaplaincy works or not is where the other staff, particularly nursing staff, understand what a chaplaincy is for. We often have nursing staff who, particularly in hospices, are driven by Christian faith, or by other faiths actually, and will frequently pick up on on a patient who says no but means yes, or will be able to say I think this person may benefit from a conversation. The thing is that, as the NHS is now, you are generally reliant on that happening on the ground, and that is so patchy. Again, we can equip those of our congregations who work in hospitals and encourage those of our congregations who work in hospitals to have that mind working because the NHS will not stop you from saying maybe this person might want to see a chaplain, even though we often think that the NHS will. We have built up our own fear story and at the same time there have been elements of discomfort amongst folk but definitely, the best referrals I get are from nursing staff who say I think this person needs to see a chaplain but they do not know it yet.

JENNY ELLWOOD: Just very briefly, I can remember the days when we had lavender bag ladies. Does anyone remember the volunteers coming round with lavender bags with texts on to give to the patients? It is going back some years.

REVD DR JONG: Were they printed on the bags?

JENNY ELLWOOD: Bible verses, yes.

REVD DR JONG: Interesting.

DAVID LYMINGTON: I am just a bit troubled. Correct me if I am wrong; yes, Cecily Saunders was fantastic and treated the whole person and everything, but just the way you spoke to me sort of implied that you thought Christianity, and perhaps even your section of Christianity, had a bit of a monopoly on this whole person idea. Maybe I have misunderstood that but I think this idea is quite prevalent in secular society. There is a danger of Christian people thinking they are better than secular people. I do not believe that.

REVD DR BELL: I spend most of my time telling Christians they are not better than other people, so I agree with you. I think the reason I particularly focused on total pain is that came out of Ciceley Saunders’ Christianity. In the health system we focus quite a lot on biopsychosocial pain which is similar but different to total pain because it sees that being taken into account in the biological, psychological and social but not necessarily seeing how they interrelate with one another, and not necessarily grounding it in a particular theological belief. The thing that Cecily Saunders offers us in a Christian context is a way to think through these things in the Christian context. I do not think that suggests that it is not possible to do the same or the same is not being done in other contexts. The reason I focused on Saunders so much is I feel like the Church could learn from her to resituate our own work as Christians within that particular structural understanding. However, I agree that you will often find nurses of different religions, and indeed of none, who will absolutely see that the whole person is the thing that needs to be engaged with and treated and spoken to and all the rest of it. It is certainly not only a Christian virtue by any means but I think Saunders’ version of this within Christianity is a particularly helpful one for Christians to hang on to and help to engage with hospices.

DAVID LYMINGTON: That is a good answer. Thank you.

A SPEAKER: On a more practical level rather than a spiritual level, I have great reservations about the lengths which medical professionals will go to keep elderly people alive. At what point do we let go and how far do we go to keep people alive?

REVD DR BELL: That is a really helpful question. It is interesting because in some parts of the Church, not necessarily within the Church of England but certainly some parts of Roman Catholicism, there is a real determination to keep people alive at all costs. We do find it helpful to see some of the narratives, particularly with tragic cases where it is children with very life limiting illnesses and so on, and they say if only we could take this child to Rome or to Madrid, or whatever else it is and then we will be able to keep this person alive for longer. Often that is really hope rather than reality, or frankly, optimism rather than reality. There is definitely a thread of Christian thought that suggests that we should really keep fighting until the bitter end and we should not take quality of life into account in the way that I might want to.

I agree with you there is also a determination among medics never to admit defeat, and defeat in the context of medicine is death. There is a real fear that if we say that is it, and there is nothing more we can do, then we end up essentially giving up on that person. I do not like the phase, as I said in the talk “there’s nothing more we can do”, because I do not think it is true. There is always something more we can do. The something more you can do is maybe make that person comfortable, or identify what they want to do in their last few weeks, or whatever else it might be. I think particularly in the context of healthcare in the 21st century, we have grown in such a way, both as socialised medical professionals and also as a medicalised society, that we believe we can cure everything, and we really think we can treat everything, and therefore, when people find out they are going to die from something, people are genuinely outraged that we are not able to cure it or treat it in a particular way. There are some groups, and I agree with older people, where we need to listen more to what older people actually want. We are really good at getting people in many places to write their advance directives; we are not very good at listening to them. I think again that is one of the things the Church should spend some time doing is helping to equip older people to say what is it, if I get sick, that is my priority here. We have the ability to do it. We have the documents and all the rest of it, but they are not as well-used as they might be.

Should we be treating people with advanced dementia for pneumonia? In reality, people live for years by aggressively treating, but is that the right thing to do in different circumstances? For some people it might be and for other people it might not be, and who makes those decisions, and how do we make those decisions, and all the rest of it? But the problem is as doctors we are absolutely socialised into keeping people alive at all costs, and the problem is that “at all costs” is sometimes a bigger cost than allowing someone in the later stages of their life to go to glory. I would go on to say it also falls back to the question of whether we are more willing to try to keep people alive when we do not think there is anything after it. So, given that society basically thinks that you only get what is on the page and after the page finishes, it is over, you might as well have another couple of lines. I think that is one thing that sits through a lot of our decision‑making in clinical practice. I agree with you, it is a challenge. I think it is something that medicine and society need to take more seriously as we move to an ageing population.

DAVID LYMINGTON: It was an argument you seemed to be making that the Church accepts death and there is this world out there that is somehow death denying. I do not believe it.

REVD DR BELL: I am not sure I would argue that that Church accepts death, actually. I am not really worried about who it is that does and does not accept death, it is more the fact we need to do more to accept it. I think there are plenty of people in the world who say, “That’s it, I’m done, I’ve had my 70 years, I’m happy.” Not many actually: it is more, “90 years and I’m happy.” That idea passes through the Church and through the world. I do not think it is specifically for the Church. I think the difference is that if the Church proclaims something beyond then the Church has a particular responsibility to interpret life in the context of life everlasting, in a way which those who do not have a belief do not have that responsibility to do. In a sense, you are interpreting life through a different lens. That does not mean you will come to a different answer, but it means that the responsibility on those who do believe there to be something beyond life is probably stronger because we should be always making decisions on life based on the longer term, as in eternity rather than just on the years we have on earth.

JENNY BREEWOOD: With listening to all the different things about your ministry and about the role of the doctors and nurses and everything that happens, death is a very difficult and dark thing to have to deal with, and very painful for the loved ones and relatives. I feel that it is very important to understand that we know that God gives and he takes away, and death is going to happen: we just do not know when it will happen. For me what has come out of this is it is very important to understand that there is something that we all can do, if not directly with your jobs in the hospital and the nurses and so on: we can pray. We can pray for the ones that are dying, or we know that are suffering, and in that prayer we can also receive healing for ourselves knowing that we will lose the person that is closest to us. I think maybe emphasis in this nation has been lost for the importance of prayer, whether it is done in a church or it is done privately. I think it is very important that we have an acknowledgement of God who has created us and that we connect personally with God in prayer, and trust that He knows and we can rely on Him in this particular situation, praying for ourselves to prepare for the death and also for the person who is dying. I feel it is very important for our prayer, and for me that is a big takeaway for today.

REVD DR BELL: I think that is very helpful and I think recognising for all that we think we are in control ‑ and I am preaching to myself as a doctor here – for all we think we are in control, we are actually not. We might be in control of some things but even then not particularly in control of them. But the recognition that this is part of a wider circle, and each of us is part of a union, and each of us has our own narrative, and that narrative is not ours to write but ours to participate in, is a key thing that underlies who we are as human beings and how we understand ourselves as Christians. I am not suggesting that there is nothing we can do so you might as well pray, I think you might as well pray before there is nothing else you can do, because, first, it is not going to hurt, and, secondly, it might be quite helpful not just for the person in front of you but also for yourself. I think you are right, you can never have too much prayer. I think that is absolutely right. I think remembering our participative role and not our creative role is an extremely important thing for us to understand, not just in death and dying but throughout the whole Christian life.

JENNY ELLWOOD: Again on this “nothing more we can do”, can I tell you a short story about a patient of mine who was very agitated when she knew that she was going to die very soon, and it came out that she was very concerned that she had lied to her husband all these years, 20 or 30 years, that their son was not his. This has been on her mind all her life and she wanted to die knowing that he knew the truth. We managed to get her home for a weekend so she could see her husband and tell him this story. She came back on the Monday a totally different woman. She was radiant. She had made peace with her husband and her son and all was well and she was at peace with herself. I just wanted to mention that.

REVD DR BELL: What Saunders would probably say is that that woman’s symptoms could have also been not just about her feeling bad, she might have said she had pain somewhere. That is part of the whole concept of total pain: those different elements are interacting with one another and expressing them in ways you do not understand. Someone comes in and says, “I have got this terrible pain in my side,” we do examination after examination, x-rays and all the rest of it and turns out it is because her son is not her husband’s son. And then she goes and tells her husband and she comes back and the physical pain has gone. I think we omit that kind a treatment at our peril. It is not just good for the soul, it is also good for the body, unsurprisingly.