Going to meet death: The art of dying in the early part of the twenty-first century

Hastings Center Report

Volumn 39, Issue 4, 2009, Pages 37-45

  Hardwig, John ^a  

^a NONE

Author keywords

[No Author keywords available]

Indexed keywords

DEATH; HEALTH BELIEF; HEALTH CARE PERSONNEL; MEDICAL DECISION MAKING; MEDICAL ETHICS; REVIEW; SPIRITUAL CARE; TERMINAL CARE; ARTICLE; ATTITUDE TO DEATH; EUTHANASIA; HISTORY; HUMAN; TERMINALLY ILL PATIENT;

ATTITUDE TO DEATH; EUTHANASIA; HISTORY, 21ST CENTURY; HUMANS; TERMINALLY ILL;

EID: 70349581240     PISSN: 00930334     EISSN: 1552146X     Source Type: Journal    
DOI: 10.1353/hcr.0.0151     Document Type: Review

References (19)

1. One indication of the prevalence of this fear is the widespread and growing support for physician-assisted suicide and euthanasia. Blendon, Szalay, and Knox found in 1991 that almost two-thirds of the American public supported physician-assisted suicide and euthanasia. R. J. Blendon, U. S. Szalay, and R. A. Knox, "Should Physicians Aid Their Patients in Dying? "Journal of the American Medical Association 267(1992):2658-62.
2. I assume for the purposes of this paper that aging and its accompanying frailty, limited mobility, and dementia will not be "cured" in our time if, indeed, they can be cured at all. It is an interesting but largely speculative question whether more life would always be a good if it were accompanied by good health and no physical or mental deterioration. I do, however, now have a few students who say they expect to live to be four hundred years old.
3. S. J. Olshansky and A. B. Ault, "The Fourth Stage of the Epidemiological Transition: The Age of Delayed Degenerative Diseases, "Milbank Memorial Fund Quarterly Health and Society 64(1986):355-91.
4. Although it should be obvious, I should state explicitly that this is not a paper about younger people. There are important differences between death in your thirties and death in your seventies or eighties. I am discussing the latter. In one sense, death can come too late for a thirty-two-year-old with a budding career and two small children. Her terminal illness may take too long to kill her, and she may justifiably take steps to shorten her dying process. But there is also a sense in which her death, unlike that of a much older person, comes too soon. As Daniel Callahan has pointed out, there is something tragic in her death that there can no longer be in that of an old person.
5. "Prudential virtues" may have an unfamiliar ring-ethicists normally associate virtues with ethics. But there clearly are prudential virtues: saving for retirement, exercising enough to maintain your health, resisting the lure of a promotion that will involve unsatisfying work. But we are tempted to go on a nice vacation instead of saving, to skip the planned workout, and to bask in the light of the more prestigious position. None of these things are immoral, but they are temptations to act imprudently. Though he did not explore this insight and most commentators also skip quickly over it, Kant clearly recognized that there are "hypothetical imperatives, "and that these are genuine imperatives. Impulses and specific desires tempt us not to follow the imperatives of prudence, just as they tempt us to disobey the categorical imperative.
6. The ethics required by our new kind of death is beginning to get attention. Some of the first articles were: M. P. Battin, "Age Distribution and the Just Distribution of Health Care: Is There a Duty to Die? "Ethics 97(1987):317-30;
7. R. D. Lamm, "Death: Right or Duty? "Cambridge Quarterly of Healthcare Ethics 6(1997):111-12;
8. and J. Hardwig, "Is There a Duty to Die? "Hastings Center Report 27, no. 2(1997):34-42.
9. J. Lynn, "Living Long in Fragile Health: The New Demographics Shape End of Life Care, "Hastings Center Report Special Report 35, no. 6 (2005) : S14. I also owe to Lynn the idea that many dying people are not exactly choosing what they want. Rather, they are trying to live out some model of how one is supposed to die. It is, after all, our last chance to do something well, and our one chance to make a good final impression.
10. Certainly, there are also lives that have contained few opportunities for the good things in life. As they draw to a close, part of the tragedy of such lives is that the opportunities they never had are now irretrievably lost.
11. Obviously, those who believe that "rage, rage against the dying of the light" is an appropriate attitude at any age will disagree-Dylan Thomas, for one. He famously said, "old men should rage against the dying of the light. "
12. Needless to say, there are also deep existential or spiritual reasons for prolonging life indefinitely, even in the face of great pain and suffering. Some of these continue to make sense deep into dementia (to others, even if not any longer to the demented person). But exploring these reasons would be the subject of a different paper.
13. I use the word "spiritual" here to refer simply to one's most basic beliefs, values, and attitudes-the beliefs and values that orient one in life. These beliefs and values may or may not contain a religious element. Also, one's religion may or may not provide one's spiritual orientation.
14. For example, "professional psychiatric and psychological training reinforces the view that suicide is a manifestation of psychological disturbance. As such, mental health clinicians typically view suicide, regardless of context, as an outcome that should be prevented at all costs." And this in an anthology about palliative care for the terminally ill! B. Rosenfeld et al., "Suicide, Assisted Suicide, and Euthanasia in the Terminally Ill, "in H. M. Chochinov and W. Breitbart, eds., Handbook of Psychiatry in Palliative Medicine (New York: Oxford University Press, 2000), 53.
15. I persist in using the word "suicide" despite pleas from some who are sympathetic to my position that I change my vocabulary. This word has overwhelmingly negative-even pejorative-connotations, and some mainstream health and medical organizations (such as the American Public Health Association and the American Academy of Hospice and Palliative Medicine) have adopted more value-neutral terminology such as "aid in dying." Undoubtedly, this change serves their purposes well. But I think it is misleading to talk about physician "aid in dying" for someone who has no terminal illness. Although in one sense, it could still be "aid in dying, "the problem is often precisely that death has not shown up. Better, perhaps, to try to rehabilitate the once respectable way to end a life than to substitute a somewhat misleading euphemism. There are ethical and unethical suicides; prudent and foolish suicides; suicides resulting from mental illnesses and depression, and suicides resulting from wisdom and courage. Indeed, my basic thesis is that advances in medical technology require many of us to learn to end our lives. The blanket condemnation of all suicides may serve as a useful rhetorical deterrent, but it will not withstand scrutiny.
16. One study found that 52 percent of patients with metastatic cancer in home-based hospice care received terminal sedation. Another reported that 48 percent of 143 patients in a hospice received terminal sedation. A third found retrospectively that 31 percent of hospice patients had received terminal sedation. References to these and other studies can be found in P. Rousseau, "The Ethical Validity and Clinical Experience of Palliative Sedation, "Mayo Clinic Proceedings 75(2000):1064-69.
17. L. Ganzini et al., "Nurses' Experiences with Hospice Patients Who Refuse Food and Fluids to Hasten Death, "New England Journal of Medicine 349(2003):359-65. Of course, hospice nurses are talking about people with very serious illnesses.
18. But is a deliberate decision not to eat suicide? Some would find that option morally preferable to or easier than more active forms of ending life. This issue, too, has not been worked out. Certainly if I stopped eating and drinking today, everyone would say that I committed suicide. The health care literature has developed an alternative vocabulary-"voluntarily stopping eating and drinking" (VSED)-and there is an emerging discussion of the ethics of this option. See T. E. Quill, B. Lo, and D. W. Brock, "Palliative Options of Last Resort: A Comparison of Voluntarily Stopping Eating and Drinking, Terminal Sedation, Physician-Assisted Suicide, and Voluntary Active Euthanasia, "" Journal of the American Medical Association 278(1997):2099-2104, and discussions referring to this article. But again, VSED is usually assumed to be limited to terminally ill patients. Why?
19. Daniel Callahan coined the term "technological brinksmanship" and wrote insightfully about it in The Troubled Dream of Life (New York: Touchstone, 1994), 40.